Citation Nr: 1540540 Decision Date: 09/21/15 Archive Date: 10/02/15 DOCKET NO. 11-22 293 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUE Entitlement to an initial rating in excess of 30 percent for anxiety disorder not otherwise specified with posttraumatic stress disorder (PTSD) symptoms (formerly rated as PTSD). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD G. Slovick, Counsel INTRODUCTION The Veteran served on active duty from February 1968 to November 1969. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a January 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado, which granted service connection for PTSD and assigned a 10 percent initial rating, effective from November 15, 2006. The file was subsequently transferred to the jurisdiction of the St. Paul, Minnesota RO. In a May 2011 Decision Review Officer decision, a higher initial rating of 30 percent was assigned, effective from November 15, 2006 through March 13, 2010 and then from May 1, 2010 forward. (A 100 percent disability rating was assigned from March 14, 2010 through April 30, 2010 for a period of hospitalization over 21 days.) An April 2012 rating decision recharacterized the service-connected psychiatric disability as anxiety disorder, not otherwise specified, with PTSD symptoms, and continued the 30 percent rating. As the 30 percent rating is still less than the maximum benefit available, the appeal is still pending. AB v. Brown, 6 Vet. App. 35, 38 (1993). In November 2012, the Veteran testified at a hearing before the undersigned Veterans Law Judge, via videoconference. A transcript of the hearing is associated with the claims file. The issue was remanded by the Board in May 2014 for further development, the requested development has been accomplished and the appeal is ready for adjudication. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability rating for compensation purposes based on individual unemployability (TDIU) is part of an increased rating claim when such claim is raised by the record. In this case, the record does not indicate, and the Veteran does not contend, that his service connected anxiety disorder with PTSD symptoms renders him unemployable. Thus entitlement to a TDIU need not be considered. FINDING OF FACT The Veteran's service-connected anxiety disorder with PTSD is manifested symptoms (including chronic sleep disturbance, anxiety, depression, and irritability) productive of functional impairment comparable to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for service-connected anxiety disorder with PTSD symptoms are not met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2015); 38 C.F.R. §§ 3.102, 3.159, 4.130, Diagnostic Code (DC) 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION VCAA As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2015); 38 C.F.R. § 3.159 (2015). VA must inform the Veteran about the information and evidence that is necessary to substantiate the claim, the information and evidence that VA will seek to provide, and the information and evidence that the Veteran is expected to provide. 38 U.S.C.A. § 5103(a)(1); 38 C.F.R. § 3.159(b)(1). The appeal for a higher initial rating for anxiety disorder with PTSD symptoms arose from a disagreement with the initial evaluation assigned following the grant of service connection for PTSD. As such, there is no duty to provide further VCAA notice. 38 C.F.R. § 3.159(b)(3). Rather, VA is only required to provide notice of the decision (under 38 U.S.C. § 5104) and a statement of the case (under 38 U.S.C. § 7105 ). The record reflects that these notices have been provided to the Veteran. VA satisfied the duty to assist the Veteran under the VCAA by gathering relevant records. VA has a duty to assist in obtaining the Veteran's service medical records, VA medical records and other relevant records. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c). The Veteran's service treatment records, VA treatment records and private records have been obtained and are associated with the claims file. Additionally, VA satisfied the duty to assist the Veteran by providing medical examinations to the Veteran. VA provided PTSD examinations to the Veteran in November 2010, April 2012 and July 2014. Each examiner interviewed the Veteran and conducted a mental status examination, recorded clinical findings, and documented the Veteran's subjective complaints. As these examinations included sufficient detail as to the severity of the Veteran's service-connected disability, the Board concludes that these examinations are adequate for evaluation purposes. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The Board remanded the issue on appeal in May 2014 in order to obtain additional treatment records and to afford the Veteran a new VA examination. The Board finds that the RO substantially complied with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board finds the record as it stands includes adequate evidence to allow the Board to decide the issue on appeal. Additionally, the Veteran has not identified any relevant evidence that is outstanding. Thus, VA satisfied its duties to notify and assist the Veteran with his appeal for a higher initial rating for his service-connected psychiatric disability. As such, appellate review may proceed without prejudice to the Veteran. Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2015). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). In resolving this factual issue, only the specific factors as enumerated in the applicable rating criteria may be considered. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41(2015). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board notes that where, as in this case, the current appeal is based on the assignment of an initial rating for a disability following an initial award of service connection, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, 'staged' ratings may be assigned for separate periods of time. Id. When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev'd on other grounds, Moore v. Shinseki, 555 F.3d 1369 (2009). With the exception of assignment of a temporary total hospitalization rating pursuant to 38 C.F.R. § 4.29 for the period from March 14, 2010 through April 30, 2010, the Veteran's service-connected anxiety disorder with PTSD symptoms is rated as 30 percent disabling in accordance with the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9411. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation, obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work like setting), and an inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. Id. In evaluating the Veteran's level of disability, the Board has considered the Global Assessment of Functioning (GAF) scores as one component of the overall disability picture. GAF is a scale used by mental health professionals and reflects psychological, social, and occupational functioning on a hypothetical continuum of mental health illness and is relevant in evaluating mental disability. See Carpenter v. Brown , 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The Board notes that, during the appeal period, a new version of the DSM was promulgated (DSM-5). In this version, GAF scores are not included with regard to evaluating psychiatric disorders. However, since much of the medical evidence gathered during this appeal period was developed prior to the DSM-5, the Board will include and consider as relevant evidence the GAF scores assigned to the Veteran during the appeal period. GAF scores between 70 and 61 reflect some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and with some meaningful relationships. Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)(hereinafter "DSM-IV"). Scores in the 51 to 60 range indicate moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers. Id. Factual Background and Analysis A December 2006 VA medical center psychotherapy treatment note included the Veteran's reports of conflicts with his wife, noting that she would not be moving with him to Minnesota. The Veteran expressed confusion about his marriage. In a February 2007 mental health treatment note the Veteran indicated that his relationship with his wife had become more complicated. He stated that he was changing for the better since receiving treatment for PTSD and he felt his wife was not accepting those changes as easily as he did. In a March 2009 statement in support of his claim, the Veteran reported that he had trouble sleeping and that he had bad dreams and flashbacks. He reported intrusive thoughts which are violent as well as thoughts of revenge. The Veteran described doing perimeter checks in his home. He described having impaired concentration and short and long term memory deficiencies and relationship problems. The Veteran was afforded a VA examination in November 2010. During his examination, the Veteran reported that he retired in March 2010 because his children did not want him to drive a truck so frequently. The Veteran explained that he missed work and was considering working again. The Veteran stated that he had been married since 1972 but his wife left him in 2006 and that she told him he had PTSD. He stated that when they separated he contacted VA and began to realize more symptoms of PTSD. He stated that he was now divorced and lived alone but visited family frequently. Mental status examination revealed no impairment of thought process or communication, no delusion or hallucinations were found. The Veteran's eye contact was good and his behavior was appropriate. There was no current suicidal or homicidal thoughts, ideation, plans or intent. The Veteran maintained minimal personal hygiene and other basic activities of daily living. He was fully oriented. There was no evidence of memory loss or impairment, there was no obsessive or ritualistic behavior and speech was normal. There was no history of panic attacks but the Veteran did report feeling anxious in crowds, especially if someone spoke a foreign language. The Veteran reported that he experienced anxiety in 2006 during his divorce and retirement but he explained that he was better able to recognize symptoms since that time. There was no impairment of impulse control. Sleep was described as marked by nightmares and difficulty getting to sleep when the Veteran did not take medications was noted. The Veteran reported dreams once or twice a week of his combat experiences and it was noted that he avoided talking about these experiences. He stated that he now understood he isolated from his family and noted that he had his own "bunker" in the basement. He reported becoming irritable easily and stated that he related this to hypervigilance. The examiner explained that the Veteran described avoidance and numbing, trauma experiencing, particularly through nightmares, and heightened physiological arousal due to his experience in Vietnam. Psychological testing was not conducted as it was not deemed necessary by the examiner; a diagnosis of PTSD and a GAF score of 65 were assigned. It was noted that the Veteran had some mild symptoms including insomnia with nightmares and hypervigilance which caused some difficulty in social situations and led him to an occupation where he was not around others but that the Veteran functioned pretty well and never missed work over PTSD symptoms. Some meaningful interpersonal relationships were noted especially with family and supportive group members at the Denver VAMC. The Veteran's PTSD was described as chronic and mild. The examiner noted that thought processes and communications were not impaired and employment was never impacted due to psychiatric issues. It was noted that his marriage was difficult near the end partially perhaps due to PTSD symptoms and probably also because his wife had spent all of their savings. In a March 2012 psychiatry consult the Veteran reported learning several skills and coping tools at a seven week PTSD program he attended. He reported that he found the Denver VA as a "safe haven" and reported that he still had nightmares but that he was able to calm himself down. He reported that his son noticed he was "building a bunker" in the basement and it was removed. The Veteran stated that he felt more depressed and with less energy lately but denied thinking that these symptoms were negatively impacting his functioning. Mental status examination revealed appropriate appearance, cooperative behavior, normal speech and a euthymic mood. Affect was congruent, thought process was goal oriented and content was recovery focused. Hallucinations were not endorsed. Judgment was good and insight was moderate. A GAF score of 68 was assigned. At an April 2012 VA examination, it was noted that the Veteran did not meet the full diagnostic criteria for PTSD and instead was found to have a diagnosis of anxiety disorder with PTSD symptoms. During his examination the Veteran stated that he was beginning a romantic relationship which he described in positive terms. The Veteran described a good relationship with his children and he stated that he maintained contact with his siblings. The Veteran stated that he had a few friends whom he had met at the Denver VA medical center. He stated that he enjoyed fishing and hunting as well as bike rides in his leisure time. Mental status examination reviewed intermittent brief depressed mood, chronic sleep impairment and mild memory loss. The Veteran presented adequately groomed in casual dress, he appeared to be alert and well oriented, and affect was stable and relaxed. Thought and speech was logical and coherent. The Veteran described his typical mood as improved. He reported occasional depressed mood but said his children kept him busy in activities to help him avoid prolonged periods of sadness. He denied feelings of hopelessness or suicidal ideation. Energy was variable; there were no recent changes in weight and appetite. The Veteran did not describe significant anxiety nor did he describe panic attacks or obsessive compulsive symptoms. The Veteran denied problems with anger and irritability, stating that he used techniques he learned in the VA medical center for coping with stress. The Veteran stated that his sleep was horrible, stating that he had trouble staying asleep and describing an average of six hours of sleep. He said memory and concentration were horrible stating that the tended to misplace items and forgot to pay his bills. The examiner stated that the Veteran's reliability and credibility of self report was fairly good. The examiner noted, however, that Minnesota Multiphasic Personality Inventory test (MMPI-2) results were in marked contrast to his presentation during the interview. The examiner noted that the Veteran's responses yielded an invalid profile with the Veteran endorsing deviant items suggesting that he was experiencing a level of psychological distress "that would be atypical even among an inpatient psychiatric population. It appears that [the Veteran] greatly exaggerated his level of symptomology, perhaps in an effort to seek secondary gain." The examiner noted that the Veteran's occupational and social impairment was best summarized as causing occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation. In an August 2012 statement, the Veteran reported that he was having panic attacks about two to three times a week. In November 2012, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. During his hearing, the Veteran described a startle response triggered by jet planes and helicopters. He stated that he didn't panic like he used to. The Veteran stated that his wife divorced him because of his PTSD and stated that he isolated himself but that his children made him socialize. The Veteran described going down in the basement "bunkering down" because it was quiet. He described having a strong reaction to hearing foreign languages as well as trouble sleeping even with medication. The Veteran stated that after he retired he had trouble with his wife and he was always on edge. He stated that his medications helped his symptoms and described trouble remembering things. In a December 2012 psychiatry evaluation and management note, the Veteran reported that overall his mood had been good. He reported continued episodes of hyper startle response and stated that he tended to isolate at home but that his family had pushed him to isolate less which he was ok with; he stated that he occasionally preferred just to be left alone. The Veteran reported that he planned on going on a trip with friends in the winter and that he was looking forward to it. He thought mediation continued to benefit him. Mental status examination revealed that the Veteran was oriented, speech was fluent, mood was reported as ok, affect was pleasant, thought was goal directed, there was no suicidal or homicidal ideation or psychosis. Memory was intact and judgment was good. The Veteran's treating physician stated that the Veteran was involved with a new girlfriend which was going well for him. It was noted that the Veteran had a good relationship to his children and friends and no imminent safety concerns. A GAF score of 64 was assigned. An April 2014 psychiatric evaluation and management note reported that the Veteran's mood had been good, he explained that he and his girlfriend were dating again and that he traveled and saw many friends. It was noted that his girlfriend was still bothered by certain avoidance behaviors. The Veteran stated that he reported some memory problems. The Veteran was found to be oriented, speech was fluent and goal directed with no loose associations and thought content showed no suicidal ideation, homicidal ideation or psychosis. Memory was intact insight and judgement were good. At a July 2014 VA examination, the Veteran reported that he lived alone and had a significant other for two and a half years who lived in Colorado. He stated that his relationship had its ups and downs and stated that he visited his significant other once a month. The Veteran described a great relationship with his children two of whom he saw one to two times a week and saw his other child once every three months. The Veteran stated that he was close to several siblings. He stated that he had "a few friends" but did not hang out with them. He stated that he went to a lunch with former coworkers once every three months and that he did not belong to any social organizations. The Veteran was found to have recurrent, involuntary and intrusive distressing memories of traumatic events one to two times a week, recurrent distressing dreams twice per month, intense or prolonged psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of traumatic events. He reported persistent and negative beliefs about himself and others and a persistent inability to experience positive emotions were noted. The Veteran was also noted to have hypervigilance, problems with concentration, and sleep disturbance. The Veteran was found to have a depressed mood, chronic sleep impairment and mild memory loss. The examiner noted that the Veteran was alert and oriented. He was casually dressed and appropriately groomed. Speech, eye contact, and gait were within normal limits. The Veteran interacted in a logical coherent and cooperative fashion. Affect was neutral. The Veteran described his general mood as "lousy" noting that if he was busy he felt ok. He had fleeting thoughts of worthlessness and hopelessness, he denied suicidal ideation. No signs of a thought disorder, hallucinations, or delusions were noted. It was noted that the reliability and credibility of the Veteran's reports were diminished due to symptom over-endorsement on MMPI testing and marked discrepancy between test results and presentation during his examination and recent mental health treatment notes. The examiner noted that the Veteran's occupational and social impairment was best summarized as causing occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation. An August 2014 mental health consult note noted that the Veteran's treatment records indicated some mental health intervention related to marital problems during his first marriage. The Veteran acknowledged a period of depression to the point of suicidal ideation in 2004 when his wife spent their savings and he was diagnosed with kidney cancer. Mental status examination revealed that the Veteran was oriented, affect was pleasant and appropriate with an episode of tearfulness when reporting on the change in relationship with his family after military service. No psychotic symptoms were noted. The Veteran's thought process was logical, speech was normal, behavior during testing indicated good task persistence although the Veteran reported having poor sleep the night before due to concern about the evaluation. Following testing, the examiner noted the Veteran's improved emotional status with current mental health treatment, and the Veteran was encouraged to maintain this treatment. Additional monitoring of sleep behavior was recommended to assure stability or improvement. The Board finds that the evidence supports a 30 percent rating, and no higher, for the Veteran's service-connected anxiety disorder with PTSD symptoms. The level of occupational and social impairment due to a psychiatric disorder is the primary consideration in determining the severity of a psychiatric disorder for VA purposes and not all the symptoms listed in the rating criteria must be present in order for a rating to be warranted. See Mauerhan v. Principi, 16 Vet. App. 436, 443-44 (2002) (finding that the psychiatric symptoms listed in the rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings). First, the Veteran's GAF scores must be assessed. The GAF is a scale reflecting the 'psychological, social, and occupational functioning on a hypothetical continuum of mental health - illness.' Carpenter v. Brown , 8 Vet. App. 240, 242 (1995) (quotation omitted). A GAF score is highly probative, as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey, 7 Vet. App. at 207. Here, the Veteran's GAF scores predominantly in the range of 60 to 68, indicating evidence of mild to moderate symptoms or moderate impairment in social and occupational functioning. Thus, the Veteran's GAF scores alone reflect anxiety disorder with PTSD symptoms of an overall mild to moderate nature. These scores do not merit the assignment of a 50 percent rating for the Veteran's service-connected anxiety disorder as a 50 percent rating requires a more severe impairment manifesting in deficiencies in reduced reliability and productivity that is not supported by the Veteran's mild to moderate presentation. The Veteran's GAF scores alone cannot serve as the sole basis for evaluating his higher initial rating claim for major depressive disorder and PTSD. All pertinent evidence of record must be considered and the Board's decision must be based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. The Veteran is shown to endorse such symptoms as some anxiety, hypervigilance, irritability and mild impairment of memory as well as trouble sleeping. The Veteran is shown to have good relationships with his family, demonstrating functionality socially and his ability to function occupationally is well documented, in fact the evidence, and the Veteran himself suggest his symptoms increased upon leaving work, and the Veteran noted that he considered returning to work. Moreover, VA examiners have found no occupational impairment. Additionally, the Veteran exhibited psychiatric symptoms specific to PTSD that are not listed in the rating criteria, but contributed to his overall impairment. The symptoms included nightmares, avoidance of thoughts, withdrawal, hypervigilance, and exaggerated startle response. These PTSD-specific symptoms must be considered in determining the appropriate rating because the list of symptoms in the rating criteria is a non-exhaustive list. See Mauerhan, 16 Vet. App. at 442. The Board notes in this regard the Veteran's statements regarding his symptoms. The Veteran is competent to testify as to the severity of the symptomatology associated with his service-connected anxiety disorder with PTSD symptoms during the time period in question. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Of note, however, the Veteran's credibility is found to be limited secondary to findings of exaggeration on clinical testing as demonstrated by the April 2012 and July 2014 VA examiners. Therefore, to the extent that the Veteran has stated that his symptoms are more severe than those described in the 30 percent rating criteria, his assertions are not considered to be credible. More significant, then, are the findings of the VA examiners, all of whom have consistently stated that the Veteran's impairment is best described by the 30 percent rating criteria. All of this evidence persuasively suggests that the Veteran's service-connected anxiety disorder with PTSD symptoms was manifested by symptoms productive of functional impairment comparable to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks because such symptoms were more moderate and appeared to be better controlled. The evidence does not demonstrate functional impairment comparable to occupational and social impairment with reduced reliability and productivity. The Veteran reports panic attacks, however he is shown to be of limited credibility, speech is consistently normal as is thinking and while some mild impairment of memory is reported, thinking and judgment are normal and the Veteran is not shown to have difficulty establishing and maintaining effective work and social relationships as demonstrated by his success occupationally and strong relationships with family and some friends. Nor does the evidence demonstrate functional impairment comparable to occupational and social impairment, with deficiencies in most areas, which would approximate and warrant an increased rating of 70 percent. While the Veteran is shown to report some isolation and "bunkering" his social impairment does not reach the level of severity described in the 70 percent (or even 100 percent) disability rating, and this level of occupational deficiency is not demonstrated anywhere in the evidence of record. A disability that justifies a 100 percent rating is so severely disabling that some of the examples of symptoms include posing a "persistent" threat of danger to self or others and not knowing one's own name, the names of close relatives, or one's occupation. The Veteran does not have a history of having such symptoms productive of functional impairment comparable to that severity. The Board has considered whether this case should be referred to the Director, Compensation and Pension Service, for extraschedular consideration for rating of the Veteran's service-connected psychiatric disability. The governing norm in such exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). As discussed at length above, the Veteran's symptomatology, as attributable to all diagnosed psychiatric disorders, is productive of the level of functional impairment contemplated by the rating criteria for a 30 percent rating, and the Veteran's psychiatric disability has not been shown to be manifested by symptoms productive of a level of functional impairment that more nearly approximates the criteria for a rating of 50 percent, or any symptoms of similar severity, duration or frequency as those set forth for a rating of 50 percent. Accordingly, referral for an extraschedular rating for PTSD is not warranted. Moreover, the Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual condition fails to capture all the service-connected disabilities experienced. However, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple service-connected conditions. Thus, no basis for referring the case for an extraschedular consideration is presented in this case. As the preponderance of the evidence is against a rating in excess of 30 percent for service connection for the a psychiatric disability, the benefit of the doubt rule is not for application in resolution of the matter on appeal. See generally Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial rating in excess of 30 percent for anxiety disorder not otherwise specified with posttraumatic stress disorder (PTSD) symptoms is denied. ____________________________________________ U.R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs