Citation Nr: 1328147 Decision Date: 09/04/13 Archive Date: 09/10/13 DOCKET NO. 09-34 120 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to an initial rating greater than 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a low back disorder. REPRESENTATION Appellant represented by: Illinois Department of Veterans Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S.K.C. Boyce, Associate Counsel INTRODUCTION The Veteran served on initial active duty for training from July 1998 to February 1999 and on active duty from June 2004 to May 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which denied the above claims. In a subsequent rating decision issued in August 2009, the Chicago RO increased the initial rating assigned for PTSD to 30 percent. The issue of service connection for a low back disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The Veteran's PTSD is primarily manifested by symptoms of nightmares, flashbacks, avoidance behaviors, sleep disturbance, irritability, outbursts of anger, anxiety, and depression, occasionally severely exacerbated when exposed to intrusive triggers, causing occupational and social impairment with reduced reliability and productivity. 2. The Veteran's PTSD does not result in occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for an initial 50 percent rating, and not higher, for service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) When an application for benefits is received, VA has certain notice and assistance requirements under the VCAA. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). Before the initial VA decision on a claim for benefits, the Veteran must be notified of the information and evidence (1) needed to substantiate the claim, (2) that VA will attempt to obtain, and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); 38 C.F.R. § 3.159(b); see also Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). These notice requirements apply to the downstream elements of the rating and effective date assigned if the disability is service connected. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006). The Veteran was provided with this information in a letter dated September 2008, prior to the initial adjudication of the claim for a higher initial rating for PTSD. VA also has a duty to assist a claimant in obtaining the evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty has been fulfilled as all available records relevant to the claim for a higher rating for PTSD have been obtained, including the Veteran's service treatment records and VA treatment records, and VA examination reports dated November 2008 and August 2012 are of record. The VA examiners reviewed the Veteran's history and described his disability in sufficient detail to allow for a fully informed evaluation and the August 2012 VA examiner provided a contemporaneous assessment of the severity of the Veteran's service-connected PTSD. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Board will proceed with adjudication of the claim for a higher initial rating for PTSD as there is no indication that any prejudice to the Veteran has resulted from the timing or substance of the notice or assistance provided in this case or that additional development would serve any useful purpose. See Shinseki v. Sanders, 556 U.S. 396, 410 (2009); Marcinak v. Brown, 10 Vet. App. 198, 201 (1997) (error is harmless where there is no resulting prejudice to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (there is no basis for a remand where there would be no benefit to the Veteran). II. Evidentiary Standards The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive, and provide the reasons for the rejection of any material evidence favorable to the Veteran. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). When all the evidence is assembled, VA will determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990); see also 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. When evaluating lay evidence, the Board will determine whether the particular disability is the type of disability for which lay evidence is competent and, if so, weigh that evidence against the other evidence of record. Kahana, 24 Vet. App. at 433 n.4. Lay witnesses are not competent to offer expert medical testimony but may testify on firsthand observations of the Veteran's visible symptoms. Chotta v. Peake, 22 Vet. App. 80, 84 (2008). Lay statements alone may constitute competent evidence of worsening observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010). The Board has reviewed all of the evidence in the Veteran's claims folder and electronic records file with emphasis on the evidence relevant to this appeal. The Board must provide the reasons and bases supporting the decision but is not obligated to specifically refer to every piece of evidence or analyze and discuss the entire evidentiary record in the text of the decision. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); 38 U.S.C.A. § 7104(d)(1). The analysis below focuses on the relevant evidence and the elements of service connection met or not met by that evidence. See Timberlake v. Gober, 14 Vet. App. 122 (2000). III. Evaluation of the Initial Rating Assigned for PTSD In December 2008, the RO granted service connection for PTSD and, in August 2009, increased the initial rating assigned to 30 percent under Diagnostic Code 9411. The Veteran disagrees and contends that a rating higher than 30 percent is warranted. Specifically, the Veteran contends that VA did not consider his occupational difficulties caused by working with colleagues who are not Veterans or did not have combat service in Iraq when assigning his initial disability rating for PTSD and asks VA to consider the arguments he has had with his wife about his mental state. The Veteran punched a wall during one argument resulting in injury to his right hand; this contention was separately adjudicated as a claim for compensation benefits for residuals of a right hand injury in an October 2011 rating decision and is not on appeal. A. Governing Law and Regulations Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In a claim arising from disagreement with the initial disability rating assigned upon a grant of service connection, the Veteran's complete medical history will be reviewed to ensure that the rating accurately reflects the elements of disability present. Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. If the Veteran's history from the date of initial application for service connection to the present shows differing levels of severity of symptomatology over distinct time periods, different disability ratings will be assigned for each distinct "stage." See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When assigning an initial disability rating for PTSD, VA will assign the rating that most accurately describes the Veteran's overall disability picture under 38 C.F.R. § 4.130, DC 9411. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Currently, the Veteran is assigned an initial 30 percent disability rating for PTSD, warranted where the evidence shows occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to such symptoms as depressed mood; anxiety and suspiciousness; weekly (or less often) panic attacks; chronic sleep impairment, and mild memory loss, such as forgetting names, directions, and recent events. 38 C.F.R. § 4.130, DC 9411. Otherwise, generally satisfactory functioning will be shown by evidence demonstrating, for example, routine behavior, self-care, and normal conversation. Id. A higher disability rating of 50 percent is warranted where the evidence shows occupational and social impairment with reduced reliability and productivity caused by symptoms like flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands, impairment of short and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficultly in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where the evidence shows occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. Lastly, a 100 rating will be awarded where the evidence shows total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. All cases are not expected to show all findings specified in the applicable diagnostic code. 38 C.F.R. § 4.21. The symptoms listed under § 4.130 are not intended to serve as an exhaustive list of the symptoms that VA may consider but as examples of the type of degree of symptoms, or the effects, that would warrant a particular rating. Mauerhan, 16 Vet. App. at 442. The Veteran's actual symptomatology, and resulting social and occupational impairment, will be the primary focus when assigning a disability rating for a mental disorder, and the Veteran may qualify for a particular rating by demonstrating the particular symptoms associated with that percentage, or other symptoms of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The rating schedule for mental disorders uses terms based on the nomenclature in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. § 4.130. The DSM-IV includes a Global Assessment of Functioning (GAF) scale. GAF scores ranging from zero to 100 represent the level of psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health and mental illness. Higher scores correspond to a higher degree of mental health and lower scores correspond to a higher degree of mental illness. When evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). The evaluation must be based on all evidence showing occupational and social impairment and not just the examiner's assessment of the level of disability at the moment of the examination. Id. The extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). B. Review of the Evidence The Veteran sought VA treatment for PTSD shortly after his discharge in August 2005. VA treatment records from September 2005 show that he reported symptoms of sleep problems, flashbacks, nightmares, hypervigilance, irritability, difficulties with family, low tolerance, and difficulty managing excessive anger. He denied suicidal or homicidal thoughts, was alert, and did not exhibit any psychotic symptoms. A comprehensive psychological evaluation was completed and shows complaints of nightmares resulting in increased anxiety. The Veteran said that he talked during sleep, and that it upset his wife so much that she slept away from him for a week. The Veteran described himself as short-tempered and easily agitated and said that he injured his hand by punching his truck during an argument with his wife. He also reported fear of confrontation with gang members in his neighborhood, increased anxiety in crowds, and that he felt naked without his service weapon. He continued to deny suicidal or homicidal ideation, auditory or visual hallucinations, and delusional or paranoid ideations. Mental status examination data shows that he was alert, attentive, oriented, cooperative, reasonable, and appropriately groomed. His speech was at a normal rate and rhythm and language was intact. The examiner described his mood and affect as anxious. The Veteran's thought processes were normal and coherent with no unusual content, and he had good insight, good judgment, intact memory, and an above average fund of knowledge. No psychotic content was expressed during the interview. He was diagnosed with PTSD and assigned a GAF score of 60, corresponding to moderate symptoms (e.g., flat affect, circumstantial speech, or occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends or conflicts with peers or co-workers). At an October 2005 VA PTSD evaluation, the Veteran said that his wife had become increasingly frightened and upset with his behavior in the home. He endorsed symptoms of intrusive distressing recollections, such as daytime intrusive memories with strong accompanying emotions and recurrent distressing dreams with traumatic content, acting or feeling as if events from service were recurring, intense psychological distress and reactivity at exposure to cues, and intense physical anxiety symptoms. He also reported symptoms of avoidance, including avoidance of thoughts, feelings, and conversations associated with the trauma; avoidance of activities, places or people that arouse recollections; markedly diminished interest in significant activities; feelings of detachment or estrangement from others; and a sense of foreshortened future. The evaluation shows that PTSD was also associated with persistent symptoms of increased arousal, such as difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and an exaggerated startle response. His mental status examination data shows that he was neat and cooperative with articulate and "to the point" speech. His thought processes were described as linear and rational, but his thought content showed preoccupation with his problems. There were no perceptual abnormalities. His affect and mood were described as irritable, anxious, angry, and frustrated. His insight and judgment continued to be good. His diagnosed was confirmed as chronic PTSD and he was assigned a GAF score of 50, indicative of serious symptoms (e.g. suicidal ideation, severe obsessional rituals, and frequent shoplifting) or serious impairment in social, occupational, or school functioning (e.g., no friends or unable to keep a job). In a November 2005 counseling session, the Veteran discussed recent events in which he almost got in trouble with the police for displaying a weapon to a person not authorized to be in his building. The psychologist noted that he was open to the possibility that he was using military rules and reflexes that do not always apply in civilian society. His GAF score at this time was 50. Subsequently, after several attempts to schedule the Veteran for additional counseling sessions, he was discharged from the outpatient treatment program due to lack of attendance in October 2007. The Veteran was provided with a VA compensation and pension examination in November 2008. The report shows that he had been married for 4.5 years at that time and worked in security. The Veteran reported increased alcohol use of approximately 24 beers and half a liter of vodka per weekend. He also reported difficulty falling and staying asleep, nightmares, feeling uncomfortable around people, being suspicious and guarded, and recurrent intrusive recollections of his experiences during service. He also reported several past instances of suicidal ideation when he was around people who were dying. Upon examination, he was irritable and guarded. His answers were coherent and relevant, but brief, and his memory for recent and remote events was good. He denied current suicidal or homicidal thoughts, hallucinations, and delusions. The examiner described his mood as depressed and irritable. The examiner diagnosed with PTSD with frequent symptoms of moderate severity with a duration lasting from minutes to hours. The Veteran reported losing a few hours from work due to these symptoms. The examiner did not note any impairment of thought processes and social functioning and did not find that the Veteran met the criteria for substance abuse. He was assigned a GAF score of 62, indicating 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), with generally good functioning and some meaningful interpersonal relationships. In March 2011, the Veteran underwent a second PTSD evaluation when he decided to seek additional mental health treatment after a series of potentially dangerous incidents. The Veteran said that he had twice shoved his wife during an argument, pulled a gun on someone who tried to take his parking space, and hit a man in a bar fight who had a pacemaker and needed hospitalization. He also reported that he had been drinking heavily, but denied ever using any other drugs. He said he had gotten into shouting matches with a colleague at work and had trouble taking the train to get to work. The report shows that he continued to have a full array of PTSD symptoms, and he was diagnosed with PTSD and alcohol dependence. April 2011 VA treatment records show that the Veteran was highly symptomatic for PTSD. The Veteran expressed interest in watching a documentary featuring his unit in order to gain insight into his condition and was advised to do so with caution. In May 2011, he reported continuing intrusive recollections that caused great distress. A VA mental health treatment plan was completed in May 2011. Manifestations of PTSD included re-experiencing symptoms of recurrent, distressing intrusive recollections of the traumatic event; acting or feeling as if the event were reoccurring; intense psychological distress at exposure to reminder stimuli. Avoidance symptoms included avoidance of stimuli likely to arouse trauma recollections and feelings of detachment or estrangement from others, and mistrust of others. Hyperarousal of physiological processes when reminded of trauma was noted, as well as symptoms of increased arousal such as irritability or outbursts of anger and difficulty falling or staying asleep. Long-term therapy goals included reducing the frequency and intensity of intrusive recollections, increasing quality of restful sleep, reducing avoidant behavior, reducing the frequency of irritable mood and outbursts of anger, increasing comfort in social situations, increasing the ability to relax, and increasing interest in enjoyable activities. The Veteran's identified strengths his commitment to therapy and empathy for other Veterans. His identified weaknesses were his habitual avoidance of thinking about traumatic events and impulsive behaviors. The treatment plan notes that the Veteran is likely to experience severe exacerbation of symptoms when intrusively triggered into trauma-reliving. The Veteran was provided with a second VA examination in August 2012. He was assigned a GAF score of 53, indicating moderate symptoms. The examiner determined that there was occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks with otherwise generally satisfactory functioning with normal routine behavior, self-care, and conversation. He was not undergoing treatment at the time of the examination. His symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. In June 2013, the Veteran testified to continuing symptoms of intrusive thoughts, outbursts, nightmares, avoiding crowds, panic attacks, and periods of depression. He avoided experiences that might remind him of his service, like fireworks. He also testified that his wife was intimidated or afraid of him and said he "was crazy." He was working as a mental health counselor and reported some occupational impairment due to similarities between himself and his patients, some of whom also had PTSD, and flashes of anger experienced in response to the violent threats made by some of the patients. Occasionally he had to take time off from work when these incidents occurred too frequently. The Veteran's employer tried to avoid assigning him patients with homicidal thoughts and behaviors in order to avoid these occurrences. His friendships were mostly with other Veterans. He was not currently receiving treatment for his PTSD due to time constraints and did not take any medication for PTSD because he did not want to take additional medication that may cause drowsiness in addition to the medication he took for his low back disorder. C. Factual Findings The Veteran's VA treatment records and examination reports are largely consistent and probative on the issue of the severity of his symptoms and resulting social and occupational impairment. The Veteran is competent to testify to his symptoms of PTSD and his written statements and oral testimony are credible as they are consistent with each other and the other evidence of record. The lay and medical evidence of record shows that the Veteran's PTSD is primarily manifested by symptoms of intrusive thoughts including nightmares and flashbacks, avoidance behaviors, sleep disturbance, irritability, outbursts of anger, anxiety, and depression, occasionally severely exacerbated when exposed to intrusive triggers, causing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Though other symptoms appear throughout the record, such as hypervigilance, feelings of detachment or estrangement, and diminished interest in activities are noted in the record, they are noted less frequently and are less prevalent and significant than his other symptoms, though the Board will still consider any impairment caused by these other symptoms in assessing his overall level of social and occupational impairment. The Veteran is married and reports a good relationship with his son and some friendships. Impaired social functioning is shown by the problems with his wife and altercations with strangers noted in the evidence of record. The Veteran's circle of friends is restricted to other Veterans and he avoids crowds. He has problems relaxing and finding enjoyment in activities. The Veteran is successfully employed as a mental health counselor, but continued occupational impairment is shown by the Veteran's need to select patients that, if possible, do not mirror his own symptoms in order to avoid inappropriate anger and the risk of outbursts. The Veteran has experienced outbursts when interacting with colleagues in past positions and was unable to continue employment in the occupational field of security. He occasionally takes leave from his current job to deal with these symptoms. D. Analysis Overall, review of the lay and medical evidence reveals incidents where the Veteran's symptoms are exacerbated by intrusive stimuli or environmental changes, like a change of occupation, but generally the Veteran consistently exhibits symptoms of moderate severity throughout the period on appeal. See 38 C.F.R. § 4.126(a). His GAF scores from September 2005 and August 2012 correspond to moderate symptoms. Though his GAF scores of 50 in October 2005 and November 2005 correspond to serious symptoms and his GAF score of 62 in November 2008 corresponds to mild symptoms, these scores are either just below or above the range for moderate symptoms and do not, therefore, show significant deviation from the general trend of symptoms of moderate severity. The November 2008 examiner, despite the GAF score assigned, otherwise described the Veteran as having frequent symptoms of moderate severity. Though there are reports of increased alcohol use in November 2008 and a diagnosis of alcohol dependence in March 2011, no associated increase in the Veteran's overall level of impairment or severity of symptoms is associated with the evidence of increased alcohol use. Further, as the evidence does not otherwise demonstrate the existence of distinct time periods with differing levels of symptomatology during the period on appeal, there is no need to assign staged ratings. See Fenderson, 12 Vet. App. at 126. The Veteran's primary symptoms of intrusive thoughts including nightmares and flashbacks, avoidance behaviors, sleep disturbance, irritability, outbursts of anger, anxiety, and depression, and less frequently reported symptoms of hypervigilance, feelings of detachment or estrangement, and diminished interest in activities, are exacerbated when exposed to intrusive triggers, but generally of moderate severity. These moderate symptoms cause occupational and social impairment with reduced reliability and productivity, as contemplated by a 50 percent disability rating. Thus, the Board finds that such a rating is in order in this case. The exemplar symptoms associated with a 70 percent evaluation reflect a degree of severity of symptoms indicative of a greater degree of impairment than the moderate social and occupational impairment experienced by the Veteran. See Mauerhan, 16 Vet. App. at 442. The interference with the Veteran's social and occupational functioning largely appears to be due to intermittent outbursts and anger, and is therefore occasional, and not continuous. Further, he does not have deficiencies in most areas, including work, school, family relations, judgment, thinking, or mood, as his judgment and cognitive ability have been shown to be largely without any impairment throughout the appellate period. Though instances of substance abuse are noted in the record, the Veteran also expressed interest in seeking treatment for this problem and no additional impairment is shown to be associated with his alcohol use. While the evidence does show significant intermittent periods of social and occupational impairment, the Veteran is successfully employed and has maintained ongoing family and other social relationships. See Vazquez-Claudio, 713 F.3d at 116-17. He has marital difficulties but has maintained an ongoing marital relationship with his wife of several years and reports having a good relationship with his son. He has friendships with other Veterans and currently has a successful relationship with his employer. His occupational difficulties are generally linked to his issues with inappropriate anger, and are intermittent and accommodated by his employer or the occasional use of sick leave. Therefore, as the Veteran's symptoms of moderate severity result in intermittent occupational impairment and some impairment to otherwise ongoing family and other social relationships, entitlement to a rating greater than 50 percent is not warranted. E. Extraschedular Consideration Generally, it is sufficient to evaluate a disability using either the corresponding or analogous diagnostic codes contained in the rating schedule. "However, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating." Thun v. Peake, 22 Vet. App. 111, 114 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The determination of whether a claimant is entitled to extraschedular rating under is a three-step inquiry. Id. at 115. First, the Board must determine whether the evidence presents "such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. To do this, the Board must determine whether the criteria found in the rating schedule reasonably describe the claimant's disability level and symptomatology. If so, the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is, therefore, adequate, and no referral is required. Id. However, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology, VA will move to the second step of the analysis. Id. at 115-16. Under the second prong, the RO and Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Id. In sum, if the Board determines that the schedular evaluation does not contemplate the claimant's level of disability and symptomatology, and the disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization, the case must be referred for completion of the third step-to determine whether, "to accord justice," an extraschedular rating must be assigned. Id. The symptoms associated with the Veteran's PTSD are not shown to cause any impairment not already contemplated by the application of DC 9411, requiring consideration of all actual symptoms associated with PTSD and the resulting social and occupational impairment under Vazquez-Claudio, 713 F.3d at 117, and Mauerhan, 16 Vet. App. at 442. Therefore, the rating criteria reasonably describe his disability and referral for consideration of an extraschedular rating is not warranted. ORDER Entitlement to an initial rating of 50 percent, and not higher, for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND The Veteran has submitted private treatment records showing that he is scheduled for surgery for a herniated disc of the lumbar spine. The Veteran contends that he has suffered from lower back problems since he fell 10 feet from a ladder to the ground climbing down from a tower while under hostile fire. His service treatment records document treatment for a lower back problem in service. Therefore, the claim for service connection for a low back disorder must be remanded for a VA medical examination. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). He should be given an opportunity to identify or submit any additional relevant private treatment records and his outstanding VA treatment records should be obtained on remand. Accordingly, the case is REMANDED for the following action: 1. Obtain all of the Veteran's outstanding relevant VA treatment records. All information which is not duplicative of evidence already received should be associated with the claims file or the Veteran's electronic claims folder. 2. Ask the Veteran to submit any additional relevant private treatment records that he has in his possession or to identify (i.e., provide the names, addresses, and approximate dates of treatment) his private health care providers for his lower back disorder and to furnish signed authorizations for release of any records identified. Make arrangements to obtain all records that are adequately identified and for which signed authorizations have been obtained. 3. Then, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his low back disability. The claims file and a copy of this Remand must be made available to and reviewed by the examiner in conjunction with the examination. Any indicated evaluations, studies, and tests should be conducted. The examiner is requested to provide a diagnosis of any lower back disorder found to be present. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any diagnosed low back disorder had its clinical onset during active service or is related to any in-service disease, event, or injury, including a 10 foot fall from a ladder to the ground while climbing down from a tower under hostile fire. The examiner should note that the Veteran states that he did not alert medical personnel of his back pain at separation to avoid delaying discharge. If any requested information cannot be provided without resort to speculation, indicate whether the inability to provide a definitive opinion is due to a need for further information, because the limits of medical knowledge have been exhausted, or for some other reason. The examiner must identify the facts relied on in reaching any opinion provided and provide a full explanation as to why those particular facts support the examiner's conclusions. 4. Finally, readjudicate the claim on appeal. If the claim remains denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court (Continued on the next page) of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs