Citation Nr: 1600412 Decision Date: 01/06/16 Archive Date: 01/21/16 DOCKET NO. 12-09 189 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to an increased evaluation for posttraumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. REPRESENTATION Veteran represented by: New York State Division of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Krunic, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1968 to March 1970, with service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York. In that rating decision, the RO assigned an increased rating of 50 percent for PTSD. The Board notes that, in July 2012, the Veteran testified at a videoconference hearing before a Veterans Law Judge who has since retired. A transcript of that hearing is of record. In February 2015, the Veteran was notified that he could attend another hearing conducted by a different Veterans Law Judge who would decide his appeal. See 38 U.S.C.A. § 7107(c) (West 2014); 38 C.F.R. § 20.707 (2015) (requiring that the Veterans Law Judge who conducts a hearing on an appealed issue must participate in any decision made on that appeal). The Veteran responded in March 2015 that he did not wish to appear at another hearing and requested that the Board proceed with the adjudication of his appeal. In June 2014 and May 2015, the Board remanded the case for further development. That development was completed, and the case has since been returned to the Board for appellate review. This appeal was processed using the Veterans Benefits Management System (VBMS) and the Virtual VA paperless claims system. Virtual VA contains relevant VA records; the remaining documents are irrelevant to the issue on appeal or are duplicative of what is in the claims file. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of these electronic records. FINDING OF FACT The Veteran's PTSD more closely approximates manifestations of occupational and social impairment with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for an evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Upon receipt of a substantially complete application for benefits, VA must notify the claimant of what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and, (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). These notice requirements apply to all five elements of a claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). With regard to claims for increased disability ratings, VA must notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. §5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing his or her entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Notice should be provided to a claimant before the initial unfavorable decision on a claim by the Agency of Original Jurisdiction (AOJ). Pelegrini v. Principi, 18 Vet. App. 112, 115 (2004). However, the notice requirements may be satisfied notwithstanding errors in the timing or content of the notice if such errors are not prejudicial to the claimant. Id. at 121. In this case, the AOJ provided the Veteran with a notification letter in June 2011, prior to the decision on the claim in August 2011. Therefore, the timing requirement of the notice as set forth in Pelegrini has been met. Moreover, the June 2011 letter notified the Veteran of the evidence needed to substantiate his claim for an increased evaluation. The letter also informed him of the division of responsibilities in obtaining the evidence to support his claim and explained how disability ratings and effective dates are determined. The duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records and all identified, available post-service medical records, and Social Security Administration (SSA) records have been associated with the claims file and were reviewed by both the AOJ and the Board in connection with the claim. The Veteran has not identified any other outstanding records that are pertinent to the issue currently on appeal. The Veteran was afforded VA examinations in July 2011 and July 2014 in connection with his increased rating claim. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Although the July 2011 examiner noted that he had reviewed the Veteran's electronic claims folder but did not have access to his paper claims file, he stated that the lack of review of the paper file did not impair or hinder his ability to conduct a full examination of the Veteran for compensation purposes. Nevertheless, the Board finds that the VA examinations are adequate, when considered together, because the 2014 examination was predicated on a review of the claims file, and both were full psychiatric examinations during which a history was solicited from the Veteran. The examinations contain all necessary findings regarding the relevant diagnostic criteria. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations for the issue on appeal has been met. Additionally, the evidence does not indicate that there has been a material change in the severity of the Veteran's PTSD since he was last examined. 38 C.F.R. § 3.327(a) (2015). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion for the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2015). During the July 2012 videoconference hearing, the Veterans Law Judge clearly set forth the issue to be discussed, sought to identify pertinent evidence not currently associated with the claims folder, and elicited further information when appropriate. Essentially, the Veteran agreed to attend a VA examination to ascertain the current severity of his PTSD symptoms as he had claimed that his condition had worsened since his last examination in July 2011. As such, the Board finds that VA complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). Finally, the AOJ substantially complied with the Board's June 2014 and May 2015 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, pursuant to the remands, a VA examination and SSA records were obtained with respect to the Veteran's claim for an increased evaluation for PTSD. Thus, the AOJ has substantially complied with the Board's instructions. The Board concludes that the Veteran was provided the opportunity to meaningfully participate in the adjudication of his claims, and he did, in fact, participate. Washington v. Nicholson, 21 Vet. App. 191 (2007). For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. Hence, there is no error or issue that precludes the Board from addressing the merits of this appeal. The Veteran contends that he is entitled to a higher evaluation for his service-connected PTSD. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating 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. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. 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; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or "staged" ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). In this case, as explained below, a uniform rating is warranted throughout the appeal period. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran's PTSD is currently assigned a 50 percent disability evaluation pursuant to 38 C.F.R. § 4.130, Diagnostic Codes 9411. Under the criteria for the General Rating Formula for Rating Mental Disorders, a 50 percent rating is warranted when the psychiatric disorder results in 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent rating is warranted when the psychiatric disorder results in 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); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted when the psychiatric disorder results in 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; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be an exhaustive list. The Board need not find all or even some of the symptoms to award a specific rating. If the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002); Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). In addition, evaluation under § 4.130 is symptom-driven in that a veteran may only qualify for a given disability rating under this criteria by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Furthermore, § 4.130 requires not only the presence of certain or similar symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In assessing the degree of psychiatric disability, Global Assessment of Functioning (GAF) scores are for application and reflect the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996); see also 38 C.F.R. § 4.125, 4.130. However, a GAF score assigned in a case is not entirely dispositive of the evaluation issue. Rather, the GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. 38 C.F.R. § 4.126(a). In an April 2011 submission, the Veteran's wife reported that he was depressed. She stated that he has nightmares and wakes up in a sweat. She stated that he has slept on recliner throughout their marriage. She reported that the Veteran did not like to be in crowds and missed family get togethers. She also reported emotional detachment. A June 2011 Psychiatric Evaluation conducted for the purpose of obtaining SSA disability benefits, shows the Veteran was diagnosed with mild PTSD and adjustment disorder with depressed mood. The Veteran endorsed symptoms of mild depression, nightmares, loss of interest, social isolation, and exaggerated startle response. He stated that he had never been suicidal. The Veteran reported that his PTSD symptoms have become milder over the years. Upon examination, insight and judgment were fair and he was alert and oriented. The Veteran's recent and remote memory skills were found to be intact. Attention and concentration were noted to be mildly impaired. The Veteran's affect was restricted yet pleasant. His speech was fluent and thought processes were coherent and goal directed. In addition, the Veteran was noted to have mild problems dealing appropriately with the normal stressors of life. In an October 2011 notice of disagreement, the Veteran asserted that he has obsessional rituals that interfere with his routine activities. He stated that he has to do the same things every morning and cannot eat until he has been up for at least two hours. He reported hypervigilance, panic attacks, and depression, which affect his ability to function independently. He stated that his spouse had to remind him to shave. The Veteran was afforded a VA examination in July 2011 at which time the examiner diagnosed PTSD and mild depressive disorder, not otherwise specified that was comorbid with PTSD. The Veteran endorsed symptoms such as chronic sleep impairment due to nightmares, depression, social isolation, hypervigilance, and an exaggerated startle response. The Veteran also described frequent checks of windows and doors including getting up in the middle of the night to check them. The Veteran reported that he kept a loaded revolver in the pocket of his recliner in the living room. The Veteran stated he had low moods and depression but was not suicidal or homicidal. The Veteran reported he strongly disliked being in crowds or public venues; he can endure them, but experiences great tension. The Veteran thus has had a decline in his capacity to enjoy social activities. He spends a great deal of time by himself. The Veteran reported that his wife complains. Upon examination, the Veteran's appearance, attitude, and behaviors were generally within normal limits. His hygiene and grooming were good and his attire was casual, neat, and appropriate. The examiner noted that the Veteran's speech was relevant, coherent, and productive, although it was lacking in spontaneity which the examiner attributed to some distress noted during the examination. The Veteran's thought processes were rational and goal directed and there was no evidence of hallucinations or delusions. The examiner also stated that there was no evidence of specific obsessions, compulsions, phobias, or ritualistic behaviors. The Veteran was oriented and short-term memory and concentration skills were intact per mental status testing. The Veteran's cognitive functioning, recent, and remote memory was reported to be good. In addition, the Veteran had good insight and judgment. The examiner observed that the Veteran's mood was mildly distressed during the examination and at one point, the Veteran became somewhat tearful as he discussed the history of his PTSD symptoms. In this regard, his affect was constricted with some sadness noted. The examiner concluded that the severity of the Veteran's symptoms were moderate and assigned a GAF of 55. The examiner stated that the Veteran's personal and social adjustment is moderately impaired but the Veteran had marked impairment in terms of hypervigilance and startle response. With respect to employment, the Veteran reported he last worked in 2009 as a truck driver. He also reported that historically, his PTSD symptoms never caused any major work difficulties but had worsened in the past couple of years. The examiner found mild to moderate work-related difficulties which produced reduced reliability and productivity due to the disruptive effects of his intrusive thoughts, flashbacks, startle response, and social anxiety. The examiner noted recurring impairments and deficiencies in judgment, thinking, mood, and family relations. The examiner noted that the activities of daily living that were affected for the Veteran were primarily social, noting that he can care for his personal needs and grooming, can manage funds, can drive a car ,and can perform simple household chores. A March 2012 Mental Health Treatment plan note revealed that the Veteran was seen in order to initiate PTSD treatment. He reported twice weekly nightmares, hypervigilance, avoidant behavior, irritability; poor sleep quality, social isolation, and flashbacks. The Veteran was found to have a mild to moderate level of anxiety and denied experiencing panic attacks. He reported that he never had thoughts of suicide and had never made a suicide attempt. The Veteran stated that he was hypervigilant and always had to look out every window of his house as soon as he woke up and throughout the day. He reported that he did not sit anywhere with his back to the door and needed to know where the exit was everywhere he went. He was assigned a GAF score of 60. Treatment records show that thereafter, the Veteran attended weekly sessions of a PTSD/depression group, but did not attend individual sessions. During a July 2014 VA examination, the Veteran reported depressed mood, anxiety, flashbacks 3 to 4 times per week, intrusive memories almost daily, social discomfort, avoidant behavior, hypervigilance, emotional detachment, marked startle response, mild memory problems, irritability, and poor sleep patterns with ongoing nightmares. The Veteran reported he continued to live in his home with his wife of 41 years. He has been married twice. He continued to be uncomfortable in social situations as he cannot tolerate crowds and prefers to be home as much as possible. He describes himself as a loner with few friends. The Veteran continued to enjoy some occasional fishing when he is physically able. He stated that he enjoyed being with his children and grandchildren, but rarely socialized outside the family setting. Upon examination, the Veteran was alert and oriented, smiled freely, and was pleasant with appropriate laughter. He was neatly groomed and appropriately and casually dressed. The Veteran's speech was normal in rate, rhythm, and volume. His attention and concentration were good. The examiner noted the Veteran's mood was euthymic and reactive with full range. He had good insight and judgment and his impulse control was adequate. The Veteran denied suicidal or homicidal ideation and did not have hallucinations or delusions. The examiner found there was an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner noted that the Veteran's mental status examination continued to be normal and his PTSD symptoms continued to be moderate in severity with impaired emotional, social, and interpersonal functioning. The examiner concluded that there was there was no evidence of significant changes to suggest a decline in functioning or increase in symptom expression since the last VA examination in July 2011. With regard to occupational functioning, the examiner stated that it was highly unlikely at this stage in his life that the Veteran would be able to secure and maintain gainful employment due to a combination of physical and mental impairment. However, the examiner did note that PTSD symptoms alone caused a moderate degree of work-related difficulties which would result in reduced reliability and productivity. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an evaluation in excess of 50 percent for PTSD. The evidence of record demonstrates that the Veteran's PTSD symptomatology is not indicative of a 70 percent rating. First, despite the 2011 VA examiner's findings, the evidence does not show deficiencies in most areas. The Veteran has an impaired mood and likely impairment in occupational functioning. But the evidence consistently shows good judgment and logical and goal directed thoughts with no delusions or hallucinations. Additionally, the Veteran enjoys spending time with his family, to include his children and grandchildren. Second, the evidence does not show an inability to establish and maintain effective relationships. Although the Veteran clearly socially isolates, he has maintained a 41 year marriage and enjoys time with his family. Furthermore, he has a few friends. The Veteran's social functioning is clearly impaired, but an inability has not been shown. Third, the Veteran's symptoms do not rise to the level of the examples listed in the rating criteria. The 2014 VA examiner did note that the Veteran's hygiene was intermittently not taken care of. However, although he reported suicidal ideation at the Board hearing, the Veteran consistently denied current suicidal ideation at his examinations and was noted to have good impulse control. Although the Veteran reported that his obsessional activities, to include his hypervigilance, interfered with routine activities, the evidence showed he was independent in his hygiene and activities of daily living. Both examiners found the Veteran fully oriented with normal speech. The evidence does not show that the Veteran's depression affects his ability to function independently. The 2011 VA examiner noted the Veteran was able to conduct his own hygiene, manage funds, drive a car, and do household chores. With regard to occupational impairment, the Veteran had steadily worked full time for many decades in construction, masonry, and truck driving. As previously stated, he reported that his PTSD symptoms never caused any major work difficulties. During a June 2011 psychiatric evaluation, the Veteran stated that he stopped working as a truck driver with Walmart in 2009 because the trucking firm had lost their contract with Walmart. In addition, a review of the Veteran's SSA records and Disability Determination and Transmittal indicate that he was awarded disability benefits based on his physical disabilities, namely chronic obstructive pulmonary disease and a back disorder. Therefore, the evidence does not establish that the Veteran has difficulty in adapting to stressful circumstances including work as considered in a 70 percent rating. The record clearly demonstrates occupational and social impairment. Although the Veteran has endorsed some symptoms consistent with a 70 percent evaluation, during the appeal period, the severity of those symptoms are not consistent with the general level of impairment warranting a 70 percent evaluation or akin to the enumerated symptoms listed in the rating criteria. Mauerhan, supra. In reaching this decision, the Board has considered the Veteran's GAF scores, which are but one factor for consideration in assigning a rating in this case. GAF scores ranging between 61 and 70 are assigned when there are 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 when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores from 51 to 60 are indicative of 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). Lower GAF scores of 41 to 50 represent serious symptoms (e.g., suicidal ideations, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning. The Veteran's GAF scores throughout the appeal period have ranged from 55 to 60, indicating mild to moderate symptoms. Thus, the Veteran's scores during the appeal period provide greater support for a 50 percent rating and do not mandate the assignment of a 70 percent evaluation. As outlined above, the Board finds that, when all of the evidence and findings contained therein are considered, including the degrees of social and occupational impairment, the Board finds that the scheduler criteria for the next higher 70 percent disability evaluation have not been met. The preponderance of the evidence is against a finding that an increased evaluation is appropriate; therefore, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b);Gilbert, 1 Vet.App. at 54-56. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's PTSD is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-scheduler basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The manifestations of the Veteran's PTSD include occupational impairment, social impairment, sleep disturbance, obsessional rituals, depressed mood, hypervigilance, and anxiety, which are contemplated by the schedular criteria set forth in the General Rating Formula for Mental Disorders. As discussed above, there are higher ratings available under the diagnostic code, but the Veteran's disability is not productive of such manifestations. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected PTSD under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). Finally, the Board notes that in a February 2015 rating decision, the RO granted entitlement to a total disability rating based on individual unemployability (TDIU). Thus, there is no implicit claim for a TDIU based on the Veteran's service-connected PTSD. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). ORDER Entitlement to an initial evaluation in excess of 50 percent for PTSD is denied. ____________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs