Citation Nr: 1003151 Decision Date: 01/21/10 Archive Date: 02/01/10 DOCKET NO. 05-20 092 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUE Entitlement to an increased rating for posttraumatic stress disorder (PTSD), evaluated as 30 percent disabling through September 25, 2007, and as 70 percent disabling beginning September 26, 2007. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant, Appellant's friend ATTORNEY FOR THE BOARD J. Fussell, Counsel INTRODUCTION The Veteran had active service from August 1966 to October 1977. This matter comes before the Board of Veterans' Appeals (Board) from a February 2005 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. Following a June 2006 Travel Board hearing, a transcript of which is on file, the Board remanded this case for additional development in August 2007. In a November 2007 rating decision the Appeals Management Center (AMC) increased the evaluation for PTSD from 30 percent to 70 percent, effective September 26, 2007 (date of VA psychiatric rating examination). The Board again remanded this case in May 2008 for additional development. The issues of service connection for diabetes and a TDIU rating (based on two or more service-connected disabilities with a combined rating of at least 70 percent or more and with at least one rated 40 percent or more) have not yet been adjudicated. Accordingly, these matters are referred for initial consideration. FINDINGS OF FACT 1. Prior to September 26, 2007, the Veteran had signs and manifestations of PTSD with impaired mood, suicidal and homicidal ideation but no plans or intent, irritability, sleep disturbance, nightmares and intrusive thoughts of Vietnam but he was fully oriented and had no impairment of speech, insight, judgment or memory and had no thought disorder, delusions or hallucinations. 2. Since September 26, 2007, the Veteran's PTSD has been manifested by constricted affect, panic attacks, suicidal and homicidal ideation but no plans or intent, and mild memory impairment as well as obsessional and ritualistic behavior consisting only of a desire to be alone but he had not had disorientation, delusions, hallucinations, impaired insight or judgment or inappropriate behavior. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 30 percent for PTSD prior to September 26, 2007, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.21, 4.126, 4.130, Diagnostic Codes (DC) 9411 (2009). 2. The criteria for a rating higher than 70 percent for PTSD since September 26, 2007, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.7, 4.21, 4.126, 4.130, Diagnostic Codes (DC) 9411 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The VCAA notice was intended to be provided before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a claim for increase, the VCAA notice requirements include notice to provide, or ask VA to obtain, medical or lay evidence of increased severity and the impact thereof on employment to substantiate the claim; and providing examples of types of medical or lay evidence that may be submitted, or that VA can be asked to obtain, which are relevant to establishing an increased rating. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), affm'd in part by Vazquez-Flores v. Shineki, 580 F.3d 1270 (Fed.Cir. 2009). Historically, and October 2002 rating decision granted service connection for a depressive disorder (also claimed as PTSD) and assigned an initial 30 percent disability rating effective July 10, 2001. In September 2004 he requested to "re-open service connected claim for PTSD for an upgrade." The RO provided the Veteran with pre-adjudication VCAA notice by letter, dated in October 2004. The notice included the type of evidence needed to substantiate the claim for increase, namely, evidence of an increase in severity. He was informed that VA would obtain VA records and records of other Federal agencies, and that private medical records could be submitted or VA could be authorized to obtain such records. He was informed of the elements needed for a grant of service connection for PTSD. Following a January 2004 VA psychiatric examination, a February 2005 rating decision confirmed and continued the 30 percent rating for what was then characterized as PTSD, formerly diagnosed as a depressive disorder. Following an August 2007 Board remand, the Veteran was informed of how VA determined effective dates and disability ratings. He was informed that VA would consider evidence of the nature and symptoms of the condition, the severity and duration, and impact of the condition and symptoms on employment. Examples of types of evidence which could be considered were listed. Following remand of the case in May 2008, the RO sent the Veteran a letter, dated in January 2009, for compliance with the holding in Vazquez-Flores, Id. All potential disability ratings under the General Rating Formula for the evaluation of psychiatric disabilities were listed. As for content of the VCAA notice, the documents substantially comply with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence), of Charles v. Principi, 16 Vet. App. 370 (2002) (identifying the document that satisfies VCAA notice); and, of Pelegrini, supra (38 C.F.R. § 3.159 notice); of Dingess v. Nicholson, 19 Vet. App. 473 (2006) (notice of the five elements of a service connection claim), aff'd Hartman v. Nicholson, 483 F.3d 1311, 2007 WL 1016989 (C.A. Fed. 2007); and of Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), affm'd in part by Vazquez- Flores v. Shineki, 580 F.3d 1270 (Fed.Cir. 2009). Duty to Assist As required by 38 U.S.C.A. § 5103A, VA has made reasonable efforts to identify and obtain relevant records in support of the claims. The Veteran and a friend testified at a travel Board hearing before the undersigned in June 2006. A transcript of that hearing is on file. The RO has obtained the Veteran's service treatment records and VA treatment records. Also, records of the Veteran's award of disability benefits by the Social Security Administration are on file. The Veteran was afforded VA examinations for the claim for increase. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). And all this was in substantial compliance with the Board remands. Substantial, rather than absolute or strict, remand compliance is the appropriate standard for determining remand compliance under Stegall v. West, 11 Vet. App. 268 (1998)). Chest v. Peake, No. 2007-7303, slip op (July 21, 2008 Fed. Cir.); 2008 WL 2796362 (Fed.Cir.); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (citing Dyment v. West, 13 Vet. App. 141, 146-47 (1999)). As there is no indication that the Veteran was unaware of what was needed for claim substantiation nor any indication of the existence of additional evidence for claim substantiation, the Board concludes that there has been full VCAA compliance. Background The Veteran's other service-connected disabilities are a hearing loss of the left ear, rated 10 percent disabling; tinnitus, rated 10 percent disabling; residuals of a through and through gunshot wound of the left side of the head manifested by dizziness and expressive aphasia, by history, rated 10 percent disabling; and a noncompensable rating is assigned for residual scars of the left side of the head. In pertinent part, the Veteran has had a combined 50 percent disability rating since July 10, 2001, and an 80 percent combined disability rating since September 26, 2007. On VA psychiatric rating examination in November 2004 it was noted that the Veteran was service-connected for a depressive disorder and not for PTSD. So, diagnostic clarification was requested. Past diagnoses on VA psychiatric examination in May 2002 of a depressive disorder, not otherwise specified; a generalized anxiety disorder; and specific phobia, situational type (enclosed spaces) were noted, as was a Global Assessment of Functioning (GAF) score of 65. It was noted that he had not met the criteria under Criterion C for PTSD because he did not report enough of the required avoidant behaviors or symptoms. It was noted that there had been no interval change in the Veteran's living situation. He continued to work as a custodian for a public school. His work attendance was excellent but he continued to limit, as much as possible, contact with others in the performance of his job duties. On game nights at school, job demands and resultant stressors were notable increased. He remained abstinent of alcohol and of all non-prescribed drugs. He was followed by his private physician, who prescribed Celexa, twice daily. He was not followed in individual or group psychotherapy. He reported that he carved pictures on antlers, which he then sold, as a way of relaxing. Since his last VA psychiatric examination he had not been hospitalized for psychiatric treatment, although he had noted increased job pressures, more dysphoric days, and greater irritability. On mental status examination the Veteran was alert, fully oriented, and cooperative. His speech was fluent and goaled directed as well as normal in rate, flow, and intensity. Content of his verbalization revealed logical thought processes, intact critical judgment, fair insight, and unimpaired memory. He denied auditory and visual hallucinations. He was not delusional and had no thought disorder. His mood was at once apprehensive and dysphoric, and there was little variation of his affective responsiveness over the course of the interview. He complained of persistent suicidal and homicidal thoughts but denied any present plan or intent. Because November was an anniversary month and was the month of Veteran's Day, he had frequently been weepy. Irritability remained a major complaint, but he attempted to avoid any situation which seemed provocative. The Veteran had a chronic sleep pattern disturbance, with difficulty falling asleep and an inability to remain asleep. On a good night, he got 5 hours of sleep but on a bad night only 2 hours was more likely. He complained of nightmares of combat occurring 4 times weekly but he had daily intrusive thoughts of Vietnam. He reported that his wife and son were supportive and understanding. However, he felt estranged from all others. He was concerned about his finances and particularly about the future of his job in the current environment of school budget short-falls and cut-backs. Nonetheless, he strived to meet job requirements, to minimize confrontation, and to avoid conversations of Vietnam. He was competent. The diagnoses were chronic combat-related PTSD; depressive disorder, not otherwise specified; and specific phobia, situational type (enclosed spaces). His GAF score was 58. It was noted that he continued to exhibit symptoms consistent with a depressive disorder, not otherwise specified, as well as a phobia of enclosed spaces as articulated in the prior VA psychiatric examination report. Because he had avoidance of conversations about Vietnam, in particular outside of a therapy setting, feelings of estrangement from all but his wife and son, and a chronic sense of a foreshortened future, he satisfied the requirements of Criterion C for PTSD. His GAF score of 58 indicated a moderate degree of symptoms, most particularly irritability and outbursts of anger, sleep pattern disturbance, nightmares, and depressed mood. These symptoms significantly and negatively affected his social interactions and had at least a moderate impact in industrial functioning. VA outpatient treatment records in 2004 and 2005 show that X- rays in November 2004 revealed mild degenerative changes of both acromioclavicular joints. He also received outpatient treatment for PTSD. At the Travel Board hearing on June 12, 2006, the Veteran testified as to his inservice combat gunshot wound in Vietnam. Page 4. He received VA treatment for PTSD. He had panic attacks twice weekly. He had lost his job because another company had been hired to take over the custodial work at the high school where he had worked. This created a financial burden, stress, and increased his anxiety. Page 5. He had suicidal thoughts about twice monthly. Medication seemed to help. As to obsessional ritual, he sometimes went for a walk in the woods with his gun and did not know if he was going to come back. He kept his gun under his bed. Page 6. His wife was very supportive. She helped remind him to take his medications if he had a memory lapse. She became irritated if he forgot to do things or if he kept asking her about things that he was suppose to remember that she had told him to do. Page 7. A friend of the Veteran's testified that he had known the Veteran for about 16 years. The Veteran was hyperalert. He had a lot of mood swings and he sometimes became excitable. Page 8. The Veteran testified that he had no relationship with his family and had difficulty communicating his problems with his family. He had lost his employment as a school custodian when the school system decided to contract that work out to private contractors. He had been employed by the school system for about 8 years. Page 9. He had lost his job on June 30, 2005. He had been unable to find employment since then. He had been rejected for one job because of his impaired hearing. Page 10. However, potential employers had not mentioned his PTSD. One of the jobs for which he had applied had been in a hardware store. Page 11. Another was manual labor in construction but he was not trained for any skill labor, e.g., carpentry, electrician or sheet metal work. He had not been hired as an art teacher because he had no degree in art. Page 12. Once in a while he got paid for teaching art through an art foundation but the art teach with whom he had been associated had retired last year and no new work had come through. Page 13. The Veteran testified that he had been married for 15 years to the same woman. He had no contact with family, except for his wife and teenage son. He got along fine with his wife and son. Page 14. His estrangement from other family members was due to his PTSD. Page 15. The Veteran's friend testified that the Veteran had a lot of nightmares. Page 16. VA outpatient treatment records show that in May 2007 type II, diabetes mellitus was diagnosed. In an August 2007 letter a VA clinical psychologist reported that the Veteran was being treated for PTSD. His symptoms included a depressed mood, social isolation, sleep disturbance, increased anxiety, flashbacks, nightmares and intrusive thoughts of combat, irritability, emotional numbing. His typical features of PTSD included lack of motivation and energy as well as guilt and shame. He was being seen in individual psychotherapy, as well as medication management and education. His PTSD had had a significant impact on his life, interpersonally, socially, emotionally, and occupationally. His PTSD problems were chronic and refractory to change. On VA psychiatric examination on September 26, 2007, the Veteran's claim file was reviewed. It was noted that the Veteran received VA outpatient treatment care since 2004 for PTSD but had not been hospitalized for a psychiatric disorder. He took medication and received individual therapy, and he reported that both of these helped him. Prior to his current marriage, he had been married from 1978 to 1989, which had ended because of his unstable mood and problems with his temper. He had few friends and did not like to socialize much. He watched TV but avoided war stories. He liked to hunt and fish but not as often as he use to because of his agrophobia due to PTSD from his Vietnam experiences. He had no history of suicide attempts and no history of violence or assaultiveness. On mental status examination the Veteran was clean and neatly groomed. His psychomotor activity was unremarkable. His speech was unremarkable and spontaneous. He was spontaneous, friendly, and relaxed. His affect was constricted and his mood was depressed. He was able to perform serial 7's and could spell the word "world" forwards and backwards. He was oriented. His thought processes were unremarkable. He had no delusions. As to his judgment, he understood the outcome of behavior. He had insight. He had no hallucinations. He had no inappropriate behavior. He interpreted proverbs appropriately. He had obsessive or ritualistic behavior in that he preferred to be alone. He had panic attacks when in crowds and, as a result, he avoided crowds. He had suicidal and homicidal thoughts but no plans or intent. He had good impulse control and had not had episodes of violence. He was able to maintain minimum personal hygiene and had no problems with the activities of daily living. His immediate and remote memory were normal but he had mild impairment of recent memory, in that he was more forgetful and had headaches, which he felt were from having been shot in the head as well as from stress and anxiety. The Veteran reported that his symptoms of PTSD were chronic and present constantly. He preferred to be alone. His anxiety attacks were worse when he was in a crowd. He had emotional numbing, sleep disturbance, and flashbacks. He had social dysfunction as to others, mood changes, and difficulty dealing with stress. He was not currently employed. He had retired in 2005. However, it was also reported that he had been laid off in 2005 and had not been able to find work in a variety of occupations because of his PTSD and physical problems. The diagnoses were PTSD and alcohol depended in remission. His GAF score over the past year was 42. It was reported that his PTSD affected the quality of his life, limited his social life, and affected his health. It was commented that he was not able to work because of loss of job skills, ongoing physical problems, hearing problems, and PTSD. He had social issues and difficulty getting along with others. Even when he had been able to work, he was only able to do night-time custodial work. Records from the Social Security Administration include voluminous VA outpatient treatment records. They also include a Work History Report which reflects that he had work experience in factory maintenance. An Adult Functional Report shows that he had experience as a certified welder but had difficulty using his left arm and could no longer manage his money. In a Field Office Disability Report the Veteran reported that the illnesses that limited his ability to work were PTSD, hearing loss in the left ear, tendonitis, facial nerve damage, and a refractive error in his right eye. He had become unable to work on July 1, 2005. A report of a psychiatric evaluation indicated that he had mild restriction of the activities of daily living. He had mild difficulty in maintaining social functioning and had moderate difficulty maintaining concentration but had no episodes of decompensation. Rating Principles Service-connected disorders are rated by comparing signs and symptoms with criteria in separate diagnostic codes which identify various disabilities listed in VA's Schedule for Rating Disabilities, based on average impairment in earning capacity. 38 U.S.C.A. § 1155. Disabilities are viewed historically and examination reports are interpreted in light of the history, reconciling the report into a consistent picture to accurately reflect the elements of disability present. 38 C.F.R. §§ 4.1, 4.2. A higher rating is assigned if a disorder more nearly approximates the criteria therefore but not all disorders will show all the findings specified for a particular disability rating, especially with the more fully described grades of disabilities but coordination of ratings with functional impairment is required. 38 C.F.R. §§ 4.7, 4.21. Separate ratings may be assigned either initially or during any appeal for an increased rating for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119 (1999) (initial staged ratings) and Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007) (staged ratings during the appeal of any increased rating claim). Under 38 C.F.R. § 4.126 (a) and (b) consideration is given to the frequency, severity, and duration of psychiatric symptoms as well as the length and capacity for adjustment during periods of remission. While consideration is given to the extent of social impairment, a psychiatric rating will not be assigned solely on the basis of social impairment. Under 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders PTSD warrants a 50 percent disability evaluation if it is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships). A 70 percent rating contemplates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating contemplates 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. Analysis The Veteran's claim for an increased rating was received in September 2004 and, so, the time period which is relevant for adjudicating this increased rating claim is from September 2003, one year before the claim was filed, until the present. See generally Hart, 21 Vet. App. 505. The Global Assessment of Functioning Scale (GAF) "is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994)." Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF Score of 71 to 80 indicates that if symptoms are present they are transient and expectable reactions to psychosocial stressors, e.g., difficulty concentrating after a family argument; with no more than slight impairment in social, occupational or school functioning, e.g., temporarily falling behind in school work. A GAF score of 61 to 70 indicates that the examinee has 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 generally functions pretty well with some meaningful interpersonal relationships. Fifty-one (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 co-workers). Forty-one (41) to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job). See Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score of 31 to 40 indicates that the examinee has 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 person avoid friends, neglects family, and is unable to work). Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM- IV). PTSD evaluated as 30 percent disabling through September 25, 2007 The Veteran has not worked since 2005 but his testimony shows that he did not lose his job due to PTSD but due to a budget cutback. He has not genuinely endorsed suicidal or homicidal ideation, impaired speech, memory impairment, impairment in judgment or insight. He had irritability, sleep disturbance, nightmares and intrusive thoughts of Vietnam. But he was fully oriented and had no impairment of speech, orientation, insight, judgment or memory and had no thought disorder, delusions or hallucinations which would warrant a rating in excess of 30 percent. Although he testified at the Travel Board hearing that he had obsessional rituals, this consisted of no more than attempting to be alone and as such it did not interfere with routine activities. The Veteran's difficulties establishing effective work and social relationships is encompassed in the 30 percent rating and, overall, he did not display the signs, symptoms or manifestations of psychiatric disability which, prior to the September 26, 2007, VA psychiatric examination, warranted a rating in excess of 30 percent. This is corroborated by the GAF score of 58 on VA examination in November 2004 which was indicative of only moderate difficulty in social and occupational functioning. Accordingly, the Board concludes that the schedular rating criteria for a rating in excess of 30 percent prior to September 26, 2007, have not been met. PTSD evaluated as 70 percent disabling beginning September 26, 2007 Since the September 26, 2007, VA psychiatric rating examination the Veteran has not manifested the signs or symptoms which would warrant a 100 percent schedular rating for PTSD. That is, he has not had 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. Moreover, his GAF score of 42 indicates no more than serious, or severe, impairment in social and occupational functioning and not the total occupational and social impairment which is contemplated in a 100 percent schedular rating. Accordingly, the Board concludes that the schedular rating criteria for a rating in excess of 100 percent since September 26, 2007, have not been met. Other Considerations With respect to a TDIU rating within the context of the increased rating claim for PTSD, the Board observes that in the September 2009 Supplemental Statement of the Case, the RO notes that "[t]he evidence does not show that [the Veteran was] found too disabled to work." In fact, at his July 2006 personal hearing, the Veteran testified that he had lost his school custodian position when the school system decided to contract that work with a private contractor; and that he was rejected for one job due his impaired hearing, and for other jobs because he did not possess the qualifications for those positions. Similarly, the records obtained from the Social Security Administration show the Veteran reported that his ability to work was limited by PTSD, left ear hearing loss, tendonitis, facial nerve damage, and right eye refractive error. Clearly, by the Veteran's own admissions, it is the combined effect of his former employer's decision to out source its operations and both his service-connected and nonservice-connected conditions, rather than the service- connected PTSD alone, that have a significant impact on his ability to work and have rendered him unemployed. For these reasons, the Board determines that the RO properly considered-and declined to apply-38 C.F.R. § 4.16 as part of the discrete claim for increased compensation for the underlying PTSD. Cf. Rice v. Shinseki, No. 06-1445 (U.S. Vet. App. May 6, 2009 (per curiam). Accordingly, to the extent the issue of a TDIU rating has been reasonably raised by the record based on two or more service-connected disabilities, with at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more, such matter has been referred to the RO for appropriate action. Extraschedular consideration under 38 C.F.R. § 3.321(b)(1) is addressed when either raised by the claimant or the evidence, and requires a three-step analysis. First, is whether the schedular criteria are adequate and, if they are, no extraschedular referral is required. Second, if inadequate, determine whether there is an exceptional disability picture considering such related factors as marked interference with employment (but not marked interference obtaining or retaining employment) or frequent periods of hospitalization. Third, if the rating criteria are inadequate and the related factors are present, the case must be referred for a determination of whether an extraschedular rating should be assigned. Thun v. Peak, 111, 115-16 (2008) (citing VA Gen. Coun. Prec. 6-1996, para. 7, and Fisher v. Principi, 4 Vet. App. 57, 60 (1993)) aff'd Thun v. Peake, 572 F.3d 1366 (Fed.Cir. 2009). Here, the schedular rating criteria are comprehensive and contemplate the full range impairment due to the Veteran's PTSD. There is no evidence of frequent periods of hospitalization for PTSD, and there is also no evidence of marked interference with employment. Thus, the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate. So, the criteria for submission for consideration of an extra-schedular rating are not met. Thun, Id. For the reasons expressed, the preponderance of the evidence is against the claim and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). ORDER A rating for PTSD in excess of 30 percent prior to September 25, 2007, and to a rating in excess of 70 percent since September 26, 2007, is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs