Citation Nr: 1313544 Decision Date: 04/23/13 Archive Date: 05/03/13 DOCKET NO. 09-01 035 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. REPRESENTATION Veteran represented by: American Red Cross WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Megan C. Kral, Associate Counsel INTRODUCTION The Veteran had active duty service from December 1968 to July 1970. This matter came to the Board of Veterans' Appeals (Board) from a July 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was remanded in January 2011 for further development. A review of the record shows that the RO has complied with all remand instructions by taking appropriate action to obtain VA treatment records, providing a VA examination and issuing a supplemental statement of the case. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran testified at a hearing before the Board in October 2010. The Board acknowledges the judicial holding in Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In that decision, the United States Court of Appeals for Veterans Claims (Court) held that a request for a total rating based on individual unemployability (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate 'claim' for benefits, but rather, can be part of a claim for increased compensation. In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue whether a TDIU is warranted as a result of that disability. During the course of the appeal the Veteran was, and remains, employed as a house keeping aid at a VA hospital. As such, the Board does not find an indication in the record that reasonably raised a claim of entitlement to a TDIU. FINDING OF FACT The Veteran's PTSD results in occupational and social impairment with reduced reliability and productivity with symptoms that result in difficulty in establishing and maintaining effective work and social relationships, but is not generally characterized by deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as speech that is 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, and neglect of personal appearance and hygiene. CONCLUSION OF LAW The criteria for entitlement to a disability evaluation in excess of 50 percent for the Veteran's service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including §§ 4.7, 4.130 and Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Duty to Notify Upon receipt of a complete application, 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. 38 U.S.C.A. § 5103(a); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice requirements apply to all five elements of a service connection claim: (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/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, a timely letter sent in April 2008 provided the notice contemplated by Dingess. The Veteran was provided with notice of the types of evidence necessary to establish a disability rating and an effective date for any rating that may be granted, and this letter explained how VA determines disability ratings and effective dates. The RO provided the Veteran with additional notice in September 2008 which listed the criteria for a rating PTSD and was otherwise compliant with Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. 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). Duty to Assist VA has obtained pertinent treatment records, assisted the Veteran in obtaining evidence, afforded the Veteran VA examinations in May 2008 and October 2011, and afforded the Veteran the opportunity to give testimony before the Board in October 2010. All known and available treatment records relevant to the issue on appeal have been obtained and associated with the Veteran's claims file; and the Veteran and his representative have not contended otherwise. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. Legal Criteria The Board notes that is has reviewed all of the evidence in the Veteran's claims file, as well as in "Virtual VA" (VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000)(VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The present appeal involves the Veteran's claim that the severity of his service-connected PTSD warrants a higher disability rating. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Under the criteria for PTSD (set forth at 38 C.F.R. § 4.130, Diagnostic Code 9411), a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment, with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty 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 is assigned when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; 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 schedular rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relative, own occupation or own name. The Board notes here that the symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) scale reflects the psychological, social and occupational functioning under a hypothetical continuum of mental illness. See American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown , 8 Vet. App. 240, 243 (1995). According to the DSM-IV, a GAF score between 51 and 60 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers); a GAF between 61 and 70 is indicative of mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Factual Background Pertinent evidence of record includes VA medical center (VAMC) treatment records, the Veteran's testimony, and VA examinations. A VA psychiatric note from June 2007 noted the Veteran sought treatment for morning fatigue due to non-combat nightmares which awakened him in sweat and feeling fearful. The Veteran reported his mood was good and reported only minimal symptoms of PTSD, including minimal hyperarousal and minimal isolation. The treating physician noted the Veteran was calm and cooperated. His mood was euthymic and his affect was appropriate. The Veteran's thought process was logical and goal directed without psychotic symptoms. It was noted the Veteran's judgment was intact, his insight preserved, and his impulse control was good. There was no gross clinical indication of cognitive deficit. Homicidal thinking or violent thoughts towards others were absent. Suicidal thought and intent were absent. The physician provided the Veteran with sleep hygiene techniques and advised against evening naps and caffeinated tea in the evening. The Veteran was also prescribed Trazodone for occasional use. A psychiatric follow-up occurred in February 2008. At this time it was noted the Veteran was stable. It was noted the Veteran used the Trazodone sparingly with good result, but with some brief morning hangover. The Veteran reported working regularly, keeping active in his church, and generally keeping busy and active. The Veteran reported experiencing sleep difficulties in which he would awaken in cold sweats, and reported violent, but non-combat, nightmares most nights. The Veteran also reported he is awakened by urinary urgency as a result of his benign prostatic hyperplasia (BPH). The treating physician noted the Veteran was alert, fully oriented, cooperative, but figidity. His mood was euthymic and his affect was appropriate. His thought process was logical and goal directed without psychotic symptoms. Thought content was normal, except for re-experiencing. It was noted that his judgment was intact, insight was preserved and his impulse control was good. There was no gross clinical indication of cognitive deficit. Homicidal thinking or violent thoughts towards others were absent. Suicidal thought and intent were absent. Hyperarousal symptoms were moderate, and it was noted that he did not have much avoidance behavior. The examiner increased the Trazodone prescription and diagnosed the Veteran with PTSD, and a GAF score of 63. The medical record shows, the Veteran attended weekly PTSD outpatient group sessions. It was noted that during these sessions the Veteran's participation was mild to moderately interactive. The Veteran expressed continued personal benefit from participation in the group. The Veteran was afforded a VA examination in May 2008. The Veteran reported working at the VA hospital in housekeeping, and keeping hours Monday through Friday from 7 AM to 3:30 PM. He can drive, able to shop, and cares for his own apartment. It was noted that the Veteran can socialize well. The Veteran reported his symptoms of PTSD include having dreams, sometimes several times a night, which are violent, but not always related to the military. He did not report any additional symptoms of PTSD, did not describe flashbacks or difficulties of an interpersonal nature. No time was lost from work related to a mental disorder, and although there was a history of problemative alcohol and drug use it has been in remission since 2001. The VA examiner noted the Veteran was a pleasant appearing individual who spoke clearly, coherently, and logically. His affect was euthymic, and he did not appear to be anxious. He was not homicidal or suicidal. The examiner noted there was no obvious loosening of thought, mutism, autistic thinking or preoccupations. Hallucinations and delusions were not elicited. The Veteran's attention and concentration were intact. The examiner noted the Veteran could recall his social security number and recall items after delay. He was oriented to time, place, person, and situation. It was noted his behavior during the interview was completely appropriate. It was noted the Veteran could complete activities of daily living (driving, shopping, working, and caring for himself) completely independently. The examiner opined that the Veteran would be able to manage any VA benefits to which he might be entitled. He was diagnosed with PTSD, and his GAF score was 70. In May 2008, the Veteran submitted a statement which stated that he has problems sleeping, which were getting worse. He stated that he was having night sweats, nightmares, and trouble returning to sleep once awakened. He reported taking Trazodone to sleep, which makes him tired the next day. VAMC records indicate the Veteran keeps all medical and psychiatric appointments and takes his medicine daily. It was noted the Veteran monitors his hypertension and follows a diet. He pays all his bills on time, including rent, car payment and car insurance, and keeps a monthly budget. In June 2008, it was reported the Veteran keeps in touch with family regularly. In November 2008, it was noted that the Veteran had difficulty falling and staying asleep, with pronounced sweating at night, but was not aware of any nightmares. The Veteran reported having "drug dreams" often during this time, as it was around the anniversary of his date of sobriety, which caused a significant amount of stress for him. He reported working full time and attending Bible study and church. The Veteran's hygiene was good, his mood was noted as "it's coming along", affect was stable, speech was normal, and thought process was logical and goal directed. There were no reports of suicidal or homicidal ideations, no reported auditory or visual hallucinations or paranoia. The Veteran's judgment and insight were noted to be good. During a VAMC psychiatric follow-up appointment in January 2009, the Veteran reported finding his current job to be frustrating, feeling talked-down to and belittled by supervisors. The Veteran reported being proud of his job, but feels he is over-assigned and overly monitored. He remained active in Bible study. It was noted that the Veteran's hygiene was good, his mood was "so-so", his affect was stable, speech normal, and thought process was logical and goal directed. There were no reports of suicidal or homicidal ideations, no reported auditory or visual hallucinations or paranoia. The Veteran's judgment and insight were noted to be good. The Veteran testified before the undersigned in October 2010. The Veteran testified that he suffered from sleeplessness, night sweats, difficulty falling to sleep, and dreams. He testified that he averaged five to six hours of sleep, but experiences dreams one to three times a week. He reported his dreams are violent, but non-combat, and when they wake him, he struggles to get back to sleep. The Veteran testified that he continues to attend PTSD group sessions, although he expressed frustration that the sessions no longer are moderated by a commissioner. The Veteran testified that he continues to work, and did not report any missed time off from work, except to say he walks away from confrontation with his supervisors. He testified that his supervisors call him lazy, and he sometimes disagrees with the instructions given to him. He further testified that although he does have coworkers he prefers to work by himself. With regard to personal relationships, the Veteran testified he was divorced, and that while he tries to be in relationships, he finds relationships to be confrontational. He testified that he has two children who he speaks to once a year on his birthday, and three grandchildren he attempts to see once a year. The Veteran expressed that while his children were growing up he abused drugs for thirty-one years, and that this put a strain on his family. The Veteran testified a bad day for him is going to work and having a problem with his supervisors. He testified that while he never thought of hurting himself, he thought of hurting others, but explained this was why he walked away from confrontation. The Veteran also testified that on some days he will go without taking a bath or changing clothes. In December 2010, the Veteran underwent a Mental Health Evaluation. The Veteran reported PTSD symptoms including, insomnia, night sweats, nightmares, avoidance of people, friends described him as "grumpy", he tried to walk away from things that anger him, and mild depression. The Veteran denied any suicidal ideation. On examination, it was reported the Veteran's appearance was kept. His social interaction and affect were appropriate and congruent; his mood was fair. The Veteran's attention was focused; his judgment and insight were good. The Veteran denied hallucinations, rituals, phobias, clairvoyance, obsessive thoughts, fugue states, delusions, depersonalization, magical thoughts, déjà vu, derealizations, ideas of reference, bizarre ideations, superstitions, recurrent illusions, and compulsive behaviors. The Veteran was diagnosed with PTSD and his GAF score was 60. The Veteran's prescription for Trazodone was again increased to treat his insomnia and mild depression. A follow-up occurred in January 2011. The Veteran reported sleeping better. His continuing PTSD symptoms included insomnia; night sweats; nightmares; avoidance of people, socializing, and crowds. He reported attending NA meetings, PTSD aftercare group, and church. He also reported walking away from things that anger him, mild depression, and denied suicidal or homicidal ideation. No psychosis was elicited. The Veteran underwent a second VA examination in October 2011. The VA psychologist confirmed the Veteran's diagnosis of PTSD. No other diagnosis was provided. The Veteran's GAF score was listed as 68. The examiner reported the Veteran experienced a level of occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or; by symptoms controlled by medication. On examination, it was noted the Veteran lived alone and that he talked to his children once or twice a year, and talks to his sister regularly. No significant friendships were noted, but he has "off and on" romantic relationships. The Veteran continued to work daily from 7AM to 3:30 PM at the VA hospital as a house keeping aid. The Veteran noted that work is somewhat hectic because of his supervisors. He stated that he gets irritated by the younger supervisors, and that even though he's been there for seven years, he doesn't get the best ratings. There were no days missed from work other than planned appointments. He did report getting into a shouting match with a chief about a year prior because the chief was a pointing a finger and talking down to a Veteran. Outside of work, the Veteran reports mainly watching TV. The Veteran continues to use Trazodone for sleep, but reports that he has difficulty falling asleep and maintaining sleep due to "problems with his prostate". He reported night sweats when he doesn't take the medication, but that the medication makes him feel sluggish and it impacts his performance at work. He averages about six hours of sleep per night. He reported nightmares. The Veteran denied significant recurring thoughts about in-service stressors, and noted that he tries to keep those thoughts from his mind. He stated that he finds it helpful to talk about his experiences and continues to attend weekly group sessions. He reported that he does not like to be around the busiest part of the hospital, but his job allows him to be more isolated. He has no problem going to the grocery store when it's not crowded. The Veteran noted that when he is in a crowded area, he is able to speak to people and get through it without difficulty. The Veteran denied thoughts of hurting himself, and denied plans to kill himself or others. The examiner noted that there was no evidence of psychosis during the interview, and the Veteran appeared appropriate and attentive. He wore a mask due to a cold and was congested. His mood was good, affect congruent. The examiner found the Veteran re-experiences his stressor events through recurrent distressing dreams of the event. The examiner noted the Veteran takes effort to avoid activities, places or people that arouse recollections of the trauma, and maintains a feeling of detachment or estrangement from others. The examiner noted the Veteran's difficulty falling or staying asleep, and his irritability or outbursts of anger. As a result, the examiner opined the PTSD symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner concluded that overall the Veteran is functioning fairly well at work and maintaining self-care. The most prominent difficulties are chronic sleep impairment and irritability which impacts both work and personal relationships. This impairment is transient. Analysis For the reasons set forth below, the Board finds that the current 50 percent rating adequately reflects the current level of impairment. When considering the impact of the Veteran's symptoms on his overall level of occupational and social impairment, there were few deficiencies. During the course of the appeal, it was noted that the Veteran maintained full time employment as a house keeping aid with a VA hospital. At the last VA examination, it was noted the Veteran has held this position for seven years and has not missed work (other than scheduled absences) as a result of his PTSD. Although the Veteran testified that he struggles with his supervisors, as there is a confrontational nature between them, he has developed methods of dealing with them, including walking away from confrontation and working independently. There is no evidence of record that shows the Veteran cannot perform his job as a result of his PTSD. Most telling, at the hearing, the Veteran was asked to detail what a bad day consists of for him in dealing with his PTSD. The Veteran testified that a bad day consists of going to work and dealing with his supervisors. Even on a bad day, he is still able to go to work. Further evidence of the Veteran's functionality includes his reported GAF scores. In February 2008, his GAF score was 63; in May 2008, 70; in December 2010, 60; and most recently, in October 2011, his GAF score was 68. Only in 2010 was his GAF score indicative of moderate symptoms or moderate difficulty in social or occupational functioning. All additional scores, including the most recent score of 68, are indicative of mild symptoms or some difficulty in social or occupational functioning, but generally functioning pretty well. With regard to the Veteran's family and social relationships, he has two children which he speaks to once a year on his birthday. He admits though, as an alcoholic and drug abuser for thirty-one years, this put a strain on his family. As to relationships, the Veteran is divorced, and testified that he finds relationships difficult because they are confrontational. However, on examination, the Veteran indicated that he maintains "off and on" romantic relationships. The Veteran is also active in church, Bible study, and his PTSD group, in which he is interactive and reported receiving personal benefit from attending. Though he prefers to be independent and away from crowds, the Veteran noted during examination, that when he is in a crowded area, he is able to speak to people and get through it without difficulty. While the Veteran testified there are some days he goes without bathing or changing his clothes, over the course of the appeal, his appearance has continuously been noted as appropriate. There is no noted lack of hygiene in any of the medical evidence. Throughout the history of the appeal, the Veteran's judgment, thinking, and mood have been noted to be good. He is responsible to pay his own bills on time, including rent, car payment, and car insurance. He was noted to watch his diet and his hypertension. And he is able to drive, go grocery shopping, and maintain a full time work schedule. The main symptoms of the Veteran's PTSD are violent, but non-combat dreams, cold sweats, and interrupted sleep. However, his difficulty sleeping has been alleviated by medication, when the Veteran chooses to take the medication. Even with the dreams and cold sweats the Veteran testified he averages five to six hours of sleep per night. And although the Veteran testified his sleeplessness makes him tired and interferes with his daily activities, there is no evidence of this assertion in the record. Further, the Veteran has not been noted to have such symptoms as suicidal ideation; obsession rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; or difficulty in adapting to stressful circumstances (including work or a work like setting). The Board acknowledges the fact that the Veteran's PTSD results in some impairment. In making the above findings, the Board has considered all PTSD symptoms and the resulting impairment, not just symptoms set out in the diagnostic criteria as guidance as to the severity of symptoms contemplated by the ratings set out in the rating schedule. However, the Board finds that the rating now in place contemplates the demonstrated impairment resulting from his PTSD. The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In general, the schedular disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The application of such schedular criteria was discussed in great detail above. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the RO is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. Id. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. § 3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe a Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe a Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. If the RO or the Board finds that the schedular evaluation does not contemplate a Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether a Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, the symptoms described by the Veteran fit squarely within the criteria found in the relevant Diagnostic Codes for the disability at issue. In short, the rating criteria contemplate not only his symptoms but the severity of his disability. For these reasons, referral for extraschedular consideration is not warranted. In summary, for the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against the claim of entitlement to an increased disability rating for PTSD in this case. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Assignment of a staged rating is also not applicable. Fenderson, supra. ORDER Entitlement to a disability evaluation in excess of 50 percent for the Veteran's service-connected PTSD is not warranted. The appeal is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs