Citation Nr: 1339344 Decision Date: 11/29/13 Archive Date: 12/13/13 DOCKET NO. 10-13 093 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a skin disorder (claimed as left leg rash and vitiligo). 2. Entitlement to a compensable initial evaluation for pelvic inflammatory disease (PID). 3. Entitlement to an initial evaluation in excess of 10 percent for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) (previously rated as an adjustment disorder) prior to May 24, 2012; and greater than 50 percent thereafter. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services WITNESSES AT HEARING ON APPEAL Appellant and registered nurse ATTORNEY FOR THE BOARD S. Grabia, Counsel INTRODUCTION The Veteran served on active duty from April 1979 to July 1983 and from November 1985 to February 1986. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the Roanoke, Virginia, Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in June 2011. A transcript of the hearing is associated with the claims file. The provisions of 38 C.F.R. § 3.103(c) (2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: the duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the June 2011 hearing, the undersigned clarified the issues on appeal and inquired as to the etiology, continuity, and severity of the Veteran's asserted disabilities. The Veteran was offered an opportunity to ask the undersigned questions regarding his claim. The Board, therefore, concludes that it has fulfilled its duty under Bryant. The Board remanded the claims in May 2012. Upon remand, the RO issued a rating decision in September 2013. The RO recharacterized the Veteran's adjustment disorder as PTSD. The assigned 10 percent evaluation was increased to 50 percent from May 24, 2012. In light of this, the Board has recharacterized the issue as set forth on the title page. Applicable law provides that absent a waiver, a claimant seeking a disability rating greater than assigned will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and that a claim remains in controversy where less than the maximum available benefits are awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran has not withdrawn the appeal as to the issues of disability ratings greater than assigned for PTSD; and, as higher ratings are available for PTSD, the claim for a higher rating, as reflected on the title page, remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board acknowledges the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009), that a total rating based on individual unemployability, due to service-connected disability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. In this case, however, the record does not suggest, and the Veteran does not allege, that her service connected disabilities have rendered her unemployable. Rather, she is employed currently by VA. Accordingly, entitlement to TDIU is not for consideration at this time. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. FINDINGS OF FACT 1. The Veteran's currently diagnosed skin disorder (claimed as left leg rash and vitiligo) is not shown to have been manifested in service and is not otherwise attributable to her active military service. 2. The service-connected PID is not shown to require continuous medical treatment. 3. Prior to May 24, 2012, the Veteran's acquired psychiatric disability has been manifested by no more than occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. 4. Since May 24, 2012, the Veteran's acquired psychiatric disability has been manifested by no more than occupational and social impairment with reduced reliability and productivity; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for a skin disorder (claimed as left leg rash and vitiligo), have not been met. 38 U.S.C.A. §§ 1101, 1112, 1131, 5103, 5107 (West 2002 & West Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 2. The criteria for a compensable evaluation for PID have not been met. 38 U.S.C.A. § 1155, 5103A, 5107 (West 2002 & West Supp. 2013); 38 C.F.R. § 4.116 including Diagnostic Code 7699-7614 (2013). 3. The criteria for a disability evaluation in excess of 10 percent prior to May 24, 2012; and in excess of 50 percent thereafter, for the Veteran's PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & West Supp. 2013); 38 C.F.R. Part 4, including § 4.7 and Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and medical or lay 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. 38 C.F.R. § 3.159(b) (1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's increased rating claims arise from an appeal of the initial evaluations following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Regarding the service connection claim, the Veteran was sent letters in January 2008 and January 2009 that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal. The letters also explained what type of information and evidence was needed to establish a disability rating and effective date. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of a claim. This duty includes assisting her in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service VA examination reports. The Board notes that the Veteran's service treatment records for her second period of active service, from November 1985 to February 1986, are not available for review. In this regard, there is a heightened obligation to assist a claimant in the development of his case, a heightened obligation to explain findings and conclusions and to consider carefully the benefit of the doubt rule in cases, such as in this situation, in which records are presumed to have been or were destroyed while the file was in the possession of the government. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). Several attempts have been made to obtain additional copies of these service treatment records, including from the Veteran; such attempts to date have proved fruitless. In January 2008 the National Personnel Records Center (NPRC) was contacted and reported that all available STRS had been mailed. These were received by VA in February 2008 but contained STRS only for the first period of service from March 1979 through November 1986. A special request was made in June 2009 to NPRC for the records from November 1985 through February 1986. A negative response was received. A formal finding of unavailability of the Veteran's service treatment records was made in July 2009. The Veteran was also contacted in January 2008 and again in June 2009 requesting all medical records she may have that were relevant to the claim. She did not respond to either request. The Veteran's statements in support of her claims are of record, including testimony provided at a June 2011 videoconference before the undersigned. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims. The Board has considered whether an examination should be afforded as to the claimed skin disorder. However, given the gap in time between the post-service manifestations and discharge from active duty, the threshold for an examination, low that it may be, has not been met. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In so finding, the Board has considered the lay evidence, but as discussed in the body of the decision, the statements of record indicative of continuous symptoms, which generally would trigger VA's duty to provide an examination, are not deemed credible here. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service connection Applicable law provides that service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that a disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995); 38 C.F.R. § 3.303(a). Under § 3.303(b), an alternative method of establishing the second and/or third element is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (38 C.F.R. § 3.303(b) does not apply to any condition that has not been recognized as chronic under 38 C.F.R. § 3.309(a)). Continuity of symptomatology may establish service connection where a chronic disease under 38 C.F.R. § 3.309(a) shown as such in service or within the presumptive period, manifests at a later date. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required where the condition noted during service or the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. In this regard, the Board notes that lay persons may provide evidence of diagnosis and nexus under 38 U.S.C.A. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (vacating a decision that stated categorically that a valid medical opinion was required to establish nexus and that a lay person was not competent to provide testimony); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (lay evidence can be competent and sufficient to establish a diagnosis of the lay person is reporting a contemporaneous medical diagnosis); see also Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection). It is the Board's responsibility to evaluate the entire record on appeal. 38 U.S.C.A. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, reasonable doubt will be resolved in each such issue in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. An appellant need only demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. To deny a claim on its merits, the evidence must preponderate against the claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Alemany v. Brown, 9 Vet. App. 518 (1996). Background In this case, the Veteran contends that she is entitled to service connection for a skin disorder that began on her left leg and developed into vitiligo over her extremities and body. Specifically, she asserts that she was treated for a rash on her left leg shortly after discharge from her second period of service. She also claims to have received treatment while stationed in the Southwest Asia Theatre of Operations during her second period of active duty. For a Persian Gulf veteran who served in the Southwest Asia theater of operations during the Persian Gulf War, service connection may also be established under 38 U.S.C.A. § 1117 ; 38 C.F.R. § 3.317. A "Persian Gulf veteran" means a veteran who served on active military naval, or air service in the Southwest Theater of operations during the period which commenced on August 2, 1990, through a date to be prescribed by Presidential proclamation or law. 38 C.F.R. § 3.2(i) (2013). The record, however, reveals that the Veteran saw service in Saudi Arabia from November 1985 to February 1986, or 41/2 years before the commencement of the Gulf War. As the Veteran's period of active service ended in February 1986, she is not a Persian Gulf War veteran, and 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317, are not applicable. There are no service treatment records available from this period of service. The first medical evidence of a left leg skin rash is seen in May 1989 post-service USAF hospital treatment records. The Veteran reported a six-month history of an itchy scaly rash on the left leg. The impression was tinea vs. folliculitis. The examiner determined that it was probably a fungal type of inflammation of the left leg. It was treated with hydrocortisone cream and apparently resolved. At the June 2011 videoconference hearing the Veteran testified that her skin condition was related to her service in the Persian Gulf. It began after she returned from her tour in Riyadh, Saudi Arabia. She noticed a rash on her leg which was itchy, scaly, and brown on the back of her leg. She went to the emergency room. An antifungal cream was prescribed and the rash went away. She later began to notice little white spots on her legs, hands and around her joints area. As time went by it progressed to cover her entire body. She could not remember exactly when they first began. She has not received regular treatment for her skin condition. The file contains a January 2008 VAMC requested private consultation report from the Virginia Skin and Vein, LLC. The examiner noted multiple large well demarcated macules with complete loss of pigment on both hands, arms, and both legs. It was noted that this was an autoimmune condition. Analysis Based on the foregoing, the Board finds that entitlement to service connection for a skin condition is not warranted. Here, the Veteran has been diagnosed with current vitiligo. However, despite her contentions of being treated during service, when she was first treated for a rash on the back of her left leg in May 1989, over 3 years after separation, she did not report a history of symptoms dating back to active duty. Moreover, while she had service in Saudi Arabia, this was 41/2 years before the commencement of the Gulf War, and she is therefore not a Persian Gulf veteran. There is no evidence of a skin disorder of the left leg or of vitiligo during service. There is no evidence of a skin disorder of the left leg until approximately three years after service and of vitiligo until an even later date. There is no medical opinion offered in support of the Veteran's claim. The Veteran has contended on her own behalf that her claimed skin disability was related to her active service. In this regard, lay witnesses are competent to provide testimony or statements relating to symptoms or facts that the lay witness observed and are within the realm of his or her personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir. 2007) (noting that lay testimony may be competent to identify a particular medical condition). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). However, while VA must consider lay evidence, it may give it whatever weight it concludes the evidence is entitled to, and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require VA to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010); see also Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance, J. concurring) ("the Board should avoid overbroad statements about the competence of laypersons and should carefully distinguish its treatment of lay testimony of symptoms and its analysis of lay competence on issues of diagnosis or causation"). Although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). The Board finds that the diagnosis and etiology of the Veteran's skin disabilities are complex medical questions, beyond the competency of a layperson. The Board further finds that the questions regarding the relationship between such disabilities and military service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Therefore, as the Veteran has only provided her own conclusory statements regarding diagnosis and causation, the Board finds that the Veteran's statements to be of little probative value as she is not competent to opine on such complex medical questions. While the Veteran is competent to indicate a history of symptoms, an award of service connection based solely on continuity is not for application in this case, as the claimed disorder is not a chronic disease under 38 C.F.R. § 3.309(a). Walker, 708 F.3d 1331 (Fed. Cir. 2013). Moreover, as noted above, her reported history upon first receiving treatment in 1989 is not consistent with continuous symptoms dating back to service- rather, she reported a skin problem of only 6 months duration. Thus, even if applicable, the lay evidence here is not found credible. Accordingly, such evidence does not prompt the need to obtain an opinion of etiology in this case. In summary, the Board concludes that the preponderance of the evidence is against the Veteran's claim. Because the preponderance of the evidence is against the claim, the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). III. Increased Ratings Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. Where, as in the instant case, the appeal arises from the original assignment of disability evaluations following award of service connection, the severity of the disabilities at issue are to be considered during the entire period from the initial assignment of the disability ratings to the present time. See Fenderson v. West, 12 Vet.App. 119 (1999). III.a. PID The Veteran's service-connected PID is rated under 38 C.F.R. § 4.116, Diagnostic Code 7614. Under this code, symptoms that do not require continuous treatment are rated as noncompensable; symptoms that require continuous treatment are rated at 10 percent; and symptoms not controlled by continuous treatment are rated at 30 percent. 38 C.F.R. § 4.116, Diagnostic Code 7614. The Veteran is currently assigned a noncompensable evaluation for service-connected PID. To warrant a compensable evaluation, there would need to be evidence showing that the Veteran's PID symptoms require continuous treatment. In this case, the medical records on file do not show any current or continuous treatment for PID. In a January 2009 VA examination the examiner noted that the Veteran had been hospitalized in 1990 with a diagnosis of PID. She was treated with intravenous antibiotics for a week and released with oral antibiotics. Examination revealed normal genitalia with a normal uterus. The examiner diagnosed a history of PID. In a May 2012 VA examination, the examiner noted a history of PID in 1990. Currently, the Veteran had intermittent pain and cramps. She took naproxym as required for pain. Her symptoms did not require continuous treatment. The Veteran was not been diagnosed with any current gynecological conditions. Consequently, an initial compensable evaluation for the service-connected PID is not assignable under the applicable rating criteria. Moreover, there are no other relevant diagnostic codes for consideration. III.b. PTSD The Veteran's service-connected PTSD has been rated by the RO under the provisions of Diagnostic Code 9411. Under this regulatory provision: A 10 percent rating is warranted when the Veteran experiences occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent disability rating is warranted when there is 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 is warranted if the Veteran experiences 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; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent is warranted when the Veteran experiences occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. A 100 percent rating 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. The symptoms listed in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list but, rather, serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating for a mental disorder. In addition to the symptoms listed in the rating schedule, 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). See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The DSM-IV provides for a global assessment of functioning (GAF), a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the DSM-IV). A GAF of 61-70 indicates 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 with some meaningful interpersonal relationships. A GAF of 51-60 indicates 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). A GAF of 41-50 indicates 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). A GAF of 31-40 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). A GAF of 21-30 indicates behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g. sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g. stays in bed all day; no job, home, or friends.) American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) (Fourth Edition); see 38 C.F.R. § 4.130 (2013). Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Background At the June 2011 videoconference hearing, the Veteran testified that she can get very anxious when around men and her heart begins to race. She was undergoing treatment for her psychiatric disorder and was seeing a little improvement, although her depression was not easing up. She was employed at the VAMC as a nursing assistant and worked primarily with male Veteran's. She had some reservations and had others come in the treatment rooms with her. She noted that she had to confront her fears to get better. She also endorsed symptoms including nightmares and periods where she lacked concentration. She indicated that she had fairly close relationships with her immediate family. However, due to a lack of trust in people, she did not have friendships with other women. The Veteran underwent an initial VA PTSD examination in January 2009. The examiner noted a history of treatment for mental health issues in 1995, primarily for alcohol and substance abuse. She was currently in group therapy at the VAMC for depression. The Veteran had previously been married with no children. She has remained in a long term relationship since her divorce in 1992. She was currently living in a recovery house with other recovering people. Upon examination, the Veteran was clean and appropriately dressed. Her psychomotor activity was unremarkable. Speech was clear and coherent and she was cooperative and friendly. Affect was full, mood good, and attention intact. She was oriented to person, place, and time. Her thought process and content were unremarkable. Judgment was fair, insight was good, she was of average intelligence, and her memory was intact. There were no homicidal or suicidal ideations, or hallucinations. She was able to maintain standards of personal hygiene; and, she had no problem with activities of daily living. The Veteran had some PTSD symptoms including intrusive and distressing memories about sexual assaults and trauma. She was able to keep close to men socially but had control issues with sexual encounters. She had depressed moods most days. She had been employed since March of the previous year. The diagnosis was cocaine dependence in full remission; depression due to vitiligo; and an adjustment disorder with anxiety. The examiner opined that the adjustment disorder with anxiety was as likely as not related to service; however, the Veteran did not meet DSM-IV requirements for PTSD. The examiner assigned a Global Assessment of Functioning (GAF) score of 70. At a May 2012 VA psychiatric examination, the examiner noted that the Veteran met the full criteria for a diagnosis of PTSD. She was currently working as a nursing assistant at the Salem VAMC. She was also currently enrolled in a PTSD treatment program at the Salem VAMC. The Veteran endorsed chronic sleep disturbance; nightmares about sexual assaults; intrusive and distressing thoughts; she avoided crowds; was hypervigilant; and, felt detached. She admitted to suicidal ideations; but denied a history of homicidal or suicidal attempts. She revealed symptoms of depression; sadness; anxiety; suspiciousness; panic attacks; chronic sleep impairment; hopelessness; worthlessness; and, reduced interest in social relationships. Upon examination, the Veteran was alert and cooperative, clean and appropriately groomed. Her psychomotor activity was unremarkable. Her speech was clear and coherent. Her eye contact was good, affect was congruent and mood was anxious, speech was of normal rate, rhythm, and volume. She was oriented to person, place, and time. Her thought process was unremarkable. She became tearful at times. She was able to manage activities of daily living. The examiner opined that her PTSD was as likely as not caused by sexual assaults in service. The examiner found that the Veteran was able to personally handle money and manage financial affairs. The examiner assigned a Global Assessment of Functioning (GAF) score of 50. Recent mental health records found on Virtual VA have been reviewed, but these do not reflect a greater degree of social or occupational impairment that already described above. Such records reflect that she was in an on and off relationship with someone who had become threatening. Her cognitive and communication skills showed no deficit and there was no suicidal or homicidal ideation. Analysis - An evaluation in excess of 10 percent for PTSD prior to May 24, 2012. In order to warrant a rating in excess of 10 percent prior to May 24, 2012, the Veteran's disability must be manifested by 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). In her initial VA PTSD examination in January 2009, the examiner noted that the Veteran was under treatment at the VAMC for depression and substance abuse and was living in a recovery house. She had maintained a long term relationship since 1992. Her interests included sewing. She was able to maintain personal hygiene. She was also employed since March of the previous year. She was cooperative and friendly. The Veteran had no problem with activities of daily living. The examiner assigned a Global Assessment of Functioning (GAF) score of 70. The VA examiner noted numerous PTSD symptoms, but overall found the Veteran did not meet the full criteria for a diagnosis of PTSD. The examiner specifically answered "no" when asked if the Veteran experienced reduced reliability and productivity due to PTSD symptoms. Moreover, the assigned GAF of 70 indicates 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 with some meaningful interpersonal relationships. For the forgoing reasons, the Board finds that a preponderance of the evidence weighs against a finding that a rating in excess of 10 percent is warranted. Analysis- An evaluation in excess of 50 percent for PTSD since May 24, 2012. In order to warrant a rating in excess of 50 percent since May 24, 2012, the Veteran's disability has to be manifested by occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. At the May 2012 VA examination, the examiner noted that Veteran was currently employed at the Salem VAMC and also enrolled in the PTSD treatment program at the VAMC. The examiner assigned a Global Assessment of Functioning (GAF) score of 50. The May 2012 VA examiner noted numerous PTSD symptoms, but overall found the Veteran's functionality to be only occasionally impaired. The examiner found that the PTSD symptoms caused clinically significant distress or impairment in social and occupational areas of functioning. However, most of the symptoms listed under the criteria for a 70 percent rating were not present. The Board acknowledges the Veteran's disturbances of mood, including suicidal ideation. While the examiner assigned a GAF of 50 indicating 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); the Board finds conflicting indications in the May 2012 examination. The Veteran did not exhibit obsessional rituals, or frequent shoplifting. She did not exhibit serious impairment in social, occupational, or school functioning. With respect to the Veteran's ability to establish and maintain effective work and social relationships, she indicated that she had been in a long term relationship since 1992. She was fully employed as a nursing assistant treating mostly male veterans at the VAMC. She specifically testified that while she became anxious in an enclosed area with males, she now stayed to confront her panic, she was under ongoing treatment and "the trauma seems to be getting a little better." The evidence also demonstrates that the Veteran had a strong relationship with her immediate family. While having trust issues that prevented friendships, this is deemed contemplated by the criteria for a 50 percent evaluation. For the forgoing reasons, the Board finds that a preponderance of the evidence weighs against a finding that a rating in excess of 50 percent is warranted. IV. Extraschedular considerations The Board has considered whether this case should be referred for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b) (1). An extra-schedular rating is warranted if a case presents such an exceptional or unusual disability picture, with such related factors as marked interference with employment or frequent periods of hospitalization, that it would be impracticable to apply the schedular standards. Analysis under this provision involves a three-step inquiry, and extra-schedular referral is necessary only if analysis under the first two steps reveals that the rating schedule is inadequate to evaluate the claimant's disability picture and that such picture exhibits such related factors as marked interference with employment or frequent periods of hospitalization. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Here, the manifestations of the Veteran's PID and psychiatric disability are fully contemplated by the schedular rating criteria. The rating criteria reasonably describe the disability levels and symptomatology, and the rating schedules are adequate to evaluate the Veteran's disability picture. It is unnecessary to discuss the second prong, i.e., whether there are related factors such as marked interference with employment or frequent periods of hospitalization. See id. Moreover, there have been no hospitalizations for PID or for psychiatric disability during the course of the appeal. The Veteran is employed by the VAMC and while she has reported some work difficulties due to her mental health, there is no indication of marked interference. Rather, this interference is contemplated by the assigned ratings, as the schedular percentages are intended to account for considerable interference with employment. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. As such, referral for consideration of an extra-schedular rating is not necessary. See Thun, 22 Vet. App. at 115-16. Finally, the Board has considered the benefit of the doubt rule. However, the preponderance of the evidence is against ratings in excess of the currently assigned ratings for the Veteran's PID and psychiatric disabilities. As such, the benefit of the doubt doctrine does not apply, and the claims must be denied. 38 C.F.R. § 4.3. ORDER Service connection for a skin disorder (claimed as left leg rash and vitiligo) is denied. Entitlement to an initial compensable evaluation for PID is denied. Entitlement to an initial evaluation in excess of 10 percent for an acquired psychiatric disorder, to include PTSD prior to May 24, 2012; and greater than 50 percent thereafter is denied. ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs