Citation Nr: 1800437 Decision Date: 01/04/18 Archive Date: 01/19/18 DOCKET NO. 10-36 761 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD B. J. Komins, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from August 1967 to July 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board remanded the case for additional evidentiary development in November 2016 and June 2017. The case has returned to the Board for further appellate review. FINDING OF FACT From January 12, 2009, the preponderance of evidence shows that the Veteran's PTSD more nearly approximated occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran's PTSD has not been shown to be productive of 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. CONCLUSION OF LAW The criteria for a disability rating in excess of 70 percent disabling for the Veteran's PTSD have not been met or approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION I. Remand Concerns As noted in the Introduction, the case was remanded to the RO in November 2016 and June 2017 for additional development. The Board is satisfied that there has been substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-67 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1999) (holding that the Board errs as a matter of law when it fails to ensure compliance with its remand orders). II. Duties to Notify and Assist VA has a duty to notify for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran has appealed with respect to the propriety of the assigned ratings for PTSD, for which the RO granted service connection in November 2009. VA's General Counsel has held that no VCAA is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability, 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). VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's increased rating claims. Service treatment records (STRs), VA treatment records, private medical records, Vet Center records, and lay statements have been associated with the electronic claims file. Here the Board notes that the RO has attempted to obtain the Veteran's treatment records from both the Fort Lauderdale and Miami Vet Centers from August 2009 to July 2017. However, the Veteran has not provided wholly accurate information concerning his dates of treatment and, moreover, precisely at which Vet Center treatment took place. Here, the RO has provided extensive assistance within its realm of competency to obtain all extant Vet Center records; however, the duty to assist in obtaining these records is not absolute. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street. If a veteran wants help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence"). VA's duty to assist includes providing a medical examination or obtaining a medical opinion when necessary to decide a claim. See 38 U.S.C.A. § 5103A(d) (West 2014); 38 C.F.R. § 3,159(c)(4) (2017). As discussed below, the Veteran was afforded multiple VA examinations for psychiatric issues throughout the period on appeal. The Board finds that an additional medical examination or opinion is not necessary to decide the Veteran's claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) ("A medical opinion is adequate when it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability in sufficient detail so the Board's 'evaluation of the claimed disability will be a fully informed one.'"). Schedular Ratings for PTSD A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). See generally 38 C.F.R. § Part 4 (2017). The percentage ratings contained in the Rating Schedule represent, as far as can practicably be determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. See 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.27 (2017). VA has a duty to acknowledge and to consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. See Schafrath v. Derwinski, 1 Vet. App. 589, 592-93 (1991). Where there is a question as to which of two ratings to apply, VA will assign the higher rating if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7 (2017). Otherwise, VA will assign the lower rating. Id. The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged ratings," regardless of whether a case involves an initial rating. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). PTSD is rated under 38 C.F.R. § 4.130. Diagnostic Code 9411 (2017). A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; 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. The use of the term "such as" in 38 C.F.R. § 4.130 (2017) demonstrates that the symptoms that follow the phrase are not intended to constitute an exhaustive list, but instead are to 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, 442-43 (2002). When evaluating a mental disorder, VA shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2017). VA 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 the disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2017). A Global Assessment of Functioning (GAF) score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994), which is more commonly referred to as "DSM-IV"). A GAF of 21 to 30 is defined as behavior considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriate, suicidal preoccupation) or an inability to function in almost all areas (e.g., stays in bed all day, no job, home or friends). A GAF of 31 to 40 is indicative of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or any 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; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF of 41 to 50 is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 indicates 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). A GAF of 61 to 70 is indicative of mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). The Board notes that while VA is to consider an examiner's classification of the level of psychiatric impairment by a GAF score, a GAF score alone is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95. Effective March 19, 2015, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations to remove outdated references to the DSM-IV, and replace them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 80 Fed. Reg. 53, 14308 (March 19, 2015). Evidence The Veteran served as a member of a United States Army reinforcement control group. He received a Vietnam Service Medal. The Veteran contends that the severity of his PTSD symptoms most closely approximate the criteria for an initial 100 percent rating. In March 2009, the Veteran submitted a statement in support of his claim for service connection for PTSD, via VA FORM 21-0781. The Veteran described a situation which occurred on or about April 1970. The Veteran wrote that a truck exploded in front of the truck in which he was traveling back to base camp. The Veteran also wrote that another incident occurred in on or about June 1970. Then, a soldier in front of him stepped onto a landmine and was "blown to bits." The Veteran further noted that he could do nothing but watch as he had 15 days left until discharge. Also in March 2009, the Veteran's wife submitted a statement. Concerning PTSD, she relayed the account of the truck explosion. She also stated that the Veteran threatened to kill a fellow student during a basketball game after he returned from Vietnam. Furthermore, she reported that the Veteran frequently expressed concerns about the safety of their children, noting expressions of paranoia and expressions of distrust of others. Review of treatment records from the Broward County VA Outpatient Clinic (OPC) reveals that the Veteran sought mental health consultation and psychiatric treatment in August 2009. Psychiatric notes reported that goals were to target the symptoms and active psychosocial stressors manifested by decreased concentration, depressed mood, and sleep disturbance. An examiner took note of his well-groomed appearance, grossly intact cognitive functioning, euthymic mood, and linear thought process. Suicidality, homicidal thoughts, and delusions were not reported. The Veteran was afforded a VA initial evaluation for PTSD examination in October 2009. The examiner reviewed the Veteran's claims file, lay accounts of his medical and psychiatric history, and conducted an examination and in-depth interview. The examiner noted that the Veteran received individual psychotherapy at a local Vet Center and was prescribed antidepressant medication. The Veteran reported that had been experiencing significant decreases in his ability to concentrate and complete tasks since his discharge from active service. The examiner indicated that the Veteran had 12 months of combat experience in Vietnam. Opining as to his post-military psychosocial history, the Veteran reported some tension in his marital and family relationships. He also indicated that he had few friends; more specifically, he was pulling away from friendships when he felt that they were becoming too close. The Veteran indicated that he experienced no problems with alcohol use, substance use, or assaultive behavior. Upon examination, the Veteran was clean, neatly groomed, and appropriately dressed. His psychomotor activity, speech, and affect were unremarkable. Moreover, the examiner noted that the Veteran was cooperative and friendly. The Veteran's mood was described as frustrated; however, he showed no signs of short attention span, or orientation deficit-to person, time, or place. Thought process was normal; thought content was unremarkable, albeit preoccupied with one or two topics; delusions were absent; and the Veteran's judgment showed that he understood the outcome of his behavior. The examiner further opined that the Veteran partially understood that he had a problem. The Veteran reported sleep impairment, namely awakening throughout the night and an inability to return to sleep. While the Veteran had no homicidal thoughts, he, according to the examiner, endorsed passive suicidal ideations without intent or plan. Impulse control was fair, with the Veteran reporting specifically that he had occasional poor verbal impulse control. The Veteran exhibited a mildly impaired intermediate memory, exemplified by some forgetfulness of tasks. As to stressors, the Veteran indicated his combat experiences in Vietnam. There, he experienced intense fear, feelings of hopelessness, and feelings of horror. The Veteran stated that the truck ahead of him struck a road bomb and he witnessed bodies "getting blown up." He also expressed distress at having to pack up the belongings of dead soldiers to send home to their families. As to PTSD symptoms, the examiner reported that the Veteran persistently experienced the traumatic event through intruding recollections; persistently avoided stimuli associated with the trauma and a numbing of general responsiveness; and persistent symptoms of arousal, including exaggerated startle response. Furthermore, according to the examiner's findings, the disturbance caused clinically significant stress or impairment in social, occupational, or other important functional areas. The Veteran reported that he experienced chronic symptoms since discharge of moderate severity. The Veteran further indicated that these symptoms had lessened in frequency and intensity in the intervening years. However, the Veteran denied ever experiencing a time of complete remission or the capacity for adjustment during remission. The Veteran attributed social avoidance; inability to get close to other out of fear of loss; poor sleep; intrusive thoughts; and poor verbal impulse control to this past stress exposure. Diagnostically, the examiner indicated that the Veteran had the mental capacity to handle his financial affairs. Moreover, he was self-employed and had not experienced down time during the previous year. However, his occupational functioning was impacted by his decreased concentration. The Veteran did meet the DSM-IV criteria for a diagnosis of PTSD. The examiner opined that the Veteran's PTSD resulted from combat experiences in Vietnam, as indicated in medical literature. As a psychological summary, the examiner reported that the Veteran had a fair prognosis, given some improvement in symptoms with treatment. Total occupational and social impairment were not reported. A July 2010 mental health outpatient note from the Broward OPC reported that the Veteran reported that he was doing fine with his current medications. He stated that he had nightmares about Vietnam combat twice a week; however, he declined to change his medication regimen to treat this. The Veteran also expressed interest in PTSD group therapy, requesting a referral to the PTSD clinic. Furthermore, the Veteran expressed concerns about memory, which currently scored 30/30 on Folstein scale. The examiner opined that the Veteran appeared well-groomed, calm, and cooperative. Moreover, cognitive functioning was 30/30 on the Folstein scale; mood was euthymic; thought processes were linear and logical. Delusions, suicidality, and homicidal thoughts were absent. The examiner assigned a GAF score of 60. In August 2010, a letter was received from Dr. A., a private psychologist. In pertinent part, Dr. A. wrote that the Veteran had been referred to him for treatment for a psychological evaluation secondary to his service in Vietnam. Dr. A. reported that the Veteran reported symptoms consistent with PTSD and substance abuse. Dr. A. conducted a clinical interview, reviewed the Veteran's records, and administered a Minnesota Multiphasic Personality Inventory (MMPI-2). As to DSM-IV symptoms, Dr. A. opined that the Veteran "sometimes" experienced recurrent intrusive thoughts related to the truck incident, as described above. Persistent arousal, according to Dr. A., consisted of anhedonia, insomnia, and difficulty concentrating; while persistent avoidance or numbing was exemplified by the Veteran's description of a history of an intensive effort geared towards the avoidance of thoughts, feeling, conversations, activities, places, and people associated with traumatic experiences. The Veteran reported moreover that depressive symptoms have manifested themselves for 15 years prior to the immediate assessment. Upon examination, Dr. A. opined that the Veteran was extremely cooperative and pleasant. Impulse control, as "demonstrated" by reported substance abuse and reported angry outbursts, fell below normal. Speech and thought were reported to fall within normal limits. However, thought content was consistent with suicidal ideation. Homicidal thoughts and perceptual abnormalities were absent. The Veteran was oriented to all three spheres; however, his degree of concentration fell below normal limits. Short-term memory also fell below normal limits. Likewise, judgment and insight fell below normal limits. Dr. A. provided a GAF score of 48. He also provided diagnostic impressions of PTSD; Depressive Disorder Not Otherwise Specified (NOS); Problems Related to the Social Environment; Economic Problems; and Other Psychosocial Issues. As a recommendation, Dr. A. encouraged group therapy aimed at treating symptoms of PTSD and depression. Psychiatric symptom management was also recommended. Dr. A. provided a guarded prognosis. September 2010 progress notes from the Broward OPC took note of the Veteran's decreased concentration, depressed mood, and sleep disturbance. An examiner's note indicated that the Veteran denied suicidal or homicidal ideation, intent, or plan. In June 2012, the Veteran submitted a lengthy letter in which he expressed his dissatisfaction with his rating for PTSD and another disability not before the Board. In pertinent part, he noted that PTSD has impaired all his life and he requested compensation for "all of his suffering." He wrote that he has not been able to make close friends or share dreams and hopes. His relationships with his family were poor and he had trouble trusting others. He also contended that he was depressed a lot. In September 2012, the Veteran's representative submitted a VA 646 Statement. In pertinent part, he stated that the Veteran's VA examination was "stale" and he warranted a new VA examination. Furthermore, he contended that the Veteran's symptoms included depression; intrusive/distressful memories; flashbacks; marked avoidance; (people, places, activities, and memories); sleep disturbances; impaired concentration; psychomotor activity; spontaneous speech; startle response; and multiple suicide attempts. He also indicated that the Veteran had a GAF score of 60. A review of Broward OPC treatment records from March 2012 to April 2014 shows that the Veteran frequently sought consultation for his PTSD symptoms, such as nightmares, high alert, and avoidance. Throughout this period, examiners provided impressions of PTSD with depression. Furthermore, there are notations as to the Veteran's memory problems. These records also reveal that the Veteran participated in PTSD and Relationships group therapy. At various times, examiners noted that the Veteran's appearance and attitude were calm, cooperative, and appropriate. In a September 2013 psychiatric note, an examiner opined that the Veteran's cognitive functioning was grossly intact. Likewise, the examiner noted that his thought processes were linear and goal directed; his thought content exhibited neither delusions nor obsessions; and there was no evidence of suicidality or homicidal thought. In June 2014, the Veteran was afforded a VA examination for PTSD. The examiner reviewed the Veteran's virtual file, considered the Veteran's accounts of the onset and nature of his symptoms, and provided clinical findings. The examiner indicated that PTSD presented occupational and social impairment with reduced reliability and productivity. Concerning social, marital, and family history, the examiner noted that the Veteran reported that he got along with his children "okay," and his relationship with his spouse was "on and off." Moreover, the Veteran reported that as his worked slowed down, his PTSD symptoms increased. The examiner indicated that the Veteran was taking antidepressant medication. His current reported symptoms included: frustration; angry outbursts; poor concentration; intrusive thought of Vietnam; anhedonia; poor motivation to complete tasks; nightmares about Vietnam three times weekly; irregular sleep patterns; difficulty trusting others; frequent episodes of crying; impulsive spending; and hypervigilance. The examiner noted the presence of all diagnostic criteria. The examiner's reported symptoms included depressed mood, anxiety, suspicious, sleep impairment, mild memory loss, mood disturbance, and relationship impairment. Judgment, insight and attitude were adequate. Suicidal ideation and homicidal ideation were present. The examiner indicated that he utilized DSM-5 criteria. A March 2015 Report of General Information (VA For 27-0820) noted that a representative from the RO called the Veteran about his Vet Center records. The Veteran, according to the report, indicated that he did not know why the records were not in his possession. The Veteran also indicated that he was told the Vet Center records were destroyed by a fire. In March 2015, the RO sent a formal written request to the Fort Lauderdale Vet Center for the Veteran's records from September 2009 to March 2015. At the same time, the RO sent the Veteran a letter which explained that the Vet Center records had been requested. Later in March 2015, the RO submitted a second formal written request to the Fort Lauderdale Vet Center for the Veteran's records from September 2009 to March 2015. At this time, the RO sent a letter to the Veteran noting that it is his responsibility to ensure that VA receives these requested records. The Veteran sent a signed VA FORM 21-4142 to the RO the same month, authorizing release of records from both the Fort Lauderdale and Miami VA Centers. A review of treatment records from the Broward OPC from June 2014 to February 2015 reveal that the Veteran continued his PTSD counseling. He also sought medication consultations. Notations during this period of treatment mention memory problems. Group therapy and peer support services focused on hope, personal responsibility, education, self-advocacy, and support. In March 2015, the Fort Lauderdale Vet Center forwarded the Veteran's files to the RO, covering from February 2010 to August 2010. However, these records did not include an Intake Assessment. Review of these records reveals that the Veteran sought regular counseling to cope with anger arousal. The records also show that expected indicators included a demonstration of proficiency of anger management skills. The Veteran's counselor reported that the Veteran had a tendency to skirt issues dealing with PTSD; however, his affect puctured through this concealing veneer. The counselor also reported that the Veteran tended to intellectualize his issues and "not get into issues." Occasional anger flare-ups are noted throughout the records. The counselor regularly reported personal events in the Veteran's life, such as his brother's death. An April 2015 Report of General Information (VA For 27-0820) noted that a call was made to the Miami Vet Center to ascertain why the Veteran's records had not been sent. According to the note, the office manager stated that the office had lost some of its counselors and that the request "may have fallen through the cracks." The manager indicated that he was able to fax an authorization to expedite the records delivery in 10 days. In due course, another VA FORM 21-4142 was received and signed by the Veteran. Subsequent correspondence in April 2015 from the Miami Vet Center reported that the Veteran, in fact, was not a client. April 2015 mental health counseling notes from the Broward OPC reveal that the Veteran had successfully completed a sequence of "action management" group therapy. An examiner noted that the Veteran had successfully begun to implement new behavioral skills. There are also notations as to a multitude of missed appointments. A late April 2015 Report of General Information (VA For 27-0820) noted that the Veteran called to ascertain the status of his claim. At this time, the Veteran stated that he erred in indicating that he received treatment at the Miami Vet Center. A May 2015 Report of General Information (VA For 27-0820) memorialized a phone contact with the Fort Lauderdale Vet Center. The Vet Center reported that they had sent all of the Veteran's treatment records. The RO stated that the Veteran reported that he had been treated at that Vet Center from 2008 to 2015. A follow-up email was sent in June 2015 ascertaining as to the existence of the Vet Center records which the Veteran reported. Furthermore, a June 2015 Report of General Information (VA For 27-0820) was sent in follow-up. In June, the Ft. Lauderdale Vet Center sent an email noting that it "has been determined that [the Veteran's] first treatment date was August 2009." In turn, this email received an email response from the RO which noted that only records dating August 2011 and January 2011 were received. An August 2015 Report of General Information (VA For 27-0820) noted that yet another call was made to the Miami Vet Center for the Veteran's records. The Miami Vet Center sent an August 2015 Report of General Information (VA For 27-0820), which stated that the Center had no records under the Veteran's social security number. In August 2015, the RO sent the Veteran a letter concerning the status of his Vet Center records. In pertinent part, the RO stated that it had exhausted its efforts to obtain the Veteran's Miami Vet Center records. The RO itemized all actions performed to obtain these records. Furthermore, the RO requested any extant information that the Veteran had in reference to these records. In June 2016, the Veteran's representative submitted an Appellant's Post-Remand Brief. In pertinent part, the representative argued that the Veteran's PTSD symptomatology more approximates a higher disability rating. Review treatment records from the Miami, Florida Veterans Affairs Medical Center (VAMC) reveals that the Veteran frequently mentioned his PTSD diagnosis with clinicians. Treatment notes included impressions of PTSD with depression that is stable and controlled. Notations also addressed the Veteran's memory complaints. In January 2017, the Veteran was afforded a VA examination for PTSD by a VA psychiatrist. The psychiatrist reviewed the Veteran's claims file, considered the Veteran's lay accounts, and provided clinical findings. The psychiatrist reported that the Veteran's PTSD had been formally diagnosed, but symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication. All PTSD diagnostic criteria were present. Reported symptoms included, depressed mood; anxiety; chronic sleep impairment; and difficulty in establishing and maintaining effective work and social relationships. In June 2017, the Veteran's representative submitted another Appellant's Post-Remand Brief. In pertinent part, the representative posited that the Veteran's PTSD should be rated at 100 percent. The representative also noted that the RO did not follow the Board's remand directives to obtain Vet Center records. In November 2017, the Veteran's representative submitted a final Appellant's Post-Remand Brief. Here, the representative reiterated the contention that the Veteran's PTSD warrants a 100 percent rating, specifically arguing that the VA examinations of record do not accurately reflect the severity of the Veteran's PTSD. The representative drew the Board's attention to arguments advanced in earlier briefs. Analysis Upon review of the evidence of record, the Board concludes that the evidence of record does not support an initial evaluation of more than 70 percent disabling for PTSD. As discussed above, a higher 100 percent disability rating under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017) under the General Rating Formula, would require 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. The evidence of record, discussed above, is silent as to symptoms of 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. Moreover, while the evidence of record shows that the severity of the Veteran's PTSD indicates that he experiences occupational and social impairment in family relations and judgment, due to such symptoms as suicidal ideation, near-continuous depression affecting the ability to function independently, appropriately and effectively as well as impulse control, it does not show 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. In this respect, the Board notes that the January 2017 VA psychiatrist opined that the Veteran's PTSD symptoms were not severe enough to either interfere with occupational and social function or to require continuous medication. In reaching this conclusion, the Board has carefully considered the lay statements of the Veteran and his spouse. The Board acknowledges that, as a lay witness, the Veteran is competent to report his medical history and observable symptomatology. See Layno v. Brown, 6 Vet. App. 465, 469-79 (1994). Nevertheless, determining the requisite elements of posttraumatic stress disorder, a process involving specialized knowledge of psychology and psychological diagnostic instruments is beyond the scope of lay observation. Id. Thus, a determination as to the severity of PTSD, according to either DSM-IV or DSM-5 criteria, is not susceptible to either lay or generic opinions and requires highly specialized training. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board here notes that there are no exceptions to the Jandreau doctrine. As such, the lay statements of the Veteran and his spouse do not represent competent evidence regarding the severity of the Veteran's service-connected PTSD. See 38 C.F.R. § 3.159(a)(1) (2017) ("competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions."). In this respect, the Board also acknowledges the arguments of the Veteran's representative that the the VA examinations of record do not accurately reflect the severity of the Veteran's PTSD. However, neither the representative nor the Veteran have offered any specific examples as to why the VA examiners or their examinations fail to present a competent portrayal of the severity of the Veteran's PTSD. The reports of the examination reflect that they were based upon a review of the Veteran's claims file and medical records as well as a detailed interview of the Veteran. The opinions and conclusions were offered by medical professionals trained in the assessment of mental disorders, and there is no basis to believe that they were not objective or competent. Finally, the Board recognizes that the symptoms enumerated under the schedule for rating mental disorders serve as examples of type and degree of symptoms, or their effects, which would justify a particular rating, and are therefore not dispositive. See Mauerhan supra. However, no competent, hence probative, evidence of record indicates that an initial evaluation in excess of 70 percent is warranted here. Thus, the Board finds that the 70 percent evaluation assigned adequately portrays any impairment that the Veteran has experienced due to his PTSD. Extraschedular Consideration The Board also has considered whether referral for extraschedular consideration is warranted here. Extraschedular consideration involves a three step analysis. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, 572 F.3d 1366 (Fed. Cir. 2009). The first element requires a finding that the evidence "presents such an exceptional or unusual disability picture that the available schedular evaluations for that service-connected disability are inadequate." See id. at 115. In order to determine whether a disability is" exceptional or unusual," there "must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability." Id. "[I]f the [rating] criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, [and] the assigned schedular evaluation is, therefore adequate, and no referral is required." Id. The first Thun element is not satisfied here. The Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, therefore no referral for extraschedular consideration is required. A comparison between the level of severity and symptomatology of the Veteran's symptoms with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the disability and contemplate the Veteran's symptoms. Specifically, the Veteran's PTSD symptoms have been characterized by occupational and social impairment in family relations and judgment, due to such symptoms as suicidal ideation, near-continuous depression affecting the ability to function independently, appropriately and effectively as well as verbal impulse control. The Board finds that the record ofevidence does not reflect that the Veteran's PTSD is so exceptional or unusual that it warrants consideration of the assignment of a higher rating on an extraschedular basis. Finally, 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. See Johnson v. McDonald, 762 F.3d 1362 (2014). In this case, the Veteran is service-connected for PTSD at 70 percent disabling; internal derangement and degenerative arthritis of the left knee at 10 percent disabling; internal derangement and degenerative arthritis of the right knee at 10 percent disabling; meningitis at 10 percent disabling; and essential hypertension at a noncompensable rating. The Veteran has not alleged that his currently service-connected disabilities combine to result in additional disability or symptomatology that is not already contemplated by the rating criteria for each individual disability. Hence, extraschedular under Johnson is not for consideration. Additional Consideration Finally, a claim for a total disability rating based on individual unemployability due to service-connected disability (TDIU) is part and parcel of an increased rating claim, when such a claim is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453-4 (2009). Here, the Veteran has made no specific or implied allegations that he is unemployable because of his PTSD or other service-connected disabilities. As such, even under the most liberal interpretation of the law or interpretation of the facts of this case a claim of TDIU has not been raised by the record. In fact, the Veteran was able to run for a public position, and maintain his position as a town commissioner after prevailing in the election. He has also given lectures. Moreover, the Veteran has done some substitute teaching. In sum, a claim for a TDIU has not been raised and is not before the Board. ORDER Entitlement to an initial disability rating in excess of 70 percent for posttraumatic stress disorder is denied. ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs