Citation Nr: 1319774 Decision Date: 06/19/13 Archive Date: 06/27/13 DOCKET NO. 09-08 450 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder to include post-traumatic stress disorder (PTSD). 2. Entitlement to a rating in excess of 60 percent for asthma. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. D. Jackson, Counsel INTRODUCTION The Veteran served on active duty from September 1983 to November 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the RO in Cleveland, Ohio, which continued the Veteran's 60 percent disability rating for asthma and denied service connection for PTSD. Here, although the Veteran has claimed entitlement to service connection for PTSD, the record reflects she has been treated for a variously diagnosed disorder, to include PTSD and bipolar disorder. In light of the Clemons case, the Board finds that the claim for service connection should be considered as set forth above. Clemons v. Shinseki, 23 Vet. App. 1 (2009). In Clemons, the United States Court of Appeals for Veterans Claims (Court) clarified how the Board should analyze claims for PTSD and other acquired psychiatric disorders. Though a veteran may only seek service connection for PTSD, the claim "cannot be limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed." Id. Essentially, the Court found that a veteran does not file a claim to receive benefits only for an acquired psychiatric disorder, such as PTSD, but in fact makes a general claim for whatever mental condition may be afflicting the veteran. Thus, the rationale behind the Clemons decision is instructive and applicable here, and the issue on appeal is as stated on the first page. The Veteran testified before the undersigned at a June 2010 hearing at the RO. A transcript has been associated with the file. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veteran's Law Judge (VLJ) who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issue and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, the VLJ and the Veteran's representative asked questions pertinent to the requirements of service connection and attempted to discern whether the Veteran had symptoms meeting the schedular criteria for a higher rating. The VLJ sought to identify any pertinent evidence not currently associated with the claims and this case was remanded to procure this evidence. Moreover, as discussed below, the fact that the Veteran underwent VA examination to obtain medical opinions regarding the severity of his asthma and the etiology of his psychiatric disabilities shows that the Veteran was aware of the type of evidence that may have been overlooked. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). During the remand period, in December 2011, the AMC granted service connection for anxiety not otherwise specified (NOS). And since the Veteran did not, in response, appeal either the rating or effective date assigned for that disability it is no longer at issue. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement (NOD) thereafter must be timely filed to initiate appellate review of the claim concerning "downstream" issues such as the compensation level assigned for the disability and the effective date). FINDINGS OF FACT 1. The Veteran is service-connected for anxiety disorder (not otherwise specified). The most probative medical and other evidence of record does not establish the Veteran has additional psychiatric diagnoses to include PTSD and bipolar disorder which are related to service. 2. During the entire period, the Veteran's service-connected bronchial asthma has not been shown to be productive of FEV-1 less than 40-percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, nor did it require daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. CONCLUSIONS OF LAW 1. The Veteran does not have PTSD or bipolar disorder which were incurred in or aggravated by his military service. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5103A (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. The criteria for a rating in excess of 60 percent for bronchial asthma have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002 ); 38 C.F.R. §§ 3.102, 3.159, 4.96, 4.97, Diagnostic Codes 6602 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act The VCAA, codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations were created, codified at 38 C.F.R. § 3.159. A VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) 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 that the claimant is expected to provide. 38 C.F.R. § 3.159(b). The Court held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was provided letters dated in September 2007, May 2008, and November 2008 that indicated the types of information and evidence necessary to substantiate the claims, and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. The letters, also provides notice pertaining to the downstream disability rating and effective date elements of his claims. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Also during the pendency of this appeal, VA's regulations pertaining to the requirements for establishing a service-connection claim for PTSD were again amended effective July 13, 2010. See Stressor Determinations for PTSD, 75 Fed.Reg. 39843 (July 13, 2010) (amending 38 C.F.R. § 3.304(f)(3)). This most recent amendment liberalizes, in some cases, the evidentiary standard for establishing the required in-service stressor. Id. They do not, however, amend or modify the requirement that a Veteran have a DSM-IV diagnosis of PTSD. And absent this required diagnosis, there necessarily cannot be any linkage of this diagnosis to a traumatic event (i.e., "stressor") during his military service because there is no current disability due to this condition to attribute to his service, even were the Board to assume for the sake of argument that the claimed event(s) in service actually occurred. So this change to subpart (f)(3) has no bearing on the outcome of this appeal. The Board, therefore, is not required to remand this claim to apprise the Veteran of these revisions to this regulation. See Bernard v. Brown, 4 Vet. App. 384 (1993). All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. The evidence of record includes service treatment records (STRs), VA outpatient treatment reports, adequate VA examinations and opinions, as well as statements from the Veteran and his representative. In this regard, pursuant to the Board's September 2010 remand directive, the AMC obtained outstanding VA treatment records and his vocation rehabilitation folder. Additionally, he was provided VA compensation examinations for medical opinion concerning whether the claimed psychiatric disabilities are related to his military service, as well as the severity of his respiratory disorder. The findings were reported in a manner and format enabling the Board to address the elements needed to show entitlement to service connection, as well as a higher rating for asthma. The Board finds that the VA examinations are sufficient as they were predicated on a full reading of the VA medical records in the Veteran's claims file. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c) (4). Likewise, the Board finds that there was compliance with its September 2010 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in exhaustive detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. II. Psychiatric Disorder In general, service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to direct service connection for the claimed disability, there must be: (1) medical evidence of current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus or link between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). Service connection may be established either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Other diseases initially diagnosed after service also may be service connected if the evidence, including that pertinent to service, shows the diseases were incurred in service. 38 C.F.R. § 3.303(d). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The determination as to whether these requirements for service connection are met, regardless of the theory of entitlement alleged, is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). As already alluded to, service connection is now in effect for anxiety disorder as secondary to service-connected asthma. It is rated as 30 percent disabling effective since August 2007. However, the Veteran originally requested service connection for PTSD. The following decision addresses this matter. Service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that the claimed in-service stressor actually occurred; and (3) medical evidence of a link between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f). See also Cohen v. Brown, 10 Vet. App. 128 (1997). A diagnosis of PTSD need only be in accordance with 38 C.F.R. § 4.125(a), which simply mandates that, for VA purposes, all mental disorder diagnoses must conform to the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV). See 38 C.F.R. § 3.304(f). The Court has taken judicial notice of the mental health profession's adoption of the DSM-IV as well as its more liberalizing standards to establish a diagnosis of PTSD. The Court acknowledged the change from an objective "would evoke . . . in almost anyone" standard in assessing whether a stressor is sufficient to trigger PTSD to a subjective standard (e.g., whether a person's exposure to a traumatic event and response involved intense fear, helplessness, or horror). Thus, as noted by the Court, a more susceptible person could have PTSD under the DSM-IV criteria given his or her exposure to a traumatic event that would not necessarily have the same effect on "almost everyone." Cohen, 10 Vet. App. 128, 140-141 (1997). As explained, the most fundamental requirement for any claim for service connection is that the Veteran must have proof he has the condition claimed. See Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328 (1997) (indicating VA compensation only may be awarded to an applicant who has disability existing on the date of application, not for past disability). But see, too, McClain v. Nicholson, 21 Vet. App. 319 (2007) (further clarifying that this requirement of current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Congress has specifically limited entitlement for service-connected disease or injury to cases where such incidents have resulted in disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998). Generally speaking, a current disability means a disability shown by competent medical evidence to exist. Chelte v. Brown, 10 Vet. App. 268 (1997). In presenting his arguments the Veteran contends that his PTSD is non-combat related and that he suffered from a severe bout of asthma in early 1991 while stationed in Saudi Arabia that resulted in his hospitalization and made him fearful that he might die. (This is the same theory that provided the basis for the grant of service connection for anxiety disorder.) The Veteran's STRs show that he was sent from Saudi Arabia to Germany due to asthma problems in 1991. He was not diagnosed as having PTSD in service. Following a claims file review, the Board concludes that the Veteran does not have a current diagnosis of PTSD, so he has not satisfied his threshold preliminary burden of at least establishing he has these claimed conditions. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). In the absence of credible and competent proof he has these alleged conditions, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (indicating service connection presupposes a current diagnosis of the condition claimed). In November 2010, the Veteran was afforded a VA compensation and pension examination to reconcile the nature and etiology of his psychiatric disabilities. The consulting psychiatrist reviewed the claims file. The Veteran indicated that the PTSD stressors were not combat related but was related to his asthma attacks. Following an examination, PTSD was not diagnosed. Rather, the diagnoses were anxiety (not otherwise specified) which has been service-connected and dysthymia. Dysthymia was not attributed to service. The VA examiner also addressed the issue of whether other psychiatric diagnoses in the record were valid and related to service. As to bipolar disorder, it was opined that it was unclear as to what symptoms (e.g. mania) formed the basis for this diagnosis. It was noted that the clinical records showed that the Veteran endorsed difficulties with anger and moodiness. He also had sleep difficulties, irritability, anger problems, and moodiness, as well as some periods of grandiosity, but no other symptoms of mania. Furthermore, the Veteran had been given a number of trial medications that would be appropriate for bipolar disorder, however, as confirmed by the Veteran, these were not helpful and did not alleviate symptoms. In sum, the 2010 VA psychiatric examiner did not render a diagnosis of PTSD or bipolar disorder following a claims file review and evaluation of the Veteran. It is acknowledged that other medical evidence to include VA outpatient records suggest other psychiatric diagnoses. Specifically, VA records dated in April 2007 show that the Veteran was examined on a walk-in crisis basis and PTSD was noted. VA outpatient records dated in January 2008 also include an Axis I diagnoses of PTSD and rule out bipolar disorder. The probative value of the VA outpatient records is limited as the basis for the rendered diagnoses was not provided. Further, the 2010 VA examiner suggested that any diagnoses of PTSD and bipolar disorder appeared to be essentially inconclusive given the lack of supportive symptoms. Just because a physician or other health professional accepted the Veteran's description of his experiences in service as credible and diagnosed him as suffering from PTSD does not mean the Board is required to grant service connection for PTSD. Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). The Board is not required to accept the Veteran's uncorroborated account of his active service experiences. See Swann v. Brown, 5 Vet. App. 229, 233 (1993) and Wood v. Derwinski, 1 Vet. App. 190, 192 (1991). The Board has weighed the reported history of PTSD and bipolar disorder noted in VA outpatient treatment records against the VA compensation and pension examination addressing the issue of the nature and etiology of all of the Veteran's psychiatric problems medical nexus and places more probative value on the medical opinions directly addressing the issue of causation. The Board gives greater probative weight to the report and opinion of this evaluating VA psychiatrist because of the consideration of the Veteran's pertinent medical and other history-as accomplished by reviewing the evidence in the claims file, but more so based on the discussion of the underlying rationale of the opinion, which instead is where most of the probative value is derived. See Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008) (indicating "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion."). This examiner also has medical expertise, which is another relevant consideration adding to this opinion's greater probative value. Moreover, this examiner's opinion is mostly supported by the other evidence of record, which, as mentioned, does not show the requisite criteria to substantiate diagnoses for either PTSD or bipolar disorder. In sum, post-service medical evidence is devoid of the necessary symptomatology required for diagnoses of PTSD or bipolar disorder in accordance with the DSM-IV criteria. And because the medical evidence of record does not establish the required DSM-IV diagnoses, the claims necessarily must be denied because there is no current PTSD or bipolar disorder to attribute to any incident that may have occurred during the Veteran's military service. Absent this required confirmation that he has these alleged conditions, these claims must be denied because the preponderance of the evidence is against them, so no reasonable doubt to resolve in the Veteran's favor. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Dela Cruz v. Principi, 15 Vet. App. 143, 148-49 (2001). Even if the Board were to assume, for argument purposes, that the Veteran does indeed have additional psychiatric diagnoses such as PTSD and bipolar disorder. There is absolutely no competent and credible evidence linking such disorders to service or a service-connected disability. III. Whether a Higher Rating Than 60 Percent is Warranted for Asthma Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board notes that staged ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In January 1992, the RO granted service connection for bronchial asthma, evaluated as 10 percent disabling, under 38 C.F.R. § 4.97, Diagnostic Code (DC) 6602. In May 1994, the RO decreased the Veteran's evaluation to 0 percent. In January 1996, the RO increased his rating to 10 percent. In November 1997, the RO increased his rating to 30 percent. In April 2001, the RO increased his rating to 60 percent. The Veteran filed his current claim for an increase in January 2007. Respiratory disorders are rated under 38 C.F.R. § 4.97, Diagnostic Codes 6600 through 6817 and 6822 through 6847. Under DC 6602, a 60 percent evaluation is assignable for bronchial asthma with FEV-1 of 40-to 55-percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; at least monthly visits to a physician for required care of exacerbations, or; intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids. A 100 percent evaluation is assignable for FEV-1 less than 40-percent predicted, or; FEV-1/FVC less than 40 percent, or; more than one attack per week with episodes of respiratory failure, or; requires daily use of systemic (oral or parenteral) high dose corticosteroids or immune-suppressive medications. 38 C.F.R. § 4.97, DC 6602. In March 2007, the Veteran underwent a VA examination for his asthma. It was noted that he complained of chest tightness, wheezing, shortness of breath, and medication side effects, which included puffiness of the face, sleep impairment, jitteriness, and hoarseness. He missed 60-75 days of work per year as a postal worker. He reported daily attacks and every other month they are severe enough to send him to the emergency room. He is hospitalized twice a year for 3-4 days due to asthma. He used Albuterol nebulizer daily. His post-bronchodilator pulmonary function test (PFT) results were FEV-1, 73 percent and FEV-1/FVC, 108 percent. The results of the March 2007 VA examination do not support the criteria for a 100 percent rating under DC 6602. Another VA examination was conducted in June 2008. He reported that he was unable to continue in his job as a mail handler due to exertion-induced shortness of breath. He had to go to the emergency room six times a year due to work exertion. He reported that he was incapacitated by an asthma attack once during the previous year. The examiner determined that there had been no clinical change in his exercised induced asthma since his last PFT in March 2007, thus she did not find a need to perform another test. The next PFT ratings date in February 2009. His post-bronchodilator PFT results were FEV-1, 89 percent and FEV-1/FVC, 109 percent. The results of the VA examination do not support the criteria for a 100 percent rating under DC 6602. At his hearing, the Veteran reported that he had to change jobs due to his asthma. He now delivered medications to various locations. He continued to seek treatment at VA. He used a nebulizer with an Albuterol solution three-times a day. Moreover, he was now prescribed the maximum dose of Advair. He also used Proventil, Albuterol, and Prednisone. He also stated that he experienced hoarseness that resulted from his asthma medication. He reported a past history of emergency room treatment for asthma as a result of work. The most recent VA examination was conducted in January 2012. On the examination report, it was noted that his respiratory condition required the chronic low dose use of oral corticosteroid. He used an inhational bronchodilator therapy and anti-inflammatory medication on a daily basis. His medications included Metasone Furoate (corticosteroid), Montelukast, Ipratropium, and Albuterol. He did not have any asthma attacks with episodes of respiratory failure or a physician's visit within the previous 12 months. His March 2012 post-bronchodilator PFT results were FEV-1, 93 percent and FEV-1/FVC, 110 percent. These results do not support the criteria for a 100 percent rating under DC 6602. As reflected in the rating criteria, a 60 percent rating is assigned for intermittent (at least three per year) courses of systemic (oral or parenteral) corticosteroids and a 100 percent evaluation is assignable for daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications. The Board takes notice that Metasone Furoate contains a corticosteroid. And as reported by the most recent VA examiner the Veteran's corticosteroid dosage is considered a low dose by medical standards. As such, the Board finds that a daily usage of such medication more nearly approximates the criteria for a 60 percent rating. Accordingly, the criteria for a 100 percent rating are not met. 38 C.F.R. §§ 4.7, 4.97, DC 6602; see Hart, 21 Vet. App. 505. The above determinations are based upon application of the pertinent provisions of VA's rating schedule. Furthermore, the Board finds that the record does not reflect that the Veteran's service-connected asthma is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular 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. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). In this case, the Board finds that the rating criteria found in 38 C.F.R. § 4.97, DC 6602, reasonably describe the Veteran's disability level and symptomatology. Consequently, his disability level is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate. For these reasons no extraschedular referral is required. 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). ORDER Service connection for PTSD and bipolar disorder is denied. An increased rating in excess of 60 percent for bronchial asthma is denied. ____________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs