Citation Nr: 0725136 Decision Date: 08/13/07 Archive Date: 08/20/07 DOCKET NO. 99-01 638 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Determination of proper initial rating for irritable bowel syndrome with psychogenic vomiting, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Eckart, Counsel INTRODUCTION The veteran had active service from May 1989 to April 1998. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 1998 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which granted service connection for irritable bowel syndrome with psychogenic vomiting and assigned an initial 10 percent rating. The veteran subsequently timely appealed the RO's decision. In September 2001, he testified before the undersigned Veterans Law Judge at a hearing at the RO (Travel Board hearing). A copy of the hearing transcript has been associated with the record. Following a Board remand for further development in December 2001, this case underwent appellate adjudication by the Board in July 2003, which denied his claim. The veteran appealed the July 2003 Board decision to the United States Court of Appeals for Veterans Claims (Court). Following a July 2004 "Joint Motion for Remand" (Joint Motion), a July 2004 Court Order vacated and remanded the July 2003 Board decision. The matter was returned to the Board which remanded this issue in December 2004 in order to comply with the Court's remand. At present, the appellant's case is once again before the Board for appellate consideration. FINDINGS OF FACT 1. The veteran's psychiatric complaints primarily consist of some adjustment symptoms due to family conflicts, fatigue, and sleep problems, with a Global Assessment of Functioning (GAF) of 65 on most recent examination. 2. The veteran's gastrointestinal disability is the predominant disability for rating purposes. 3. The veteran's gastrointestinal disability consists of moderate symptoms with complaints of some nausea about 3 times a week, constipation about once a week and diarrhea about 3 times a month, but with no evidence that he suffers from a severe irritable colon syndrome with more or less constant abdominal distress. CONCLUSION OF LAW The criteria for an initial evaluation greater than 10 percent disabling for irritable bowel syndrome with psychogenic vomiting have not been met. 38 U.S.C.A. §§ 1155 5103, 5103A, 5107 (West 2002 & Supp. 2006); 38 C.F.R. §§ 3.102, 3.159, 3.321(a), 3.326, 4.1, 4.3, 4.7, 4.10, 4.126(d), 4.114, Diagnostic Code 7319 (2006). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to notify and assist The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2006); 38 C.F.R. § 3.159 (2006). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2006); 38 C.F.R. § 3.159(b) (2006); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VA 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; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). Such notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board finds that any defect with respect to the notice requirement in this case was harmless error for the reasons specified below. See VAOPGCPREC 7-2004. In the present case, the veteran's service connection claim was received in May 1998. After adjudicating this claim and granting service connection, the RO provided initial notice of the provisions of the duty to assist as pertaining to entitlement to an increased rating in a June 2002 letter, which included notice of the requirements regarding an increased rating, of the reasons for the denial of this claim, of his and VA's respective duties, and he was asked to provide information in his possession relevant to the claim. Additional duty to assist letters were sent by the agency of original jurisdiction in January 2005, March 2005 and August 2006. The duty to assist letters specifically notified the veteran that VA would obtain all relevant evidence in the custody of a federal department or agency. He was advised that it was his responsibility to either send medical treatment records from his private physician regarding treatment, or to provide a properly executed release so that VA could request the records for him. The veteran was also asked to advise VA if there were any other information or evidence he considered relevant to this claim so that VA could help by getting that evidence. VA must also make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a); 38 C.F.R. § 3.159(c), (d). Service medical records were previously obtained and associated with the claims folder. VA and private records were obtained and associated with the claims folder. Assistance shall also include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The evidence of record includes examination reports, and following the Board's December 2004 remand, the most recent examination reports of March 2005 and April 2005 along with addendums from September 2006 confirming claims file reviews provide a recent assessment of the veteran's service-connected disability based on examination of the veteran. During the pendency of this appeal, the Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. In the present appeal, the veteran was not provided with notice of the type of evidence necessary to establish an earlier effective date. However, since an increased rating is being denied, the failure to send such a letter is harmless error. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004); Bernard v. Brown, 4 Vet. App. 384 (1993); see also 38 C.F.R. § 20.1102 (harmless error). II. Increased Initial Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where entitlement to compensation already has been established, and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is entitlement to a higher initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1994). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2006). In this matter, service medical records revealed that the veteran was treated for problems with gastrointestinal symptoms such as nausea, vomiting and diarrhea, as well as anxiety symptoms and complaints of stress beginning in October 1996 he was treated for such symptoms. In November 1996, he was diagnosed with psychiatric factors affecting medical condition and irritable bowel syndrome. He continued treatment including psychotherapy and marriage counseling throughout the rest of service from 1997 to March 1998 for such symptoms of stress and psychogenic vomiting. These records indicated that he felt high stress while in positions in a submarine and later as a recruiter. The veteran filed his current claim on appeal in May 1998. Service connection for irritable bowel syndrome with psychogenic vomiting was granted in a September 1998 rating decision that assigned an initial 10 percent rating. The veteran appealed this decision. The report of a July 1998 VA general examination gave a history of irritable bowel syndrome with complaints of diarrhea under stress or when anxious. During such episodes he had an average of 10 to 12 times a day of watery stools with no blood or mucus. He had a job interview this week and was having diarrhea because he was anxious. He also had vomiting while anxious. He developed symptoms when he had to work a high pressure job. He was noted to be prescribed dicyclomine by the VA. He complained of crampy abdomen pain relieved by bowel movements when he had diarrhea. He also had complaints of flatulence and history of constipation. No other symptoms were reported in the general medical examination. The physical examination revealed him to be 6 feet and 3 inches tall and weighed 184 pounds. One year ago he was said to weigh 163 pounds. He was well nourished and his abdomen was soft and supple. There was no organomegaly or tenderness. Bowel sounds were active. He was diagnosed with irritable bowel syndrome with psychogenic vomiting. VA treatment records from 1999 through 2005 repeatedly showed that post-traumatic stress disorder (PTSD) and depression screenings periodically done were negative. A December 1999 general office note revealed the veteran to be rated at 10 percent disabling for irritable bowel syndrome and used 10 milligrams of Bentyl for relief of gastrointestinal symptoms. He was in good health otherwise and abdomen was negative on physical examination. The impression was history of IBS. A July 2000 VA examination revealed the veteran to describe a history of diarrhea and vomiting in service diagnosed with irritable bowel syndrome. He taking dicyclomine 10 milligrams 3 times a day. His current symptoms were occasional diarrhea and vomiting. He denied any blood in his stool. He had occasional colicky abdomen and increased flatulence. He denied history of anemia, hernia or cancer. Physical examination revealed his abdomen to be soft, with bowel sounds present. There was no organomegaly, tenderness, rebound tenderness or masses palpated. The veteran refused rectal examination. Labs showed no anemia. The diagnosis was irritable bowel syndrome with cycling vomiting. An August 2000 barium enema was normal. An October 2000 VA general office visit revealed him to have irritable bowel syndrome and to miss work sometimes because of diarrhea which occurred about 3 or 4 times a month. He had nausea without vomiting and no bloody stools. An examination barium enema was noted to be negative. A gastrointestinal outpatient note also from October 2000 revealed his history of irritable bowel syndrome for 4 years with complaints of recurrent diarrhea, but no bloody stools. This would occur about 3 times a month which affected his work schedule. The diarrhea was said to be present about 5 years and was on and off, nonbloody and without weight loss, but did have weight gain. He would have liquid bowel movements to loose stools which were more common than the liquids on average of 2 to 5 times a day, but not at night. He had small amounts each time, cramps and gas with urgency at times but was able to control his urges until a bathroom was available or when he takes dicyclomine. The diarrhea was more frequent during stressful times and was about 3 times a month lasting 1 day, without mucus, vomiting or weight loss. He had relief with bowel movements. He had a history of irritable bowel syndrome and barium enema of 2 months ago was normal. Physical examination revealed his abdomen to be soft, nontender with positive bowel sounds. He refused rectal examination. Lab tests were reviewed and showed no anemia. The assessment was clinical pictures of irritable bowel syndrome with continued management and fiber. The veteran refused a flexible sigmoidoscopy. The veteran testified at his September 2001 Travel Board hearing that he has alternate symptoms of constipation and diarrhea. However he denied that he has continous problems with constipation. He described the diarrhea as more or less a problem with "loose stool" rather than full blown diarrhea symptoms. He testified that he takes regular medication for his symptoms. He also indicated that he experiences nausea from time to time that he described as stress related. He testified that he missed work about once every few months due to his symptoms. A November 2002 VA examination of digestive condition revealed a past history of irritable bowel syndrome and frequent episodes of nausea, vomiting and loose bowel movements up to the present time. His medical history was said to include a diagnosis of irritable colon in 1995 that was stress induced, and he was working as a recruiter at the time. He now had loose bowel movements, dry heaves and psychogenic vomiting. He was currently taking dicyclomine which seemed to help with the loose bowel movements and dry heaves. He worked as a mechanic in the Post Office and liked his job. He had not missed work in 90 days due to irritable bowel syndrome. He felt the irritable bowel syndrome was stress induced. He was slightly apprehensive about the VA examination and had stress related to the demands of the upcoming holidays. Physical examination revealed him to be 6 feet and 2 inches tall and weighted 205 pounds. His body mass index was 27. His abdomen was soft, nontender, with no guarding or tenderness on deep palpation. Bowel sounds were normal. The diagnosis was irritable bowel syndrome. The examiner commented that the veteran has occasional bouts of irritable bowel syndrome with diarrhea and queasy feeling alleviated with dicyclomine 10 milligrams as needed. Episodes were about 1 time per week, usually stress related. VA treatment records from January 2005 revealed his active symptomatology included irritable bowel syndrome. He continued to work in the Post Office and he had interim diarrhea and about once or twice had bright red rectal blood (BRRB) usually in the toilet tissue. Screening for PTSD type symptoms in January 2005 was negative. The report of a March 2005 VA intestine examination included no claims file review prior to the examination. The veteran gave a history of being diagnosed with irritable bowel syndrome in 1995 and developed symptoms of nausea, vomiting and bloody diarrhea. He said he was treated but did not recall the medication. He continued to have problems with intermittent constipation and diarrhea. He currently was followed up with the VA and used dicyclomine. He was supposed to take 3 pills but only took one per day because more than that "binds" him. Otherwise his medical history indicated he had a slight weight gain as he gets older. He did experience some nausea about 2 to 3 times per week, which he thought was due to stress. He had no vomiting. He had constipation about once a week and diarrhea about 3 times a month. He did have loose stools about 3 times per week. There was no history of anal fistula, malnutrition or anemia. Physical examination revealed he weighed 205 pounds. His abdomen was soft, with bowel sounds present. There was no organomegaly or tenderness elicited. He had no masses palpated. Rectal examination revealed normal sphincter tone and no external hemorrhoids. His stool was negative for blood. Lab studies done in January 2005 were negative for anemia. The diagnosis was irritable bowel syndrome. Regarding the symptoms effect on occupational and functional impairment, he stated he did miss about 1 or 2 days per month due to diarrhea. It was more likely then not that he did miss some work due to irritable bowel syndrome symptoms. A September 2006 addendum drafted by the examiner from the March 2005 VA intestines examination confirmed that the claims file was reviewed and there was no change in the opinion given. The report of an April 2005 VA psychiatric examination noted that the veteran was referred for an evaluation of his service-connected irritable bowel syndrome with psychogenic vomiting to render an opinion as to whether the psychiatric disorder or the physical disorder was the dominant aspect of his condition. The examination was also to determine the effect of the irritable bowel syndrome disorder on his earning capacity and whether it has caused marked interference with his employment or required frequent hospitalization. Review of the medical records showed no recent history of psychiatric treatment or hospitalization for psychiatric problems. He did not take psychiatric medications. There was no history of legal problems, substance abuse, violence or assaultiveness. He had symptoms related to irritable bowel syndrome. He described an essentially normal childhood, and did well in school. During service he had no problems during basic training. He served 6 years in a submarine program and then became a recruiter. His submarine had one collision that was scary for a few seconds. He thought his experience as a recruiter was particularly stressful. He had problems with diarrhea and vomiting before work. He had no combat and served until 1998. After service, he worked 8 months as a cable TV installer and for 6 1/2 years in the Post Office repairing postal machines. He did not find work overly stressful. There were no problems with human resources. He was married for 12 years and had an 8 year old son. He had some problems with his wife with occasional arguments and having her yell at him. He denied any problems with domestic violence. He thought the fact his wife worked full time was stressful as they had different days off. He also complained about her spending habits resulting in more debt than he would like to have. His main source of stress was described as family problems. He and his wife owned their home and shared household chores. He enjoyed watching sports, playing with his son and visiting friends. He did drink frequently with his friends about 12 beers per week. He had no history of compulsive alcohol use. He had some marriage counseling and some individual counseling in service but no recent treatment for mental health problems. Mental status examination revealed the veteran to be a well- nourished, amiable individual who was casually and neatly dressed. He was oriented times 3. His psychomotor and speech were within normal limits. His affect was friendly, varied, mood was congruent. His thought processes were goal oriented and he had no derailment, loose or changing associations, thought blocking or neologisms. He had no delusional or paranoid thought. He denied problems with feeling nervous, sweaty, shaky, racing heartbeat, or having feelings of impending death. He generally though his mood was good and he had no problems with depression, poor motivation, decreased appetite, poor self esteem or weight changes. He had no suicidal ideations and felt reasonably well about himself and that life was worthwhile. He slept about 4 to 5 hours a night and felt this was not enough sleep. As a result, he experienced fatigue. He did not have periods of racing thoughts, distractibility, pressured speech, increased energy or going without sleep, increased activity or dangerous behavior. He denied current visual or auditory hallucinations, delusions, paranoid thoughts, special messages or thought broadcasting, special powers or other frank indicators of psychosis. He was able to handle his finances. There was no psychometric testing done. The diagnosis was based on signs, symptoms, occupational and social functioning described above, the veteran met the DSM- IV criteria for adjustment disorder. It did not appear directly related to military events. There did not appear to be multiple mental disorders. The Axis I diagnosis was adjustment disorder, unspecified. Axis II was deferred. His Axis III diagnosis was irritable bowel syndrome. His GAF score was 65. This GAF was assigned because of the overall low number, frequency and intensity of symptoms associated with minimal reduction of social, vocational and mental functioning. The examiner opined that it was at least as likely that the veteran's physical problems appeared to be the dominant aspect of his conditions. The psychogenic vomiting was not a DSM IV diagnosis. If one were to assume that the previous clinician was referring to a somatization disorder, the veteran currently did not meet the criteria for such a disorder. He did appear to have some distressing adjustment problems from family stressors, however the adjustment problems did not appear to have a significant impact on social or vocational performance. Since there were no records present and he voiced no obvious or serious past effects on his job performance, any past relationships between stressors, somatization symptoms and vocational problems could not be resolved without mere speculation. Since he described himself as functioning adequately, but suffering some distress, it was more likely than not that his problems had little effect on his employability or earning capacity. There was little evidence that his adjustment problems caused any interference with employment and there were no hospitalizations. A September 2006 addendum from the VA examiner in the April 2005 examination stated that the claims file was sent for review and there did not appear to be any more recent mental health treatment records since the VA examination was conducted. There was reference to anxiety and psychogenic vomiting secondary to job related stress in 1997. He was noted to have attended several sessions with mental health for anxiety related symptoms. He had problems with nausea and vomiting related to the stress of being a military recruiter. Given the description of symptoms it was at least as likely as not that the veteran had either an unspecified anxiety disorder or adjustment disorder present and treated during service. Regarding the above opinions the psychogenic vomiting was at least as likely as not an anxiety symptom and part of either an unspecified anxiety disorder or an adjustment disorder present and treated during military service. These problems were described as being related to the stress of his job as a recruiter which was described as very stressful. He continued to have some adjustment difficulties but did not appear to meet the criteria for an anxiety disorder nor did the vomiting appear to be a problem. The difficulties described in the examination were quite mild and the shift of the diagnostic focus or new information did not change this examiner's previous opinion that there was very little if any mental health effect on his employment capability. The above diagnosis was likely residual but more likely than not chronic mild adjustment problems related to common family issues rather than being caused by or related to events or diagnoses during service. A September 2006 e-mail from the examiner who conducted the April 2005 VA examination clarified that he reviewed the claims file. As shown by the evidence, the veteran's service-connected disorder consists of both physical manifestations of a gastrointestinal nature and psychological manifestations. When evaluating a mental disorder, the VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA 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. 38 C.F.R. § 4.126(a) (2006). When evaluating the level of disability from a mental disorder, the VA 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). Under 38 C.F.R. § 4.126(d), when a single disability has been diagnosed both as a physical condition and as a mental disorder, the rating agency shall evaluate it using a diagnostic code which represents the dominant (more disabling) aspect of the condition. The agency of original jurisdiction should clearly explain what aspect of his service-connected condition represents the dominate aspect of his condition. The veteran is currently rated at 10 percent for irritable bowel syndrome under 38 C.F.R. § 4.114, Diagnostic Code 7319. This has been considered by the RO to be the dominant aspect of the condition. However the Board will consider the veteran's psychiatric manifestations pursuant to the criteria for evaluating psychiatric disorders to determine whether such manifestations may be the dominant aspect warranting greater than the initial 10 percent rating in effect under the criteria for digestive disorders. According to the General Rating Formula for Mental Disorders in effect since November 7, 1996, a 100 percent evaluation is warranted for the following: 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. A 70 percent evaluation is warranted for the following symptoms: 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. A 50 percent evaluation is warranted for the following symptoms: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 30 percent evaluation is warranted for the following symptoms: 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 10 percent evaluation is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. In addition, the evaluation must be 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. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126 (2006). The GAF is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FOURTH ED, American Psychiatric Association (1994) (DSM-IV), p.32; 38 C.F.R. §§ 4.125(a), 4.130 (2005). ). GAF scores of 81 to 90 indicates absent or minimal symptoms (e.g. mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, with no more than everyday problems (e.g. an occasional argument with family members.) GAF scores of 71 to 80 indicates that, if symptoms are present at all, they are transient and expectable reactions to psychosocial stressors with no more than slight impairment in social and occupational functioning. Scores of 61 to 70 are indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. Scores of 51-60 involve moderate symptoms, such as flat affect and circumstantial speech, occasional panic attacks, or moderate difficulty in social or occupational functioning (e.g., few friends or conflicts with peers or co-workers.) Scores ranging from 41 to 50 reflect 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). Id. Scores ranging from 31 to 40 reflect 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 younger children, is defiant at home, and is failing at school). Id. Scores of 21-30 indicate that behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). Based upon review of the evidence, the Board agrees with the RO's findings that the psychiatric manifestations shown by the veteran are not the predominant factor of disability. His overall psychiatric condition would not exceed the criteria for 10 percent under the General Rating for psychiatric conditions as they are generally mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. The April 2005 VA psychiatric examination in particular showed his psychiatric manifestations to be no more than mild, with his complaints generally centered around the normal stresses of marriage and family, as well as some complaints of fatigue from sleeping only 4 to 5 hours a night. He has not had treatment or counseling for psychiatric complaints since the service. His work has not been adversely affected by psychiatric complaints and he had a good social life. His GAF was said to be 65 which suggests only mild symptoms; his overall lack of psychiatric symptoms described in detail in this examination suggest only minimal symptomatology, if any. Compared to the mild psychiatric complaints with no history of treatment since service, the records and examination reports do confirm the predominant disability to be the veteran's gastrointestinal complaints of irritable bowel syndrome and neurogenic vomiting. He is shown to have missed work at times due to symptoms and has sought treatment throughout the pendency of this appeal for gastrointestinal complaints. Thus having determined that the veteran's gastrointestinal complaints are the predominant disability, the Board must consider whether an initial rating in excess of 10 percent disabling is warranted for such complaints under the applicable criteria. Under Diagnostic Code 7319, irritable bowel syndrome will be rated as noncompensably disabling when mild, with disturbances of bowel function and with occasional episodes of abdominal distress. In order to warrant a 10 percent rating, the disability must be moderate with frequent episodes of bowel disturbance with abdominal distress. For severe disability, with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress, the rating will be 30 percent. 38 C.F.R. § 4.114, Diagnostic Code 7319. A review of the evidence fails to show the veteran's irritable bowel syndrome symptoms warrant an initial rating in excess of 10 percent disabling. Although he is shown to have symptoms of alternating constipation and diarrhea, his symptoms are not shown to be severe with more or less constant abdominal distress. To the contrary, his symptoms are shown to be alleviated with dicyclomine. Although he sometimes still experiences nausea, vomiting is no longer shown to be a problem in the more recent VA examination from March 2005, which indicates the dicyclomine helped with this. The records and VA examination reports, including the most recent VA examination report of March 2005 failed to show evidence consistent with constant abdominal distress on objective examinations which repeatedly showed no tenderness and normal bowel sounds. He was said to only miss about 1 or 2 work days per month from diarrhea in March 2005. Overall the evidence from the time from initial entitlement reflects the veteran's irritable bowel syndrome symptoms to be no more than moderate and thus warranting no more than initial 10 percent rating in effect. Thus the preponderance of the evidence is against an initial rating in excess of 10 percent for the veteran's irritable bowel syndrome with psychogenic vomiting. The Board also finds that the criteria for invoking the procedures for assignment of a higher evaluation on an extra- schedular basis have not been met in the absence of evidence showing that the veteran's service-connected irritable bowel syndrome disorder resulted in marked interference with employment (i.e., beyond that contemplated in the assigned evaluation); warranted frequent periods of hospitalization; or otherwise has rendered impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial disability rating in excess of 10 percent for irritable bowel syndrome with psychogenic vomiting is denied. ____________________________________________ A. BRYANT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs