Citation Nr: 1313248 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 08-13 651 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an increased disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to August 31, 2011. 2. Entitlement to an increased disability rating in excess of 70 percent for PTSD from August 31, 2011. 3. Entitlement to an increased compensable disability rating for hemorrhoids with history of anal fissurectomy prior to November 8, 2012. 4. Entitlement to an increased disability rating in excess of 10 percent for hemorrhoids with history of anal fissurectomy from November 8, 2012. REPRESENTATION Appellant represented by: Alabama Department of Veterans Affairs ATTORNEY FOR THE BOARD A. Hinton, Counsel INTRODUCTION The Veteran served on active duty from January 1973 to December 1976, and from October 1977 to November 1997. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which denied increased ratings for PTSD and hemorrhoids with history of anal fissurectomy, in excess of 30 percent and zero percent, respectively. In a December 2012 rating decision, the RO increased the rating for PTSD to 70 percent, effective from August 31, 2011, and increased the rating for the hemorrhoids disability to 10 percent, effective from November 8, 2012. The Veteran continued his appeal for higher ratings. AB v. Brown, 6 Vet. App. 35, 38 (1993). FINDINGS OF FACT 1. The Veteran's PTSD prior to August 31, 2011 was productive of occupational and social impairment with reduced reliability and productivity; and was not productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, or an inability to establish and maintain effective relationships. 2. The Veteran's PTSD from August 31, 2011 is productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, or an inability to establish and maintain effective relationships; and is not productive of total occupational and social impairment. 3. The Veteran's hemorrhoids with history of anal fissurectomy prior to November 8, 2012, was productive of no impairment of sphincter control of the rectum and anus, without leakage, and no more than mild or moderate hemorrhoids; and was not productive of impairment of sphincter control with constant slight, or occasional moderate leakage, or external or internal hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrence. 4. The Veteran's hemorrhoids with history of anal fissurectomy from November 8, 2012, is productive of constant slight, or occasional moderate leakage; and is not productive of occasional involuntary bowel movements, necessitating wearing of pad, or external or internal hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 50 percent prior to August 31, 2011 for PTSD, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an evaluation in excess of 70 percent from August 31, 2011 for PTSD, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for a compensable evaluation prior to November 8, 2012 for hemorrhoids with history of anal fissurectomy, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 4. The criteria for an evaluation in excess of 10 percent from November 8, 2012 for hemorrhoids with history of anal fissurectomy, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). The Veterans Claims Assistance Act of 2000 (VCAA) On receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. A number of letters dated between October 2004 and October 2011 satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). These letters also notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was informed of the need to show the impact of disabilities on daily life and occupational functioning. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), rev'd in part sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The RO informed the Veteran of the specific criteria to substantiate his claim for an increased rating. The claim was subsequently readjudicated, most recently in a January 2013 supplemental statement of the case. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The Veteran's service treatment records and VA and private medical treatment records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159 (c) (2). A number of VA examinations of the Veteran's PTSD and hemorrhoid disability were conducted since November 2004. The Veteran has not argued, and the record does not reflect, that these examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Applicable Law for Evaluation of Disabilities Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002). Evaluations of a service-connected disability require review of the entire medical history regarding the disability. 38 C.F.R. §§ 4.1, 4.2. If there is a question that arises as to which evaluation to apply, the higher evaluation is for application if the disability more closely approximates the criteria for that rating; otherwise, the lower rating is for assignment. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25; see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). However, the evaluation of the same disability under various diagnoses is to be avoided. See 38 C.F.R. § 4.14; Fanning v. Brown, 4 Vet. App. 225 (1993). When a disability is not specifically listed in the Rating Schedule, it may be rated under a closely related injury in which the functions affected and the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran is competent to report complaints regarding symptoms capable of lay observation. 38 C.F.R. § 3.159(a)(2) (2012). However, these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002). PTSD Posttraumatic stress disorder has been rated at 50 percent prior to August 31, 2011, and 70 percent from August 31, 2011, under 38 C.F.R. § 4.130, the General Rating Formula for Mental Disorders, Diagnostic Code 9411. Under the General Rating Formula for Mental Disorders, Diagnostic Code 9411, 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130 , Diagnostic Code 9411. 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 work like setting); inability to establish and maintain effective relationships. Id. 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 of others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Ratings are assigned according to the manifestation of particular symptoms, but the use of the term "such as" in the General Rating Formula demonstrates that the symptoms after the phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436(2002). Accordingly, the evidence considered in determining the level of impairment from posttraumatic stress disorder under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411. Rather, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified with the diagnosis of posttraumatic stress disorder in DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM-IV at 32. A GAF score of 61 to 70 represents some mild symptoms, or some difficulty in social occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates that the examinee has 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). A GAF score of 41 to 50 indicates that the examinee has 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). Neither the number of symptoms, nor the type of symptoms, nor the GAF score controls in determining whether the criteria for the next higher rating have been met. It is the effect of the symptoms, rather than the presence of symptoms, pertaining to the criteria for the next higher rating, that is determinative. Rating in Excess of 50 Percent for the Period Prior to August 31, 2011 A November 2004 VA examination report shows that the Veteran reported he was on Paxil that had recently been increased. The Veteran reported problems with sleeping, hypervigilance, and exaggerated startle response. He hates large crowds and reported he had panic attacks. On examination he was casually dressed, alert and oriented times four. His mood was all right and his affect was congruent with his mood. His thought process was coherent. He had no suicidal or homicidal ideation, and his insight and judgment were adequate. The examiner assessed PTSD, and assigned a GAF score of 68. The examiner commented that the Veteran was working and was independent in his daily activities. In a May 2005 statement, a VA clinical psychologist certified that the Veteran was being treated in a VA PTSD treatment program for a diagnosis of PTSD with comorbid major depressive disorder. The psychologist commented that the PTSD and major depressive disorder were recurrent conditions, serious, and may eventually render the Veteran unable to continue in his current occupational capacity. The psychologist assigned a GAF score of 46. In a July 2006 statement, the VA clinical psychologist certified that the Veteran was being treated in a VA PTSD treatment program for a diagnosis of PTSD with comorbid major depressive disorder. The examiner commented that the PTSD and major depressive disorder were recurrent conditions, serious, and likely to render the Veteran unable to continue in his current occupational capacity. The psychologist assigned a GAF score of 47 (as of December 2005). A June 2008 VA examination report shows that the Veteran reported receiving treatment including medication and individual psychotherapy, with fair effectiveness. The Veteran reported complaints including feeling depressed, fluctuating appetite, and passive suicidal ideation. On examination, he was clean, neatly groomed, and appropriately dressed. Psychomotor activity and speech were unremarkable. Speech was clear and coherent. The Veteran was cooperative and relaxed, with appropriate affect. His mood was dysphoric, his attention intact, and he was oriented as to person, time, and place. His thought process and content were unremarkable. He had no delusions, his intelligence was average, he had judgment to understand the outcome of behavior, and he had insight to understand he had a problem. The Veteran reported that he had sleep impairment and was unable to remain asleep, resulting in daytime fatigue; no hallucinations, inappropriate behavior, or homicidal thoughts; and he had obsessive/ritualistic behavior, and suicidal thoughts. He had good impulse control. He had no problem with activities of daily living and was able to maintain minimum personal hygiene. Memory was normal. The examiner commented that the Veteran was employed full time for the last nine years. He reported some absenteeism due to migraines, amounting to three weeks in the last twelve months. The report contains an Axis I diagnosis of PTSD, moderate, depressive disorder not otherwise specified. The examiner commented that the PTSD was associated with symptoms of arousal, avoidance, and reexperiencing. His depressive disorder symptoms overlapped with the PTSD and these are difficult to differentiate. The examiner assigned a current GAF score of 58. The examiner opined that due to the PTSD signs and symptoms, there was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but with generally satisfactory functioning (routine behavior, self-care, and conversation normal). The examiner opined that the Veteran did not have more serious symptoms that are associated with higher evaluations under relevant diagnostic code criteria of Diagnostic Code 9411. In a statement dated at the time of the June 2008 VA examination report, a VA clinical social worker, assessed the Veteran with PTSD and occupational related distress, which were chronic and severe conditions with social and occupational impairment. She assessed a GAF score of 50 for the Veteran's PTSD. The clinical record prior to August 31, 2011 does not show evidence that the Veteran's PTSD is productive of the criteria listed under 38 C.F.R. § 4.130, Diagnostic Code 9411 for a 70 percent rating. During comprehensive VA examinations during this period the GAF scores were assessed as 68 in November 2004 and 58 in June 2008. A GAF score of 68 would only represent some mild symptoms, or some difficulty in social occupational, or school functioning, but generally functioning pretty well, and having some meaningful interpersonal relationships. A GAF score of 58 would represent 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). Such assessments do not comport with criteria for a rating in excess of 50 percent as they do not reflect occupational and social impairment, with deficiencies in most areas, or an inability to establish and maintain effective relationships or other manifestations of similar severity. There are VA treatment records and supportive statements from VA treatment providers that include GAF scores ranging from 46 to 68. A GAF score ranging from 41 to 50 would indicate 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). However, the most recent VA examination in June 2008 shows that the examiner opined only that the PTSD resulted in occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but with generally satisfactory functioning. The examiner opined that the Veteran did not have more serious symptoms. To the extent that the GAF scores noted in VA treatment records are not consistent with the VA examination reports, the Board assigns more probative value to the examination reports because of the qualifications of the examiners and the extensive detail contained in the examination reports which fully support the GAF scores assigned. None of the evidence shows that the Veteran's PTSD has resulted in occupational and social impairment, with deficiencies in most areas. Although the Veteran reported he has had some suicidal ideation, he has not demonstrated such symptoms as 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; spatial disorientation; or neglect of personal appearance and hygiene. Although he has had some difficulty in adapting to stressful circumstances at work, the evidence does not show an inability to establish and maintain effective relationships. The Veteran has continued in a long-term occupation with VA during the period prior to August 31, 2011. Based on the foregoing, a rating in excess of 50 percent for the period prior to August 31, 2011 is not warranted for the Veteran's PTSD. The preponderance of the evidence is against the grant of an increased rating; there is no doubt to be resolved; and an increased rating is not warranted prior to August 31, 2011. Rating in Excess of 70 Percent for the Period From August 31, 2011 An August 2011 VA examination report shows that the Veteran had recurrent and distressing recollections, and intense psychological distress at exposure to cues. He made efforts to avoid thoughts associated with the trauma and to avoid activities that arouse recollections. He had markedly diminished interest in activities, and feeling of detachment from others. He had difficulty falling or staying asleep; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and exaggerated startle response. The Veteran had symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty establishing and maintaining effective work and social relationships, and suicidal ideation. The Veteran also had moderately severe symptoms of depression. The examiner diagnosed chronic PTSD, and depressive disorder not otherwise specified. The examiner opined that it was not possible to differentiate what portion of impairment is caused by each disorder. The examiner opined that the depression appeared to be largely secondary to the PTSD. The examiner opined that the Veteran's occupational and social impairment due to PTSD was best summarized as: occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. The examiner found the impairment due to PTSD was not productive of total occupational and social impairment. The examiner opined that the Veteran did not appear to be unemployable due to his PTSD symptoms, but it appeared that his current employment was significantly exacerbating symptoms of PTSD, and the Veteran would have less impairments in functioning if he had a different job. The report noted that the Veteran was working and had worked for 13 years as a VA service officer. Based on the foregoing, the evidence for the period from August 31, 2011 does not show that the Veteran's PTSD results in a total occupational and social impairment. Notably, the Veteran is shown to be employed and the examiner's opinion is that the Veteran does not appear to be unemployable due to his PTSD symptoms. Further, though the Veteran has reported having had suicidal ideations, the evidence does not show that the Veteran's PTSD has demonstrated such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self of 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. See 38 C.F.R. § 4.130 , Diagnostic Code 9411. The preponderance of the evidence is against the grant of an increased rating; there is no doubt to be resolved; and an increased rating is not warranted for the period from August 31, 2011. Hemorrhoids with History of Anal Fissurectomy The Veteran's service-connected hemorrhoids with history of anal fissurectomy, is evaluated under criteria of the Rating Schedule for the digestive system at 38 C.F.R. § 4.114. The disability is evaluated as noncompensable prior to November 8, 2012; and as 10 percent disabling from that date, under the criteria of a hyphenated diagnostic code, 38 C.F.R. § 4.114, Diagnostic Code 7336-7332. This hyphenated diagnostic code indicates that the service-connected disability is considered to be hemorrhoids, external or internal (7336) associated with a residual condition of impairment of sphincter control of rectum and anus (7332). See 38 C.F.R. § 4.27 (2012). Diagnostic Code 7332 provides that assignment of a zero percent rating is warranted for impairment of sphincter control of the rectum and anus that is healed or slight, without leakage. A 10 percent rating is warranted for impairment of sphincter control of the rectum and anus with constant slight, or occasional moderate leakage. A 30 percent rating is warranted for occasional involuntary bowel movements, necessitating wearing of pad. A 60 percent rating is warranted for extensive leakage and fairly frequent involuntary bowel movements. A 100 percent rating is warranted for complete loss of sphincter control. 38 C.F.R. § 4.114, Diagnostic Code 7332 (2012). Diagnostic Code 7336 provides that assignment of zero percent rating is warranted for mild or moderate hemorrhoids, external or internal. A 10 percent rating is warranted for external or internal hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent rating is warranted for external or internal hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. 38 C.F.R. § 4.114, Diagnostic Code 7336 (2012). As for other provisions under the Rating Schedule, the Veteran's hemorrhoids with history of anal fissurectomy have never resulted in stricture of the rectum or anus or prolapse of the rectum and Diagnostic Codes 7333 and 7334 are not for application. Compensable Rating Prior to November 8, 2012 A November 2004 VA examination report shows that the Veteran reported that he had developed hemorrhoids and anal fissure in service and had surgery on three occasions in service, most recently in 1995 for pain and bleeding. He did fairly well until about a year ago when he had some bleeding and a colonoscopy was performed, showing normal anus and rectum. There were no hemorrhoids seen, and a 6 mm sessile polyp was removed 25 cm in the colon. He had had no bleeding since then. About six months ago he had some anal pain and itching but no bleeding. Examination showed external skin tags at two positions and the Veteran's sphincter was tender. There were scars palpable in the rectal canal from prior surgery. No hemorrhoids were visible or palpable. The examiner diagnosed: (1) anal pain, probably small fissures or proctitis from hemorrhoidal surgery residuals, but no hemorrhoids are present; and (2) history of small 6 mm sessile colon polyp removed for bleeding with no recurrence. A September 2007 VA examination report shows that the Veteran reported complaints of rectal pain and incontinence with onset in 1978. He reported he had a fissure that was surgically corrected in 2005, and in 2006 he began to experience bowel urgency and incontinence at least twice weekly. Then he began to have pain with bowel movements, and pain in the rectum with prolonged standing. The report noted a history of occasional rectal bleeding, and no rectal prolapse, anal infections or proctitis. The Veteran's current reported symptoms included anal itching, burning, and pain. There was no current diarrhea, difficulty passing stool, tenesmus, or swelling. There was a history of hemorrhoids, but no history of bleeding, recurrence, or thrombosis. The Veteran reported a history of fecal incontinence with moderate extent of leakage, with pads required; and occasional involuntary bowel movement. On examination, the examiner found no present hemorrhoid, anorectal fistula, anal or rectal stricture, sphincter impairment, or rectal prolapse. There was tenderness at all four quadrants. The report notes that the Veteran was currently employed fulltime for the past 10 years, and had lost one week of work in the last 12 months due to bowel incontinence. The examiner diagnosed "hemorrhoids-no disease present otherwise to cause incontinence." The examiner commented that rectal pain and incontinence were associated with the diagnosis, with significant effects on his usual occupation due to the impact of fecal incontinence, and pain. The examiner commented that there were varying effects of the problem on usual daily activities ranging from none, to moderate in the case of sports. The medical evidence prior to November 8, 2012 does not show that the Veteran's hemorrhoids with history of anal fissurectomy are productive of internal hemorrhoids that are large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences. At the November 2004 VA examination there were no hemorrhoids visible or palpable and the examiner diagnosed that there were no hemorrhoids present. At the September 2007 VA examination the examiner found no hemorrhoids were present. The medical evidence prior to November 8, 2012 also does not show that the Veteran's hemorrhoids with history of anal fissurectomy are productive of impairment of sphincter control of the rectum and anus with constant slight, or occasional moderate leakage. The examiner at the November 2004 examination made no such findings of any sphincter control impairment. At the September 2007 VA examination the examiner specifically found there was no anorectal fistula, anal or rectal structure, sphincter impairment, or rectal prolapse. There are no objective findings prior to November 8, 2012 of any leakage associated with impairment of sphincter control of the rectum and anus. The preponderance of the evidence is against the grant of a compensable disability rating; there is no doubt to be resolved; and an increased rating is not warranted prior to November 8, 2012. Rating in Excess of 10 Percent for the Period From November 8, 2012 A November 2012 VA examination report shows that the Veteran reported that he had blood on the toilet paper four or five times a month, that he has to push the hemorrhoids back inside; and that he has occasional incontinence, varying day to day. He reported he did not wear them on a regular basis; it is an urge incontinence. The symptoms included mild or moderate internal or external hemorrhoids. The report indicates that symptoms did not include large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences; or persistent bleeding; or secondary anemia; or with fissures. Symptoms included impairment of rectal sphincter control with leakage necessitating wearing of pad. Symptoms did not include constant slight leakage, occasional moderate leakage or involuntary bowel movements, or more severe impairment of sphincter control. The Veteran did not have rectal prolapse, rectal stricture, or anal/perianal fistula. The Veteran had skin tags only, and no external hemorrhoids. He did have moderate internal hemorrhoids felt on palpation, with no blood, redness, or pain on palpation. The Veteran did have pruritus ani, with persistent itching requiring topical creams. The Veteran had surgical scars that were not painful, unstable, or with a total area of greater than 39 square centimeters (six square inches). The examiner diagnosed internal or external hemorrhoids, and opined that there was no functional impact on the Veteran's ability to work. The evidence for the period from November 8, 2012 as reflected in the VA examination of that date, does not show that there are external or internal hemorrhoids with persistent bleeding and with secondary anemia, or with fissures. At that time the Veteran had skin tags only, no external hemorrhoids, and only moderate internal hemorrhoids with no blood on palpation. The evidence for the period from November 8, 2012 also does not show that the service-connected hemorrhoids with history of anal fissurectomy is productive of impairment of sphincter control of the rectum and anus with associated symptoms of occasional involuntary bowel movements, necessitating wearing of pad. At the November 2012 VA examination, the Veteran reported he had occasional incontinence and he did not wear a pad on a regular basis; he reported that this was an urge incontinence. The examiner made findings that the impairment of rectal sphincter control resulted in leakage necessitating wearing of pad. However, the examiner clearly indicated that the condition did not result in more severe symptoms, including that it was not productive of constant slight leakage, occasional moderate leakage, or occasional involuntary bowel movements. There are no objective findings for the period from November 8, 2012 of any conditions of external or internal hemorrhoids with persistent bleeding and with secondary anemia, or with fissures; or of occasional involuntary bowel movements, necessitating wearing of pad The preponderance of the evidence is against the grant of an increased rating; there is no doubt to be resolved; and an increased rating is not warranted from November 8, 2012. Conclusions An extraschedular rating may be provided where: (1) the schedular criteria are inadequate to describe the severity and symptoms of the claimant's disability; (2) the case presents other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating is in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Veteran has not described any unusual or exceptional features associated with his PTSD or hemorrhoids with history of anal fissurectomy. The rating criteria are adequate to evaluate the disabilities, and referral for consideration of extraschedular rating is not warranted. A claim for a total disability evaluation based on individual unemployability (TDIU) is part of an increased rating claim when such TDIU claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). As the Veteran is shown to be employed on a full time basis with VA, entitlement to a TDIU is not raised by the record and will not be further discussed. ORDER 1. Entitlement to an increased disability rating in excess of 50 percent for PTSD prior to August 31, 2011, is denied. 2. Entitlement to an increased disability rating in excess of 70 percent for PTSD from August 31, 2011, is denied. 3. Entitlement to an increased compensable disability rating for hemorrhoids with history of anal fissurectomy prior to November 8, 2012, is denied. 4. Entitlement to an increased disability rating in excess of 10 percent for hemorrhoids with history of anal fissurectomy from November 8, 2012, is denied. ____________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs