Citation Nr: 1325656 Decision Date: 08/14/13 Archive Date: 08/16/13 DOCKET NO. 08-29 329 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent prior to November 3, 2008 for an acquired psychiatric disability. 2. Entitlement to an initial rating in excess of 50 percent as of November 3, 2008 for an acquired psychiatric disability. 3. Entitlement to an initial rating in excess of 20 percent from August 17, 2006 to March 10, 2009 for pars defect, lumbar spine L5-S1 (lumbar spine disability). 4. Entitlement to an initial rating in excess of 40 percent as of September 1, 2009 for pars defect, lumbar spine L5-S1 (lumbar spine disability). REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and her sister ATTORNEY FOR THE BOARD T. Blake, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1989 to January 2002, with service in the National Guard. This case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. The RO, in pertinent part, granted service connection for a lumbar spine disability assigned at 20 percent disabling, effective August 17, 2006, and granted service connection for major depression, assigned at 30 percent disabling, effective August 17, 2006. During the course of the appeal, the evidentiary development has resulted in evidence showing psychiatric diagnoses of major depression, bipolar disorder, and anxiety disorder. In light of the evidence of record and the decision in Clemmons v. Shinseki, 23 Vet. App. 1 (2009), the Board has characterized the issue, formerly claimed as major depression, as service connection for an acquired psychiatric disability, which includes all psychiatric diagnoses. In a May 2010 supplemental statement of the case (SSOC), the RO increased the 20 percent disability rating for the lumbar spine disability to 100 percent disabling from March 11, 2009 to August 31, 2009 and to 40 percent as of September 1, 2009. The RO also increased the 30 percent disability rating for an acquired psychiatric disability to 50 percent disabling as of November 3, 2008. The Veteran was advised of the May 2010 SSOC, but did not express agreement or withdraw the appeals. 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. Since the assigned 20 percent rating from August 17, 2006 to March 10, 2009 and the 40 percent rating as of September 1, 2009 are not the maximum benefits available for the service-connected lumbar spine disability, this appeal continues for these identified initial rating periods. Similarly, since the assigned 30 percent rating prior to November 3, 2008 and the 50 percent rating thereafter are not the maximum benefits available for the service-connected acquired psychiatric disability, this appeal continues for these identified initial rating periods. In April 2009, the Veteran testified at a local hearing before a Decision Review Officer (DRO). A copy of the transcript is of record in the physical claims file. In April 2013, the Veteran and her sister testified at a Board hearing held before the undersigned Veterans Law Judge in Indianapolis, Indiana. A copy of the transcript is in the Veteran's file on the "Virtual VA" system. During the April 2013 Board hearing, the Veteran and her representative presented testimony on the issues of entitlement to specially adapted housing and special home adaptation. The Board notes that these issues were denied by the RO in a November 2012 rating decision. In November 2012, the Veteran submitted a notice of disagreement for these issues on a VA Form 9, and the RO subsequently issued a December 2012 statement of the case (SOC). Although testimony was provided regarding these issues at the Board hearing; the Board finds that review of the record does not indicate a substantive appeal (VA Form 9) has been filed for these issues after issuance of the December 2012 SOC. As a result, these issues are not currently before the Board for appellate consideration. During the course of this case, a claim for a total disability rating based upon individual unemployability (TDIU) was inferred by the RO in January 2010. In a February 2011 rating decision, the RO granted TDIU benefits from September 1, 2009 to September 29, 2010. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Although testimony was provided regarding this issue at the April 2013 Board hearing, the Board finds that review of the record does not indicate a notice of disagreement has been filed for this issue after issuance of the February 2011 rating decision. Moreover, the Veteran has been in receipt of a combined schedular rating of 100 percent from March 11, 2009 to August 31, 2009 and as of September 29, 2010. As a result, this issue is not currently before the Board for appellate consideration. 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. From August 17, 2006 to November 2, 2008, the service-connected acquired psychiatric disability more closely approximated a manifestation of occupational and social impairment with evidence of occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to psychiatric symptomatology, and not productive of occupational and social impairment with reduced reliability and productivity due to psychiatric symptomatology. 3. From November 3, 2008 to October 16, 2012, the service-connected acquired psychiatric disability more closely approximated a manifestation of occupational and social impairment with reduced reliability and productivity due to psychiatric symptomatology, and not productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood due to psychiatric symptomatology. 4. As of October 17, 2012, the service-connected acquired psychiatric disability more closely approximates a manifestation of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood due to psychiatric symptomatology, and not productive of total occupational and social impairment due to psychiatric symptomatology. 5. From August 17, 2006 to March 10, 2009, the service-connected lumbar spine disability more closely approximated a manifestation of limited forward flexion, at worst, to 60 degrees, painful motion, tenderness, and diagnoses of lumbar spondylosis, spondylolisthesis, bilateral foraminal stenosis, degenerative joint disease, and degenerative disc disease, and not productive of forward flexion to 30 degrees or less or ankylosis of the entire thoracolumbar spine. 6. As of September 1, 2009, the service-connected lumbar spine disability more closely approximates a manifestation of limited forward flexion, at worst, to 30 degrees, painful motion, tenderness, muscle spasm, and diagnoses of spondylosis, lumbosacral strain, and post operative lumbar fusion, and not productive of ankylosis of the entire thoracolumbar spine. CONCLUSIONS OF LAW 1. From August 17, 2006 to November 2, 2008, the criteria for an initial disability rating in excess of 30 percent for an acquired psychiatric disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9434 (2012). 2. From November 3, 2008 to October 16, 2012, the criteria for an initial disability rating in excess of 50 percent for an acquired psychiatric disability have not been met for any period. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9434 (2012). 3. As of October 17, 2012, resolving all reasonable doubt in the Veteran's favor, the criteria for an initial evaluation of 70 percent, but no greater, for an acquired psychiatric disability have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9434 (2012). 4. The criteria for an initial rating in excess of 20 percent from August 17, 2006 to March 10, 2009 and in excess of 40 percent as of September 1, 2009 for pars defect, lumbar spine L5-S1 (lumbar spine disability) have not been met for any period. 38 U.S.C.A. §§ 1155, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.71a, Diagnostic Code 5237 (2012). 5. The criteria for an initial rating in excess of 40 percent as of September 1, 2009 for pars defect, lumbar spine L5-S1 (lumbar spine disability) have not been met for any period. 38 U.S.C.A. §§ 1155, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.71a, Diagnostic Code 5237 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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). 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 the 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 the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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. 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 claims on appeal. Acquired Psychiatric Disability Pursuant to the rating criteria for mental disorders, the Veteran's service-connected acquired psychiatric disorder is rated at 30 percent disabling prior to November 3, 2008 and at 50 percent disabling thereafter under Diagnostic Code 9434. 38 C.F.R. § 4.130. 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). Id. 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; see also Carpenter v. Brown, 8 Vet. App. 240, 242-44 (1995). Higher scores correspond to better functioning of the individual. Id. A score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). Id. A score of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. 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). Id. 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. Rating in excess of 30 percent from August 17, 2006 to November 2, 2008 Private outpatient behavioral health treatment records from October 2006 to November 2006 document the Veteran's belief that work likely exacerbates her mood problem and she feels down. Objective observations noted attentive/cooperative behavior, good eye contact, constricted affect, depressed mood, psychomotor agitation, relevant and logical thought process, well-groomed appearance, orientation to date, place, and person, normal speech, and no delusions or hallucinations. At a December 2006 VA psychiatric examination, the Veteran complained of interrupted sleep at night, transient suicidal ideation, socially withdrawn, and easily paranoid. She denied hallucinations, delusions, and homicidal thoughts. Following examination and review of the claims file, the examiner observed the Veteran is alert and oriented to time, place, and person, speaks clearly, provides coherent and relevant answers, displays a congruent affect and good recent and remote memory, and able to manage her benefits. There were also no findings of impairment of thought process or communication, effects on employment, or problems dressing, feeding, or bathing self. Axis I diagnosis listed recurrent major depression and a GAF score of 58. In an October 2007 statement, the Veteran asserted her major depression has gotten worse and is being treated for bipolar disorder. She also reported having trichotillomania, has been bulimic for at least 10 years, diagnosed with bipolar disorder because of mood swings, panic and anxiety attacks, low self esteem, and feeling angry, and frustrated all the time. In addition, friends have deserted her because of her mood swings, and she has not been in a steady relationship since 2002 due to lack of trust, which she blames on her father. She also feels people are watching and talking about her and forgets to take her medication. A March 2008 VA medical statement notes the Veteran's psychiatric diagnoses are bipolar disorder not otherwise specified (NOS), severe bulimia, trichotillomania, and anxiety disorder NOS. VA outpatient treatment records from February 2008 to August 2008 reveal the Veteran's complaints of manic depressive episodes, frequent mood swings, nightmares, sluggishness, irritability, and occasional depression. She appeared appropriately dressed, alert and oriented to person, place, and time, calm, and cooperative. She displayed euthymic mood, appropriate affect, good eye contact, animated affect, coherent and logical thoughts, good judgment and insight, and speech was spontaneous, appropriate, clear, and articulate. There were no findings of psychomotor agitation. She denied suicidal and homicidal ideation, auditory and visual hallucinations, and delusions. Axis I diagnoses listed bipolar disorder, bulimia nervosa, trichotillomania. The GAF scores assigned during this appeal period were 50 (VA outpatient treatment records dated March 2008, June 2008, and August 2008), 51 (February 2008 VA outpatient treatment record), and 58 (December 2006 VA examination report). The Board notes that higher scores correspond to better functioning. These assigned GAF scores are found to be consistent, overall, with the demonstrated symptomatology of record for the entire appeal period from August 17, 2006 to November 2, 2008. The GAF score of 50 indicate serious symptoms or any serious impairment in social, occupation, or school functioning, while the scores of 51 and 58 indicate moderate symptoms or moderate difficulty in social, occupational, or school functioning. When considering the evidence as a whole, the Veteran's psychiatric symptomatology does not justify the assignment of a higher disability rating at any time during this appeal period solely based on the assignments of a 50 GAF score. As discussed above, the Veteran's symptomatology more closely approximates a moderate degree of disability, rather than serious impairment. See also 38 C.F.R. § 4.126(a). After a full review of the record and consideration of whether the assignment of separate (staged) ratings for separate periods of time is warranted, the Board finds that a preponderance of the evidence is against an initial disability rating in excess of 30 percent for the service-connected acquired psychiatric disability from August 17, 2006 to November 2, 2008. As discussed above, the evidence of record indicates the service-connected disability more closely approximates a manifestation of occupational and social impairment with evidence of occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to psychiatric symptomatology, and not productive of occupational and social impairment with reduced reliability and productivity due to psychiatric symptomatology. Rating in excess of 50 percent from November 3, 2008 to October 16, 2012 VA outpatient treatment records from November 3, 2008 to October 2012 document the Veteran's ongoing complaints and treatment for the service-connected acquired psychiatric disability. Such complaints and symptomatology included illusions which started with the death of her grandmother, fleeting passive suicidal thoughts associated with the potential need to file bankruptcy, depression, sleep impairment, and thoughts of beating up and cursing people from work. She also reported in February 2010, June 2010, and November 2010, respectively, that she thinks she hears something when there is a noise in the house or she sees some bright flashing light for a while, occasionally sees spots or darkness, and sometimes displays paranoid worrying that one of her brothers is going to hurt her. Objective findings documented the Veteran displayed good grooming and hygiene, anxious and depressed mood, appropriate and constricted affect, alert and oriented to self, place, and time, fair and good judgment and insight, no psychomotor agitation, and no suicidal or homicidal ideation, auditory or visual hallucinations, or delusions. At the April 2009 DRO hearing, the Veteran reported quitting her employment as a certified nursing associate (CNA) due to irritability with patients and ignoring their needs. At the time, she was also having panic attacks, impairment judgment with obsessive spending on food and lottery tickets, and mood swings. A September 2009 VA psychiatric examination report noted the Veteran has limited social activities and history of mood disorder with mood swings and depression. The Veteran was alert, oriented to time, place, and person, answered questions appropriately, depressed, anxious mood, intact judgment, decreased memory, limited insight into her psychiatric problems, and displayed a limited range in affect and cordial behavior. She denied delusions and hallucinations. There were no findings of psychoses, suicidal or homicidal ideations, plans, or impulses, impairment of thought process or communication, or problems dressing, feeding, or bathing self. The examiner concluded a mild effect on social functioning, no effects on employment, and symptoms are moderate in severity and occur sporadically. The Axis I diagnosis was changed from major depressive disorder to bipolar disorder, and a GAF score of 48 was assigned to reflect the impact of bipolar disorder on limitation of the Veteran's social functioning. Approximately one year later at a September 2010 VA psychiatric examination, the Veteran reported she has not been hospitalized for any emotional problems, regularly continued outpatient treatment, and took prescribed medications since the last examination. During the prior 12 months, she also noted "I am very sensitive and quick tempered. Go off on people who have not done anything to me. I sit there. I think. I wish I was dead sometimes." She denied having a social life because of shyness and very self conscious, as well as having periods of hyperactivity or engaging in risky behaviors. She reported daily mood swings, racing thoughts, crying spells every day, cannot concentrate, sleep impairment, and bothered by feelings of insecurity, inferiority, and guilt. She further noted suicidal thoughts with no plans. On examination, she was neatly and casually dressed, pleasant, speech was spontaneous, mood varied from on guard to relaxed, oriented to time, place, person, and judgment was intact. She did not exhibit any perceptual disorder or disturbance in thoughts. Axis I diagnosis listed major depressive disorder, the ongoing manifestation of bipolar II disorder, and a GAF score of 61 was assigned. The examiner opined it is as likely as not the Veteran can be employed in a sedentary job. The GAF scores assigned during this rating period were 40 (December 2011 VA outpatient treatment record); 42 (February 2009 VA outpatient treatment record); 45 (July 2012 VA outpatient treatment record); 48 (September 2000 VA examination report); 50 (VA outpatient treatment records dated November 2008, March 2009, November 2009, February 2010, September 2010, January 2011, July 2011, March 2012, October 2012); and 61 (September 2010 VA examination report). The GAF score of 40 indicates some impairment in reality resting or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. The GAF scores of 42, 45, 48 and 50 contemplate serious symptoms or any serious impairment in social, occupational, or school functioning, and the GAF score of 61 indicates some mild symptoms or some difficulty in social, occupational, or school functioning. These GAF scores, with consideration of the overall clinical disability pictures are found to be consistent with the demonstrated mild and moderate symptomatology of record. However, when considering the evidence as a whole do not justify assignment of the next higher rating at any time during this appeal period. See also 38 C.F.R. § 4.126(a). As discussed above, the Veteran's acquired psychiatric disability has been characterized as mild and moderate without deficiencies in most areas of her life. In addition, her psychiatric symptomatology, to include suicidal thoughts, irritability, mood swings, decreased memory, anxious mood, sleep impairment, and difficulty concentration, are contemplated in the assigned 50 percent evaluation. After a full review of the record and consideration of whether the assignment of separate (staged) ratings for separate periods of time is warranted, the Board finds that a preponderance of the evidence is against an initial disability rating in excess of 50 percent for the service-connected acquired psychiatric disability from November 3, 2008 to October 16, 2012. As discussed above, the evidence of record indicates the service-connected disability more closely approximates a manifestation of occupational and social impairment with reduced reliability and productivity due to psychiatric symptomatology, and not productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood due to psychiatric symptomatology. Rating of 70 percent, but no higher, as of October 17, 2012 After a full review of the record and consideration of whether the assignment of separate (staged) ratings for separate periods of time is warranted, the Board finds that entitlement to an initial 70 percent evaluation is warranted as of October 17, 2012 and a preponderance of the evidence is against an initial evaluation in excess of 70 percent for any period thereafter. At an October 2012 VA Disability Benefits Questionnaire (DBQ) examination for mental disorders, the Veteran's diagnosis of chronic major depressive disorder was confirmed, and was assigned a GAF score of 48. The examiner marked the following statement best summarizes the Veteran's disability picture "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." Clinical findings revealed symptoms of depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting. In a November 2012 substantive appeal, via a VA Form 9, the Veteran reported she enrolled and dropped out of college classes three semesters in a row, she has no social life, has lashed out at so many people, and it is hard to be around anyone without feeling paranoid. She contemplates suicide sometimes but does not have the courage to do it. Pursuant to VA outpatient treatment sessions, the Veteran requested an increase in medication because she is more irritable with people on October 18, 2012. A November 23, 2012 VA outpatient treatment session, the Veteran was assigned a GAF score of 35. Subsequent VA outpatient treatment records from November 2012 to December 2012 further note the Veteran's suicidal thoughts, family stress, and additional psychiatric diagnosis of bipolar disorder. As noted above, the GAF scores assigned during this rating period were 35 (November 2012 VA outpatient treatment record), which indicates some impairment in reality testing or communication or major impairment in several areas, such as work, school, family relations, judgment, thinking, or mood, and 48 (October 2012 VA DBQ examination report), which contemplates serious symptoms or any serious impairment in social, occupational, or school functioning. The Board finds these assigned GAF scores are found to be consistent with the demonstrated symptomatology of record and do not justify the assignment of a total disability rating at any time as of October 17, 2012. See also 38 C.F.R. § 4.126(a). The Board finds the evidence of record indicates the service-connected disability more closely approximates a manifestation of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood due to psychiatric symptomatology. Such symptomatology includes anxiety, chronic sleep impairment, irritability, disturbances of motivation and mood, paranoia, suicidal ideation, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, diagnoses of major depressive disorder and bipolar disorder, and GAF scores of 35 and 48. Accordingly, the Veteran's psychiatric symptoms are more appropriately rated under the criteria for a 70 percent disability rating as of October 17, 2012. The Board also finds that a preponderance of the evidence is against an initial evaluation in excess of 70 percent as of October 17, 2012 as the service-connected acquired psychiatric disability is not more closely productive of total occupational and social impairment due to psychiatric symptomatology. The Board acknowledges the November 2012 VA outpatient record documented a GAF score of 35 which indicates some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. Nevertheless, a showing of total occupational and social impairment due to psychiatric symptomatology has not been demonstrated at any time as of October 17, 2012. Particularly, such impairment is not shown as 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. The October 2012 VA DBQ examiner characterized the Veteran's psychiatric disability picture as "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation." Moreover, the Veteran's report of having no social life, dropped out of college classes, and suicidal thoughts are contemplated in the currently assigned 70 percent evaluation. With respect to the entire initial rating period on appeal, the Board is aware that the symptoms listed under the next-higher ratings are essentially examples of the type and degree of symptoms for those ratings, and that the Veteran need not demonstrate those exact symptoms to warrant a higher initial rating. See Mauerhan, 16 Vet. App. at 436. Moreover, entitlement to a 50, 70, or 100 percent evaluation for the respective appeal periods requires sufficient symptoms of the requirements, or others of similar severity, frequency, or duration, that cause the specific type of occupational and social impairment. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117-18 (Fed. Cir. 2013) (holding that a veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration). In this case, the Board has considered the next higher ratings for the respective appeal periods but finds that the periods on appeal are rated appropriately. Fully considering the lay and medical evidence for the respective initial rating periods on appeal, the reported symptomatology, as discussed above, more closely approximate a manifestation of the currently assigned disability ratings under Diagnostic Code 9434. Therefore, the lay and medical symptomatology does not more closely approximate a manifestation of the rating criteria for the assignment of a higher disability rating, and a preponderance of the evidence is against a disability rating in excess of 30 percent from August 17, 2006 to November 2, 2008, 50 percent from November 3, 2008 to October 16, 2012, and 70 percent as of October 17, 2012 for the service-connected acquired psychiatric disability. 38 C.F.R. §§ 4.3, 4.7. Lumbar Spine Disability Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 205 (1995). It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. Id. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology or evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. The factors involved in evaluating, and rating disabilities of the joints include weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; incoordination (impaired ability to execute skilled movements smoothly); more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); or pain on movement, swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. 38 C.F.R. § 4.59. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Id. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. Pursuant to the rating criteria for the spine, the Veteran's service-connected lumbar spine disability is rated at 20 percent disabling from August 17, 2006 to March 10, 2009 for limited forward flexion, at worst, to 60 degrees, painful motion, and tenderness. See 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2012). This disability is also rated at 40 percent disabling as of September 1, 2009 for limited forward flexion, at worst, to 30 degrees, painful motion, tenderness, and muscle spasm. Id. The rating criteria, in pertinent part, provides a 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is assigned for unfavorable ankylosis of the entire spine. Again, these ratings are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5242. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. 38 C.F.R. § 4.71a, Note (2). The combined range of motion refers to the sum of the range of forward flexion, extension, and left and right lateral flexion, and left and right rotation. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. Rating in excess of 20 percent from August 17, 2006 to March 10, 2009 In December 2006, the Veteran exhibited a normal gait at a VA general medical examination and VA examination for the spine. She also exhibited the ability to toe raise and heel raise, full forward flexion to 90 degrees, and full combined range of motion to 240 degrees. X-ray findings revealed a pars defect at L5-S1 and no evidence of any significant spondylosis or spondyloschisis. At an October 2008 private treatment session with Dr. M. C., the Veteran displayed limited flexion to 70 degrees and extension to 20 degrees. November 2008 private magnetic resonance imagining (MRI) results revealed degenerative disc disease, degenerative joint disease, isthmic spondylolisthesis, and bilateral foraminal stenosis. At a February 2009 private independent medical evaluation, conducted by Dr. S. S., the Veteran exhibited limited forward flexion to 60 degrees and normal gait and posture. She was diagnosed, in pertinent part, with lumbar degenerative disc disease and lumbosacral spondylosis. VA outpatient treatment records from December 2005 to August 2008 and February 2009 to March 2009 also reveal the Veteran showed a normal gait and diagnosed with degenerative disc disease in March 2008. After a full review of the record and consideration of whether the assignment of separate (staged) ratings for separate periods of time is warranted, the Board finds that a preponderance of the evidence is against an initial disability rating in excess of 20 percent for the service-connected lumbar spine disability from August 17, 2006 to March 10, 2009. As discussed above, the evidence of record indicates the service-connected disability more closely approximates a manifestation of limited forward flexion, at worst, to 60 degrees, painful motion, tenderness, and diagnoses of lumbar spondylosis, spondylolisthesis, bilateral foraminal stenosis, degenerative joint disease, and degenerative disc disease under Diagnostic Code 5237. Additionally, the evidentiary record did not demonstrate findings of limited flexion to 30 degrees or less or ankylosis of the entire thoracolumbar spine. Rating in excess of 40 percent as of September 1, 2009 On September 6, 2009, the Veteran underwent a VA examination for the spine. Upon physical examination, she exhibited paraspinal muscle spasm with tenderness on palpation, limited forward flexion to 30 degrees with painful motion, and gait was slow and leaning to the right-sided area. X-ray findings revealed spondylosis posterior fusion with metallic cage at L5-S1. Pursuant to a September 2010 VA general medical examination, the Veteran displayed an antalgic gait and limited forward flexion to 30 degrees with painful motion. The Veteran was diagnosed with severe lumbosacral strain with spondylosis and fusion at L5-S1. Most recently, at an October 2012 VA Disability Benefits Questionnaire (DBQ) examination, the Veteran showed limited forward flexion to 40 degrees with painful motion, and the report listed the Veteran's diagnosis as post operative lumbar fusion. After a full review of the record, the Board finds that a preponderance of the evidence is against an initial disability rating in excess of 40 percent for the service-connected lumbar spine disability as of September 1, 2009. As discussed above, the evidence of record indicates the service-connected disability more closely approximates a manifestation of limited forward flexion, at worst, to 30 degrees, painful motion, tenderness, muscle spasm, and diagnoses of spondylosis posterior fusion with metallic cage at L5-S1, severe lumbosacral strain with spondylosis and fusion at L5-S1, and post operative lumbar fusion under Diagnostic Code 5237. Additionally, the evidentiary record did not demonstrate findings of ankylosis of the entire thoracolumbar spine. With respect to both initial ratings on appeal, the Board finds that a higher rating is not warranted under Diagnostic Code 5243 as the clinical evidence of record does not show the Veteran has incapacitating episodes due to intervertebral disc syndrome for any period. See 38 C.F.R. § 4.71a. At the December 2006 VA examination, the Veteran described no incapacitating episodes. At the September 2010 VA examination, the Veteran reported getting 15 flare-ups per month and daily pain that is not incapacitating. The VA examiner noted the Veteran has incapacitating episodes requiring bed rest prescribed by her physician in the last 12 months; however, no diagnosis of intervertebral disc syndrome was assessed, nor were there notations of prescribed bed rest of record. Most recently, the October 2012 VA DBQ examiner explicitly noted the Veteran does not have intervertebral disc syndrome. Next, the Board finds that a separate disability rating may be warranted for any period due to any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, under an appropriate diagnostic code. See 38 C.F.R. § 4.71a, Diagnostic Codes 5235-5243, Note (1). With regard to the initial rating period from August 17, 2006 to March 10, 2009, the Board acknowledges the Veteran's complaints of radicular pain in the lower extremities, particularly on the left side. Such complaints are noted in the December 2006 VA examination report, private treatment records dated October 2008, November 2009, and January 2009, as well as a June 2008 VA outpatient treatment record. Nevertheless, no findings of a neurological abnormality in the lower extremities were diagnosed as due to the service-connected lumbar spine disability during this specified appeal period. Specifically, at the December 2006 VA examination, evaluation of the lower extremities revealed no radiation of pain or decreased sensation, full motor functions, negative straight leg raise test results, and the examiner noted there were no neurologic findings or effect on the usual occupation or daily activities. The October 2008 private treatment record documented neurological examination of the lower extremities showed mild weakness in the left ankle and great toe dorsiflexion, decreased sensation to pin prick in the left foot, and negative straight leg raise test results. The November 2009 private independent medical evaluation report documented the Veteran has left greater than right tingling with walking and the Veteran reported feeling "weak" in the left leg; however, bilateral straight leg raise testing was negative and strength in the upper and lower extremities were normal. Moreover, the March 2008 VA outpatient treatment record noted the Veteran's denial of lower extremity paresthesias and weakness and a finding of full bilateral lower extremity strength. With regard to the initial rating period, as of September 1, 2009, service connection for radiculopathy of the left and right lower extremities as secondary to the service-connected lumbar spine disability has been granted, both in effect as of March 24, 2009. Moreover, the Board finds the evidentiary record does not indicate any other associated objective neurological abnormalities related to the lumbar spine disability for any period on appeal. The Veteran described and denied no bowel or bladder incontinence at the December 2006 VA examinations for the spine, February 2009 private independent medical evaluation, and VA outpatient treatment sessions in March 2008 and August 2012. The Veteran informed the September 2009 VA examiner she has constipation as a side effect from pain medications and denied any bowel incontinence, but noted some urinary incontinence about two or three times a day and does not use any disposable pads, rather simply changes more frequently. At the September 2010 VA general medical examination, she characterized the urinary incontinence as due to stress, and the examiner concluded no findings of bowel or bladder incontinence. Most recently, an August 2012 VA DBQ examination report for urinary tract conditions documented the Veteran does not have or has ever been diagnosed with a condition of the bladder or urethra of the urinary tract, nor a voiding dysfunction. The examiner acknowledged the Veteran has urgency and initial tingling on urination which resolves during urination, and concluded there is no relationship between stress incontinence and the Veteran's service-connected lumbar spine disability because the Veteran does not have any stress incontinence. The October 2012 VA DBQ examiner also affirmed no findings of any other neurologic abnormalities related to the service-connected lumbar spine disability. Next, the Board finds that the evidentiary record, to include the Veteran's reported symptomatology, as discussed in detail below, does not demonstrate additional functional impairment beyond what is contemplated in the currently assigned disability ratings for any period. At the December 2006 VA examination for the spine, the Veteran's long history of chronic low back pain was noted. She wears a back brace and takes Vicodin for pain relief, and does not require an assistive device for ambulation. She exhibited painful motion and some mild tenderness to palpation along the spinal process. There were findings of paraspinal musculature spasms. Ranges of motion during passive, active, and three repetitive motions were the same, and the examiner concluded there was no additional functional impairment due to pain, weakness, fatigability, incoordination, or flare-ups. October 2008, January 2009, and September 2009 private treatment records from Dr. M. C. note the Veteran's complaints of worsening lower back pain, and physical evaluation of the lower back in October 2008 revealed moderate tenderness and painful motion. At the February 2009 private independent medical evaluation, she complained of low back pain and physical evaluation revealed tenderness and no paraspinal muscle spasm. VA outpatient treatment records also document the Veteran's complaints of back pain and tenderness to palpation on the left side in March 2008 and low back pain in June 2008. The September 2009 VA examination report noted the Veteran's use of a back brace and cane with walking. The Veteran reported back pain is precipitated by repetitive activity, and she has additional limitation of motion and functional impairment during flare-ups. After three repetitions, forward flexion decreased from 30 degrees to 25 degrees, which the Veteran attributed to pain and fatigue. The examiner also noted no incoordination. The September 2010 VA general medical examination report documents the Veteran is on medication for skeletal muscle spasm. During flare-ups, there is additional functional impairment due to pain, as well as additional weakness, fatigability, and lack of endurance. There was tenderness on palpation. After three repetitions, forward flexion decreased from 30 degrees to 20 degrees with additional pain, functional impairment, fatigability, weakness, and lack of endurance. Most recently, the October 2012 VA DBQ examination report noted the Veteran's daily low back pain and there was no additional limitation in range of motion of the back following repetitive-use testing. Functional loss and/or impairment included less movement than normal and pain on movement. She also testified at the April 2013 Board hearing about difficulty getting around, standing up, and sleeping in certain positions. The Board finds that the Veteran's complaints of pain and fatigue and symptomatology of tenderness and muscle spasms are adequately contemplated in the currently assigned disability ratings and the mere presence of pain does not by itself constitute functional loss. Rather, the pain must affect some aspect of the normal working movements of the body such as strength, speed, coordination, or endurance. See 38 C.F.R. § 4.40, 4.45, 4.59, DeLuca, 8 Vet. App. at 205, Mitchell v. Shinseki, 25 Vet. App. 3 2, 37-43 (2011). The Board notes that the assigned 40 percent rating as of September 1, 2009 contemplates the September 2010 VA general medical examination notation of additional weakness, fatigability, and lack of endurance during flare-ups of pain. The Board considered whether a separate rating is warranted under the diagnostic codes for a skin disability. See 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 (2012). Although the October 2012 VA DBQ examination report noted the Veteran does not have any scars related to the service-connected lumbar spine disability, the September 2009 VA examiner noted the Veteran has a 4 inch, midline scar, 1/16 inch in width, linear, running along the spine in the low lumbar area to the sacral area. Since the evidence of record shows the Veteran's scar is not 144 square inches or greater to warrant application of Diagnostic Code 7802, scars, other than head, face, or neck that are superficial and do not cause limitation of motion. The evidence does not show the scar is unstable or painful to warrant application of Diagnostic Code 7803, superficial, unstable scars or Diagnostic Code 7804, superficial, painful on examination scars. Additionally, the evidence of record does not indicate the Veteran's scar limits her motion to warrant application of Diagnostic Code 7801, scars, other than head, face, or neck, that are deep or that cause limited motion; or Diagnostic Code 7805, scars, other, which are rated on limitation of function of the affected part. Therefore, 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 do not assist the Veteran in obtaining a higher rating for the service-connected lumbar spine disability for any period. Fully considering the lay and medical evidence for the respective initial rating periods on appeal and any functional loss due to pain, the reported symptomatology, as discussed above, more closely approximate a manifestation of the currently assigned disability ratings under Diagnostic Code 5237 and DeLuca, 8 Vet. App. at 202. Therefore, the lay and medical symptomatology does not more closely approximate a manifestation of the rating criteria for the assignment of a higher disability rating, and a preponderance of the evidence is against a disability rating in excess of 20 percent from August 17, 2006 to March 10, 2009 and in excess of 40 percent as of September 1, 2009 for the service-connected lumbar spine disability. 38 C.F.R. §§ 4.3, 4.7. Additional Considerations for the Service-Connected Disabilities The Board has considered all other potentially applicable provisions of 38 C.F.R. Parts 3 and 4, as required by the Court. See Schafrath, 1 Vet. App. at 594. 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 a higher evaluation for any period. The Board has considered the Veteran's reported history of symptomatology regarding the service-connected acquired psychiatric disability and lumbar spine disability, as discussed above. The Board acknowledges she is competent to report such symptoms because this requires only personal knowledge as it comes through ones senses; nonetheless, she is not competent to identify a specific level of the service-connected disability on appeal according to the appropriate diagnostic code. In this case, such competent evidence concerning the nature and extent of the service-connected disabilities on appeal has been provided in the medical evidence of record. As such, the Board finds these records to be more probative than the Veteran's subjective evidence of complaints and increased symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994); Bostain v. West, 11 Vet. App. 124, 127 (1998); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). 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. The Court has held that VA's disability-by-disability interpretation of 38 C.F.R. 3.321(b)(1) is not unreasonable, plainly erroneous, or inconsistent with the regulation or the statutory and regulatory scheme when viewed as a whole, thus the Board was not required to consider whether a veteran's was entitled to referral for extra-schedular consideration of the service-connected disabilities on a collective basis. See Johnson v. Shinseki, WL 1224810 (Vet. App. March 27, 2013). With regard to the service-connected acquired psychiatric disability, the Board finds that the symptomatology and impairment caused by the Veteran's acquired psychiatric disorder is specifically contemplated by the schedular rating criteria, and no referral for extra-schedular consideration is required. The schedular rating criteria, Diagnostic Code 9434, 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 acquired psychiatric disorder, to include majore depression and bipolar disorder, has been manifested by psychiatric symptomatology, discussed in detail above, which are part of or similar to symptoms listed under the schedular rating criteria. In this case, it is clear that the disabilities in question have become worse during the appeal period, which is why the RO increased the evaluation several times. The Board has carefully reviewed these facts and finds the current findings to fit the Veteran's situation with the rating criteria, to the extent possible. In this regard, it is important for the Veteran to understand that not all evidence support the current evaluations, let alone higher evaluations. However, with consideration of the evidence as a whole, and the Veteran's concerns, the current findings can be made. The schedular rating criteria specifically include occupational and social impairment, as indicated by reduced reliability and productivity, and as caused by specific psychiatric symptoms. The schedular rating criteria also include 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 the acquired psychiatric disorder. For these reasons and in the absence of exceptional factors, the Board finds that the schedular rating criteria is adequate to rate the Veteran's acquired psychiatric disorder, and referral for consideration of an extra-schedular evaluation is not warranted for any initial rating period on appeal. With regard to the service-connected lumbar spine disability, the Board finds that the schedular rating criteria do not adequately contemplate and describe the symptoms and functional impairment caused by the service-connected lumbar spine disability. Specifically, as noted above, the Veteran testified at the April 2013 Board hearing as to having difficulty sleeping in certain positions due to the back pain. Nonetheless, the Board finds the Veteran's exceptional disability picture does not exhibit other related factors such as those provided by 38 C.F.R. § 3.321(b)(1) as "governing norms," to include marked interference with employment or frequent periods of hospitalization due to the service-connected lumbar spine disability during the initial rating periods on appeal. As a result, referral for extra-schedular consideration for the service-connected lumbar spine disability is not required for the periods from August 17, 2006 to March 10, 2009 and as of September 1, 2009. Duties 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. The Board finds that the VCAA notice requirements have been satisfied by an October 2006 letter. In this letter, VA informed the Veteran that in order to substantiate a claim for service connection, the evidence needed to show she 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 she was to provide to VA and which information and evidence VA would attempt to obtain on her behalf, VA informed the Veteran it had to obtain any records held by any federal agency. This letter also informed the Veteran that on her 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 letter told the Veteran that she could obtain private records herself and submit them to VA. 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, the October 2006 letter included the type of evidence necessary to establish a disability rating and effective date. 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 claims on appeal, the evidence of record includes the Veteran's service treatment records, VA outpatient treatment records, private treatment records, statements from the Veteran, statement from the Veteran's mother, and VA examination reports dated December 2006, September 2009, September 2010, and October 2012. 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 has not obtained Social Security Administration (SSA) records although a February 2013 letter from SSA provided a summary of information regarding her current Social Security benefits, to include the specified amount she receives each month beginning December 2012 as a disabled individual. The Veteran also testified at the April 2013 Board hearing that all the records from SSA are VA records, particularly from her VA psychiatrist. As a result, the Board finds these records need not be obtained in this instance because the Veteran's statements indicate VA is already in possession of such records and are not relevant to the service-connected lumbar spine disability. 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). In this case, the Veteran has clearly indicated that the Board has all pertinent records from SSA. If the Board did remand this case, all it would receive from SSA are copies of its own records. In April 2013, the Veteran testified at a hearing held before the undersigned Veterans Law Judge. See Bryant v. Shinseki, 23 Vet. App. 488 (2010) (holding the Veterans Law Judge who conducts a hearing fulfill the duty to fully explain the issues and the duty to suggest the submission of evidence that may have been overlooked). In this case, the undersigned Veterans Law Judge explained the issue on appeal and asked questions focused on the nature and severity of the service-connected disabilities on appeal. Moreover, the Veteran was assisted at the hearing by an accredited representative from the American Legion, and neither the Veteran nor her representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and that any error in notice provided during the Veteran's hearing constitutes harmless error. For the foregoing reasons, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the claims on appeal. The evidence of record provides sufficient information to adequately evaluate the claims, all obtainable evidence identified by the Veteran relative to the claims 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). ORDER An initial rating in excess of 30 percent from August 17, 2006 to November 2, 2008 for an acquired psychiatric disability is denied. An initial rating in excess of 50 percent from November 3, 2008 to October 16, 2012 for an acquired psychiatric disability is denied. An initial rating of 70 percent, but no higher, for an acquired psychiatric disability as of October 17, 2012 is granted, subject to the criteria applicable to the payment of monetary benefits. An initial rating in excess of 20 percent from August 17, 2006 to March 10, 2009 for pars defect, lumbar spine L5-S1 (lumbar spine disability) is denied. An initial rating in excess of 40 percent as of September 1, 2009 for pars defect, lumbar spine L5-S1 (lumbar spine disability) is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs