Citation Nr: 1617852 Decision Date: 05/03/16 Archive Date: 05/13/16 DOCKET NO. 11-33 943 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent prior to January 20, 2012 for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial rating in excess of 50 percent from January 20, 2012, to September 17, 2014, and in excess of 70 percent since September 18, 2014, for PTSD. REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD J. Rothstein, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1966 to September 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado, which, in part, granted service connection for PTSD, assigning a 30 percent rating, effective October 12, 2010. In May 2014, the Veteran and his spouse testified at a video conference hearing before the undersigned Acting Veterans Law Judge. A copy of the hearing transcript is of record. At that time, he submitted additional evidence with a written waiver of initial RO consideration. 38 C.F.R. § 20.1304(c) (2015). In August 2014, the Board remanded the appeal to the Agency of Original Jurisdiction (AOJ) for further development. After completion of the requested actions, the RO issued a December 2014 rating decision, awarding an increased rating of 50 percent, effective January 20, 2012, and 70 percent, effective September 18, 2014, for PTSD. As those awards did not result in the maximum rating available, the claim remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (where a claimant has filed a notice of disagreement as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). At the same time, the RO also issued a December 2014 supplemental statement of the case (SSOC), denying an initial rating in excess of 70 percent for PTSD, and returned the appeal to the Board. In November 2015, the Board remanded the Veteran's claim for issuance of a revised SSOC. Thereafter, the RO issued a December 2015 SSOC, denying an initial rating in excess of 30 percent prior to January 20, 2012, in excess of 50 percent from January 20, 2012, to September 17, 2014, and in excess of 70 percent since September 18, 2014, for PTSD. The Veteran's VA claims file has now been returned to the Board for further appellate proceedings. The Board notes that a claim for entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU) is part of an increased rating claim and is properly before the Board when such claim is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). In this case, however, consideration of a TDIU is not warranted as the Veteran was awarded a TDIU, effective September 18, 2014, in a May 2015 rating decision and has not expressed disagreement with that decision. In addition, as shown more fully below, there was no evidence that the Veteran's employment had become marginalized until September 18, 2014, at which time the Veteran, for the first time, noted that he was only doing deliveries at the rate of 1 hour a day or 7 hours a week. Thus, the Board also does not find that the record has raised an implied claim for TDIU for the period prior to September 18, 2014. FINDINGS OF FACT 1. Prior to January 20, 2012, the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment comparable to that of reduced reliability and productivity. 2. From January 20, 2012, to September 17, 2014, the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment comparable to no more than that of reduced reliability and productivity. 3. Since September 18, 2014, the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment comparable to no more than that of deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for a rating of 50 percent for PTSD, prior to January 20, 2012, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2015). 2. The criteria for a rating in excess of 50 percent from January 20, 2012, to September 17, 2014, and in excess of 70 percent since September 18, 2014, for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2014), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2015), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Concerning the issues decided herein, the Board notes that VA's General Counsel has held that VCAA notice is not required for "downstream" questions. VAOPGCPREC 8-2003. Additionally, the United States Court of Appeals for Veterans Claims has held that "the statutory scheme contemplates that once a decision granting service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). Here, the Veteran's claim of service connection for PTSD was granted in March 2011, and he was assigned a disability rating and an effective date in that decision. As the issue currently before the Board stems from a disagreement with a "downstream" question, no additional notice is required with respect to these issues because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007). Next, the VCAA also requires VA to make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate his or her claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)-(d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his or her claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(1)-(4). All available evidence pertaining to the issues decided herein was obtained by the VA and associated with the claims file. The relevant evidence obtained includes the Veteran's service treatment records, post-service treatment records, VA examination reports, and statements from the Veteran. The Veteran has not alleged that there is any additional outstanding evidence pertinent to his claim, and the Board is unaware of any such evidence. Further, the Veteran has been afforded several VA examinations to assess the severity of his PTSD. The examination reports contain sufficient evidence by which to evaluate the severity of the Veteran's PTSD in the context of the rating criteria and throughout the appeal period. Moreover, since the last VA examination conducted in March 2015, the Veteran has neither alleged, nor presented evidence to suggest, that his PTSD has worsened since that time. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Accordingly, there is no indication that there is a need for additional examinations or medical opinions. Based on the foregoing, the Board finds that VA has complied, to the extent required, with the VCAA duty to assist requirements. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)-(d). II. Higher Initial Ratings Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2015). Where, as here, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a staged rating are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, "[w]here 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 required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7. Here, the Veteran's PTSD is currently evaluated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Prior to January 20, 2012, the Veteran's PTSD is evaluated as 30 percent disabling. A 30 percent rating is found to be warranted where the disorder is manifested by 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). 38 C.F.R. § 4.130, DC 9411. From January 20, 2012, to September 17, 2014, his PTSD is evaluated as 50 percent disabling. A 50 percent rating is warranted where the disorder is manifested by 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. Id. Since September 18, 2014, his PTSD is evaluated as 70 percent disabling. A 70 percent rating is warranted where there is 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 evaluation is warranted where there is 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 ability 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. When evaluating a mental disorder, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2015). Also, the rating agency shall assign an evaluation 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. Id. Moreover, 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 exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Accordingly, VA must consider all symptoms of a veteran's condition that affect the level of occupational and social impairment. See id. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. The GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) (DSM-IV). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). Id. GAF scores ranging from 51 to 60 reflect 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. The GAF score assigned, however, like an examiner's assessment of the severity of a condition, is not 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. See 38 C.F.R. § 4.126(a). A. Prior to January 20, 2012 In December 2010, the Veteran was afforded an initial VA examination for PTSD. The examiner noted that the Veteran presented with the following psychiatric symptoms: re-occurring thoughts of Vietnam, nightmares (about Vietnam and approximately three to four times per week), difficulty falling and staying asleep (often waking within an hour of falling asleep and averaging five to six hours of sleep per night), avoidance, irritability, anger outbursts, difficulty concentrating, hypervigilance, anxiety and depression. The examiner also noted that the severity of these symptoms were moderate and episodic, "fluctuating or wax and wane." At that examination, the Veteran reported that he was working as a sheet metal installer, and that his relationship with his supervisor and co-workers was good. He also reported that he was married, and that his relationship with his wife was good. However, the Veteran indicated that these symptoms affected total daily functioning which resulted in him isolating from others at work. He asserted that his mental condition had caused the following major changes in his daily activities and social functions: no longer following orders; avoiding crowds, being bothered by frequent nightmares, never sitting with his back to the door, and no longer enjoying social functions. The examiner concluded that the effects of the Veteran's PTSD symptoms on his employment and overall quality of life included him often feeling depressed and troubled by intrusive thoughts of Vietnam. He assigned the Veteran a GAF score of 60. In December 2011, the Veteran was referred to the VA clinic for a mental health intake/assessment by the Vet Center. At that time, he presented with complaints of being easily startled, hypervigilant, emotional detachment, flashbacks, intrusive thoughts, and nightmares. He endorsed having feelings of anxiety, restlessness, boredom, and anger. He denied either suicidal or homicidal ideation and denied auditory and/or visual hallucinations. He reported that he lost his job in February 2011, and that since losing his job, he had been doing housework, cooking his own meals, walking his dogs, and visiting with friends. The psychiatrist noted that the Veteran's thought process was linear and logical. At this intake/assessment, the Veteran was assigned a GAF score of 58. In January 6, 2012, during a visit to the VA clinic, the Veteran continued to have complaints of being easily startled, hypervigilant, emotional detachment, flashbacks, intrusive thoughts, and nightmares. He also described feeling depressed, sad, isolated, "blank," short-tempered, irritable, and occasional tearfulness. He reported having some trouble with energy and motivation. He denied suicidal and/or homicidal ideation. He continued to report that since losing his job, he had been doing housework, cooking his own meals, walking his dogs, and visiting with friends. The psychiatrist noted that the Veteran's thoughts were coherent and logical, and that he had no auditory and/or visual hallucinations and no delusions. At that visit, the Veteran was assigned a GAF score of 50. Based on the foregoing, and in consideration of the benefit-of-the-doubt doctrine, the Board finds that, for the period prior to January 20, 2012, the Veteran's PTSD more nearly approximates the criteria required for at least a 50 percent rating. In this regard, the Board points out that in evaluating the severity of the Veteran's PTSD, "it is not the symptoms, but their effects, that determine the level of impairment." Mauerhan, 16 Vet. App. at 443. Indeed, the evidence of record shows that the Veteran consistently experienced symptoms suggestive of the 50 percent rating criteria such as flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran also consistently endorsed having intrusive thoughts, nightmares, flashbacks, sleep disturbances, depression, irritability and anger, which in effect he asserted was majorly impairing his daily activities and social functions. Notably, in consideration of the Veteran's reported symptoms, he was assigned GAF scores ranging from 50 to 60 during the relevant time period. The Board finds highly probative the fact that multiple mental health professionals assigned GAF scores that reflected their determination that the Veteran's PTSD symptoms were at least moderate in degree. Accordingly, the Board finds that an initial 50 percent rating for PTSD is warranted for the time period prior to January 20, 2012. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.130, DC 9411. B. From January 20, 2012 to September 17, 2014 In January 2012, the Veteran was afforded another VA examination for PTSD. At that examination, he reported being laid off in February 2011 and that he had been unable to find another job since. He indicated that he lost his job due to physically slowing down and to worsening memory for recent events/instructions. The examiner noted the Veteran as having the following symptoms: recurrent and distressing recollections; recurrent distressing dreams; markedly diminished interest or participation in significant activities; irritability or outbursts of anger; hypervigilance; and exaggerated startle response. The examiner also noted the following additional symptoms: depressed mood, anxiety, mild memory loss (such as forgetting names, directions or recent events), flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner assigned the Veteran a GAF score of 54. In February 2013, during a visit to the VA clinic, the Veteran reported that he was having more difficulty with his sleep. He also indicated that he continued to experience the following symptoms: depression, isolation, tearfulness, sadness, short-temper, irritability, low energy, and no motivation. The psychiatrist noted that the Veteran's thoughts were coherent, logical, and goal-oriented, and that he had no auditory and/or visual hallucinations and no delusions. The psychiatrist also noted that he had no thoughts of harm to self or others. The Veteran reported being busy with the Honor Guard. At that visit, the Veteran was assigned a GAF score of 50. In March 2014, during another visit to the VA clinic, the Veteran reported that he had found a job working 17 hours a week delivering burritos in the morning time. The psychiatrist noted that it was "a nice job with his PTSD, in that it is quiet, he does not have to interact with many people, and gets home before the 'workday' around town really starts." This is also not described as marginal employment. The psychiatrist observed that the Veteran's thoughts were coherent, logical, and goal-oriented, and that he had no auditory and/or visual hallucinations and no delusions. The psychiatrist noted that the Veteran had no thoughts of harm to self or others and exhibited good judgment. In September 17, 2014, an assessment report was completed by the Vet Center. According to the examiner, the Veteran presented with complaints of intrusive and stressing memories of combat experiences, physiological arousal, disturbed sleep, fatigue, problems with focus and concentration, isolation, emotional numbing, and depressed mood. The examiner noted that the Veteran reported having a marked loss of pleasure in activities he normally enjoyed, pervasive negative thoughts about himself, and feelings of hopelessness, worthlessness, and shame that contributed to a markedly depressed mood. The examiner indicated that the Veteran disclosed that he had periodic suicidal thoughts of a passive nature in the past. Also, the examiner noted that the Veteran described his relationship with his wife as being "fair," adding that "we communicate, but not really well." The Veteran was administered the following tests: Millon Clinical Multiaxial Inventory - III (MCMI-III) and Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). The results of the MCMI-III test showed that he was experiencing clinical syndromes of anxiety, depression, and posttraumatic stress of a severe nature. The results of the CAPS-5 test showed that he was experiencing symptoms at a severe level, with a corresponding level of impairment in both social and occupational functioning. The examiner concluded that the patterns of symptoms described by the Veteran were indicative of a diagnosis of PTSD that was affecting his social and occupational functioning at a severe level. Although generally consistent with the more detailed findings provided the following day at the Veteran's VA examination on September 18, 2014, the additional findings are found to be what warranted the assignment of a 70 percent rating as of the date of the VA examination, instead of the September 17, 2014, assessment, and the Board is therefore in agreement with the assignment of this effective date. Based on the foregoing, and in consideration of the benefit-of-the-doubt doctrine, the Board finds that the Veteran's PTSD, from January 20, 2012, to September 17, 2014, does not warrant a rating in excess of 50 percent. While the evidence of record shows that the Veteran consistently experienced intrusive thoughts, sleep disturbances, depression, and isolation, the evidence of record reveals that symptoms such as 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, spatial disorientation, and neglect of personal appearance and hygiene, were absent. Even though the Veteran's reported symptoms may suggest suicidal ideation, impaired impulse control, a difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships, the evidence of record reveals that such symptoms still did not result in occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. This is so because the Veteran has indicated that he has been able to maintain more than marginal employment, his marriage with his wife, and participation in extra-curricular activities. Hence, although during this period, the Veteran had a single GAF score and test results (from MCMI-III and CAPS-5), reflecting severe symptoms, his occupational and social impairment was not shown to rise to such a level that the Veteran was deficient in most areas of his life. Accordingly, the Board finds that a rating in excess of 50 percent is not warranted from January 20, 2012 to September 17, 2014. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.130, DC 9411. C. Since September 18, 2014 In September 18, 2014, the Veteran was provided another VA examination for PTSD. The Veteran reported that he was working part-time delivering burritos in the early morning, and that his job did not require him to interact much with others. He also stated that he was laid off in February 2011 due to a slowdown in business, but that he thought his age and difficulty reading blueprints played a role. He reported that he had been married to his wife for 14 years. At the time of the examination, the examiner observed that the Veteran was alert, coherent, dully oriented, dressed in clean casual clothes, and polite and cooperative in manner. He also observed that the Veteran's thought process was logical and goal-oriented. The examiner initially noted that the Veteran was having panic attacks when around crowds and that they were likely due to PTSD symptoms of hypervigilance and/or excessive startle. With regard to other PTSD symptoms, the examiner indicated that the Veteran had the following symptoms: recurrent, involuntary, and intrusive distressing memories; recurrent distressing dreams; dissociative reactions (e.g., flashbacks); persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame); markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; persistent inability to experience positive emotions; irritable behavior and angry outbursts; problems with concentration; and sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). The examiner also indicated that the Veteran experienced the following additional symptoms: depressed mood, anxiety, suspiciousness, mild memory loss (such as forgetting names, directions or recent events), difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances (including work or a worklike setting), and passive suicidal ideation. Concerning occupational impairment, the examiner stated that the Veteran's symptoms of PTSD caused some occupational impairment, noting that he was last successfully employed as a sheet metal worker in 2011 but would likely have problems in these employment settings involving crowds and some difficulties with sustained concentration. In terms of social impairment, the examiner stated that the Veteran's symptoms of PTSD also caused some social impairment, noting that irritability and emotional detachment/numbing has affected his marriage, that he has no close friends, that he doesn't desire or enjoy socializing with others, that he avoids crowds, and that he has no enjoyable hobbies. In March 2015, the Veteran was provided with another VA examination for PTSD. He reported that his wife had passed away from cancer in December 2014, and that he was experiencing increased mental health symptoms since her death. He also reported that he had no friends and was highly socially isolated. He indicated that he was involved in monthly commitments at the Marine Corps League, the American Legion, and the Honor Guard, but he also claimed that he had only acquaintances but not friendships there. He stated that he did not like to be around a lot of people due to increased anxiety, increased risibility, and difficulty trusting. He also stated that he continued to work part-time delivering burritos, but only for one hour a day or seven hours a week. With regard to PTSD symptoms, the examiner indicated that the Veteran had the following: recurrent, involuntary, and intrusive distressing memories; dissociative reactions; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; persistent inability to experience positive emotions; irritable behavior and angry outbursts; hypervigilance; exaggerated startle response; problems with concentration; and sleep disturbance. The examiner also indicated that the Veteran experienced the following additional psychiatric symptoms: depressed mood, anxiety, suspiciousness, panic attacks (two times a month), difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, and passive suicidal ideation. At the time of the examination, the examiner observed that the Veteran was well-groomed and that his thought process was logical with no evidence of delusions. Concerning occupational and social impairment, the examiner opined that the Veteran was likely to have moderate to severe impairment with noted deficiencies in most areas. Regarding occupational impairment, the examiner commented that it is "noted as veteran is only able to maintain work that is 1hr/day or 7hrs/week and involves limited contact with others and his occupational role is adversely impacted by fatigue, concentration difficulties, increased irritability when around others, and occasionally flashbacks are triggered by environmental cues." For social impairment, the examiner stated that it is "noted as veteran is highly isolated and makes significant effort to avoid social interactions, is fearful of having his irritability activated and makes effort to avoid any situation that could evoke irritability; is detached from others and struggles to have positive emotional experiences (although he desires to have them)." Based on the foregoing, and in consideration of the benefit-of-the-doubt doctrine, the Board finds that the Veteran's PTSD does not warrant a rating in excess of 70 percent since September 18, 2014. Here, the Veteran consistently experienced the following symptoms: recurrent, involuntary, and intrusive distressing memories; recurrent distressing dreams; dissociative reactions; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; persistent inability to experience positive emotions; irritable behavior and angry outbursts; hypervigilance; exaggerated startle response; problems with concentration; sleep disturbance; depressed mood; anxiety; suspiciousness; panic attacks; difficulty/inability in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; and passive suicidal ideation. However, the evidence of record shows that the Veteran did not experience the following symptoms: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability 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. Moreover and nonetheless, the evidence of record does not establish that the Veteran's reported symptoms caused total occupational and social impairment, as he indicated that he was able to maintain a part-time job, the maintenance of his marriage with his wife until her death, and participation in extra-curricular activities. Therefore, the Board finds that a rating in excess of 70 percent is not warranted since September 18, 2014. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.130, DC 9411. III. Additional Considerations The Board has also considered the propriety of a referral for extraschedular consideration. However, the Board finds that the Veteran's PTSD symptomatology does not warrant referral for extraschedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extraschedular disability rating is made. 38 C.F.R. § 3.321(b)(1) (2015). There is a three-step analysis for determining whether an extraschedular disability rating is appropriate. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). First, there must be a comparison between the level of severity and symptomatology of a claimant's service-connected disability and the established criteria found in the rating schedule to determine whether a claimant's disability picture is adequately contemplated by the rating schedule. Id. at 115. If the disability picture is not adequately contemplated by the rating schedule, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as "governing norms." Id. at 115-16; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are found to exist, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. at 116. In this case, the evidence of record does not reveal that the Veteran's PTSD alone or in conjunction with his hearing disabilities is so unusual or exceptional in nature as to render his schedular rating inadequate. The Veteran's PTSD has been evaluated under the applicable diagnostic code that has specifically contemplated the level of occupational and social impairment caused by the service-connected disability. In addition, the Veteran's psychiatric symptoms such as his depressed mood, suspiciousness, panic attacks, mild memory loss, and sleep difficulties, among others, are specifically enumerated and contemplated under the applicable diagnostic code. Therefore, referral for assignment of an extra-schedular evaluation in this case is not in order. See id. at 115; Floyd v. Brown, 9 Vet. App. 88, 95 (1996). ORDER Entitlement to an initial rating of 50 percent prior to January 20, 2012, for PTSD is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to an initial rating in excess of 50 percent from January 20, 2012, to September 17, 2014, and in excess of 70 percent since September 18, 2014, for PTSD, is denied. ____________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs