Citation Nr: 1608590 Decision Date: 03/03/16 Archive Date: 03/09/16 DOCKET NO. 09-41 845 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUE Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) for the period beginning on December 15, 2009. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. J. In, Counsel INTRODUCTION The Veteran served on active duty from December 1967 to July 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating action of the above Regional Office (RO), which granted service connection for PTSD and assigned an initial disability rating of 50 percent effective from April 30, 2008. In May 2013, the Board issued a decision that denied an initial disability rating in excess of 50 percent for PTSD from April 30, 2008 to December 14, 2009 and remanded the issue of entitlement to initial disability rating in excess of 50 percent for the period from December 15, 2009. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court). In an October 2014 Memorandum Decision, the Court affirmed the Board's May 2013 decision denying an initial disability rating in excess of 50 percent for PTSD from April 30, 2008 to December 14, 2009. The remanded issue of entitlement to an initial disability rating in excess of 50 percent for the period from December 15, 2009 is now returned to the Board for appellate review. The Veteran provided testimony before a Decision Review Officer (DRO) at the RO in October 2013. A transcript of that hearing is associated with the claims file. FINDING OF FACT From December 15, 2009, the Veteran's PTSD has been manifested by symptoms productive of functional impairment comparable to occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for a disability rating in excess of 50percent for PTSD are not met. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 4.126, 4.130, Diagnostic Code 9411(2015). REASONS AND BASES FOR FINDING AND CONCLUSION Pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The issue of entitlement to a higher initial rating for PTSD arises from the Veteran's disagreement with the initial disability rating assigned to this condition following the grant of service connection. Once service connection is granted the claim is substantiated, additional VCAA notice is not required. 38 C.F.R. § 3.159(b)(3) (2015). Rather, the Veteran's appeal as to the initial rating assignment here triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here, as the Veteran was issued a copy of the rating decision on appeal, and a statement of the case which set forth the relevant law applicable for assignment of diagnostic codes for rating the disability at issue, and included a description of the rating formulas for all possible schedular ratings under these diagnostic codes. Nevertheless, VA letters issued in May 2008 and July 2009 satisfied the duty to notify provisions with respect to increased ratings and notified the Veteran of the regulations pertinent to the establishment of an effective date and disability rating. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009); Dingess, 19 Vet. App. at 484. In addition, the duty to assist the Veteran has been satisfied in this case. The RO has obtained the Veteran's service treatment records and post-service treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In compliance with the Board's May 2013 remand, updated VA treatment records were obtained from the Fargo VA Medical Center and the Veteran was provided a VA examination in July 2013, reflecting sufficient details to determine the current severity of the Veteran's service-connected PTSD, including information concerning the functional aspects of the disability. Consequently, the Board concludes that this examination is adequate for VA purposes. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). During the October 2013 RO hearing, the Veteran reported that he felt the VA compensation examination was not adequate as the examiner only asked a few questions. However, review of the July 2013 VA examination report reveals clinical findings far more detailed than can be obtained by asking a few questions. In this regard, the Court and the United States Court of Appeals for the Federal Circuit have held that the Board is entitled to presume the competence of a VA examiner and specific challenges to a VA examiner's competency must be raised by the appellant to overcome this presumption. Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009); Bastien v. Shinseki, 599 F.3d 1301 (Fed. Cir. 2010); Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (citing Hilkert v. West, 12 Vet. App. 145, 151 (1999)). Here, the Veteran has not attacked the competency of the examiner, rather, he has asserted that the examiner was not thorough in his examination. As described however, the examination report does contain sufficient details to determine the current severity of the Veteran's PTSD. The Board points out that there is a presumption of regularity under which it is presumed that government officials "have properly discharged their official duties." United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926). The Court has applied the presumption of regularity to "all manner of VA processes and procedures." Woods v. Gober, 14 Vet. App. 214, 220 (2000). The presumption of regularity is not absolute; it may be rebutted by the submission of clear evidence to the contrary. Statements made by a Veteran, without more, do not constitute the type of clear evidence to the contrary which would be sufficient to rebut the presumption of regularity. Jones v. West, 12 Vet. App. 98 (1999), Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994). The Board therefore finds that the VA examination was adequate. Based on the foregoing, the Board concludes that there has been substantial compliance with its prior remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). The provisions of 38 C.F.R. § 3.103(c)(2) (2015) require that the RO official who conducts a hearing fulfill two duties to comply with the above the regulation. 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. During the Veteran's DRO hearing, the Veteran was assisted at the hearing by an accredited representative from Disabled American Veterans. The DRO solicited information regarding any outstanding evidence pertinent to the claim on appeal and asked questions to ascertain the current state of the Veteran's service-connected PTSD, including its functional effects. The hearing focused on the evidence necessary to substantiate the Veteran's claim for increased rating. No pertinent evidence that might have been overlooked and that might substantiate the claims was identified by the Veteran or the representative. Therefore, the Board finds that, consistent with Bryant, the duties set forth in 38 C.F.R. § 3.103(c)(2) have been satisfied. The Veteran contends that his service-connected PTSD is more disabling than is reflected in the current 50 percent disability rating for the period beginning on December 2015. Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2015). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2015). Evaluation of a service-connected disability requires a review of a veteran's medical history with regard to that disorder. However, the primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Further, where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119 (1999). The Court has also held that staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield; 21 Vet. App. 505 (2007). The analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. As noted previously, service connection for PTSD was established by an April 2009 rating decision, which assigned a 50 percent disability rating from April 30, 2008, under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411. Ratings are assigned according to the degree of occupational and social impairment resulting from manifestations of the disability at issue. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Under the provisions for rating psychiatric disorders, a 50 percent disability rating requires evidence of 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 warranted 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.). Id. A 100 percent 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 relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan, 16 Vet. App. 436. Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). While not determinative, a GAF score is highly probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Effective August 4, 2014, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and replaced them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014. The provisions of this interim final rule apply to claims that had been certified for appeal to the Board prior to August 4, 2014. VA adopted as final, without change, the interim final rule, effective March 19, 2015. 80 Fed. Reg. 53, 14308 (March 19, 2015). This appeal was certified to the Board in February 2010. As such, the provisions of DSM-5 are not for application. According to DSM-IV, a GAF score ranging from 31-40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A GAF score of 41-50 reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g. no friends, unable to keep a job). GAF score of 51-60 represents 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 co-workers). Evidence relevant to the severity of the Veteran's service-connected PTSD includes both VA clinical records, and VA examination reports. In a May 2010 VA psychiatry treatment record, the Veteran complained of interrupted sleep, waking up and checking up the house, level mood, hyperarousal, and hypervigilance. He was easily irritated but able to control his temper. Objectively, the Veteran was pleasant, engaged, and cooperative. He was mildly irritated and eye contact was fleeting. His speech was normal spontaneous, somewhat tense. His thoughts were linear and coherent, and non-psychotic. The diagnoses were PTSD and depressive disorder, not otherwise specified (NOS), and a GAF score of 53 was noted. VA psychiatry treatment records dated in July 2010 and November 2010 show the Veteran complained of disrupted sleep due to nightmares. He has not had a recent anger outburst but still had periods of irritability, hyperarousal and continuing hypervigilance. He lived with his wife and they got along fairly well. Objectively, the Veteran was pleasant, engaged, and cooperative. He was fully awake and oriented. His eye contact was fair. His speech was normal and spontaneous. His mood was low and his affect was mildly constricted. He denied real suicidal or homicidal ideations although he had intermittent fleeting passive suicidal thoughts. His thoughts were linear and coherent, and non-psychotic. The diagnoses were PTSD and depressive disorder, NOS. In a May 2011 VA psychiatry note, the Veteran seen for depression and anxiety. Objectively, the Veteran was pleasant, engaged, cooperative, fairly groomed, fully awake and oriented. His speech was normal and spontaneous. His mood was fairly stable and depressed, and his affect was full and appropriate. He denied suicidal or homicidal ideations. His memory and cognition were fairly intact. His thoughts were linear, coherent and non-psychotic. His insight and judgment were fair. The diagnoses were PTSD and depression, and a GAF score of 51 was given. A November 2011 VA psychiatry note shows that the Veteran had erratic sleep. Objectively, the Veteran was fully awake and oriented. He was anxious. His mood was low and his affect was constricted but appropriate to thoughts. He had intermittent passive suicidal thoughts, with no plans or intent. His thoughts were coherent and non-psychotic. The diagnoses were PTSD and depression. A May 2012 VA psychiatry note shows that the Veteran reported trouble sleeping, intermittent nightmares, hyperarousal, and hypervigilance. He got along with his wife and usually spent time fixing trucks. Objectively, the Veteran was pleasant, engaged, and cooperative. He was fully awake and oriented. His speech was normal and spontaneous. His mood was low, and his affect was full and appropriate. He denied suicidal or homicidal ideations. His thoughts were linear, coherent, and non-psychotic. The diagnoses were PTSD and depressive disorder, NOS. In November 2012, the Veteran was seen for mood and anxiety problems. He lived with his wife but really did not do things together and spent most of his time in his shed working on tractors. Mental status examination revealed fair grooming, limited speech, poor eye contact, low mood, and restricted affect. He denied suicidal or homicidal ideations. His thoughts were linear, coherent and nonpsychotic. A June 2013 VA mental health record shows diagnoses of PTSD and depressive disorder, NOS, and a GAF score of 55 is listed. At a July 2013 VA examination, the Veteran reported increased irritability since his last VA examination in 2009. During the interview, he was frequently tearful and avoided eye contact, and had difficulty discussing his PTSD. He described disturbing thoughts and memories of trauma, nightmares, flashbacks, physiological and psychological distress, avoidance of things that remind him of his military trauma, avoidance of crowds, loss of interest in things he used to enjoy, feeling cut off from others, difficulty staying asleep, irritability that leads to conflict in his relationships, reduced concentration, hypervigilance, and exaggerated startle response. He reported moderately depressed mood "that comes and goes." He denied any suicidal or homicidal ideations or symptoms of mania. He endorsed a sense of hopelessness. He denied any significant cognitive impairment. He denied any legal or behavioral problems or any drug or nicotine use. In terms of social functioning, the Veteran reported that he lived with his wife of over 40 years but stated "we still live together, we don't communicate much, and we don't do much." He would work in the yard and garden with his wife. He denied having any other hobbies. He had minimal contact with his children. He stated that he isolated and stayed mostly to himself and that his only social contact was with his wife and children, but limited contact. In terms of occupational functioning, he has been self-employed refurbishing truck and he preferred working by himself. He stated that he and his wife financially "are getting by." The examiner found that the Veteran's level of occupational and social impairment with regard to all his mental diagnoses was best summarized as occupational and social impairment with reduced reliability and productivity. The examiner noted the Veteran's PTSD symptoms included depressed mood, anxiety, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, and inability to establish and maintain effective relationships. He was capable of managing his financial affairs. The examiner opined that although the Veteran's subjective experience was that his irritability has worsened citing increased conflict with his wife and increased isolation, given the Veteran's symptom presentation and review of available records, the Veteran's symptoms and the severity of the symptoms remained relatively unchanged since his last examination in 2009. The diagnoses were PTSD and depressive disorder, NOS, and a GAF score of 51 was assigned. Subsequent VA psychology notes dated from August 2013 to November 2013 reflect that the Veteran was appropriately dressed and groomed. His overall mood was anxious and depressed. He reported distressing memories, feeling distant toward his family, nightmares, and avoidance behaviors. He has reported longstanding suicidal ideation but denied any current suicidal intent or plan. Judgment was intact for safety purposes. The diagnoses were chronic and severe PTSD and depressive disorder, NOS. During the October 2013 RO hearing, the Veteran reported continuing treatment at the Fargo VA Medical Center and attending group and individual treatment since June 2013. He reported irritability, nightmares, and that he did not engage in social activities. He reported that he had been working on his own for home-based business refurbishing trucks for the last 40 years. He did not have a lot of public contact with this business and got his customers by word of mouth. By applying the Veteran's psychiatric symptomatology to the rating criteria described above, the Board finds that his total disability picture most closely approximates the criteria for a 50 percent rating from December 15, 2009. In this regard, the Board determines that the Veteran's psychiatric disability has been productive of symptomatology resulting in functional impairment comparable to occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas or total occupational and social impairment. The record shows the Veteran's disability was found to be consistently manifested by the symptoms of depressed mood, anxiety, nightmares, sleep difficulty, intrusive thoughts, irritability, social isolation, exaggerated startle response, hypervigilance, hyperarousal, and fleeting passive suicidal thoughts. The evidence does not otherwise show significant disturbance of affect or mood, speech suggestive of disorders of thought or perception, difficulty understanding commands, or impairment of memory, judgment, or abstract thinking. Despite his suicidal ruminations, according to the Veteran he had no active suicidal plans and he has required no inpatient psychiatric treatment. The relevant clinical findings largely show periods when the Veteran was doing worse and, at other times doing better, but in general show that his symptoms were under control. The Board observes that the July 2013 VA examiner checked off 'inability to establish and maintain effective relationships' as one of the Veteran's PTSD symptoms. However, a disability rating is based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's characterization of a symptom. While the Veteran's isolative behavior makes social interactions complicated, he does have the ability to establish and maintain relationships as shown by his long-term marriage to his wife, albeit with strain. To that effect, he has reported that although he and his wife did not communicate well and do things together, during his psychiatric treatment sessions in 2010 and 2012, he has indicated that they got along fairly well. Further, there is no evidence that he has significant decreases in work efficiency. The Board finds it probative that despite his PTSD symptoms, the Veteran has been able to maintain his work relationships sufficiently to remain relatively stable in his employment and manage his own business since service discharge. During the October 2013 RO hearing, he reported that he had been working on his own for home-based business of refurbishing trucks for the last 40 years. Although he did not have a lot of public contact with this business and he preferred working by himself, he got his customers by word of mouth and he and his wife financially "are getting by," which reflects that he has been, in fact, able to establish and maintain effective relationships with his customers. The Board also finds it significant that no abnormalities were found with regard to the Veteran's thought processes, speech and communication. He denied any legal/criminal problems. He is capable of managing his financial affairs. The record consistently shows that his speech was normal and spontaneous, that his thoughts were linear, coherent and nonpsychotic, and his memory and cognition were intact, and his judgment and insight was fair. He was fully oriented and there were no delusions. His impulse control was good. Mental status examination indicated that there was no obvious gross impairment in orientation, attention, and memory. Thus, deficiencies in the areas of judgment or thinking are not shown. Other symptoms demonstrative of the level of functional impairment required for a higher 70 percent rating are neither complained of nor observed by medical health care providers, including obsessional rituals, illogical, obscure, or irrelevant speech, or impaired impulse control. The Veteran has not been shown to have symptoms equivalent in, nature or severity to the criteria required for a higher rating. There is also no evidence of psychotic symptoms or cognitive deficits. In general, the Veteran was adequately groomed and able to take care of himself physically. The evidence also does not show spatial disorientation-the substantial weight of the evidence shows that he was fully oriented. Such findings are consistent with the rating criteria required for a 50 percent rating, and do not approximate the criteria required for assignment of a 70 percent or higher rating. While the clinical findings of record describe, experiences, thoughts, and emotions due to PTSD that have had some impact on the Veteran's interpersonal relationships, particularly those within his immediate family, the evidence, overall shows that he was able to function fairly well. In other words, the Veteran's tendency for isolative behavior suggests difficulty in establishing and maintaining effective work and social relationships with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, as is required for the next higher rating of 70 percent. Bowling v. Principi, 15 Vet. App. 1, 11(2001); Vazquez-Claudio v. Shinseki, 2012-7114, (Fed. Cir. Apr. 8, 2013) (holding, that a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation). The Board has also taken into account that the VA examiners who have examined the Veteran for treatment purposes or have evaluated him to assess the nature, extent and severity of his service-connected PTSD, have estimated GAF scores of 51 to 55 which, according to the DSM-IV, denote moderate symptoms (e.g., flat effect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or co-workers). Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). These GAF scores are consistent with the symptomatology noted and do not provide a basis for a higher rating for the Veteran's PTSD in excess of 50 percent from December 15, 2009. Accordingly, the Board finds that the Veteran's impairment due to PTSD for the period from December 15, 2009 is more consistent with a 50 percent rating and that the level of disability contemplated in Diagnostic Code 9411 to support the assignment of a 70 percent or rating or higher is absent. It is also noted that the Veteran was found to have significant symptoms associated with depressive disorder in addition to symptoms of PTSD. This disorder is not service-connected, but, according to the evidence, causes some level of additional social and occupational impairment. However, in the absence of a medical opinion that clearly separates the symptoms of the Veteran's service-connected PTSD from the nonservice-connected depressive disorder, the Board has resolved all reasonable doubt in the Veteran's favor and has considered all of his psychiatric symptomatology in evaluating the severity of the service-connected PTSD. See Mittleider v. Brown, 1 it Vet. App. 181 (1998) (which stipulates that the Board is precluded from differentiating between symptomatology attributed to a service-connected disability and another service-connected disability in the absence of medical evidence which does so). Yet, for the reasons discussed herein, the evidence of record does not warrant ratings higher than the currently-assigned 50 percent evaluation at any time from December 15, 2009, for the service-connected PTSD. The Board has carefully considered the Veteran's contentions in making this decision. The level of disability shown is encompassed by the rating assigned and, with due consideration to the provisions of 38 C.F.R. § 4.7, a higher rating is not warranted for this disability for any portion of the time period under consideration. See Fenderson, 12 Vet. App. at 126. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extraschedular evaluation. 38 C.F.R. § 3.321(b)(1) (2015). Otherwise, the schedular rating is adequate, and referral is not required. Thun, 22 Vet. App. at 116. In this case, the schedular rating in this case is not inadequate. The Veteran's PTSD is evaluated by the rating criteria which specifically contemplate the level of occupational and social impairment caused by this disability. See 38 C.F.R. § 4.130, Diagnostic Code 9411. When comparing the Veteran's symptoms with the schedular criteria, the Board finds that the Veteran does not have symptomatology associated with his psychiatric disability that have been unaccounted for by the current schedular rating. See id. The Veteran has not identified any factors which may be considered to be exceptional or unusual so as to render impractical the application of the regular schedular standards, and the Board has been similarly unsuccessful. As discussed above, there are higher ratings available for the Veteran's service-connected PTSD, but the required manifestations have not been shown in this case. Accordingly, a comparison of the Veteran's symptoms resulting from his service-connected disability with the pertinent schedular criteria does not show that his service-connected disability present "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Moreover, the evidence does not establish that the Veteran's PTSD necessitates frequent periods of hospitalization and VA examinations are void of any findings, of exceptional symptornatology beyond that contemplated by the schedule of ratings. Although the Board has no reason to doubt that the Veteran's PTSD symptomatology adversely impacts his employability, this is specifically contemplated by the 50 percent schedular rating currently assigned. As such, referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. The Board notes that under Johnson v. McDonald, 762 F.3d 1362, 1366 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. In this case, the Veteran's service-connected disabilities include PTSD, tinnitus and hearing loss. The Veteran has not alleged that his currently service-connected disabilities combine to result in additional disability or symptomatology that is not already contemplated by the rating criteria for each individual disability. Further, there is no medical evidence indicating that the Veteran's PTSD, tinnitus or hearing loss combine or interact either with each other in such a way as to result in further disabilities, functional impairment, or additional symptomatology not accounted for by the rating criteria applicable to each disability individually. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating for compensation purposes based on individual unemployability (TDIU), either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran has not argued, and the record does not reflect, that the disability at issue renders him unable to secure and follow substantially gainful employment. The record reflects that the Veteran has been self-employed for the last 40 years. Accordingly, the Board concludes that a claim for a TDIU has not been raised. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A disability rating for PTSD in excess of 50 percent from December. 15, 2009 is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs