Citation Nr: 1623133 Decision Date: 06/09/16 Archive Date: 06/21/16 DOCKET NO. 10-18 799 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD) from December 23, 2013. 2. Entitlement to an evaluation in excess of 30 percent for PTSD prior to December 23, 2013. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Saikh, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1968 to February 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee, which granted service connection for PTSD with depressive disorder and assigned a 30 percent rating. The Veteran initially requested a Board hearing in April 2010. However, in August 2011, the Veteran's representative requested that the hearing be cancelled and that the appeal be advanced for a decision based on the evidence of the record. Accordingly, the Board withdrew the Veteran's hearing request and proceeded with adjudication. In November 2013, the Board remanded these issues for further evidentiary development. After completing the requested evidentiary development, in January 2014, the RO issued a rating decision granting a rating of 70 percent for PTSD with depressive disorder, effective December 23, 2013. In July 2009, the Veteran claimed entitlement to a total disability rating based upon individual unemployability (TDIU). TDIU was denied in September 2009. The Veteran has not appealed that determination, and he has not alleged that he is unable to work due to service-connected disabilities. Rather, he initially alleged that his unemployability was due to nonservice-connected drug abuse. Thus, TDIU has not been reasonably raised by the record since the September 2009 denial of TDIU. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Pursuant to the Board's remand instructions, the RO also issued a supplemental statement of the case (SSOC) in April 2014. The Veteran submitted a waiver of review by the Agency of Original Jurisdiction (AOJ) of any additional evidence submitted. The case has now returned to the Board for further appellate review. FINDING OF FACT For the entire period of the appeal, the Veteran's PTSD with depressive disorder has been productive of occupational and social impairment with deficiencies in most areas, such as work, judgment, thinking and mood; however it does not rise to the level of total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for a 100 percent evaluation for PTSD, have not been met for the entire appeal period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2015); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.10, 4.130, Diagnostic Code (DC) 9411 (2015). 2. The criteria for a 70 percent evaluation for PTSD, have been met for the entire appeal period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2015); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.10, 4.130, DC 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2015); 38 C.F.R. § 3.159 (2015). The Veteran's claim for higher ratings for PTSD arises from his disagreement with the rating assigned in connection with the grant of service connection for this disability. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); VAOPGCPREC 8-2003 (2003). Consequently, further discussion of the VCAA's notification requirements with regard to the ratings issues on appeal is unnecessary. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claims. 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 claims, 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 a claim. 38 C.F.R. § 3.159(c)(4). In this case, VA fulfilled its duty to assist by obtaining all identified and available evidence needed to substantiate the claim herein decided. Service treatment records and post-service VA treatment records have been obtained, and the Veteran has been afforded multiple VA medical examinations in connection with his claim, most recently in January 2014. The Board finds that, taken together, these examinations were adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or opinion, it must ensure that the examination or opinion is adequate). In addition, lay statements of the Veteran have been associated with the record and have been reviewed. The Veteran has not asserted that there is any outstanding evidence relating to the issues on appeal. For these reasons, the Board concludes that there is no additional evidence which needs to be obtained. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. Ratings Law and Regulations Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Analysis The Veteran is in receipt of a 30 percent rating for PTSD with depressive disorder prior to December 23, 2013, and a 70 percent rating thereafter, pursuant to 38 C.F.R. § 4.130, DC 9411. All psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, a 50 percent rating is assigned 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 evaluation 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 situations (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. Finally, a total schedular rating of 100 percent is warranted when the 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 symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Nevertheless, all ratings in the general rating formula are associated with objectively observable symptomatology, and in Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." The Federal Circuit further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. Thus, "[a]lthough the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas.'" Id. at 118. As such, the Board will consider both the Veteran's specific symptomatology as well as the occupational and social impairment associated with the Diagnostic Code to determine whether an increased evaluation is warranted. As with all claims for VA disability compensation, the Board must assess the credibility and weigh all the evidence, including lay and medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert denied, 523 U.S. 1046 (1998). After reviewing all the evidence, the Board finds that the overall social and occupational impairment caused by the Veteran's PTSD most nearly approximates impairment warranting a 70 percent evaluation for the entire appeal period. A higher, 100 percent rating is unwarranted. The pertinent evidence includes VA outpatient records, as well as multiple VA psychiatric evaluations and lay statements from the Veteran. The Veteran filed his claim for PTSD in November 2008. In a lay statement submitted by the Veteran, received by the Board in January 2009, he reported having nightmares related to his service in Vietnam. To cope with his stress, the Veteran avoided thinking or talking about the war. The Veteran indicated that he was no longer working due to retirement, and that nothing, even activities he used to enjoy, could hold his attention. He avoided confrontation because he was afraid that he could not control his anger. His family had observed changes in his behavior. The Veteran reported that his sexual activity had all but ceased, and that his wife noted that it was difficult to keep him from going into a "downward spiral." The Veteran also reported that he was affected by any number of things, including, low flying helicopters, war movies, reports of war, and Vietnam documentaries, which would lead him to feel helpless and stuck. The Veteran reported that his long and short term memory were all but gone, and that he had difficulty remembering dates, times, and places. He recounted an incident where he wrote to the mayor of Chicago, threatening the city with impending violence because he was unable to find a job after returning from Vietnam. After that incident the Veteran was offered a job with the city of Chicago, which caused him to try to block out his negative thoughts and get himself together. The Veteran concluded by stating that, at present, those dormant thoughts were now resurfacing and making it difficult to cope. In March 2009 correspondence, the Veteran recounted his experiences in Vietnam, explaining the stressors that affected his PTSD. He also reported experiencing nightmares that had recently returned, causing him to have sleepless nights. In a February 2009 medical record containing results from a depression screening, the Veteran was found to screen negative for depression. He screened positive for the PTSD test, but reported not having had any experience that was so frightening, horrible, or upsetting that in the past month, the Veteran thought or had nightmares about it. However the Veteran did report having experiences that were so frightening, horrible, or upsetting that in the past month he tried to avoid thinking about it, was constantly on guard or easily startled by it, and as a result felt numb or detached. In the May 2009 VA examination, the Veteran reported having insomnia, lack of interest, lack of energy, and poor concentration. The Veteran had been diagnosed with an aortic aneurism, but did not opt for surgery as a suicidal gesture. When it ruptured, surgery was performed before it killed the Veteran. The Veteran did not suffer from panic attacks or any loss of appetite. In the 1970's, the Veteran had a history of aggression and violence. He reported kicking his wife in the stomach while she was pregnant, and getting into fights with friends. While in Vietnam, the Veteran had started to rape a girl but stopped once he realized what he was doing. The Veteran stated he was no longer violent, and that his relationship with his wife was better. He had no problems with his children and parents. He did not have any friend or hobbies, and he was no longer working. The Veteran stated that he just thought about the war all the time. The Veteran was oriented with regards to his person, time, and place. His speech, thought process, thought content, and psychomotor activity were unremarkable, his affect was blunted, and he exhibited a worried mood. The Veteran did not have any delusions, hallucinations, inappropriate behavior, obsessive/ritualistic behavior, or panic attacks. He was able to understand the outcome of his behavior, and had normal recent, remote, and immediate memory. The Veteran reported the presence of homicidal thoughts in the 1970's, during the time he exhibited violent behavior. The Veteran also reported chronic sleep impairment, which caused him to be fatigued during the day. The Veteran was able to maintain minimum personal hygiene, and did not have problems with bathing, dressing, grooming, and feeding. He did report moderate problems with driving, and that he could not perform household chores or go shopping due to his back pain. With regards to the Veteran's PTSD symptoms, the Veteran reported markedly diminished interest or participation in significant activities, feeling detached and estranged from others, efforts to avoid activities, places, and people that aroused recollections of the trauma, difficulty concentrating, and hypervigilance. These symptoms were found to cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The Veteran reported that his symptoms occurred weekly, were severe, and lasted for a couple of days. He indicated that there were times in his life when he was doing better, where he was able to work and enjoy his family. He last reported working in 2006, and that he'd not had relief since then because he wasn't working. The Veteran denied having depression, but did report being easily angered and having difficulty calming down once angry. The examiner diagnosed the Veteran with PTSD, and with depressive disorder not otherwise specified, finding that the depression was likely a function of PTSD or symptoms of PTSD. The Veteran was assigned a Global Assessment of Functioning (GAF) of 58. The PTSD symptoms and changes in impairment, in functional state, and quality of life appeared to be directly related to PTSD. The examiner opined that there was not total occupational and social impairment due to PTSD signs and symptoms, and that the Veteran's PTSD signs and symptoms did not result in deficiencies in judgment, thinking, family relations, work, mood, or school. The examiner did find that the Veteran had reduced reliability and productivity due to his PTSD symptoms. In his July 2009 Notice of Disagreement (NOD), the Veteran indicated that the RO decision did not adequately consider the effects that racism he experienced during service had on his PTSD. The Veteran also indicated that his long term drug abuse was caused by stressors experienced in Vietnam, and that it made him unemployable because he was unable to pass drug tests for employment. In an April 2010 medical record, the Veteran tested negative for both the depression and PTSD screening. He was not depressed or hopeless, and he denied losing interest or pleasure in doing things. The Veteran also denied having any nightmares, being constantly on guard or easily startled, avoiding situations, or feeling numb and detached from his surroundings. In a May 2010 medical record, the Veteran met with his psychiatrist on referral from his primary care physician because he was not interested in following up with the PTSD program and had stopped taking his medication for PTSD because it made him feel sick. The Veteran reported that he had retired from his job as a painter in 2006 because of his back problems, and that he had not gotten along with his coworkers and kept to himself. He avoided going out in public, but was comfortable in family gatherings with his children and grandchildren. He reported his daily marijuana usage. The psychiatrist found that the Veteran's thought processes were linear and logical, and his thought content appropriate. He was cognitively alert and oriented in all 4 spheres, and his attention span and concentration were adequate. His memory was intact. The Veteran described that his mood was upset, but that he did not want try any other medication or alternatives to therapy. When asked about this treatment goals for PTSD, he indicated that he wanted the United States Army to know about the racism out there and the suffering that veterans with PTSD go through. In a November 2010 medical record, the Veteran requested a different medication to treat his PTSD. The physician noted that the Veteran's symptoms were mild, and that he continued to be bothered by intrusive thoughts about Vietnam that could be triggered by daily events such as heavy rains, or seeing a flying helicopter overhead. The Veteran denied any anger problems, panic attacks, suicidal ideations, crying spells, feelings of guilt, hopelessness, and mood cycling. He did report being awake at night. The Veteran did report the death of his son, but was handling it, and although it was initially difficult, he did not report any additional depression. The Veteran also reported smoking marijuana on a daily basis. The physician found that the Veteran was cognitively alert and oriented in all 4 spheres, that his attention span and concentration were adequate, memory was intact, and that his thought content was appropriate. The Veteran denied any suicidal or homicidal ideations. The Veteran's GAF score was 60. In a September 2011 medical record, the Veteran tested negative for the PTSD screening, however he did report having an upsetting experience that caused him to have nightmares or think about it when he did not want to, to try to avoid thinking about it, that caused him to be easily startled or constantly on guard, and caused him to feel numb or detached. The Veteran's depression screen was also negative; the Veteran did not feel depressed or hopeless, nor had he lost interest or pleasure in doing things. In an October 2012 medical record, the Veteran described his mood as fairly well. He reported doing better after stopping his medication for PTSD. On a scale from 0-10, with 10 being the best mood ever, the Veteran rated his mood as 6-7. During a few days of the month, the Veteran reported a mood of 4. He denied panic attacks, anger outbursts, mood shifts, auditory or visual hallucinations, suicidal ideations, and paranoia. The Veteran's memory was fine, and cognitively he was doing well. He developed a new interest in dealing with the lives of deceased people, and his interest had kept him from worrying about Vietnam. The Veteran averaged about 7 hours of sleep per night, but smoked marijuana every day. He was not interested in trying any other psychotropic at the time. The Veteran continued to be cognitively alert in all 4 spheres. In an August 2012 medical record, the Veteran was referred by his cardiologist for a visit because he showed signs of depression. The Veteran reported being detached from activities that once interested him. He denied having crying spells, feelings of guilt, hopelessness, suicidal or homicidal ideations, perceptual disturbances, auditory or visual hallucinations, and paranoia. While the Veteran was able to execute independent activities of daily living, he did have difficulty with focusing and tended to be easily distracted. The Veteran's thought content continued to be appropriate, and his thought processes were linear and logical. He continued to be cognitively alert and oriented in all 4 spheres, his attention span and concentration were adequate, and his memory was intact. The Veteran had a GAF score of 65. The physician found that the Veteran continued to meet the criteria for mild to moderate depressive disorder, and prescribed a new medication to treat the Veteran's symptoms. In the December 2013 VA examination, the Veteran's self-report of his PTSD symptoms resulted in a measure of extreme or severe PTSD. The Veteran was also diagnosed with depressive disorder, not otherwise specified. Among other symptoms reported, the Veteran reported experiencing physical reactions when reminded of a stressful experience from the past, avoiding situations that reminded him of a past stressful experience, loss of interest in things he used to enjoy, feeling distant and cut off from others, difficulties with sleep, and difficulties concentrating. The examiner characterized the Veteran's level of occupational and social impairment as occupational and social impairment with 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. The Veteran's GAF score measured between 55-60, and his prognosis was fair even with continued psychiatric medication and individual psychotherapy. The Veteran was also found to have symptoms of depressed mood, anxiety, panic attacks occurring weekly, chronic sleep impairment, mild memory loss, flattened effect, delusions and hallucinations, difficulties in establishing and maintaining effective work and social relationships, disturbances of mood and motivation, and difficulties adapting to stressful circumstances, including work or worklike settings. The Veteran denied active suicidal ideations because he didn't show true intent to do so, and he noted that he would not commit suicide because of his family. The examiner opined that the Veteran experienced moderate occupational and social impairment as a result of his service-connected PTSD, and that the Veteran's level of impairment would adversely impact his ability to perform in an occupational setting, even in a sedentary working environment. After reviewing the evidence of record, the Veteran is entitled to a disability rating of 70 percent for service-connected PTSD with depressive disorder for the entire appeal period. The evidence shows that the Veteran had consistent symptoms productive of a 70 percent rating prior to December 23, 2013. The Veteran is not entitled to a disability rating in excess of 70 percent for service-connected PTSD with depressive disorder. The rating currently assigned accurately reflects the severity of his disorder. The evidence reflects that the Veteran's PTSD symptoms are productive of occupational and social impairment, with deficiencies in most areas, such as work, thinking and mood, due to such symptoms as suicidal ideations, concentration difficulties, difficulty with stressful situations, loss of interest in activities, and inability to establish and maintain effective relationships. The lay and medical evidence shows that consistently throughout the appeal period, the Veteran had difficulty concentrating, difficulty with stressful situations, loss of interest in activities, chronic sleep impairment, and disturbances with his mood. The Veteran had consistently reported in multiple medical records that he had no friends and did not interact with anyone besides his family. Although the Veteran lives with his wife and has good relationships with his family, the VA examination reports of record confirm that he has difficulty in establishing and maintaining effective work and social relationships. Moreover, in the most recent December 2013 VA examination, the Veteran had symptoms of memory loss, including the suppression of memories from his time in Vietnam, anxiety, weekly panic attacks, and delusions and hallucinations. Based upon the results of the December 2013 VA examination, the RO awarded a 70 percent evaluation effective to the date of examination. Notably, the Board can discern no appreciable increased severity of PTSD symptoms during the appeal period. In November 2008, there were lay reports of the Veteran having a "downward spiral" tendency with memory deficits. In May 2009, the Veteran reported a suicidal gesture which is an example supporting a 70 percent rating. Resolving reasonable doubt in favor of the Veteran, the Board finds that the social and industrial impairment due to PTSD found at the time of the December 2013 VA examination has existed for the entire appeal period. Thus, a 70 percent rating is granted for the entire appeal period. In sum, the Board finds that the Veteran's symptomatology more nearly approximates the criteria for a 70 percent rating for the entire appeal period. However, the Board finds that an evaluation in excess of 70 percent is not warranted for any time during the appeal period. A 100 percent rating is not warranted because the evidence is against a finding of total occupational and social impairment. In short, the criteria of a 100 percent rating are not met in this case. The Veteran consistently appeared at VA appointments well-groomed and with good hygiene, and was consistently alert and socially appropriate. In almost all VA consultations, examiners noted no psychotic symptoms or evidence of thought disorder. The Veteran was always oriented with regards to time and place. The record also reflects that the Veteran has a good relationship with his wife and family, and stated that he would not commit suicide because of his family - although he has some suicidal ideations. Similarly, the Veteran has not exhibited any violent or harmful behavior towards others during the period of appeal - although he has a remote history of such behavior. While the Veteran has exhibited mild memory loss, the evidence of record shows that the Veteran was always able to state his name and former occupation during medical visits, and does not show any sign of forgetting family members' names. The last VA examination noted that the Veteran had delusions and hallucinations; however that was the first instance where it was noted that the Veteran experienced those symptoms. The lay and medical evidence does not establish that such delusions or hallucinations are persistent. Thus, the Veteran's VA outpatient treatment records and examination reports (as well as his lay statements) indicate serious or moderate impairment but do not rise to the level of total impairment. The evidence, as noted above, shows that the Veteran is able to perform the activities of daily living, has strong relationships with his family, and is orientated to time and place. In sum, the Veteran's disability picture is not one of total impairment, as illustrated by the criteria for a 100 percent rating. In so holding, the Board has considered the descriptions of symptomatology and impairment by the Veteran and his spouse. As addressed above, the Board has relied on these descriptions to award a uniform 70 percent rating for the entire appeal period. However, to the extent such statements tend to support a 100 percent schedular rating, the Board finds that the preponderance of the lay and medical evidence weighs against a higher rating still. With respect to findings pertaining to the extent of impairment in thought process, thought content, orientation, etc., the Board places greater probative weight to the findings of VA examiners who have greater expertise and training than the Veteran and his spouse in evaluating psychiatric disorders. There is no further reasonable doubt to be resolved in the Veteran's favor. 38 U.S.C.A. § 5107(b). Extraschedular Consideration While the Board does not have authority to grant an extraschedular rating in the first instance, the Board does have the authority to decide whether a claim should be referred to the VA Director of Compensation Service for consideration of an extraschedular rating. 38 C.F.R. § 3.321(b)(1). The governing norm for an extraschedular rating is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or necessitated frequent periods of hospitalization, so as to render the regular schedular standards impractical. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular rating for the service-connected disability is inadequate. Id. There must be a comparison between the level of severity and symptomatology of the service-connected disability with the established criteria. 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 no referral is required. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria reasonably describe the Veteran's disability levels and symptomatology pertaining to his service-connected PTSD. The rating criteria for evaluating a psychiatric disability provides samples which support a particular rating but allows for consideration of all aspects of disability which affect social and occupational impairment. As instructed in Mauerhan, the Board has considered all of the Veteran's reported psychiatric symptomatology in the assigned 70 percent rating. The Board has also considered whether a higher rating still is warranted based upon the frequency, duration and severity of symptoms, but the criteria for a 100 percent rating are not met. In short, the Board finds that the assigned schedular evaluation is adequate. Finally, the Board notes that under Johnson v. McDonald, 762 F.3d 1362, 1365-66 (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 conditions fails to capture all the service-connected disabilities experienced. Here, the Veteran has been assigned separate ratings for his service-connected PTSD, coronary artery disease and scar associated with bypass grafting. The Board finds no lay or medical evidence suggesting that these disabilities combine to result in any additional disability not currently addressed in the assigned schedular ratings. ORDER Prior to December 23, 2013, entitlement to an evaluation of 70 percent for PTSD with depressive disorder is granted. Entitlement to an evaluation in excess of 70 percent for PTSD with depressive disorder is denied. ______________________________________________ T. MAINELLI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs