Citation Nr: 1116482 Decision Date: 04/27/11 Archive Date: 05/05/11 DOCKET NO. 07-38 198 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to rating in excess of 30 percent for posttraumatic stress disorder (PTSD) for the period prior to December 7, 2009, and a rating in excess of 70 percent for the period thereafter. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and his wife ATTORNEY FOR THE BOARD C. Fields, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1967 to September 1973. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Historically, the Veteran applied for an increased rating for his service-connected PTSD in March 2006. In a September 2006 rating decision, the RO increased the rating from 10 percent to 30 percent. The Veteran disputed the 30 percent rating, leading to this appeal. In a January 2010 rating decision, the RO granted a rating of 70 percent for PTSD, effective December 7, 2009. However, as this was not a full grant of the benefit sought on appeal, and the Veteran has not expressed satisfaction with this determination, his appeal proceeds from the initial unfavorable rating decision. See AB v. Brown, 6 Vet. App. 35, 39 (1993). This matter has been before the Board on two prior occasions. The Veteran and his wife testified before a Veterans Law Judge (VLJ) sitting at the RO in January 2009. In May 2009, that VLJ remanded the case to the agency of original jurisdiction (AOJ) for additional development. Thereafter, the VLJ who conducted the prior hearing and issued the May 2009 remand retired. As the Veteran requested another Board hearing, the case was again remanded for that purpose in January 2010. In February 2011, the Veteran and his wife testified before the undersigned VLJ at the RO. A transcript of each hearing is associated with the claims file. As discussed below, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the remand instructions and, therefore, a further remand is not required under Stegall v. West, 11 Vet. App. 268 (1998). See D'Aries v. Peake, 22 Vet. App. 97, 106 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACT 1. For the period prior to December 7, 2009, the Veteran's PTSD required continuous medication and manifested by symptoms including chronic sleep impairment with frequent nightmares, occasional flashbacks, occasional depressed mood and anhedonia, occasional constricted affect but no flat affect, anxiety with irritability and anger management problems, hypervigilance, exaggerated startle response, avoidance, occasional mild memory impairment, and some social isolation; without significant difficulties in either relationships or recreational and leisure pursuits, panic attacks more than once a week, violence, assaultiveness, suicidal or homicidal thoughts, grossly inappropriate behavior, impairment of thought process or communication, impaired judgment or reasoning, disorientation, hallucinations, delusions, obsessive or ritualistic behavior that interfered with routine activities, or neglect of personal hygiene and other activities of daily living; representing mild or moderate 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 normal conversation), approximating no more than a 30 percent rating. 2. For the period beginning December 7, 2009, the Veteran's PTSD has resulted in occupational and social impairment with deficiencies in most, but not all, areas due to symptoms including chronic sleep impairment with frequent nightmares and flashbacks, irritability, anger, significant isolation and difficulties in relationships, and occasional thoughts of suicide; without evidence of gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, inability to perform activities of daily living including maintenance of minimal personal hygiene, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name; approximating no more than a 70 percent rating. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for PTSD for the period prior to December 7, 2009, and a rating in excess of 70 percent for the period thereafter, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations require VA to provide claimants with notice and assistance in substantiating a claim. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper VCAA notice must inform the claimant of any information and evidence not in the record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186 (2002). These notice requirements apply to all elements of a claim, including the degree and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Proper VCAA notice must be provided prior to the initial unfavorable decision on the claim. Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). The Board notes that the U.S. Court of Appeals for Veterans Claims (Veterans Court) has held that, in order to comply with 38 U.S.C.A. § 5103(a), certain specific notice requirements must be met for increased rating claims. See Vazquez-Flores v. Peake, 22 Vet. App. 37, 43 (2008). However, the U.S. Court of Appeals for the Federal Circuit subsequently held that only "generic notice," and not "veteran-specific" notice is required under 38 U.S.C.A. § 5103(a) in response to the "particular type of claim." See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Further, the decision of the Veterans Court was vacated insofar as it requires VA to notify a veteran of alternative diagnostic codes or potential "daily life" evidence. Id.; see also Elliott v. Shinseki, No. 07-2622, 2009 WL 3489035, *3 (Vet. App. Oct. 30, 2009) (memorandum decision) (holding that the failure to inform the claimant of specific criteria in diagnostic codes or of potential "daily life" evidence was not a notice defect and, instead, determining whether sufficient "generic notice" was provided). In this case, the Veteran was advised in May 2006, prior to the initial unfavorable rating decision, of the evidence and information necessary to substantiate his claim, and the responsibilities of the Veteran and VA in obtaining such evidence. He was specifically advised that the evidence must show that his PTSD has increased in severity, examples of types of lay or medical evidence that would substantiate such claim, and that he should provide any VA or private treatment records or provide sufficient information to allow VA to obtain such records. Thereafter, in May 2008 and December 2008, the Veteran was advised of the evidence and information necessary to establish a disability rating and an effective date, in accordance with Dingess/Hartman. The timing defect as to this latter notice was cured by the subsequent readjudication of the claim, including in a January 2010 supplemental statement of the case. See Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370, 376-77 (2006). Accordingly, VA has satisfied its duty to notify in accordance with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159, as well as Vazquez-Flores v. Shinseki, as any notice defects did not affect the essential fairness of the adjudication of the Veteran's claim. The Board notes that the undersigned VLJ did not explain the bases of the prior determination concerning the rating for PTSD, or suggest the submission of evidence that may have been overlooked, during the February 2011 Travel Board hearing. See Bryant v. Shinseki, 23 Vet. App. 488 (2010) (discussing the requirements of 38 C.F.R. 3.103(c)(2)). However, the VLJ asked specific questions in an attempt to obtain evidence to establish the severity of the Veteran's current symptoms and substantiate this claim, and the Veteran discussed his symptoms in detail. Moreover, neither the Veteran nor his representative has argued that VA failed to comply with 38 C.F.R. 3.103(c)(2), or identified any prejudice as a result of the Board hearing. Rather, the hearing focused on the elements necessary to substantiate the claim, and the Veteran and his representative demonstrated actual knowledge of such elements via questioning and testimony. As such, VA has substantially complied with the duties set forth in 38 C.F.R. 3.103(c)(2), consistent with Bryant, and no prejudice resulted from any defects. With regard to the duty to assist, service treatment records and post-service treatment records, as well as records from the Social Security Administration (SSA) have been obtained and considered. As directed in the May 2009 remand, outstanding VA treatment records dated from 2004 forward were obtained and associated with the claims file. Additionally, the Veteran was afforded a VA examinations pertaining to his PTSD in September 2006, January 2008, and December 2009, in compliance with the prior remand instructions. While the Veteran has argued that the January 2008 VA examination was inadequate, he was afforded a new VA examination in December 2009. Neither the Veteran nor his representative has alleged any fault with the most recent VA examination. Furthermore, a review of the three examination reports reveals no inadequacies, as all rating criteria were addressed, including the Veteran's symptomatology and the degree of social and occupational impairment. The Board also notes that VA treatment records remain outstanding, as the most recent records in the claims file are dated in May 2010, and the Veteran continued to receive mental health treatment on a weekly basis through at least February 2011. However, he is not prejudiced by the absence of any such records. In this regard, the Veteran and his wife described essentially the same symptoms during the February 2011 hearing as reflected by the records currently associated with the claims file, to include at the most recent VA examination. As such, there is no indication that any outstanding treatment records would help substantiate his claim. For all of the above reasons, the Board finds that the AOJ substantially complied with the remand instructions. See D'Aries, 22 Vet. App. at 106. A further remand would serve no useful purpose, as it would unnecessarily impose additional burdens on VA with no benefit to the Veteran. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). VA has satisfied its duties to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceedings. As such, the Veteran will not be prejudiced by a decision on the merits of his claim. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board must also consider staged ratings, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Evaluation of a mental disorder requires consideration of the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. Evaluations will be assigned based on all evidence of record that bears on occupational and social impairment, rather than solely on an examiner's assessment of the level of disability at the moment of the examination. The extent of social impairment shall also be considered, but an evaluation may not be assigned based solely on the basis of social impairment. 38 C.F.R. § 4.126. Under 38 C.F.R. § 4.130, all service-connected mental health disabilities are rated pursuant to the General Rating Formula for Mental Disorders. The criteria for a 30 percent rating are: 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 normal conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). The criteria for a 50 percent rating are: 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. The criteria for a 70 percent rating are: 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 worklike setting); inability to establish and maintain effective relationships. The criteria for a 100 percent rating are: 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. The symptoms listed in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list but, rather, serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating for a mental disorder. In addition to the symptoms listed in the rating schedule, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The DSM-IV provides for a global assessment of functioning (GAF), a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the DSM-IV). In this case, the Veteran applied for an increased rating for PTSD in March 2006. As the evidence of record reflects symptoms that warrant different ratings during distinct time periods in the course of this appeal, staged ratings were assigned. See Hart, 21 Vet. App. at 509-10. Specifically, the RO awarded a 30 percent rating for the period prior to December 7, 2009, and a 70 percent rating for the period thereafter. For the period prior to December 7, 2009, the medical evidence of record reflects mild or moderate impairment in social and occupational functioning due to PTSD symptoms. Such symptoms were considered controlled and relatively stable with psychiatric medications during this period, with medication management sessions every 3-6 months and weekly group therapy. See, e.g., June 2005 SSA evaluation and July 2005 SSA psychological review summary; September 2006 and September 2008 VA examination reports; VA treatment records dated through December 2009. In particular, the Veteran had chronic sleep impairment with frequent nightmares of traumatic events during service, as well as occasional flashbacks. He also had occasional depressed mood and anhedonia, which he related to his medical problems and not being as physically able as before. There was occasional constricted affect, but no flat affect. The Veteran also had anxiety related to PTSD, with irritability and anger management problems, as well as hypervigilance and exaggerated startle response. He was prescribed anti-depressant and anti-anxiety medications, which he reported to have good effectiveness at the September 2008 VA examination, in that they improved his sleep and made him less irritable. The Veteran denied panic attacks at both the September 2006 and September 2008 VA examinations. He also denied a history of violence or assaultiveness, as well as suicidal or homicidal thoughts, and there was no evidence of inappropriate behavior during both of these examinations. Similarly, the Veteran consistently denied suicidal ideation for VA treatment purposes, including in an April 2009 group therapy session when discussing other veterans or acquaintances who had committed suicide. In addition, the Veteran had occasional mild memory impairment, such as forgetting directions, as well as mild to moderate difficulty concentrating. While there was evidence of mild memory impairment in June 2005 for SSA purposes, he was noted to have normal memory at both the September 2006 and September 2008 VA examinations. There was no indication of impairment of thought process or communication, as the Veteran had adequate speech, logical expression of thoughts and ideas, intact thought process, and no suspected cognitive limitations. He had good judgment and reasoning, and he was fully oriented to all spheres. The Veteran denied hallucinations or delusions, and there was no suggestion of psychotic process. There was no evidence of obsessive or ritualistic behavior that interfered with routine activities. Additionally, the Veteran interacted appropriately and was able to maintain minimal personal hygiene and other basic activities of daily living. While the Veteran had several prior marriages, he has been married to the same woman throughout the course of the appeal, or since early 2005, with a stable relationship. He reported a good relationship with this spouse and her children, which the Veteran's wife confirmed during a September 2006 VA examination. The Veteran has friends in group therapy, as well as a few friends outside of his family, including one close friend with medical problems as of September 2006, whom he assisted and continued to keep in contact with after the friend moved. Although there was some social isolation, the Veteran was noted to have good performance in family and social or interpersonal relationships, as well as in and recreational and leisure pursuits, during the September 2006 VA examination. Similarly, during the September 2008 VA examination, although the Veteran continued to avoid activities, people, and places related to the traumatic events during service, he endorsed activities and leisure pursuits including travel, nature, and television. The Veteran was assigned GAF scores ranging from 60 to 65 for the period prior to December 7, 2009, for mild to moderate symptoms of PTSD. A GAF score of 51 to 60 indicates the presence of moderate symptoms (e.g., flat affect, circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). 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, but generally functions pretty well with some meaningful interpersonal relationships. See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). These assigned GAF scores are consistent with reports by the Veteran and his wife during disability evaluations that his limitations were mainly due to physical disabilities, such as shortness of breath and hearing loss, and that he stopped working due to physical limitations. See, e.g., June 2005 evaluation for SSA purposes; September 2008 VA examination report. Indeed, the SSA granted disability benefits based on severe impairment from chronic obstructive pulmonary disease and peripheral neuropathy. Similarly, the September 2006 VA examiner assigned a GAF of 65 for PTSD and noted that the Veteran's psychiatric condition was likely to deteriorate over time with his health. While the Veteran began to report increased symptoms for treatment purposes in May 2009, including more frequent flashbacks and nightmares, depression, irritability, and difficulty controlling anger when provoked, these symptoms did not yet warrant a higher rating. Indeed, the Veteran was continued on his current medications and assigned a GAF of 63 at that time. The Board has considered the lay statements from the Veteran and his wife as to the severity of his symptoms throughout the appeal, including prior to December 7, 2009. In addition to the symptoms summarized above, the Veteran and his wife have asserted that he frequently wants to hurt himself or someone else, including suicidal thoughts, and he has panic attacks at least once a week. They have also asserted that the Veteran has been unable to maintain good social relationships for years, and he is very rude and obnoxious to strangers and has severe "road rage." They further state that he has significantly decreased memory, and he would not take his medications or tend to his personal hygiene or other activities of daily living without prompting. The Veteran and his wife have stated that he was afraid to report the true nature of his symptoms to his VA treating providers and examiners because he did not want to be hospitalized. See, e.g., April 2007 notice of disagreement, January 2009 and February 2011 hearing transcripts; June 2009 statement from Veteran; August 2009 and March 2010 statements from Veteran's wife. While the Veteran and his wife are competent to report observable manifestations of his PTSD, the Board finds their statements to this effect to be not credible because they are inconsistent with the medical evidence of record, as summarized above. The Veteran's statements for treatment purposes have higher probative value because he had a strong motive to tell the truth in order to receive proper care. Rucker v. Brown, 10 Vet. App. 67, 73 (1997). Further, the Veteran denied such additional symptoms, including but not limited to suicidal thoughts and panic attacks, during examinations for both VA and SSA compensation purposes. Similarly, the assertions that the Veteran was afraid to report his true symptoms to his providers are also not credible, as they are inconsistent with the fact that he did report more severe symptoms for treatment and compensation purposes starting in December 2009. Accordingly, for the foregoing reasons, the weight of the evidence reflects that the Veteran's overall disability picture for PTSD most nearly approximates a 30 percent rating for the period prior to December 7, 2009. See 38 C.F.R. § 4.7. The Veteran is currently assigned a 70 percent rating for PTSD for the period beginning December 7, 2009. To be entitled to a higher rating, or 100 percent, for this period, there must be evidence 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, or memory loss for names of close relatives, own occupation, or own name. While the Veteran began to report more severe symptoms of PTSD at the December 7, 2009 VA examination and during subsequent VA treatment sessions, the weight of the evidence of record does not demonstrate an overall disability picture that would support a 100 percent schedular rating. The Board notes that the December 2009 VA examiner opined that the Veteran has total occupational and social impairment due to PTSD because he reported being told to retire from his prior employment in 2004 due to interpersonal difficulties with coworkers. However, this is inconsistent with the reports by both the Veteran and his wife at all other evaluations during the course of the appeal that he retired due to physical limitations, as indicated above. As such, the Board assigns little weight to this aspect of the VA examiner's report. Rather, the Veteran continues to be married to his wife of several years, albeit with some marital difficulties, and he plays golf on Fridays with a former coworker. He continues to be irritable and easily angered, but he denied any homicidal ideation as well as any assaultiveness since 2004, and he was noted to have good impulse control with no episodes of violence. There is also no indication of grossly inappropriate behavior, although the Veteran can be rude to strangers. While he has reported occasional suicidal ideation, there is no plan or intent. As such, the evidence does not demonstrate that the Veteran presents a persistent danger to himself or others. Further, the Veteran continues to be fully oriented, with normal thought processes and communication, and he maintains normal hygiene and activities of daily living. While the Veteran reported daily visual and auditory flashbacks, he denied any delusions or hallucinations. He has reported hearing crickets or buzzing in his ears, but this appears to be related to his hearing disability, not to his PTSD. The Veteran has also reported forgetting to do tasks such as relaxation exercises, but there is no indication of memory loss for names of close relatives or his own name. See December 2009 VA examination report; VA treatment records dated through August 2010. The medical evidence of record concerning this period is generally consistent with the lay evidence from the Veteran and his wife. See, e.g., May 2010 statement from Veteran's wife; February 2011 Board hearing transcript. Consistent with described symptoms in the lay and medical evidence, the Veteran has been assigned GAF scores of 50 and 52 from December 7, 2009, forward, and the VA examiner and treating providers have indicated that he now manifests severe symptoms of PTSD. As noted above, a GAF score of 51 to 60 indicates the presence of moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates serious symptoms or a serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47. For the foregoing reasons, the Board finds that the Veteran is not entitled to a rating in excess of 70 percent for PTSD for the period beginning December 7, 2009. The Board notes that the Veteran's wife has reported that he would not maintain minimal hygiene without her help, which is contemplated by the higher rating. However, considering all evidence of record, the Veteran's overall disability picture does not meet the criteria for the next higher rating of 100 percent. See 38 C.F.R. § 4.7. The Board has considered all potentially applicable rating codes and finds no basis upon which to assign a higher rating for any period on appeal under any alternate diagnostic code. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Additionally, the Board has considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1). An extra-schedular rating is warranted if a case presents such an exceptional or unusual disability picture, with such related factors as marked interference with employment or frequent periods of hospitalization, that it would be impracticable to apply the schedular standards. Analysis under this provision involves a three-step inquiry, and extra-schedular referral is necessary only if analysis under the first two steps reveals that the rating schedule is inadequate to evaluate the claimant's disability picture and that such picture exhibits such related factors as marked interference with employment or frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). In this regard, the manifestations of the Veteran's PTSD, as summarized above, are fully contemplated by the schedular rating criteria. Therefore, the rating criteria reasonably describe his disability level and symptomatology, and the rating schedule is adequate to evaluate the disability picture. Moreover, there are no related factors such as marked interference with employment or frequent periods of hospitalization. The Veteran has denied any psychiatric hospitalization since the 1990s, and he retired in 2004. While PTSD affected his employment to some extent, including occasional arguments with coworkers, such interference is addressed by the rating schedule. The percentage ratings are considered adequate to compensate for considerable loss of working time from exacerbations proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Accordingly, it is not necessary to refer this case for consideration of an extra-schedular rating. See Thun, 22 Vet. App. at 115-16. In a September 2010 rating decision, the AOJ granted a total disability rating on the basis of individual unemployability due to service-connected disabilities (TDIU), effective December 7, 2009. This determination was based on the effects of the service-connected hearing loss and PTSD. There is no indication of record that the Veteran has requested appellate review of any aspect of that decision, to include the effective date. As such, no further discussion of a TDIU is necessary at this time. The preponderance of the evidence is against a rating in excess of 30 percent for PTSD for the period prior to December 7, 2009, and a rating in excess of 70 percent for the period thereafter. As such, the benefit of the doubt doctrine does not apply, and the Veteran's claim must be denied. 38 C.F.R. § 4.3. ORDER A rating in excess of 30 percent for PTSD for the period prior to December 7, 2009, and a rating in excess of 70 percent for the period thereafter, is denied. ____________________________________________ JOAQUIN AGUAYO-PERELES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs