Citation Nr: 1613332 Decision Date: 04/01/16 Archive Date: 04/13/16 DOCKET NO. 12-20 807 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUE Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Arizona Department of Veterans Services ATTORNEY FOR THE BOARD Jeremy J. Olsen, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Air Force from March 1986 to December 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona, which granted service connection for PTSD and assigned an initial 30 percent rating. That same month, the Veteran entered a notice of disagreement as to the propriety of the assigned rating. As such notice of disagreement is timely as to the rating decision, the Board finds that-in contrast to the characterization of the appeal by the RO-the issue presently on appeal stems from the initial rating assigned in the January 2012 rating decision. Consequently, the issue is characterized as shown on the title page of this decision. FINDING OF FACT For the entire appeal period, the Veteran's PTSD results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactory, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood; anxiety; chronic sleep impairment; or mild memory loss, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. CONCLUSION OF LAW The criteria for a rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2015). 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 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014). 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 a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. The Board notes that the Veteran has appealed with respect to the propriety of the initially assigned rating for PTSD, following the original grant of service connection. 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 v. Nicholson, 19 Vet. App. 473, 490 (2006). In this case, the Veteran's claim for service connection for PTSD was granted and an initial rating was assigned in the January 2012 rating decision on appeal. Therefore, as the Veteran has appealed with respect to the initially-assigned rating, no additional 38 U.S.C.A. § 5103(a) notice is required 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 private and VA treatment records have been obtained and considered. The Veteran has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was also afforded a VA examination in June 2011 in conjunction with his claim. Neither the Veteran nor his representative has alleged that such is inadequate for adjudication purposes. Moreover, the Board finds that the examination is adequate in order to evaluate the Veteran's service-connected PTSD, as it includes an interview with the Veteran, a review of the record, and a full mental status examination, addressing the relevant rating criteria. While such examination was conducted nearly five years ago, as will be described in detail below, there is additional medical evidence, including VA treatment records, that adequately addresses the level of impairment of his PTSD since the last examination and show that no worsening of the disability has occurred since that time. Allday v. Brown, 7 Vet. App. 517, 526 (1995). Moreover, the Veteran has not alleged that his PTSD has increased in severity since the June 2011 VA examination. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (mere passage of time not a basis for requiring of new examination). Therefore, the Board finds that the examination report of record is adequate to adjudicate the Veteran's increased rating claim and no further examination is necessary. 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 The Veteran disagrees with the 30 percent rating assigned for his service-connected PTSD. He contends that he experiences symptoms severe enough to entitle him to a rating in excess of 30 percent for the psychiatric disability. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, 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 Veteran's favor. 38 C.F.R. § 4.3. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). The Court has held that, in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The Veteran's PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula For Mental Disorders, to include PTSD, a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactory, 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; or 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where 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; intermittently illogical, obscure, or irrelevant speech; 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); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is assignable where 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit has held, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Additionally, consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation 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. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). In evaluating the level of disability, it is also necessary to evaluate such from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. In a September 2010 VA treatment note, the Veteran reported experiencing insomnia and what he considered to be a large amount of stress. In a November 2010 VA mental health consult, the Veteran sought assistance after speaking with his pastor, who raised concerns about the Veteran's depressed mood. The Veteran indicated that he and his wife were in the midst of a legal issue involving the death of a foster child in their care. He indicated that he had trouble sleeping, was irritated, anxious and depressed. The Veteran reported hypervigilance, trouble concentrating and issues with short term memory retention. On examination, the Veteran was found to be well groomed. His behavior was normal, as was his speech. The Veteran presented with an anxious mood and tearful affect, but his thought processes and content were normal. He denied suicidal or homicidal ideation at the time, although he admitted to fleeting suicidal ideation in the past, without a plan. The Veteran was oriented to time, place, person and situation, with memory intact and good attention, concentration and insight. In a February 2011 VA treatment note, the Veteran reported anxiety and insomnia related to legal issues. He reported being terribly depressed, but denied suicidal ideation. On examination, the Veteran was found to be well groomed, with good hygiene. His speech was normal, but mood low. The Veteran's thought process and content were both normal, with no signs of delusions, feelings of helplessness or hopelessness, or any obsessions. The Veteran denied any auditory or visual hallucinations. He was oriented times four, with memory intact. His attention, insight and judgment were all found to be good. In a February 2011 letter, the Veteran's pastor indicated that he had counseled the Veteran for 5 years. He found the Veteran to be experiencing depression, self-doubt, anxiety and fear. He indicated the Veteran had a tendency to withdraw from others, but had been participating in a group therapy setting to treat such issues. In an April 2011 VA psychiatry note, the Veteran reported being worried about the legal case, which at that time was making its way to the state Supreme Court. He indicated he was stressed by his job, but enjoyed it. The Veteran denied suicidal ideation and violent ideas, and was not psychotic. His sleep and appetite were okay if aided by medication. On examination, the Veteran was found to be well groomed with good hygiene. His behavior was found to be normal and lacking in abnormal movements or mannerisms. The Veteran's speech was normal in range, volume and articulation. His affect was normal, full and appropriate. The Veteran's mood was noted to be euthymic to mildly low, but his thought process and content were normal. There were no delusions or obsessions noted. The Veteran denied suicidal and homicidal ideation or intent. No auditory or visual hallucinations were noted. The Veteran was oriented to time, place, person and situation with intact memory. His attention, concentration, insight and judgment were all found to be good. In April 2011, the Veteran was seen at VA with general complaints related to stress and back and neck pain. At that time, he was found to be alert and in no apparent distress. He reported no suicidal ideation. It was determined at that time that he would benefit from continued therapy and medication. In June 2011, the Veteran underwent a VA PTSD examination. At that time, the Veteran reported experiencing irritability and having to work hard to avoid thoughts about his stressor event. He denied nightmares or disturbing dreams; nonetheless, he had problems with insomnia that were treated with medication. The Veteran described hypervigilant behavior, especially in crowded areas. He reported experiencing problems with focus, concentration, and short term memory retention. Occasional, passive suicidal ideation was endorsed, without any plan or intent noted. He reported past significant stress in his marriage, due to the legal issues the couple was facing; however, the relationship had recently improved significantly. The Veteran reported getting along well with his three children. As for his job, the Veteran was working at the time for VA and had been for over two years. He had not been in trouble at work and enjoyed his job. He occasionally took time off from work due to a mental health condition. The Veteran reported being active in his church and had friends from church that he saw outside of that setting. On examination, the Veteran was found to be oriented in all spheres, with satisfactory memory. His speech was normal, his thought process spontaneous, and his continuity of thought was goal-oriented and relevant. There was an absence of not only suicidal or homicidal ideation, but also delusions, ideas of reference or feelings of unreality. The Veteran's concentration was satisfactory. He displayed an anxious mood but was found to be alert, responsive and cooperative, with adequate judgment and fair insight. The examiner diagnosed chronic PTSD with overall moderate symptoms. In a July 2011 VA psychiatry note, the Veteran was found to be mildly depressed, with complaints of ongoing anxiety. At the time, he denied suicidal thinking. The Veteran reported tension, worry, poor sleep and intrusive thoughts, which were attributed to the involvement of state agencies in his life, as a result of his family's ongoing legal issues. On examination, Veteran was well groomed with good hygiene. His behavior, speech and affect were normal. The Veteran's mood was euthymic to mildly low. His thought processes were normal, logical and goal directed. The Veteran's content was also normal, with no delusions, feelings of helplessness or hopelessness, and no obsessions. He denied suicidal or homicidal ideation. There were no auditory or visual hallucinations present, nor any flashbacks. The Veteran was oriented to time, place, person and situation, and displayed an intact memory, good attention and concentration, and good insight and judgment. In an October 2011 VA psychiatry treatment note, the Veteran reported anxiety related to legal issues. He denied suicidal thoughts. On examination, he was oriented times four with memory intact. His insight and judgment were good. The Veteran was found to be well groomed, with normal speech, normal affect, and a euthymic mood. His thought processes were normal, logical and goal directed, with normal content. The Veteran exhibited no signs of delusions, hallucinations or flashbacks, and reported no feelings of helplessness. He denied suicidal or homicidal ideation. In his July 2012 substantive appeal, the Veteran indicated that he felt his symptoms varied frequently. He reported having days where he was more depressed, had illogical speech and thought processes, memory problems, increased stress, a worsened mood, and generalized issues with grooming. In a September 2012 VA psychiatry treatment note, the Veteran denied suicidal or homicidal ideation. He also denied depression, and rarely experienced nightmares. The Veteran reported experiencing some disturbing memories, thoughts and images, and was quite often upset when thinking about his legal troubles. He endorsed trouble sleeping, hypervigilance, and difficulty being around other people, to include coworkers. On examination, the Veteran was found to be well groomed, with normal speech, affect and behavior. His mood was euthymic and his thought processes and content were adjudged normal. There was no evidence of delusions, feelings of helplessness or hopelessness, and no obsessions. The Veteran was oriented to time, place, person and situation and denied hallucinations of any kind. His memory was intact and insight and judgment were good. In a December 2012 VA psychiatric treatment note, the Veteran denied suicidal thoughts or violent ideas, and reported his wife was under a lot of stress. He was found to be coping well. On examination, he was found to be well groomed, with normal behavior, speech, thought processes and content. He denied any hallucinations and was fully oriented with an intact memory. In May 2013, the Veteran informed his VA psychiatrist that he had separated from his wife, who remained under investigation in relation to the couple's legal issues. At the time, the Veteran denied depression and thoughts of self-harm. He indicated he was working for the Federal government and enjoying his job. On examination, the Veteran was found to be well groomed, with good hygiene and normal behavior and speech. His affect was normal, mood euthymic, and thought processes and content normal. There was an absence of hallucinations of any kind and the Veteran was oriented times four with good attention, concentration, insight and judgment. In an October 2013 VA treatment note, the Veteran reported feeling anxious and experiencing insomnia. His wife had been jailed as a result of the couple's legal issues; although the Veteran was not charged, he was saddened by the outcome. On examination, he was found to be well groomed with normal behavior, speech and affect. His thought processes were normal, with no suicidal ideation, obsessions, or hallucinations. He was fully oriented with good insight and judgment. At his next visit, in February 2014, the Veteran indicated that he felt less anxious and depressed than at his prior visit. He indicated that he enjoyed his new job and found support amongst the members of his church. His speech was normal, his thought processes logical, and there was no indication of suicidal or homicidal ideation, nor any evidence of hallucinations. The Veteran was fully oriented with memory intact. Having considered all the evidence of record and the applicable law, the Board finds that a rating in excess of 30 percent for the Veteran's PTSD is not warranted. In this regard, as noted previously, 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. In the instant case, the Board finds that the Veteran's PTSD symptomatology does not more nearly approximate occupational and social impairment with reduced reliability and productivity. In this regard, there is no evidence of a flattened affect; rather, such has been described repeatedly as positive. Similarly, there was no circumstantial, circumlocutory, or stereotyped speech, nor is there evidence of panic attacks of any kind. There was also no indication that the Veteran experienced difficulty in understanding complex commands; suffered impairment of short-and long-term memory beyond mild memory loss, such as forgetting names, directions, or recent events; impaired judgment; impaired abstract thinking; or disturbances of motivation and mood. With regard to the Veteran's social functioning, the evidence reveals that he maintained a good relationship with his children and made friends at his church despite his PTSD symptomatology. The Board finds that the Veteran's PTSD symptomatology does not result in more than mild social impairment as the evidence reveals that he has maintained relationships with his children and other members of his church. Furthermore, in regard to the Veteran's occupational impairment, the Board finds that his PTSD symptomatology, to include those symptoms not specifically enumerated in the rating criteria, results in, at most, an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. In this regard, the Board notes that the Veteran indicated a history of taking time off occasionally due to issues he attributed to his PTSD. However, the Veteran was able to work for many years in the same job, a job he indicated he very much enjoyed, without any issues related to his PTSD symptoms. The Board further finds that the Veteran's PTSD does not more closely approximate the criteria for a 70 or 100 percent rating. The Board finds that the symptoms of the Veteran's PTSD are not of the type and severity contemplated by the 70 percent disability rating. While the Board notes that the Veteran had some difficulty adapting to stressful circumstances, his symptoms have not been shown to be manifested by suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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; or an inability to establish and maintain effective relationships. Rather, at his examinations and VA appointments during the appeal period, the Veteran was regularly observed as clean and casually dressed, cooperative, and fully oriented. His speech was noted consistently as normal and his affect and thought processes were also consistently positive and normal. The Veteran's associations were appropriate and there was no indication of any hallucinations and delusions. While the Veteran endorsed some fleeting suicidal ideation in the past, overall he was found not to be at risk of suicide. He was also consistently found not to be a homicidal risk. Moreover, as previously discussed, the Board finds that, while the Veteran's PTSD results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, such does not more nearly approximate occupational and social impairment with deficiencies in most areas, as he was able to maintain a relationship with his children and friends from his church, and maintained regular and steady employment. The Board notes that, in his July 2012 substantive appeal, the Veteran endorsed symptoms such as illogical speech and thought processes, depression and neglect of personal appearance, all of which are arguably criteria for a 70 percent disability rating. However, the overall, objective evidence of record clearly shows that the Veteran's PTSD has been consistently manifested by criteria warranting his current 30 percent rating. No examiner or therapist has found the Veteran's speech to be illogical, or his personal appearance neglected. Rather, he has been consistently found to be intelligent, with clear speech and normal, clean dress. As for his depression, which the Veteran reports worsens on some days, such a symptom is contemplated by the criteria for his 30 percent rating. The Board also finds that the Veteran's disability picture does not more nearly approximate the criteria for a 100 percent rating at any time during this period. The Veteran's symptoms have not been manifested by 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Again, the Veteran was noted as clean and casually dressed, cooperative, and fully oriented. The Veteran's speech was noted as normal, as were his affect and thought processes. There was no evidence in the record of any hallucinations and delusions. Although there was mention of some passive suicidal ideation, such a finding does not constitute the "persistent danger" necessary to warrant a 100 rating. The Board finds that the Veteran's PTSD symptomatology does not result in total occupational and social impairment. Therefore, the Board finds that, for the entire appeal period, the Veteran's PTSD is manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactory, with routine behavior, self-care, and conversation normal) due to anxiety; chronic sleep impairment; mild memory loss; and difficulty adapting to stressful circumstances, including work or a work life setting, without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, or deficiencies in most areas, or total occupational and social impairment. Consequently, a rating in excess of 30 percent for PTSD is not warranted. The Board has considered whether staged ratings are appropriate for the Veteran's service-connected PTSD. See Hart, supra. However, the Board find that his symptomatology has been stable throughout the appeal period; therefore, assigning staged ratings for such disability is not warranted. The Board has also contemplated whether the case should be referred for extra-schedular consideration. 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 Veteran's disability picture requires the assignment of an extra-schedular rating. Id. The Federal Circuit provided guidance in rating psychiatric disabilities, emphasizing that the list of symptoms under a given rating is nonexhaustive. Vazquez-Claudio, supra. The psychiatric symptoms present in this case are either listed in the schedular criteria or are similar in kind to those listed, as discussed above. Review of the record does not reveal that the Veteran suffers from any symptoms of PTSD that are not contemplated in the nonexhaustive list of symptoms found in the schedular criteria. Furthermore, the rating schedule provides for greater compensation for greater disability than that suffered by the Veteran. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. The Board notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. However, in this case, as the appeal does not involve evaluation of multiple service-connected disabilities, further discussion of Johnson is not necessary. Therefore, 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. Furthermore, the record reflects, as discussed previously, that the Veteran's PTSD does not result in total occupational impairment. 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). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for total disability rating for compensation based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that the Veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In the instant case, the record reflects that the Veteran has been able to maintain employment for the entirety of the appeal period. While he indicated that he occasionally took a day off from work due to the symptoms of his PTSD, there is nothing in the record to indicate that the Veteran's PTSD renders him unemployable. Therefore, a TDIU is not raised in the instant case and, as such, need not be further addressed. In sum, Board finds that the preponderance of the evidence is against the Veteran's claim for an initial rating in excess of 30 percent for PTSD. 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; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER A rating in excess of 30 percent for PTSD is denied. ____________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs