Citation Nr: 1326388 Decision Date: 08/19/13 Archive Date: 08/26/13 DOCKET NO. 08-39 621 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial disability rating in excess of 10 percent for service-connected posttraumatic stress disorder (PTSD) from July 31, 2006, 30 percent from November 19, 2009, and 70 percent from June 4, 2013. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and his brother ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from November 1963 to November 1966. This matter was previously before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified before the undersigned Veterans Law Judge by videoconference from the RO in January 2013. Regrettably, a transcript of the hearing could not be produced. The Board advised the Veteran in February 2013 and offered to schedule another hearing. In March 2013, the Veteran responded that he did not desire another hearing but requested that his appeal be considered based on the record by the undersigned VLJ who presided at the hearing. The case was remanded by the Board for additional development in May 2013, and pursuant to the completion of development requested therein, a June 2013 rating decision assigned an increased 30 percent rating for PTSD effective from November 19, 2009, and a 70 percent rating for PTSD effective from June 4, 2013. As the 30 and 70 percent ratings were not assigned effective from the date of the grant of service connection, there is for consideration entitlement to a rating in excess of 10 percent for PTSD from July 31, 2006, 30 percent from November 19, 2009, and 70 percent from June 4, 2013. AB v. Brown, 6 Vet. App. 35 (1993). The issue for consideration has been listed accordingly on the Title Page. As indicated in the May 2013 remand, in an August 2012 brief, the Veteran's representative raised the issue of service connection for hypertension. In the hearing, the Veteran also raised the issue of service connection for hypertension including as secondary to service-connected PTSD. The RO denied a previous claim for service connection for hypertension, to include as secondary to PTSD, in an April 2010 rating decision. Neither the paper nor the electronic records contain new and material evidence submitted within one year or writing from the Veteran or his representative expressing timely disagreement. Therefore, the issue is not on appeal. 38 C.F.R. §§ 3.156, 20.201 (2012). As the issue of whether new and material evidence had been received to reopen a claim for service connection for hypertension had not been adjudicated by the RO, the Board does not have jurisdiction over the issue, and the matter was referred by the Board in May 2013 for appropriate action. A June 2013 memorandum by the Appeals Management Center (AMC) discussing this matter, incorrectly indicating therein that he RO had not adjudicated the matter of entitlement to service connection for hypertension as secondary to PTSD, noted that neither the Board nor the AMC had jurisdiction over the issue and requested that all appropriate action be undertaken to assist the Veteran with this issue. The record does not reflect that any action has been undertaken by the RO with regard to the issue; thus, the matter of whether new and material evidence has been received to reopen a claim for service connection for hypertension to include as secondary to PTSD is again referred to the RO for appropriate action. FINDINGS OF FACT 1. The positive and negative evidence as to whether the Veteran's PTSD has been manifested by occupational and social impairment with deficiencies in most areas and an inability to establish and maintain effective relationships from the date of the grant of service connection of July 31, 2006, is in relative balance. 2. At no time since the grant of service connection has PTSD resulted in total occupational and social impairment. CONCLUSIONS OF LAW 1. With resolution of reasonable doubt in the Veteran's favor, the criteria for an initial 70 percent rating for PTSD have been met from July 31, 2006. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2012). 2. The criteria for a 100 percent rating for PTSD are not met at any time since the grant of service connection for this disability. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.3, 4.7, 4.126, 4.130, DC 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of 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, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). \ Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. 396 (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's increased rating claim arises from an appeal of the initial evaluation for this disability following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under the VCAA as to the issues adjudicated herein. Notwithstanding this fact, a May 2008 letter provided the Veteran with the notice required for increased rating claims set forth in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated on other grounds sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). VA's duty to assist the Veteran has also been satisfied in this case. 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(c)(1)-(3). Reports from the Social Security Administration (SSA), VA outpatient treatment reports documenting treatment for PTSD, and reports from VA psychiatric examinations, most recently from one conducted in June 2013, have been obtained. Taken together, the examinations that have been provided to the Veteran are adequate because they contain histories obtained from the Veteran and thorough clinical findings relevant to the applicable rating criteria for the psychiatric disability as issue. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) (2012) requires that any Veterans Law Judge who chairs a hearing fulfill two duties to comply with the VCAA. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant, 23 Vet. App. at 488. Here, during the January 2013 hearing, the undersigned Veterans Law Judge adequately explained the claim on appeal and suggested evidence that may support this claim. The Board accordingly concludes that the notice requirements under Bryant were effectively satisfied. To the extent any such notice may have been inadequate, this was effectively cured both by actual knowledge as evidenced by statements of record from the Veteran, and well as by the Board providing such explanation of the issue and suggesting submission of evidence in the subsequent remand the Board issued to develop this claim. As indicated, the appeal was remanded by the Board in May 2013, and that remand conferred upon the appellant the right to compliance with the instructions therein. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The instructions of this remand were to contact the Veteran and afford him the opportunity to submit additional evidence or argument to support his claim; obtain all records of VA mental health care since June 2008; obtain pertinent records from the SSA; and arrange for a VA psychiatric examination to determine the severity of his PTSD. The record revels that all these actions were completed; as such, the Board finds that there has been substantial compliance with its remand. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that there must be substantial compliance with the terms of a Court or Board remand). There is no indication in the record that additional evidence relevant to the issue decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. at 121-22. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 542-43 (2006), aff'd, Mayfield v. Nicholson, 499 F.3d 1317 (2007); see also Dingess/Hartman, 19 Vet. App. at 486. As such, the Board may proceed to adjudication of this appeal. II. Factual Background, Legal Criteria, and Analysis The Board notes that it has reviewed all of the evidence of record, to include in the Veteran's claims file and the Virtual VA file, with an emphasis on the evidence relevant to this appeal. (The Virtual VA file reflects VA outpatient treatment reports not physically of record dated through May 2013 that are documented to have been considered in the June 2013 supplemental statement of the case). Although there is 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 analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Additionally, if two evaluations are potentially applicable, the higher evaluation is assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. Compare Francisco v. Brown, 7 Vet. App. 55, 58 (1994) [where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern]. In Fenderson, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a Veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2007). The service connected PTSD has been rated under DC 9411, and the criteria for rating such psychiatric disability are set forth in the General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Under the General Rating Formula, 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. Id. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. The symptoms recited in the criteria in the rating schedule for evaluating 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, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the "American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders" (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). As indicated, the RO in a June 2013 rating decision assigned a 30 percent rating for PTSD effective from November 19, 2009, and a 70 percent rating for PTSD effective from June 4, 2013. The dates for these increases were assigned on the basis of clinical findings from VA psychiatric examinations conducted on November 19, 2009, and June 4, 2013. With regard to the 70 percent rating, the RO in its June 2013 supplemental statement of the case explained that this was awarded on the basis of the GAF score of 55 assigned by the VA examiner at the June 2013 VA examination as well as findings at this examination of the Veteran having difficulty in adapting to a worklike setting, suicidal ideation, disturbances of motivation and mood, chronic sleep impairment, and a depressed mood. With regard to the bases for the 70 percent rating said to have been demonstrated at the June 2013 VA examination, the record reflects that many of these indicia for such a rating were shown well prior to this examination. In this regard, depression and severe sleep disturbances due to memories of the Veteran's documented [he is in receipt of the Combat Infantry Badge] Vietnam combat service were shown as early as a report from VA psychiatric outpatient treatment on December 23, 2002. Moreover, reports from psychiatric outpatient treatment rendered on September 22, 2006 and October 4, 2006, reflect a GAF score of 55, severe sleep disturbances due to memories of the Vietnam combat service, and a depressed mood. With respect to suicidal ideation, passive suicidal ideation was referenced prior to the June 2013 VA examination as reflected on a report from VA outpatient psychiatric treatment on August 30, 2007. Finally, and with respect to overall severity of the Veteran's PTSD prior to the June 2013 VA examination, clinical evidence from as early as the reports form an October 2007 VA psychiatric examination indicated that the symptoms of PTSD were so severe as to require continuous medication. In addition to the fact that the bases cited for the 70 percent rating were, as highlighted above, shown prior to the June 2013 VA psychiatric examination, from review of statements made by the Veteran, it could be said that the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas and an inability to establish and maintain effective relationships from at least the time of the filing of his claim for service connection for PTSD, thereby warranting the assignment of a 70 percent rating from that time under the General Rating Formula for evaluating psychiatric disabilities. In this regard, the Veteran in his March 2008 notice of disagreement reported that he has suffered from symptoms of PTSD, to include impaired impulse control, "ever since I was discharged" and that his fiancée felt that he was a changed person when he turned from Vietnam. Moreover, in his December 2008 substantive appeal, the Veteran reported that he broke up with his fiancée after she felt that he was not the same person she knew prior to the war and had not had any serious relationships since; that he had a "checkered" work history; and that he was a "loner" who had difficulty "relating to people in general." Finally, at the June 2013 VA examination, the Veteran reported that he had not worked since 2005 when he left his position as a bartender because he started getting "nasty" with customers. He stated that the owners did not want him to leave this position but that he felt that it was time to quit this job due to his difficulty getting along with customers. The Veteran reported at the November 2009 VA examination that he tried working again as car carrier after he left his job as a bartender but that he was fired after two months because he had problems remembering his routes and was often late. Considering the pertinent evidence in light of the applicable criteria and affording the Veteran the benefit of the doubt, the Board finds that a 70 percent rating is warranted for PTSD from the date of the grant of service connection, July 31, 2006. In making this determination, although review of the clinical evidence from July 31 2006, does not reveal clinical evidence documenting the majority of the symptoms for a 70 percent rating listed in the General Rating Formula, the symptoms listed in the criteria are meant not as an exhaustive list of symptoms, but rather, as examples of the type and degree of the symptoms or effects that would justify a particular rating. See, e.g., Mauerhan. It is the impact of a Veteran's psychiatric symptoms on occupational and social functioning that is of primary importance, and from the clinical evidence, statements of the Veteran attesting to his problems with PTSD over the years due to his documented combat service, it cannot be said that the preponderance of the evidence is against a conclusion that the criteria for a 70 percent rating were met from July 31, 2006. Unless the preponderance of the evidence is against the Veteran's claim, it cannot be denied, and when a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, supra. As such, and without finding error in the assignment of the ratings for such disability by the RO and consistent with Mauerhan, the Board will exercise its discretion to find that the evidence is in relative equipoise and conclude that the criteria for an initial 70 percent rating for PTSD have been met from July 31, 2006, the effective date of the grant of service connection. Id. As for whether a 100 percent rating may be assigned, while the Veteran's psychiatric symptoms clearly reflect diminished social and occupational functioning, the overall disability picture demonstrated by the evidence is not consistent with total occupational or social impairment, as is required for the maximum, 100 percent disability rating. In this regard, the examiner who conducted the June 2013 VA psychiatric examination was provided the opportunity, in check list fashion, to indicate which specific rating criteria as listed under the General Rating Formula for evaluating psychiatric disability were met and did not indicate that any of the criteria for a 100 percent rating; that is, this examination included the specific assessment by the examiner that PTSD did not result in 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; disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. The examiner also specifically concluded that total occupational and social impairment was not demonstrated. Review of the reports from the other VA psychiatric examinations and VA outpatient treatment also do not reveal that the criteria for a 100 percent rating are shown to any significant degree, and the evidence of record otherwise weighs against a conclusion that the Veteran has symptoms of PTSD that more nearly approximate the criteria for a 100 percent rating. In this regard, while the Veteran has described difficulty in forming relationships with others, he nonetheless is shown to have been able to live with his brother (for the past three years as set forth on the reports from the June 2013 VA examination). He also reported at the June 2013 VA examination that he still has some close friends who live in Brooklyn and that he is close to his sister and brother. His brother motivates him to avoid negative thoughts according to reports contained in the Virtual VA file from VA outpatient psychiatric treatment on May 15, 2013. In determining that the criteria for a rating in excess of 70 percent for the Veteran's service-connected PTSD are not met, the Board again has considered the applicable rating criteria not as an exhaustive list of symptoms, but rather, as examples of the type and degree of the symptoms or effects that would justify a particular rating. The Board has not required the presence of a specified quantity of symptoms in the rating schedule to warrant the assigned rating for the psychiatric disability in question. See supra, Mauerhan. The Board further finds that none of the GAF scores assigned since the effective date of the award of service connection provide a basis for the maximum, 100 percent rating for PTSD. In this regard, the Board notes that lowest GAF score assigned was 48 as reflected on February 27, 2013, and March 5, 2013, VA outpatient reports contained in the Virtual VA file. According to DSM-IV, a GAF score of between 41 and 50 represents serious, but not total, impairment in social and occupational functioning. See Carpenter, 8 Vet. App. at 242-244. This GAF score of 48 appears to be most reflective of the symptoms and overall disability picture when the Veteran's PTSD has been at its maximum level of severity since the award of service connection. In short, based on the foregoing, the Board finds that since the July 31, 2006, affective date of the award of service connection for PTSD, the Veteran's psychiatric symptomatology has not most closely approximated the criteria for a 100 percent rating. As such, the criteria for the maximum, 100 percent rating have not been met, to include on the basis of a staged rating pursuant to Fenderson. In making its determinations in this case, the Board has carefully considered the Veteran's contentions with respect to the nature of his service-connected PTSD disability and notes that his lay testimony is competent to describe certain symptoms associated with this disability. The Veteran's history and symptom reports have been considered, including as presented in the clinical evidence discussed above, and have been contemplated by the disability ratings that have been assigned. Moreover, the competent clinical evidence offering detailed specific findings is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected PTSD. As such, while the Board accepts the Veteran's testimony with regard to the matters he is competent to address, the Board relies upon the competent clinical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected PTSD. The Board has also contemplated whether the case should be referred for extra-schedular consideration for the disabilities at issue. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. The Board has carefully compared the level of severity and symptomatology of the Veteran's PTSD with the established criteria found in the rating schedule (while also being mindful of the holding in Mauerhan in that the presence of a specified quantity of symptoms in the rating schedule are not required for the assignment of a particular rating). The Board finds that the disability at issue is fully addressed by the rating criteria under which psychiatric disabilities are rated. In this regard, the specific diagnostic criteria (with the Board again in this regard being mindful of the holding in Mauerhan) adequately address the whole of the Veteran's symptoms referable to his service-connected PTSD. There are no additional symptoms of the service-connected disability at issue. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology associated with the service-connected PTSD. As such, the Board need not proceed to consider the second factor, viz., whether there are attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, as a claim for a total disability rating based on individual unemployability (TDIU) may be considered a component of a claim for higher rating (see Rice v. Shinseki, 22 Vet. App. 447 (2009)), the May 2013 remand found that, given the circumstances of this case, the examiner who conduced the psychiatric examination requested therein was to provide an opinion as to whether the Veteran's PTSD precluded all forms of substantially gainful employment. Such an opinion was provided by the psychologist who conducted the June 2013 VA examination, and it was her conclusion that symptoms of PTSD were not severe enough to preclude all forms of employment, and that the Veteran thus did not meet the criteria for TDIU. As such, and there otherwise being no persuasive evidence that the Veteran's PTSD is of such severity as to preclude all employment, entitlement to TDIU is not warranted. For all of the foregoing reasons, there is no basis for a 100 percent rating of the Veteran's PTSD, to include on the basis of a staged rating pursuant to Fenderson, or for a grant of TDIU. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a 100 percent rating or a grant of TDIU at any time since the grant of service connection, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App, 49, 53-56 (1990). ORDER For the period from July 31, 2006, entitlement to a 70 percent rating for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 70 percent for PTSD is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs