Citation Nr: 1301559 Decision Date: 01/15/13 Archive Date: 01/23/13 DOCKET NO. 10-38 235 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1966 to February 1968 and his decorations include the Purple Heart. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, which, in pertinent part, granted service connection for PTSD and assigned a 10 percent disability rating, effective February 19, 2009. In an October 2010 Supplemental Statement of the Case (SSOC), the RO increased the 10 percent initial evaluation for PTSD to 30 percent disabling, effective February 19, 2009. The Veteran was advised of the October 2010 SSOC, but did not express agreement with the decision or withdraw the appeal. In AB v. Brown, 6 Vet. App. 35 (1993), the United States Court of Appeals for Veterans Claims (Court) held that, on a claim for an initial or increased rating, a veteran will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and it follows that such a claim remains in controversy, even if partially granted, where less than the maximum benefit available is awarded. Because the assigned 30 percent disability rating is not the maximum benefit available for the service-connected PTSD, this appeal continues for the entire initial rating period. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. FINDINGS OF FACT 1. All relevant evidence necessary to decide the Veteran's appeal has been obtained. 2. For the entire initial rating period, the service-connected PTSD more nearly approximates a manifestation of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 30 percent for PTSD have not been met for any period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and the representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. In addition, 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 a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection was awarded. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the present appeal, a March 2009 letter included the type of evidence necessary to establish a disability rating and effective date for the disability on appeal. The Board finds that the VCAA notice requirements have been satisfied by the March 2009 letter. In this letter, VA informed the Veteran that in order to substantiate a claim for service connection, the evidence needed to show he had a current disability, a disease or injury in service, and evidence of a nexus between the post-service disability and the disease or injury in service, which was usually shown by medical records and medical opinions. As to informing the Veteran of which information and evidence he was to provide to VA and which information and evidence VA would attempt to obtain on his behalf, VA informed him it had to obtain any records held by any federal agency. This letter also informed him that on his behalf, VA would make reasonable efforts to obtain records that were not held by a federal agency, such as records from private doctors and hospitals. Finally, the RO told the Veteran that he could obtain private records himself and submit them to VA. The claim on appeal arises from the Veteran's disagreement with the initial disability rating of 10 percent assigned after the grant of service connection. The courts have held, and VA's General Counsel has interpreted that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-03 (separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). See also 38 C.F.R. § 3.159(b)(3)(i) (there is no duty to provide VCAA notice upon receipt of a notice of disagreement). Regarding the duty to assist, VA must make reasonable efforts to assist a 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; 38 C.F.R. § 3.159. In connection with the claim on appeal, the evidence of record includes the Veteran's service treatment records, VA outpatient treatment records, statements from the Veteran, statement from the Veteran's wife, and VA examination reports dated May 2009 and October 2011. The VA examiners reviewed the Veteran's claims file and medical history, recorded pertinent examination findings, and provided conclusions with supportive rationale. The Board notes that the VA examination reports are probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board acknowledges that VA outpatient treatment records note the Veteran reported in March 2010 that he is applying for social security and in December 2010 that he is considering applying for social security benefits. Records from the Social Security Administration (SSA) need not be obtained in this instance because the most recent VA outpatient treatment record, as noted, does not indicate the Veteran has applied for, nor is receiving, SSA benefits pertinent to his service-connected PTSD; therefore, such records are deemed to be relevant to the issue currently on appeal. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) (holding that SSA records need not be obtained if they are not relevant or potentially relevant to a claim). For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claim on appeal. The evidence of record provides sufficient information to adequately evaluate the claim, all obtainable evidence identified by the Veteran relative to the claim has been obtained and associated with the claims file, and the Board is not aware of the existence of any additional relevant evidence which was not obtained. Therefore, no further assistance to the Veteran with the development of evidence is required. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). Disability Rating Legal Criteria Disability evaluations are determined by the application of the schedule of ratings which is based on average impairment of earning capacity. See U.S.C.A. § 1155 (West 2002). Separate diagnostic codes identify the various disabilities. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). When entitlement to compensation has been established and a higher initial evaluation is at issue, the level of disability at the time entitlement arose is of primary concern. Consideration must also be given to a longitudinal picture of a veteran's disability to determine if the assignment of separate ratings for separate periods of time, a practice known as "staged" ratings, is warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). 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 a manifestation of the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2012). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. Rating PTSD In an October 2009 notice of disagreement, via a VA Form 21-4138, the Veteran expressed disagreement with the initial disability rating of 10 percent and asserted his PTSD is more severe than the evaluation assigned. In a September 2010 substantive appeal, via a VA Form 9, the Veteran contended he should receive a 50 percent disability rating for PTSD as he is taking medication, attending individual and group therapy sessions, and has been dealing with PTSD for years. Pursuant to the rating criteria for mental disorders, the service-connected PTSD has been initially rated at 30 percent disabling under Diagnostic Code 9411, effective February 18, 2009. A 30 percent disability evaluation is assigned for occupational and social impairment with evidence of 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, and mild memory loss (such as forgetting names, directions, or recent events). 38 C.F.R. § 4.130. A 50 percent disability evaluation 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 in short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and a veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2012). 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. Id. The rating agency shall also consider the extent of social impairment, but not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Moreover, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The Global Assessment of Functioning (GAF) Scale reflects the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the DSM-IV. A score of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). See Carpenter v. Brown, 8 Vet. App. 240, 242-44 (1995). A score of 61 to 70 is defined as 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, has some meaningful interpersonal relationships. Id. After a full review of the record and consideration of whether the assignment of separate ratings for separate periods of time is warranted, the Board finds that a preponderance of the evidence is against the Veteran's appeal for an initial disability rating in excess of 30 percent for PTSD for any period. As discussed below, the evidence of record indicates the service-connected disability more nearly approximates a manifestation of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to psychiatric symptomatology. Review of VA outpatient treatment records from March 2009 to December 2011, the date of the most recent record, show objective findings of the Veteran appropriately dressed with good hygiene, cooperative, and alert and oriented to time, person, and place. The Veteran displayed good eye contact, his speech was clear, spontaneous, fluent, normal in rate, tone, and volume, and no problems were observed in speech or psychomotor activity. The Veteran denied auditory or visual hallucinations and suicidal or homicidal ideation, intent, or plan, and his thoughts were characterized as logical with no problems in stream or content and not manifested by delusions. Thought process was marked as coherent, linear, and goal directed, and insight and judgment appeared fair and intact. With regard to the Veteran's mood and affect, in March 2009 he exhibited a moderate affect, in April 2009 a narrow affect, and from October 2009 to November 2010, a neutral mood and affect with mild positive mental attitude (PMA). In October 2011, his affect was noted as full, euthymic, laughing, and joking, and most recently in December 2011 the Veteran reported his mood as "disappointed, a little down" and affect was congruent with stated mood. Pursuant to such treatment sessions, the Veteran also reported complaints of sleep impairment, nightmares, and perseverative traumatic memory, and in March 2009 he reported having periods of depression and anxiety or panic attacks exacerbated by his lack of work and finances. Moreover, the Veteran underwent VA outpatient group psychiatric therapy from November 2009 to April 2010. In May 2009, the Veteran underwent a VA examination in connection with his claim to reopen the issue of service connection for PTSD. Review of his social history revealed the Veteran gets along well with all of his children, has a good relationship with close and extended family, has lots of friends and enjoys interacting with them and his family, and does not isolate or avoid contact. Results from the Beck Depression Inventory (BDI2) testing were in the severe range. The Veteran endorsed significantly less sleep, more agitation, guilty feelings, worthlessness, problems with concentration, poor energy, self-dislike, pessimism, crying spells, and irritability. Following a review of the claims file and clinical evaluation of the Veteran, the VA examiner concluded that the Veteran suffers from mild combat-related PTSD and depression, there does not appear to be any significant occupational impairment resulting from the PTSD, social impairment is mild, and emotional impairment is moderate to severe. In a May 2009 addendum opinion, the VA examiner reported that upon clinical evaluation of the Veteran's mental status, the Veteran presented neatly and appropriately groomed, made good eye contact, and was pleasant and cooperative. The Veteran became tearful when describing his traumas, was visibly anxious, and described his mood as nervous, appetite as fair, and energy as poor. He also noted sleep is impaired with difficulty falling and staying asleep and enjoys fishing, bowling, and playing games with his adult children. The Veteran noted sometimes he hears his name being called, but denied any suicidal or homicidal ideation or auditory or visual hallucinations and there were no findings of a formal thought disorder. There was mild PMA and judgment and insight were good. Most recently, at the October 2011 VA examination, the Veteran reiterated that he has a very good relationship with his family and a good social network of friends with whom he interacts regularly. Following a review of the claims file and clinical evaluation of the Veteran, the VA examiner affirmed the Veteran meets the PTSD diagnostic criteria, which encompasses findings of (1) persistent re-experience of the traumatic event, (2) persistent avoidance of stimuli associated with the trauma and numbing of a general responsiveness, and (3) persistent symptoms of increased arousal not present before the trauma. The noted symptomatology included: recurrent and distressing recollections and dreams of the event, acting or feeling as if the traumatic event were recurring, intense psychological distress at and physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event, efforts to avoid thoughts, feelings, or conversations associated with the trauma, efforts to avoid activities, places, or people that arouse recollections of the trauma, inability to recall an important aspect of the trauma, markedly diminished interest or participation in significant activities, feeling of detachment or estrangement from others, restricted range of affect, sense of a foreshortened future, difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. The VA examiner marked that the symptoms described above cause clinically significant distress and impairment in social, occupational, or other important areas of functioning. Additional symptoms that apply to the Veteran's PTSD, from a provided list, include depressed mood and anxiety, and there were no other symptoms attributable to PTSD that were not listed. The VA examiner further noted the Veteran's level of occupational and social impairment with regard to the mental diagnosis of PTSD is best summarized by "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 medication. The VA examiner also concluded that: [W]ith reasonable degree of significant certainty, there is no evidence that there has been a worsening of symptoms since [the Veteran's May 2009 VA examination.] His self-report of DSM-IV symptoms of PTSD and depression are consistent with that reported in the 2009 evaluation. When asked for specifics, he gave a vague response that he is feeling 'more depressed' but also stated that his work is stressful and this depresses him. On the other hand, he is now working and stated that he is glad to have the steady income, compared to the last evaluation during which he was unemployed. He stated that he gets along well with his coworkers and supervisors and has no difficulty functioning in that regard. Socially and interpersonally, [the Veteran] gets along well with his family and social circle, although he does not see his friends as often as he would like due to living in different parts of the city. As opined in the [May 2009 VA examination,] the impact of PTSD on [the Veteran's] functioning appears to be primarily emotional, rather than occupational or social. In a September 2010 statement, the Veteran's wife reported the Veteran's personality has changed since her July 2005 letter to VA. The Veteran barely talks, does not initiate a conversation, and arguments do not seem to phase him. He is withdrawn, gets upset at the current media portrayal of the war, and seems to have more panic attacks lately. The Veteran does not like to be in the dark so sleeps with a nightlight. She concluded that although the Veteran joined a support group through VA and the Veteran asserts it seems to help, she noted that nothing changes at home. VA outpatient treatment records reflect the following GAF scores: 59 in March 2009; 60 in March 2009, October 2009, November 2009, December 2009 and March 2010; 61 in October 2011; 62 in May 2010, August 2010, November 2010, and December 2010; and 65 in December 2011. The May 2009 VA examiner also assigned a GAF score of 60. These assigned GAF scores are found to be consistent with the demonstrated symptomatology of record for the entire initial appeal period. GAF scores from 51 to 60 and 61 to 70 are indicative of moderate and mild symptoms, respectively, but when considering the evidence as a whole, do not justify assignment of a higher disability rating for any period in this case. The Board notes that an examiner's classification of the level of psychiatric impairment, by words or a GAF score is a factor for consideration and not determinative of the percentage VA disability rating to be assigned. See also 38 C.F.R. § 4.126(a). The Board is aware that the symptoms listed under the next-higher evaluations, to include 50 percent, 70 percent, and 100 percent, are essentially examples of the type and degree of symptoms for those evaluations, and that the Veteran need not demonstrate those exact symptoms to warrant a higher initial evaluation. See Mauerhan, 16 Vet. App. at 436. The Board has considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, as required by the Court in Schafrath v. Derwinski. However, after careful review of the available diagnostic codes and the lay and medical evidence of record, the Board finds there are no other diagnostic codes that provide a basis to assign an evaluation higher than the 30 percent disability rating currently assigned for any period. The Board has considered the reported history of symptomatology regarding the service-connected PTSD by the Veteran and acknowledges that he is competent to report such symptoms because this requires only personal knowledge as it comes through ones senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board also acknowledges that the Veteran's wife is competent to report her observations of the Veteran's psychiatric symptomatology. However, the Veteran and his wife are not competent to identify a specific level of the disability on appeal according to the appropriate diagnostic code. In this case, such competent evidence concerning the nature and extent of the service-connected PTSD has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran's and his wife's subjective evidence of complaints and increased symptomatology. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). Fully considering the lay and medical evidence of record, the service-connected PTSD more nearly approximates a manifestation of occupation and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to psychiatric symptomatology. However, the symptomatology does not indicate the Veteran's psychiatric symptomatology more nearly approximates a manifestation of the criteria for an initial disability rating in excess of 30 percent for any period. The 30 percent disability rating currently assigned recognizes the Veteran's degree of occupational and social impairment due to the listed psychiatric symptomatology consistent with such a rating under Diagnostic Code 9411 for the entire appeal period. Thus, a preponderance of the evidence is against an initial disability rating in excess of 30 percent for PTSD for any period. 38 C.F.R. §§ 4.3, 4.7. Extra-Schedular Consideration The evidence of record does not raise the issue of a total disability rating based on individual unemployability (TDIU) due to the service-connected PTSD for any period. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The Board acknowledges that in an April 2009 statement, via a VA Form 21-4138, the Veteran reported, with regard to his PTSD, that he is presently unemployed and more stressed out than ever, and a March 2009 VA outpatient treatment record notes the Veteran is an unemployed electrical draftsman and searching for a new job. Nonetheless, the May 2009 VA examination report clarified that the Veteran had a service job at Sears for 14 years and was laid off due to the recession then last worked in November 2008 after 8 months as an electrical designer from which he was laid off again due to the economy. Thereafter, an April 2010 VA outpatient treatment record noted the Veteran is working full time refinishing furniture, and the October 2011 VA examiner noted the Veteran is now working and reportedly gets along well with his coworkers and supervisors and has no difficulty functioning in that regard. Most recently, a March 2011 VA outpatient telephone report noted the Veteran has a full-time job as a contract employee, and an October 2011 VA outpatient treatment record noted the Veteran is employed full time and the Veteran reportedly characterized the episodes of unemployment as stressful and traumatic. As a result, the Board finds the weight of the evidence does not show that the Veteran's period of unemployment was due to the service-connected PTSD. Next, the Board has considered whether referral for an extra-schedular evaluation is warranted for the service-connected PTSD. In exceptional cases an extra-schedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, 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. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). 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. In the second step of the inquiry, however, 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 those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. Turning to the first step of the extra-schedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extra-schedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD more nearly approximates a manifestation of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to psychiatric symptomatology during the entire appeal period. The schedular rating criteria specifically include such a decree of impairment and analogous symptoms that are "like or similar to" listed schedular rating criteria. Mauerhan, 16 Vet. App at 442; see also 38 C.F.R. § 4.21. Additionally, the Board has considered GAF scores, which are incorporated through the DSM-IV as part of the schedular rating criteria, as reflective of the degree of severity of psychiatric symptoms or overall functional impairment caused by PTSD. For these reasons, the Board finds that the schedular rating criteria is adequate to rate the Veteran's PTSD, and referral for consideration of an extra-schedular evaluation is not warranted. ORDER An initial disability rating in excess of 30 percent for PTSD is denied. ____________________________________________ MARK W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs