Citation Nr: 1635584 Decision Date: 09/12/16 Archive Date: 09/20/16 DOCKET NO. 12-09 751 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to a disability evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) after April 28, 2010. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The Veteran served on active duty from July 1971 to May 1973. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The Veteran testified before the undersigned Veterans Law Judge at a December 2014 videoconference hearing, and a transcript of that hearing is of record. In April 2015, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, D.C. to afford the Veteran a VA medical examination. The action specified in the April 2015 Remand completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT Throughout the period on appeal, the Veteran's PTSD was characterized by occupational and social impairment with reduced reliability and productivity, due to such symptoms as, for example: chronic sleep impairment and nightmares; intrusive thoughts, hypervigilance; impairment of short and long-term memory; and disturbances of motivation and mood. However, his disability was not characterized by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as, for example: obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; and inability to establish and maintain effective relationships. CONCLUSION OF LAW The criteria for entitlement to a disability evaluation in excess of 50 percent for PTSD from April 28, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.7, 4.124(a), 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has reviewed all of the evidence in the claims folder, including all virtual records. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. The Board must assess the credibility and weight of all evidence, including the 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. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R., Part 4 (2015). Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2015). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding the veteran's increased evaluation claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the U.S. Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126. Hart appears to extend Fenderson to all increased rating claims. The Veteran's PTSD is rated under the General Rating Formula for Mental Disorders, found at 38 C.F.R. § 4.130 (2015). A 30 percent evaluation is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss(such as forgetting names, directions, recent events). A 50 percent evaluation 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 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; difficult establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and 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 inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. It is further noted that the nomenclature employed in the portion of VA's Schedule for Rating Disabilities ("the Schedule") that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130 (2015). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. 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. American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th. ed., 1994). GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. GAF scores ranging between 41 and 50 are assigned when there are 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, unable to keep a job). Id. GAF scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). Id. GAF Scores between 21 and 30 are assigned when behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). Id. Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, 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) (2015). 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. Id. Further, 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) (2014). In April 2010, the Veteran was evaluated by a private clinical psychologist, Dr. S.J.. At that time, the Veteran reported that although he suffered from symptoms of PTSD since service, his symptoms had worsened over the last two years. He reported a history of alcohol abuse, but stated that he quit drinking seventeen years ago. He described nightmares every night, and often wakes up hearing voices, only to discover no one is talking. He estimated that he gets four or five hours of sleep each night. He indicated he has flashbacks that are triggered by unexpected loud noises such as a firecracker or gunshot or witnessing a car wreck in which someone is badly hurt, as well as panic attacks, but it is unclear from Dr. S.J.'s report how frequently these occur. He avoids crowds because he feels smothered by them and always sits with his back to a wall when in public. He is guarded, easily startled, and hypervigilant. He denied suicidal ideation. The Veteran has been married for thirty nine years, has two children, and four grandchildren. He was currently employed as the Mayor of his city. Prior to this, he had worked for the city for more than thirty years. The Veteran also reported that he had cancer of the tongue and as a result lost all of his teeth, his saliva, his sense of taste, a quarter of his tongue, and half his jaw. The cancer spread to the top of his head last year and he had this taken out. Dr. S.J. diagnosed the Veteran with PTSD and Panic Disorder and assigned a GAF score of 40, noting the Veteran's functioning was impacted by his ongoing and life threatening health problems and financial difficulties in addition to his emotional problems. In August 2010, the Veteran was afforded a VA examination of his PTSD. At that time, the Veteran reported that he had been seen twice for medication management and once for individual counseling since his May 2007 examination. The Veteran described symptoms of daily insomnia, sadness and feelings of hopelessness and helplessness two or three times a week, memory impairment twice a week, weekly difficulty concentrating, and loss of interest in come leisure activities. He also reported nightmares twice a week, daily intrusive thoughts of his combat experience and avoidance of stimuli, daily hypervigilance, exaggerated startle response three times a week, irritability four or five times a week, increased social isolation and decreased interest in leisure activities. He reported suicidal ideations and explained that on one occasion, he obtained a gun and loaded it, intending to kill himself, but then did not follow through. He described visual hallucination of Vietnam buddies and auditory hallucinations of explosions during nightmares and flashbacks. He reported panic attacks every three months. He denied homicidal ideations or episodes of violence. He reported that he has been married for more than forty years and has two children, one of whom lives with him. His mother is still living nearby, as are several siblings. He stated that he sees his family members daily and enjoys their company. He also has several close friends that he has had since childhood, whom he sees four or five times a month. Reported leisure activities include landscaping and working on small engines. The Veteran was cooperative and friendly with the examiner, but his affect was flat. His speech and psychomotor activity were unremarkable and he was well oriented to person, time, and place. Thought processes and content were unremarkable, with no reported delusions or obsessive or compulsive behavior. Judgement and insight were intact. However, memory and attention were impaired. He was able to maintain personal hygiene and perform activities of daily living. He reported missing less than a week of work. He was diagnosed with PTSD and assigned a GAF score of 50. The examiner characterized the Veteran's occupational and psychosocial impairment as moderate. In March 2011, the Veteran was again seen by Dr. S.J. for a follow-up appointment. His mental functioning was approximately the same as at his last appointment and flashbacks and panic attacks remained the same. The Veteran complained of increasingly disturbed sleep, and reported that it was becoming more and more difficult for him to concentrate. He also described increasing auditory hallucinations and increased difficulty being in groups of people. In May 2012, the Veteran was seen for a second follow-up appointment by Dr. S.J.. At that time, the Veteran complained that his sleep had gotten even worse, with disturbing nightmares every night. He described increasing depression and suicidal ideations. He also worried that his tongue cancer will return. He explained that as long as he keeps busy, he is okay, but if he sits still, he goes "all to pieces." The Veteran reported that he becomes angered more easily and has yelled at employees at work, sometimes unfairly. He continued to describe intrusive thoughts, panic attacks, and flashbacks. He claimed that he doesn't socialize with anyone and is extremely vigilant and cautious when he is in public. He sits with his back to the wall if he's in a public building. The Veteran was diagnosed with PTSD, major depression, and panic disorder, and a GAF score of 40 was assigned. In May 2013, the Veteran was seen by VA for a psychiatry outpatient consultation. The Veteran described problems sleeping, reporting that he wakes up every hour or so, although he is able to fall back to sleep. He complained that he is tired all of the time. He also reported that he sometimes gets depressed, with occasional suicidal ideations. He described occasional nightmares, intrusive thoughts, and jumpiness. He continued to serve as mayor of his town and stated that he enjoys helping people. The Veteran's mood and affect were depressed, but his thought content was logical, congruent, and goal directed, with no evidence of psychotic content or attending behaviors. He was fully oriented and hygiene and appearance were within normal limits. He denied experiencing voices or visions. There was no observed or reported difficulty with memory. He was diagnosed with PTSD and insomnia and assigned a GAF score of 65. In August 2013, the Veteran was again seen by VA Mental Health services. The Veteran reported that he was recently reelected to his second term as mayor. He admitted the job was stressful, but also explained that he was gratified that he is able to help others. The Veteran was pleasant and cooperative, with appropriate hygiene and appearance. Thought content was logical, congruent, and goal directed, with no observed or reported difficulty with memory. The Veteran denied any psychosis or suicidal or homicidal ideations. A GAF score of 70 was assigned. A February 2014 VA Psychiatry Outpatient Note reflects that the Veteran has been very busy with his job, helping others through a recent weather emergency. His wife's health has become increasingly poor, requiring additional care and assistance from the Veteran. However, the Veteran described his mood as "pretty good." The Veteran was observed to be pleasant and cooperative, with appropriate behavior, hygiene, and appearance. He was fully oriented, with thought content logical, congruent, and goal directed. No psychotic content or attending behaviors were observed. No difficulty with memory was observed or reported. He denied experiencing voices or visions. Upon direct query, he denied current suicidal or homicidal ideations. When he was seen again in April 2014, he complained of some difficulty with focus, but his mood was good and his affect euthymic. He was fully oriented, with thought content logical, congruent, and goal directed. No psychotic content or attending behaviors were observed. No difficulty with memory was observed or reported. He denied experiencing voices or visions. Upon direct query, he denied current suicidal or homicidal ideations. At an October 2014 VA outpatient psychiatric visit, he complained of poor sleep, with distressing memories and nightmares of Vietnam. His mood was anxious and his affect dysphoric. However, he was described as pleasant and cooperative, with appropriate behavior, hygiene, and appearance. He was fully oriented, with thought content logical, congruent, and goal directed. No difficulty with memory was observed or reported. No psychotic content or attending behaviors were observed. He denied experiencing voices or visions. Upon direct query, he denied current suicidal or homicidal ideations. In December 2014, the Veteran was preoccupied with his own and his spouse's health. His mood and affect were anxious. However, he was described as pleasant and cooperative, with appropriate behavior, hygiene, and appearance. He was fully oriented, with thought content logical, congruent, and goal directed. No psychotic content or attending behaviors were observed. No difficulty with memory was observed or reported. He denied experiencing voices or visions. Upon direct query, he denied current suicidal or homicidal ideations. He reported occasional passing thoughts, but no intent or plan to self-harm. At a March 2015 VA outpatient psychiatric visit, the Veteran reported that he was doing "pretty good", although he was having some problems managing his blood pressure. He continued to remain busy with his job as mayor, but enjoys what he does, although he stated that he is considering stepping back due to family illness. His mood was good. He was described as pleasant and cooperative, with appropriate behavior, hygiene, and appearance. He was fully oriented, with thought content logical, congruent, and goal directed. No psychotic content was observed. There was no observed or reported difficulty with memory. He denied experiencing voices or visions. Upon direct query, he denied current suicidal or homicidal ideations. In June 2015, the Veteran was afforded a new VA examination. Since his previous examination, the Veteran remained married to his wife of 44 years, stating she was his high school sweetheart. The couple have a daughter, a son, and three grandchildren. He described loving and mutually supportive relationships with his family. He reported that his spouse has had some health problems and he has taken on the role of her caregiver, including taking over her household chores due to her level of impairment. He claimed his grandchildren "make (his) life." He stated he has interests in four-wheeling in the country and spending time in the mountains, though he foregoes these pleasures to care for others in his household and in his community. He recently helped organize a city-wide high school reunion for former students for a 25-year span, and that this was a three day event. He enjoyed reconnecting with old friends, as well as watching others have a good time. The Veteran continued to serve as local mayor, a job that reportedly gives him great satisfaction, although it does not pay well. He noted he loves his community and enjoys being able to call together resources to help community members in need of housing, food, medicine, etc. He also continues to occasionally work on small engine repair projects to earn some extra money. Other than his treatment at VA, the Veteran denied any other mental health treatment. He continued to take mirtazapine about every other night. Symptoms noted by Veteran on the day of the examination included re-experiencing of his combat traumas, avoidance, negative alterations in cognition and mood, and hyper-arousal. He also suffered from depressed mood, anxiety, suspiciousness, and mild memory loss (such as forgetting names, directions or recent events). The Veteran described continued emotional reactivity to reminders of his Vietnam service. He evidenced this in his tearfulness in response to his disclosure of his symptoms of PTSD in relation to his combat traumas. He noted thoughts of his close friend who was killed in Vietnam, referring to his as "more like family than a friend." He noted he continues to hear this man's voice speaking to him from time to time, and often he becomes tearful in response. He further noted intrusive recollections of the body bags on the tarmac he saw on his arrival in Vietnam, and that these memories result in his having crying spells. He noted a remote history of trying to "block" memories of Vietnam with excessive alcohol use. He now notices he does not tolerate watching any war movies or any television programing related to Vietnam. He reported improved sleep on medication, but stated he will routinely get about four to five hours of sleep per night and awakens feeling tired. He denied any daytime problems as a result of his poor sleep, however. He stated he will awaken in the night easily to slight noises, and will go outside his home, at times laying in the grass or hiding behind a tree, to see if anyone is there to cause any harm. He described irritable outbursts as well, stating he will at times have verbal outbursts with others, and more recently this escalated into a physical altercation with one of his council members, in which the Veteran grabbed the man, pulled him out of his chair, backed him against the wall, and balled his first ready to hit him. He stated he stopped himself at that point and felt badly for his behavior. The Veteran presented a very pleasant, friendly, and cooperative demeanor throughout examination. He was alert and fully oriented. He denied current thoughts, plans, or intent of self- or other-directed violence on the day of this examination. His affective presentation was constricted and depressed, though not flat. The Veteran's appearance indicated very good attention to personal hygiene and he was dressed appropriately. He gave no indication of symptoms of thought disorder at the time of examination, though he recounted auditory and visual hallucinations that appear to be related to his flashbacks. His speech was of normal rate, rhythm, and volume. The examiner concluded that the Veteran's PTSD would result in occupational and social impairment with reduced reliability and productivity. He was considered competent to manage his benefits. Based on all the above evidence, the Board finds that entitlement to a disability evaluation in excess of 50 percent for the Veteran's PTSD is not warranted for any period after April 28, 2010 While the Veteran has described symptoms of insomnia, nightmares, depression, irritability, impaired concentration and memory, re-experiencing of traumatic events, avoidance, and hyperarousal, these symptoms do not result in deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The record reflects that throughout the period on appeal, the Veteran has reportedly maintained a close and loving relationship with his family, including a wife of more than forty years, his children, and grandchildren. At his August 2010 VA examination, he also reported regularly spending time with a number of close friends and extended family, as well as interest in a number of leisure activities. Additionally, the Veteran has been employed as a mayor for the entire period on appeal. Although he has reported that symptoms such as difficulty concentrating and angry outbursts have occasionally interfered with his occupational functioning, he has also repeatedly expressed great satisfaction with his job and the opportunity it affords him to help the members of his community. Furthermore, the Veteran was reelected to a second term in 2012, suggesting that his PTSD did not interfere with his occupational functioning to a degree that his constituents considered him unqualified. While the Board acknowledges that the Veteran's PTSD causes him real emotional suffering, the preponderance of the evidence does not support a finding that his disability is characterized by the severe cognitive and functional impairment contemplated by a higher schedular rating, due to symptoms such as obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; or neglect of personal appearance and hygiene. Throughout the period on appeal, the Veteran has been able to perform activities of daily living, including routine self-care. He has consistently been described as fully oriented, with thought content logical, congruent, and goal directed, and no evidence of psychosis. There is no evidence of psychiatric hospitalization or substance abuse and although the Veteran has reported occasional suicidal ideations, there is no recent history of suicide attempt. Indeed, overall, the Veteran has demonstrated a high level of functioning, as evidenced by his positive relationships with family and friends and his continued performance of a highly demanding job. The Board has also considered whether the Veteran's disability warrants referral for extraschedular consideration. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2015). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, it does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is not required. See Thun, supra. For all the above reasons, entitlement to a disability evaluation in excess of 50 percent for PTSD is denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2015). The Duty to Notify and Assist Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2015). Here, the Veteran was provided with the relevant notice and information. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). He has not alleged any notice deficiency during the adjudication of his claim. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). VA also has a duty to assist the Veteran in obtaining potentially relevant records, and providing an examination or medical opinion when necessary to make a decision on the claim. Here, the Veteran's service records, VA records, and identified private treatment records have been obtained and associated with the claims file. The Veteran was also provided with VA examinations which, collectively, contain a description of the history of the disability at issue and document and consider the relevant medical facts and principles. VA's duty to assist with respect to obtaining relevant records and an examination has been met. 38 C.F.R. § 3.159(c); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Finally, the Veteran testified at a Board hearing. The hearing was adequate as the Veterans Law Judge who conducted the hearing explained the issue and identified possible sources of evidence that may have been overlooked. 38 C.F.R. 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). ORDER A disability evaluation in excess of 50 percent for PTSD from April 28, 2010 is denied. ____________________________________________ M. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs