Citation Nr: 1334152 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 08-28 185 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) from September 26, 2007, through April 7, 2013. 2. Entitlement to a staged initial rating in excess of 50 percent for PTSD from April 8, 2013. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD C. Hancock, Counsel INTRODUCTION The Veteran served on active duty from July 1966 to July 1968. This case initially came before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. There, the RO granted the Veteran's claim for service connection for posttraumatic stress disorder (PTSD) and assigned a 10 percent rating effective from September 26, 2007. The Veteran perfected an appeal of the initial rating assigned following the March 2008 grant of service connection for PTSD. Fenderson v. West, 12 Vet. App. 119, 126 (1999) (holding that, where a veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim for service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found). The Board later, in July 2010, increased the disability rating assigned to the Veteran's service-connected PTSD to 30 percent. In so doing, the Board denied a rating in excess of 30 percent. In effectuating the Board's decision, the RO, as shown as part of an August 2010 rating decision, assigned an effective date of September 26, 2007, for the 30 percent disability rating. The Veteran appealed the Board's July 2010 decision, to the extent it denied a rating higher than 30 percent, to the United States Court of Appeals for Veterans Claims (Court). In April 2012, the Court issued a single judge memorandum decision vacating the July 2010 Board decision with regard to the portion which denied a rating in excess of 30 percent for the PTSD and remanded the matter for further development. In September 2012 the Board remanded this matter to the Agency of Original Jurisdiction (AO) for further development. The Court has held "that a remand by this Court or the Board confers on the Veteran or other claimant, as a matter of law, a right to compliance with the remand orders." See Stegall v. West, 11 Vet. App. 268, 271 (1998). The purpose of the remand was to afford the Veteran certain due process considerations and to arrange for the Veteran to undergo an appropriate VA examination. This is shown to have been adequately accomplished. Regarding the examination, it occurred in April 2013. After review of the complete evidentiary record, the Board has determined that compliance has now occurred with the Board's orders in the above-cited September 2012 remand and that the Board may now proceed with adjudication of the claim. The Board notes that the RO increased the rating to 50 percent effective April 8, 2013. As also noted by the Board in its September 2012 remand, a claim is shown to have been raised for service connection (on a secondary basis) for depression. The matter at that time was referred to the RO for initial adjudication. At this point, this ordered adjudication has yet to be accomplished. As such, it is again noted that the issue of entitlement to service connection for depression has been raised by the record, but has not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. For the period from September 26, 2007, through April 8, 2008, the probative evidence shows that the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment most comparable to occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. From April 9, 2008, through April 7, 2013, the probative evidence shows that the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment most comparable to reduced reliability and productivity. 3. From April 8, 2013, the probative evidence shows that the Veteran's PTSD was not manifested by symptoms productive of occupational and social impairment most comparable to deficiencies in most areas. CONCLUSIONS OF LAW 1. From September 26, 2007, through April 8, 2008, the criteria for an initial rating in excess of 30 percent for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.2, 4.7, 4.10, 4.130, Diagnostic Code (Code) 9411 (2013). 2. From April 9, 2008, through April 7, 2013, the criteria for the assignment of a 50 percent staged rating, but no higher, for the Veteran's PTSD were met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.2, 4.7, 4.10, 4.130, Diagnostic Code (Code) 9411 (2013). 3. From April 8, 2013, the criteria for the assignment of a rating in excess of 50 percent rating for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 4.2, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties To Notify And Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his/her representative, if applicable, of any information, and any 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also 73 Fed. Reg. 23,353-56 (Apr. 30, 2008). Further, upon receipt of claim for service connection for a disability, VA is required to review the evidence presented with the claim and to provide the claimant with notice of what evidence not previously provided will help substantiate his/her claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Specifically, VA must notify the claimant of what is required to establish service connection and that a disability rating and effective date for the award of benefits will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran is appealing the initial rating assignment as to his PTSD. No duty to notify arises from a notice of disagreement. 38 C.F.R. § 3.159(b)(3) (2013). Rather, the Veteran's appeal as to the initial rating assignment triggers VA's obligation to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. 38 U.S.C.A. §§ 5104 and 7105 (West 2002). In this case, the notice obligations set forth in §§ 5104 and 7105 were met when the RO issued a September 2008 Statement of the Case (SOC). The SOC provided citations to the pertinent regulations involved, a summary of the evidence considered, and notice of the decision and the reasons for the decision. 38 U.S.C.A. § 7105(d). Neither the Veteran nor his representative have argued that there was any deficiency with regard to the notice requirements. Accordingly, the Board concludes that, in this case, the RO met the notice obligations set forth in §§ 5104 and 7105 of the statute. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher rating for the service-connected disability at issue. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996). VA has also satisfied its duty to assist the Veteran in this case. The Veteran's service treatment records as well as all identified and available VA and private medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's claim. This includes VA medical records - including the report of an April 2013 VA examination report - found within "Virtual VA" (an electronic data-based system). Neither the Veteran nor his representative has identified any outstanding medical records. In addition, the Veteran was afforded VA examinations with respect to the matter on appeal in March 2008 and April 2013. 38 C.F.R. §3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The examinations here are adequate, in that they included a comprehensive review of the Veteran's medical history and also included sufficient medical findings relating the applicable rating criteria. There is also no evidence indicating that there has been a material change in the severity of the Veteran's service-connected PTSD since he was last examined in April 2013. 38 C.F.R. § 3.327(a). Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the initial rating issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). Accordingly, the duty to assist the Veteran with the development of evidence pertinent to his claim has been satisfied. Factual Background The Veteran essentially contends that the severity of his PTSD symptoms warrant the assignment of an initial rating in excess of 30 percent for the period from September 26, 2007, to April 7, 2013, and a staged rating in excess of 50 percent from April 8, 2013. Post service private medical records dated April 2008 to May 2009 (in the form of examination reports dated in April 9, 2008, and May 2009) show that the Veteran was treated intermittently for his PTSD. The Veteran complained of recurrent thoughts, flashbacks, and dreams concerning his military service. He reported responses to the sight of metal planking and the sound of helicopters. Cognitive and psychological responses to trauma cues occurred in response to the sound of helicopters. Concentrations problems were noted to be present. The Veteran described a history of intensive effort to avoid thoughts, feelings, conversations, activities, and people associated with his traumatic experiences. He reported marked problems with insomnia, waking intermittently, and terminal waking. He demonstrated hypervigilance in the form of "walking his perimeter" and repeatedly checking windows and door locks. He also reported exaggerated startle responses. The Veteran's reported daily mood ranged from good to hot headed. He described experiencing occasional feelings of worthlessness and survival guilt. He also reported recurrent thoughts of death and homicidal ideation in the form of road rage. He denied suicidal ideation. He explained that he was unable to recall numerous occurrences that took place during his service in Vietnam. The Veteran had a pattern of markedly diminished interest in participation in significant activities relative to his behavior prior to service. He complained of a restricted range of affect as well as a sense of a foreshortened future. He stated that he was depressed and there was evidence of alcohol abuse. Examination findings dated during this period revealed that the Veteran's impulse control and speech were normal. Form and thought content each fell within normal limits. Suicidal and perceptual abnormalities were denied. The Veteran's affect was normal and stable. He was oriented to person, place, and time. His attention capacity fell within normal limits. His concentration ability and immediate memory abilities fell below normal limits. His memory for recent events and past events fell within normal limits and his remote memory appeared intact. The Veteran's judgment fell within normal limits but he demonstrated limited insight into his symptoms. In the April 2008 report, the physician opined that the Veteran's history of angry outbursts and difficulties with judgment would lead to difficulty in any workplace. The Veteran was diagnosed with PTSD and depressive disorder and was assigned Global Assessment of Functioning (GAF) scores of, respectively, 47 and 40. In the course of a March 2008 VA PTSD examination, the Veteran reported that he was married and had a son with whom he had a good relationship. He also stated that he had a few friends and that he talked on the phone. The Veteran also reported that he was isolated and inactive. Upon examination, the Veteran was found to be casually dressed and unshaven. His speech was slow, his affect was constricted, and his mood was depressed. He was oriented to person, place, and time. His thought process and thought content were unremarkable. The Veteran had no delusions and his judgment was normal. The Veteran was noted as having sleep impairment with waking during the night and occasional dreams about Vietnam. The Veteran did not have hallucinations, inappropriate behavior, panic attacks, obsessive/ritualistic behavior, or suicidal or homicidal ideations. His impulse control was fair, but he got impatient with people. His remote and immediate memory were both described as normal, and his recent memory was noted to be mildly impaired. The Veteran made an effort to avoid thoughts, feelings, or conversations associated with his trauma. He had an inability to recall important aspects of the trauma. The Veteran had marked diminished interest or participation in significant activities. He had feelings of detachment or estrangement from others. He had a restricted range of affect and a sense of a foreshortened future. The examiner noted that the Veteran had recurrent and intrusive recollections and dreams of the event. He also had intense psychological distress and physiological reactivity to exposure to internal or external cues that symbolized or resembled an aspect of the traumatic event. The Veteran also had behavioral and cognitive changes such as anxiety, depression, physical symptoms, unemployment, and isolation. The examiner diagnosed the Veteran with dysthymic disorder and PTSD. He stated that the Veteran had depression secondary to a heart attack that he suffered in 2001. The examiner opined that the depression could have been aggravated by the PTSD. He assigned a GAF score of 61 and noted that the score was based solely on the PTSD and not on the PTSD and depression. The examiner opined that the depression was more severe and was the cause of the Veteran's loss in function. A July 2011 VA primary care nursing note shows that the Veteran denied both suicidal and homicidal thoughts. Likewise, an August 2012 VA primary care nursing note shows that the Veteran denied both suicidal and homicidal thoughts. Pursuant to the instructions set out in the Board's September 2012 remand, the Veteran was later afforded a VA PTSD examination. This examination, conducted on April 8, 2013, shows that the examiner diagnosed the Veteran as having both PTSD and depressive disorder, not otherwise specified. The symptoms attributable to the PTSD were noted to include reexperiencing original trauma, avoidance, and hyperarousal. The level of occupational and social impairment with regards to all mental illnesses was characterized as that with reduced reliability and productively. The examiner noted that it was not possible to differentiate which portion of the occupational and social functioning was caused by each mental disorder. The Veteran self-reported symptoms of variable mood, decreased energy, dysphoric mood, and sleep disturbances. He also reported hypervigilence in public places and he also complained of decreased memory, including long term memory. The Veteran also reported being irritable and subject to anger management issues. The examiner noted the presence of the following symptoms: depressed mood, anxiety, and chronic sleep impairment. Other symptoms included variable moods and night sweats. A GAF score of 53 was supplied. VA mental health outpatient records dated subsequent to the April 8, 2013, VA PTSD examination include an April 2013 mental health diagnostic study note which shows that severe symptoms included changes in sleep patterns, and moderate symptoms included irritability, and difficulty concentrating. Mild symptoms reportedly included suicidal thoughts or wishes. As above noted, the 2008 and 2009 private examinations assigned GAF scores of 47 and 40, respectively. The March 2008 VA examination assigned a GAF score of 61, and the April 2013 examination a GAF score of 53. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (1995); 60 Fed. Reg. 43186 (1995). GAF scores of 61 to 70 represent "Some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or schooling functioning (e.g., occasionally truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships." DSM-IV. Scores ranging from 51-60 are appropriate where there are, "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 GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. Id. Laws and Regulations Disability ratings are based upon the average impairment of earning capacity as determined by a Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. Id. An evaluation of the level of disability present also includes consideration of the Veteran's ability to engage in ordinary activities, including employment, and the effect of symptoms on the functional abilities. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Further, a disability rating may require re-evaluation in accordance with changes in a Veteran's condition. It is thus essential in determining the level of current impairment that the disability is considered in the context of the entire recorded history. This appeal originates from a rating decision that granted service connection and assigned the initial rating. Accordingly, "staged" ratings may be assigned, if warranted by the evidence. Fenderson; Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Under 38 C.F.R. § 4.130, Diagnostic Code (Code) 9411, a 30 percent rating is warranted for PTSD, for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted 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 of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent evaluation for PTSD is warranted 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; 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. Diagnostic Code 9411. Disability ratings are assigned according to the manifestation of particular symptoms, as listed in the rating formula. The list of symptoms in the rating formula above is not intended to constitute an exhaustive list, but rather shows examples of the types and degrees of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. Analysis After careful consideration of all of the evidence of record, including particularly the above-referenced privately-administered psychological evaluations (administered the Veteran in 2008 and 2009), as well as the VA PTSD examination reports dated in March 2008 and April 2013, the Board finds that the Veteran's PTSD did not warrant a rating in excess of 30 percent at any time from September 26, 2007, to April 8, 2008. The Board also finds that from April 8, 2013, a disability rating in excess of 50 percent is not for application. The Board, however, does find that the evidence of record demonstrates that, from April 9, 2008, to April 7, 2013, a disability rating of 50 percent, but no higher, is warranted for the Veteran's service-connected PTSD. In this regard, between September 26, 2007, through April 8, 2008, the medical evidence of record fails to demonstrate that the criteria set out in 38 C.F.R. § 4.130 (Diagnostic Code 9411), and necessary for the assignment of a 50 percent (or higher) rating, had been met. Review of the March 2008 VA PTSD examination report, while acknowledging that recent memory loss was present (remote and immediate were not), mood was depressed, and affect was restricted, panic attacks were not shown and judgment and thought processes were normal. The Veteran also did not report having suicidal or homicidal ideation. Further, a GAF score of 61 was provided. As noted, a GAF score of 61 to 70 is defined as demonstrating some mild symptoms. See DSM- IV. These symptoms are shown to more approximate those contemplated in the criteria to be productive of the degree of occupational and social impairment warranting a rating in excess of 30 percent. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Accordingly, a rating in excess of 30 percent is not warranted for the PTSD for the period from September 26, 2007, to April 8, 2008. The Board does find, however, that for the period from April 9, 2008, to April 7, 2013, a rating of 50 percent, but no higher, is warranted for the Veteran's service-connected PTSD. On review of the findings set out as part of the medical evidence on file dated during this time period, and documented above, the Board finds that two private psychological examination reports, dated April 9, 2008, and in May 2009, include, respectively, GAF score findings of 47 and 40. The 47 GAF score is representational of serious symptoms or a serious impairment in social, occupational, or school functioning, and the GAF score of 40 is representational of some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. The Board does find noteworthy that the May 2009 private report (wherein a GAF score of 40 was provided), while noting findings of impaired impulse control and some memory and mood-related impairment, the Veteran's speech was normal, and in the course of his examination his affect was stable. Findings of impaired judgment and impaired memory are adequately considered by the currently assigned 50 percent rating. These findings, in the opinion of the Board more nearly approximate those found in the criteria for a 50 percent rating. For this same period, however, the symptoms comparable to that contemplated in the criteria to be productive of the degree of occupational and social impairment necessary for the assignment of a 70 percent rating, such as deficiencies in most areas, such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; and neglect of personal appearance and hygiene were not demonstrated. These findings indicate to the Board a severity of psychological, social, and occupational functioning well below the severity necessary for the assignment of a 70 percent rating for the period from April 9, 2008, to April 7, 2013. See above-cited GAF score information; DSM-IV. Finally, the Board is of the opinion that, as indicated above, that from April 8, 2013, and after considering all of the pertinent evidence of record, including particularly the VA examination report dated April 8, 2013, and some subsequently dated VA outpatient treatment records, the Veteran's service-connected PTSD does not warrant a disability rating in excess of 50 percent rating. In this regard, the Board finds particularly noteworthy that in the course of the April 8, 2013, VA PTSD examination a GAF score of 53 was provided. This represents findings reflective of moderate impairment. Also symptoms of his PTSD (he also has depressive disorder, which, as of now, is not service connected) were noted to include reexperiencing original trauma, avoidance, and hyperarousal. The level of occupational and social impairment with regards to all mental illnesses was characterized as that with reduced reliability and productively. This is, according to the applicable rating criteria, in line with that of a 50 percent disability rating. The April 8, 2013, VA PTSD examination report, while including findings which may be interpreted as being indicative of complaints of impaired impulse control, did not include others mentioned as part of the criteria set out for a 70 percent rating. Also, as noted, the supplied GAF score does not lend itself to a clinical conclusion of occupational and social impairment with deficiencies in most areas. Also, the findings set out as part of the VA mental health outpatient records dated subsequent to the April 8, 2013, although indicating mild suicidal ideation, overall do not include those which would warrant a rating of 70 percent. Essentially, the findings dated from April 8, 2013, to the present fail to present a disability picture which more nearly approximates the criteria for a 70 percent rating. Accordingly, the preponderance of the evidence is against a 70 percent evaluation at any time during from April 8, 2013. In reaching these decisions, the Board considered the doctrine of reasonable doubt, however, where the preponderance of the evidence is against the appellant's claims (in part), the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Consideration The Board has also considered referral for extra-schedular consideration. Ordinarily, the VA rating schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2013). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto 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 to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected psychiatric disability. The Veteran's disability is manifested by impairment in social and occupational functioning; the rating criteria contemplate these impairments. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun. ORDER An initial disability rating in excess of 30 percent for PTSD from September 26, 2007, to April 8, 2008, is denied. From April 9, 2008, to April 7, 2013, a 50 percent staged rating, but no higher, for PTSD is granted, subject to the provisions governing the award of monetary benefits. A disability rating in excess of 50 percent for PTSD from April 8, 2013, is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs