Citation Nr: 0813521 Decision Date: 04/24/08 Archive Date: 05/01/08 DOCKET NO. 06-16 405 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to a disability rating higher than 30 percent for post-traumatic stress disorder (PTSD). ATTORNEY FOR THE BOARD Simone C. Krembs, Associate Counsel INTRODUCTION The veteran served on active duty from September 1965 to April 1969. The veteran was awarded the Purple Heart during his service. This appeal comes before the Board of Veterans' Appeals (Board) from a February 2005 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection and awarded a 30 percent disability rating for PTSD, effective July 13, 2004, and denied his claim for service connection for a low back disability. FINDINGS OF FACT 1. The veteran does not have a current diagnosis of a low back disability. 2. The veteran's PTSD has been productive of no more than occupational and social impairment with occasional decrease in work efficiency with intermittent inability to perform occupational tasks with depression, anxiety, sleep impairment, suspiciousness, weekly panic attacks, and mild memory loss, but with otherwise satisfactory routine behavior, self-care, and normal conversation. CONCLUSIONS OF LAW 1. A claimed low back disability was not incurred in or aggravated by the veteran's active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2007). 2. The criteria for a disability initial rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1-4.14, 4.125- 4.130, Diagnostic Code (DC) 9411 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000, 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2007), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The notice required by the VCAA can be divided into four elements. Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; (3) that VA will attempt to obtain; and (4) request that the claimant provide any evidence in his or her possession that pertains to the claim. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice errors are presumed prejudicial unless VA shows that the error did not affect the essential fairness of the adjudication. To overcome the burden of prejudicial error, VA must show (1) that any defect was cured by actual knowledge on the part of the claimant; (2) that a reasonable person could be expected to understand from the notice what was needed; or, (3) that a benefit could not have been awarded as a matter of law. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). In August 2004, prior to the initial adjudication of the claim for service connection for a low back disability, the veteran was notified of the evidence not of record that was necessary to substantiate the claim. He was told that he needed to provide the names of persons, agency, or company who had additional records to help decide his claim. He was informed that VA would attempt to obtain review his claim and determine what additional information was needed to process his claim, schedule a VA examination if appropriate, obtain VA medical records, obtain service records, and obtain private treatment reports as indicated. It was also requested that he provide evidence in his possession that pertained to the claim. There is no allegation from the veteran that he has any evidence in his possession that is needed for a full and fair adjudication of this claim. Under these circumstances, the Board finds that the notification requirements of the VCAA have been satisfied as to both timing and content. The purpose behind the notice requirement has been satisfied and the veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim. With respect to the Dingess requirements, the veteran was provided with notice of the type of evidence necessary to establish a disability rating or effective date for the disability on appeal in May 2006. There is no prejudice in issuing a final decision because the preponderance of the evidence is against the claim for service connection. Any questions as to the appropriate disability rating or effective date to be assigned are moot. Therefore, adequate notice was provided to the appellant with respect to his claim for service connection for a low back disability prior to the transfer and certification of the veteran's case to the Board and complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). The veteran's claim for an increased rating for PTSD arises from his disagreement with the initial evaluation assigned following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Accordingly, the Board finds that VA satisfied its duties to notify the veteran with respect to his claim for an increased rating. As to VA's duty to assist, VA has associated with the claims file the veteran's private and VA treatment records, and afforded him a VA psychiatric examination in January 2005. In addition, the veteran was offered the opportunity to testify before the RO and the Board, but he declined such offer. The Board finds these actions have satisfied VA's duty to assist with respect to both the claim for service connection for a low back disability and the claim for an increased rating for PTSD and that no additional assistance is required. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). Lastly, According to Vazquez-Flores v. Peake, -- Vet. App. -- , No. 05-0355, 2008 WL 239951 (Jan. 30, 2008), for an increased-compensation claim, section 5103(a) requires, at a minimum, that the Secretary notify the claimant that, to substantiate a claim, the claimant must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Further, if the Diagnostic Code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. As with proper notice for an initial disability rating and consistent with the statutory and regulatory history, the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation-e.g., competent lay statements describing symptoms, medical and hospitalization records, medical statements, employer statements, job application rejections, and any other evidence showing an increase in the disability or exceptional circumstances relating to the disability. In this case, the claimant was provided pertinent information in VCAA notice cited above and in the May 2006 statement of the case. Cumulatively, the veteran was informed that the applicable diagnostic code under which the service-connected PTSD is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such the global assessment of functioning (GAF) score ). The claimant was informed that should an increase in disability be found, a disability rating will be determined by applying the relevant diagnostic code. He was also informed as to the evidence that the claimant may submit (or ask the Secretary to obtain) relevant to establishing entitlement to increased compensation. As such, the Board finds that the requirements under Vazquez-Flores have been met. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2007). Service connection generally requires evidence of a current disability with a relationship or connection to an injury or disease or some other manifestation of the disability during service. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). Service connection for certain chronic diseases, including arthritis, will be rebuttably presumed if they are manifest to a compensable degree within one year following active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2007). 38 U.S.C.A. § 1154 provides a relaxed evidentiary standard of proof to grant service connection for combat veterans. Collette v. Brown, 82 F.3d 389 (1996). In the case of any veteran who engaged in combat with the enemy in service, the Secretary shall accept as sufficient proof of service- connection of any disease or injury alleged to have been incurred in or aggravated by such service, satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. See also 38 C.F.R. § 3.304(d) (2007). Accordingly, since the veteran received the Purple Heart Medal for injuries received during combat, the relaxed standard under section 1154 is application in this case. The analysis required by 38 U.S.C.A. § 1154(b), however, applies only to the second element of service connection under the test established by Caluza v. Brown, 7 Vet. App. 498 (1995). That is, whether an injury or disease was incurred or aggravated in service. It does not apply to the questions of whether there is a current disability or a nexus connecting the disability to service. See Caluza; See Collette. Competent evidence is required to establish the veteran's current disability and the nexus connecting that disability to an in service injury or disease. That is, the veteran must meet his evidentiary burden with respect to service connection. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d) (2007). For the showing of chronic disease in service, there must be a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, evidence of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (2007). Service connection may also be granted for a disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2007). The veteran's service medical records do not demonstrate any complaints, treatment, or diagnoses related to the spine. As no disorder of the back was diagnosed in service, the Board finds that chronicity in service is not established in this case. 38 C.F.R. § 3.303(b). As chronicity in service has not been established, a showing of continuity of symptoms after discharge is required to support the veteran's claim for service connection of his back disability. 38 C.F.R. § 3.303(b). In this case, however, post-service medical records also do not demonstrate a diagnosis of a low back disability. On VA psychiatric examination in January 2005 the veteran complained of experiencing back pain. There is no indication that the veteran described the difficulties he was experiencing with his back, and no assessment of his complaints was made at that time. There are no other clinical records related to complaints of low back pain. Additionally, the veteran has not submitted any statements to VA regarding the incurrence of his claimed back disability. While in September 2004 the veteran submitted a statement regarding treatment he had received, the treatment he mentioned pertained to PTSD and not the back. In short, clinical records dated from January 2005 to August 2007 do not demonstrate a current diagnosis of a low back disability. Nevertheless, the veteran is competent to offer testimony regarding the nature, frequency, and severity of the observable symptoms of his condition. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The veteran is thus competent to report that he experiences low back pain. He is not, however, competent to establish a nexus between an in-service event or injury and a medical diagnosis. See Savage v. Gober, 10 Vet. App. at 495-97; Hickson v. West, 12 Vet. App. 247, 253 (1999). Here, whether the veteran's current complaints of low back pain are related an in-service occurrence requires a medical opinion because that relationship is not capable of lay observation. Significantly, no medical professional has related the veteran's complaints of low back pain to any in-service event. In light of the insufficient medical evidence of a nexus between the veteran's complaints of low back pain and his service, VA's duty to assist the veteran in obtaining evidence sufficient to substantiate the claim is relevant. In this case, however, the Board finds that VA has satisfied its duty to assist. Because there is no evidence demonstrating low back pain at any time during service or at separation from service, and there is no competent or credible evidence of record suggesting that the veteran's current complaints of low back pain are related to his period of service, the Board finds that a VA examination is not required in this case. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). More importantly, at present there is no evidence establishing a diagnosis of a low back disability. As a low back disability has not been diagnosed, service connection for a low back disability must, necessarily, be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In sum, the Board has carefully weighed the evidence of record, the statements of the veteran, and the treatment records, in light of the applicable law, and finds that equipoise is not shown. As the weight of medical evidence fails to support the veteran's claim for service connection, the Board is unable to grant the benefits sought. Increased Rating Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § Part 4 (2007). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities (Rating Schedule), which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2007). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2007). The veteran's PTSD has been rated as 30 percent disabling under DC 9411. Under DC 9411, a 30 percent disability rating is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted where there is 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 70 percent rating is warranted where the psychiatric condition produces 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. A maximum 100 percent rating is warranted where there is total occupational or 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. 38 C.F.R. § 4.130, DC 9411. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The veteran underwent VA examination for PTSD in January 2005. At that time, he reported that he had not received psychotherapy for PTSD. He described his current symptoms as experiencing intrusive thoughts related to his experiences during the Vietnam War, which had intensified in severity and frequency since his retirement and the commencement of the war in Iraq. Mental status examination revealed a depressed mood with full affect. His speech was noted to be of normal rate and flow, and there was no impairment of his thought process. His thought content was normal, and no perceptual problems were noted. He denied suicidal and homicidal ideations. His memory was determined to be intact. With regard to his social history, the veteran reported that he had been married to his wife for 38 years. He stated that he socialized with his family and friends, noting that he had three daughters, and seven grandchildren, whom he saw often. With regard to his occupational history, the veteran reported that he had retired from the Chicago Transit Authority after a 28-year career. He estimated that he had missed several hours of work as a result of his PTSD. The examiner determined that the veteran's psychiatric problems did not impair his activities of daily living. He was diagnosed with PTSD, and a GAF of 65 was assigned. The record reflects that the veteran began undergoing therapeutic treatment for PTSD in May 2006. While records associated with this treatment dated from May 2006 are not of record, a July 2006 letter from the veteran's social worker provides a detailed account of his therapy from May 2006 to July 2006. The veteran's symptoms were described as primarily involving guilt about surviving while numerous fellow servicemen did not, and regarding many of the things he had to do in order to survive in Vietnam. The veteran also experienced recurrent and intrusive recollections of traumatic events he experienced in Vietnam, in the form of images, thoughts, nightmares, and perceptions. He described feeling angry and sad, and was noted to experience emotional decomposition with tearful episodes and a sense of vulnerability. He additionally reported feelings of detachment or estrangement from others, problems with irritability, inability to sleep, impaired concentration, hypervigilance, fear of crowds, and severe difficulties with panic disorder. The veteran's difficulties with stress and disturbances were found to cause clinically significant impairment in social, occupational, and other important areas of functioning. Specifically, remembering traumatic experiences often caused panic attacks. In effort to avoid panic attacks, the veteran admitted to persistent avoidance of stimuli associated with trauma, and numbing of general responsiveness, as indicated by efforts to avoid thoughts, feelings, or conversations associated with the trauma, efforts to avoid activities, places, or people that aroused recollections of the trauma. He was noted to have an inability to recall important aspects of his trauma, and markedly diminished interest or participation in significant activities. Based upon therapeutic treatment from May to July 2006, the veteran's social worker determined that the most appropriate diagnosis for the veteran was PTSD that was productive of severe social and occupational impairment. The extent of his occupational impairment was such as to prohibit him from securing or following any substantially gainful occupation. A GAF of 38 was assigned. VA treatment records dated from September 2006 to August 2007 show that the veteran received treatment for PTSD manifested by guilt, hypervigilance, flashbacks, hallucinations, sleep disturbance, irritability, anger, problems with concentration, occasional panic attacks, and isolation from others. He reportedly lives in the basement of his house, while his wife lives upstairs. Other findings include notations that his cognitive functions are preserved. His PTSD symptoms have reportedly been exacerbated by the Iraq War and the death of a close friend. These records also show that the veteran reportedly felt "a little cooler and calmer" with treatment, and that he felt his symptoms improved with medication, in that he felt less sad and less nervous. He additionally described his sleep as improved, noting that he was generally able to go back to sleep after awakening at night, provided that he did not awaken from a nightmare. The veteran did not seek private treatment for PTSD during this period. The January 2005 VA examination assigned a GAF score of 65. Treatment records show GAFs of 38 and 75. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (Mar. 1995); 60 Fed. Reg. 43186 (1995). Under DSM-IV, a GAF score of 38 reflects behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment, or an inability to function in almost all areas. A GAF score of 65 generally reflects 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, and having some meaningful interpersonal relationships. A GAF score of 75 suggests that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after a family argument), and that there is no more than slight impairment in social, occupational, or school functioning (e.g., occasionally falling behind in schoolwork). While the veteran has indicated that he most often isolates himself and that he lives in the basement while his wife lives upstairs, he has reported that he does socialize with his children, grandchildren, and friends. Thus, while the veteran often isolates himself, it appears that he does have some significant social contacts and social activities. Additionally, while the veteran is currently retired, it appears that he had a steady and successful career with the Chicago Transit Authority. Nevertheless, the veteran has indicated that despite a relatively successful employment history, he has consistently had difficulty controlling his temper. Additionally, he has reported that he generally prefers to isolate himself. While the veteran may occasionally experience an exacerbation of his symptoms, the Board finds that his symptoms overall appear to be in the category of mild to moderate. In any event, the emphasis in psychiatric ratings is not solely on social impairment, but rather includes an evaluation of how the mental disorder interferes with the ability to work. 38 C.F.R. § 4.126 (2007). Here, the veteran retired after a 28-year career, and the January 2005 VA examiner found that his psychiatric disability did not impair his daily functioning. The Board finds that the rather dismal GAF score assigned by the veteran's social worker does not match the veteran's better social functioning. Additionally, the Board finds it significant that the veteran himself reported an improvement in his symptoms since the July 2006 evaluation, as a result of therapy and medication (see January 2007 VA medical notations). In sum, there is no indication that the veteran's psychiatric disability overall has interfered with his ability to work beyond that contemplated by the 30 percent rating criteria. Based upon the veteran's symptoms overall since the effective date of service connection, the Board finds that the severity of the veteran's PTSD overall appears to be in the category of mild to moderate. Additionally, there is no evidence of a disorder in thought process or content, or of psychotic symptoms. These factors indicate that since the effective date of service connection, he has been not seriously occupationally and socially impaired. PTSD of a mild to moderate disability warrants a 30 percent disability rating but no more. In the judgment of the Board, the evidence as a whole demonstrates occupational and social impairment with occasional reduced reliability and productivity due to various symptoms, as required for a 30 percent rating under DC 9411. With respect to whether his disability warrants more than a 30 percent disability rating, however, the Board finds that the preponderance of the evidence is against entering such a finding. The veteran has not been shown to have overall reduced reliability and productivity, as he has close familial relationships, and his work history was stable. Nor has he been shown to have circumstantial, circumlocutory, or stereotyped speech; difficulty understanding complex commands; impairment of memory; impaired judgment; or impaired abstract thinking. Therefore, the Board finds that an evaluation in excess of 30 percent is not warranted. The Board has considered whether a higher rating might be warranted for any period of time during the pendency of this appeal. Fenderson, 12 Vet. App. at 125-26; Hart, 21 Vet. App. 505. However, the weight of the credible evidence demonstrates that a 30 percent rating but no more has been warranted since July 13, 2004, the effective date of service connection. As the preponderance of the evidence is against the claim for an increased rating, the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 50 (1990). In reaching this decision, the potential application of various provisions of Title 38 of the Code of Federal Regulations have been considered, whether or not they were raised by the appellant, as required by the holding of the Court in Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991), including the provisions of 38 C.F.R. § 3.321(b)(1). The Board finds that the evidence of record does not present "an exceptional or unusual disability picture so as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). In this case, there has been no assertion or showing by the appellant that his PTSD has necessitated frequent periods of hospitalization or that his PTSD alone has interfered with his employability. Although it can be argued that the service-connected PTSD has made it very difficult to maintain employment, any such impairment is already contemplated by the applicable schedular criteria. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). In the absence of the factors set forth above, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Service connection for a low back disability is denied. A disability rating in excess of 30 percent for PTSD is denied. ____________________________________________ C. TRUEBA Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs