Citation Nr: 1340463 Decision Date: 12/06/13 Archive Date: 12/20/13 DOCKET NO. 10-35 821 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an initial rating in excess of 10 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Tennessee Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Andrew Ahlberg INTRODUCTION The Veteran served on active duty in the U.S. Marine Corps from August 1966 to May 1970. His awards and decorations include the Combat Action Ribbon and Purple Heart Medal. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The case was remanded by the Board in May 2013 and now returns for final appellate review. In January 2013, the Veteran testified at a video-conference hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the claims file. Additionally, the Veteran and his representative were provided with a copy of the transcript in March 2013. This appeal was processed using the Virtual VA and Veterans Benefits Management System (VBMS) paperless claims processing systems. The Board observes that additional VA treatment records dated through October 2013 were associated with the Veteran's paperless file since the issuance of the July 2013 supplemental statement of the case; however, such are not relevant to the issue on appeal in that the additional records are duplicative of the evidence previously of record. Specifically, the additional records merely reiterate the Veteran's PTSD and depression diagnoses and medication for such disorders, but do not contain relevant clinical findings. Therefore, there is no prejudice to the Veteran in the Board proceeding with a decision at this time. FINDING OF FACT Since the effective date of the grant of service connection, the Veteran's PTSD has been mild in nature and has not resulted in manifestations that more nearly approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, occupational and social impairment with reduced reliability and productivity, occupational and social impairment in most areas, or total occupational and social impairment. CONCLUSION OF LAW For the entire appeal period, the criteria for an initial rating in excess of 10 percent for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (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. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on the claim for VA benefits. Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Board observes that the Veteran has appealed with respect to the propriety of the initially assigned rating for PTSD following the grant of service connection for this disability. VA's General Counsel has held that no VCAA notice is required for such downstream issues. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In addition, the Board notes that the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess, supra, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claim for service connection for PTSD was granted and an initial rating assigned by the January 2010 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating for the service-connected disability at issue, no additional 38 U.S.C.A. § 5103(a) notice is required with respect to this issue because the purpose that the notice is intended to serve has been fulfilled. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment records as well as post-service VA treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. In this regard, the Board notes that, in a statement in December 2009, he indicated that all of his treatment was through VA. The Veteran was also afforded a VA examination in December 2009 and June 2013 in conjunction with the claim on appeal. Neither the Veteran nor his representative has alleged that such is inadequate for rating purposes. Moreover, while the Board finds that the December 2009 to be accorded less probative weight as will be discussed further herein, the Board finds that the June 2013 examination is adequate to adjudicate the instant claim because, as discussed below, it was based upon consideration of the Veteran's pertinent medical history as well as his lay assertions and current complaints, and because it provides sufficient detail to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Therefore, no further examination is necessary. As noted previously, the Board remanded the case in May 2013 so as to afford the Veteran a contemporaneous VA examination. As discussed in the preceding paragraph, the Veteran was afforded a VA examination in June 2013 that addressed the nature and severity of the manifestations associated with his PTSD in accordance with the May 2013 remand directives. Therefore, the Board finds that the AOJ has substantially complied with the May 2013 remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). The Veteran also offered testimony before the undersigned Veterans Law Judge at a Board hearing in January 2013. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the January 2013hearing, the undersigned Veterans Law Judge noted the issue on appeal. Also, information was solicited regarding the nature, frequency, and severity of his PTSD symptoms as well as the effect such have on his daily life and employment. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. As the hearing discussion raised the possibility that such service-connected disability had increased in severity since the Veteran's December 2009 VA examination, the Board remanded the issue in May 2013 so as to determine the nature and severity of his PTSD. Under these circumstances, nothing gives rise to the possibility that evidence had been overlooked with regard to the Veteran's claim decided herein. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the appellant are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, he will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Ratings Schedule) found in 38 C.F.R., Part 4. The rating 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. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the appellant's favor. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating an appellant's service-connected disabilities. 38 C.F.R. § 4.14. 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). Staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran's 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 10 percent rating is assigned when there is occupational and social impairment due to mild or transient symptoms which decreases work efficiency and ability to perform occupational tasks only during periods of significant stress, or, symptoms controlled by continuous medication. 38 C.F.R. § 4.130. 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). Personality disorders are not "diseases" for which service connection can be granted, and as a "matter of law" are not compensable disabilities. 38 C.F.R. § 3.303(c); Beno v. Principi, 3 Vet. App. 439, 441 (1992). With the above criteria in mind, the relevant evidence will be summarized. The Veteran's awards and decorations document combat service during the Vietnam era, and he was awarded the Purple Heart Medal for a gunshot wound in forehead. The December 2009 VA examination resulted in the conclusion that the Veteran had PTSD as a result of combat stressors and the January 2010 rating decision on appeal granted service connection for this disability at a rating of 10 percent effective November 13, 2009, the date of receipt of the Veteran's claim for service connection. The clinical record includes VA outpatient treatment reports dated in April 2008 noting that the Veteran had recently been in a motorcycle accident resulting in a severe fracture of the spine. A VA social work note dated later in that month reflects a consultation addressing how the Veteran was coping with his back injury. Reports from a July 2008 VA psychiatric evaluation reflect complaints of nightmares unrelated to combat, and depression due to being fired as a welder two years previously. It was noted that he been taking Prozac for one month. The diagnosis was generalized anxiety disorder and the GAF score was 65. A December 2008 VA outpatient treatment report reflects a GAF score of 85 and the GAF score upon VA outpatient treatment in September 2009 was 78. A November 2009 VA social work outpatient noted nightmares "like those associated with PTSD." At the December 2009 VA examination, it was noted that the Veteran was taking psychotropic medication. It was indicated that he was lonely and no longer worked which was said to severely limit his social interaction. A history of a stab wound when the Veteran was a child was reported. Upon examination, the Veteran's speech was not remarkable and his affect was flat. It was noted that he was clean and casually dressed. His mood was anxious; attention was intact; he was oriented to three spheres; thought processes and content were unremarkable; judgment and insight were intact; and there were no delusions. However, the Veteran reported auditory hallucinations and combat-related nightmares. Additionally, the Veteran was noted to have a past history of inappropriate behavior consisting of indecent exposure. There were no obsessive/ritualistic behaviors but infrequent panic attacks that were said to go away quickly were reported. There was no homicidal or suicidal ideation; impulse control was fair; and there were no episodes of violence reported. It was noted that the Veteran did not bathe or brush his teeth regularly. The following problems with the activities of daily living were described: slight problems with toileting; moderate problems with household chores; and severe problems with grooming, shopping, and bathing. Remote, recent, and intermediate memory were normal. It was noted that the Veteran had retired in September 2009 due to age or duration of work. The diagnoses following the December 2009 VA examination were PTSD and depression, not otherwise specified. There was no diagnosis of a personality disorder. The examiner noted that the Veteran's depression was likely due to his inability to manage his trauma experiences. The examiner found the prognosis to be guarded given the Veteran's lack of social support and the chronicity of his illness and she found there to be total occupational and social impairment due to PTSD. The examiner noted that while the Veteran was retired, he would have difficulty maintaining gainful employment due to low frustration tolerance, difficulty with the activities of daily life, and anxiety attacks. The examiner noted that the Veteran is socially avoidant and had difficulty sustaining focus and attention. Additional evidence includes March and July 2010 VA outpatient treatment reports reflecting GAF scores of 58. An October 2011 VA outpatient treatment report indicated that the Veteran was coping well and his PTSD was stable with his medication. He declined to participate in any therapy at that time. During the Board hearing in January 2013, the Veteran testified that his PTSD was manifested by symptoms such as sleep disturbance (due to dreams), lack of friends, disinterest in personal hygiene, problems with temper and impulse control, and a tendency to isolate himself much of the time. He submitted lay statements from his son, daughter, and ex-wife, among others, to the effect that his condition had declined in recent years, and that he had become increasingly withdrawn, with poor personal hygiene. The report from the June 2013 VA examination, documented to have been based on a review of the VBMS file and VA treatment notes, diagnosed the Veteran with, in addition to PTSD, a personality disorder, namely, "[p]ersonality Disorder NOS with cluster B traits." In comments following the diagnosis of the personality disorder, the examiner noted as follows: The Veteran reported even as a child, he preferred to be alone. His previous [VA psychiatric examination] indicated he had a stab wound at age 8 or 9. This early trauma likely had [a] serious effect on his development. His dependency needs were not met as a child and he seeks out maladaptive ways to have those met. The GAF score assigned by the examiner was 58, and she explained that this was a "global" assessment and did not refer to PTSD alone. The examiner stated that it was possible to differentiate what symptoms were attributable to each psychiatric diagnosis. In this regard, she noted that while there were similar/overlapping symptoms, "in this case it appears [the Veteran's] need to be alone is something he has had since childhood. He also has some dependency needs which [have not been] met in a healthy manner. He tends to enlist his family to meet his emotional needs rather than seek out other relationships." In reporting what best summarized the level of occupational and social impairment resulting from all psychiatric disability as set forth in the rating criteria, the VA psychologist who examined the Veteran in June 2013 selected the statement "[o]ccupational and social impairment with reduced reliability and productivity." As such, the examiner specifically selected the level of disability characterized by a 50 percent rating under 38 C.F.R. § 4.130. With respect to this determination as to the level of occupational and social impairment, the examiner stated this it was possible to differentiate which portion of such impairment was caused by each mental disorder and stated as follows in this regard: It is believed the Personality Disorder is currently causing the most disruption in [the Veteran's] life. He prefers to be alone and uses his family to meet his few emotional needs. He appears to manipulate them since the divorce by maintaining a victim/patient stance. This is why his symptoms appear to have become more severe. PTSD appears to have remained constant and is no better and no worse. His PTSD symptoms have always been mild. (Emphasis added). The examiner noted that the Veteran was not currently taking medications for PTSD and that he indicated such medication had not been helpful. With respect to which of the symptoms described in the General Rating Formula due to PTSD were demonstrated, the examiner only selected "[d]ifficulty in establishing and maintaining effective work and social relationships" from a list of all symptoms included in the General Rating Formula, and indicated that there were no other symptoms of PTSD present (either as explicitly stated in the General Rating Formula or otherwise). She also noted that it was less likely as not that PTSD rendered the Veteran unemployable and that he did not stop working due to PTSD or medical problems. The examiner indicated that another diagnosis caused him to want to be alone; that his PTSD symptoms were mild; and that personality disorder symptoms were believed to be the reason that the Veteran was not working. From the above, there is a conflict in the assessment of the disability attributed to PTSD between that of the examiner who conducted the December 2009 VA examination and of the examiner who conducted the June 2013 VA examination. The adjudication of the Board includes the responsibility of determining the weight to be given to the evidence of record, and this includes the authority to favor one medical opinion over another. See Cathell v. Brown, 8 Vet. App. 539, 543 (1996); Owens v. Brown, 7 Vet. App. 429, 433 (1995). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. See Guerrieri v. Brown, 4 Vet. App. 467 (1993); Sklar v. Brown, 5 Vet. App. 140 (1993). Factors for assessing the probative value of a medical opinion are the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). In this case, the Board finds the assessment rendered in June 2013 to be more thoroughly supported than that rendered in December 2009, particularly with respect to the nature of the Veteran's personality disorder, which was not even discussed at the December 2009 VA examination. In addition, the determination in June 2013 that the Veteran's PTSD symptoms were mild is supported by the remainder of the record, to specifically include an October 2011 VA outpatient treatment report noting that the Veteran was coping well and his PTSD was stable. Moreover, while the December 2009 VA examination is also documented to have been based on review of the claims file, the June 2013 report reflects more specific consideration of the clinical record as well as the lay statements of record. In this regard, the June 2013 VA examination report even made specific reference to the lay statements received at the January 2013 hearing. In short, there is there is simply nothing in the record to suggest that the detailed discussion and consideration of the Veteran's global, and not just those attributed to PTSD, psychiatric problems in June 2013, resulted in an inaccurate assessment therein of the nature of the Veteran's overall psychiatric condition. As such, the Board favors the June 2013 assessment over that rendered in December 2009. Prejean, supra. The Board acknowledges that, where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). As the December 2009 VA examiner and VA treatment records show depression to be a related psychiatric disorder, the Board has considered such symptomatology in connection with evaluating the Veteran's PTSD. However, as relevant to the Veteran's personality disorder, the June 2013 VA examiner found it possible to, and did, differentiate the symptoms and impairment attributable to PTSD from those of his non-service connected personality disorder. As explained above, the Board has found nothing in the record to suggest that the assessments rendered in the June 2013 VA examination reports are inaccurate. In short therefore, the Board finds that the predominant factor in the Veteran's social and occupational impairment is his personality disorder, a disability for which service-connected compensation benefits cannot be granted. 38 C.F.R. § 3.303(c); Beno, supra. Based on the analysis above, the Board finds that, since the effective date of the grant of service connection, the Veteran's PTSD has been mild in nature and has not resulted in manifestations that more nearly approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, occupational and social impairment with reduced reliability and productivity, occupational and social impairment in most areas, or total occupational and social impairment. Thus, for the entire appeal period, an initial rating in excess of 10 percent is not warranted at any time. 38 C.F.R. § 4.130, DC 9411. In determining that the criteria for a rating in excess of 10 percent for the Veteran's PTSD are not met, it is emphasized that the undersigned 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 in determining that a rating in excess of 10 percent is not for assignment. See supra, Mauerhan. In making its determination in this case, the Board has carefully considered the Veteran's contentions with respect to the nature of his service-connected PTSD, to includes those made in sworn testimony at the January 2013 hearing, as well as the supporting statements received at the hearing, and notes that such lay testimony is competent to describe certain symptoms associated with his PTSD. The history and symptom reports have been considered, including as presented in the clinical evidence discussed above, and have been contemplated by the disability rating that has been assigned. Moreover, the competent clinical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability at issue. As such, while the Board accepts the lay testimony with regard to the matters the Veteran and the individuals submitting supporting statements are 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 condition at issue. The Board emphasizes that in making the above determination, a staged rating for the Veteran's PTSD is not warranted as such symptomatology has otherwise remained stable throughout the appeal period. See Fenderson, supra. 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 scheduler 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 scheduler 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 scheduler evaluation is, therefore, adequate, and no referral is required. Second, if the scheduler 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 service-connected disability at issue with the established criteria found in the rating schedule. The Board finds that the disability at issue is fully addressed by the rating criteria under which the Veteran's PTSD is rated. In this regard, the specific diagnostic criteria adequately address the whole of the Veteran's symptoms referable to his service-connected PTSD. Furthermore, in evaluating the Veteran's PTSD, all relevant symptomatology, to include those not enumerated in the rating criteria, are considered. See Mauerhan, supra. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology associated with the service-connected PTSD addressed above. In this regard, the VA psychologist who conducted the June 2013 VA examination found no symptoms of PTSD not contemplated by the General Rating Formula for evaluating psychiatric disabilities. 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 for is not warranted. Id.; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Finally, the Board acknowledges the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009) that a total rating based on individual unemployability due to service-connected disability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. In this case, the June 2013 VA examination reports include a specific determination that the Veteran's PTSD did not preclude employment and that the Veteran did not stop working due to PTSD. While a contrary conclusion with regard to the impact the Veteran's PTSD has on his employability was noted at the December 2009 VA examination, this conclusion did not take into consideration the impairment caused by the Veteran's personality disorder, and the Board has accorded more probative weight to the June 2013 VA examination findings as set forth above. Therefore, the issue of entitlement to a TDIU is not raised in the instant appeal and further consideration of such is not necessary. In sum, the preponderance of the evidence is against a rating in excess of 10 percent for PTSD at any time since the grant of service connection for this disability. Therefore, the benefit of the doubt doctrine is not applicable and the claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER An initial rating in excess of 10 percent for PTSD is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs