Citation Nr: 1340440 Decision Date: 12/06/13 Archive Date: 12/20/13 DOCKET NO. 98-19 913A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to an increased initial evaluation for posttraumatic stress disorder (PTSD), which is rated as 10 percent disabling prior to October 14, 2004, 30 percent disabling from October 14, 2004 to March 3, 2011, and 50 percent disabling from March 4, 2011 to December 2, 2012. 2. Entitlement to an increased initial evaluation for chronic low back strain, which is rated as 10 percent disabling prior to November 30, 1999 and 20 percent disabling from November 30, 1999 to December 2, 2012. 3. Entitlement to an increased evaluation for urinary urgency and incontinence, which is rated as 20 percent disabling from March 9, 2007 to February 21, 2010 and 60 percent disabling beginning February 22, 2010. 4. Entitlement to an evaluation in excess of 50 percent for pelvic inflammatory disease (PID). 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to December 3, 2012. REPRESENTATION Appellant represented by: Joseph R. Moore, Attorney ATTORNEY FOR THE BOARD J. W. Loeb INTRODUCTION The Veteran had active service from August 1973 to October 1976. This appeal to the Board of Veterans' Appeals (Board) arose from October 1997 and June 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa. In June 2010, the Board remanded the issue of entitlement to an increased initial evaluation for chronic low back strain, currently rated 10 percent disabling before November 30, 1999 and 20 percent disabling beginning November 30, 1999, to the RO for a current evaluation, based on an August 2009 Joint Motion For Partial Remand and an August 2009 United States Court of Appeals for Veterans Claims (Court) Order. VA evaluations of the back were obtained in March 2011 and December 2012. A February 2013 Decision Review Officer's decision granted an increased initial rating of 40 percent for low back disability effective December 3, 2012. Consequently, there has been substantial compliance with the June 2010 remand instructions. Stegall v. West, 11 Vet. App. 268 (1998) (Holding that a remand by the Court or the Board confers on the Veteran or other claimant, as a matter of law, the right to compliance with the remand orders). A January 2013 Decision Review Officer's decision granted an increased initial rating of 50 percent for PTSD effective March 4, 2011 and an increased initial 70 percent rating effective December 3, 2012; based on the December 2012 grant, the Veteran's combined ratings equaled 100 percent effective December 3, 2012. In response to a July 2013 motion from the Veteran's attorney, the Board sent the Veteran's attorney a letter on August 7, 2013 in which the Veteran was given 90 days from the date of the letter to submit additional evidence. On November 5, 2013 the Veteran's attorney submitted a brief in which it was noted that the Veteran was satisfied with the ratings assigned from December 3, 2012. Consequently, the issues currently on appeal are as listed on the title page. See AB v. Brown, 6 Vet. App. 35 (1993). Accompanying this statement was a September 2013 private psychiatric evaluation report, along with a waiver of RO review. See 38 C.F.R. § 20.1304(c) (2013). FINDINGS OF FACT 1. For the rating period on appeal from January 24, 1997 to October 13, 2004, the service-connected PTSD symptomatology is productive of functional impairment comparable to occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 2. For the rating period on appeal from October 14, 2004 to March 3, 2011, the service-connected PTSD symptomatology is productive of functional impairment comparable to 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). 3. For the rating period on appeal beginning March 4, 2011, the service-connected PTSD symptomatology is productive of functional impairment comparable to occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 4. From January 24, 1997 to November 29, 1999, there is evidence of low back pain but no more than slight limitation of motion of the lumbar spine. 5. From November 30, 1999 to December 2, 2012, there was no more than moderate limitation of motion of the lumbar spine; beginning September 26, 2003, the evidence does not show flexion of the lumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. 6. Prior to evaluation in February 2010, there is no evidence that the Veteran had urinary urgency and incontinence requiring the wearing of absorbent materials. 7. Beginning February 22, 2010, there is evidence that the Veteran's urinary urgency and incontinence requires the wearing of absorbent materials that must be changed more than four times per day; there is no evidence of renal dysfunction. 8. The evidence of record indicates that the Veteran had a complete removal of her uterus and both ovaries in 1983; she had a normal pelvic examination in March 2011. 9. The evidence of record does not demonstrate that the Veteran's service-connected disabilities preclude her from securing or following a substantially gainful occupation prior to March 4, 2011. 10. The evidence of record demonstrates that the Veteran's service-connected disabilities preclude her from securing or following a substantially gainful occupation beginning March 4, 2011. CONCLUSIONS OF LAW 1. The criteria for an increased initial evaluation for PTSD prior to March 4, 2011 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for an increased initial evaluation for PTSD of 70 percent, but no higher, beginning March 4, 2011 are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for the assignment of an initial evaluation in excess of 10 percent for chronic low back strain from January 24, 1997 to November 29, 1999 have not been met. 38 U.S.C.A. § 1155, 5103A, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.71a including Diagnostic Codes 5285 thru 5295 (1999). 4. The criteria for the assignment of an initial evaluation in excess of 20 percent for chronic low back strain from November 30 1999 to December 2, 2012 have not been met. 38 U.S.C.A. § 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.71a including Diagnostic Codes 5285 thru 5295 (2002); 38 C.F.R. §§ 4.7, 4.71a including Diagnostic Code 5242-5237 (2012). 5. The criteria for an increased evaluation for urinary urgency and incontinence, which is assigned a 20 percent rating from March 9, 2007 to February 21, 2010 and a 60 percent rating beginning February 22, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.115(a), (b), Diagnostic Code 7517 (2013). 6. The criteria for an evaluation in excess of 50 percent for PID have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.116, Diagnostic Code 7617 (2013). 7. The criteria for TDIU prior to March 4, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 3.655, 4.16 (2010). 8. The criteria for TDIU beginning on March 4, 2011, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 3.655, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Board has considered the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 and Supp. 2012); see 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. See also Quartuccio v. Principi, 16 Vet. App. 183 (2002). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied. The notice and assistance provisions of VCAA should be provided to a claimant prior to any adjudication of the claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Notice to the Veteran was not sent in this case until later in the claims process. However, VA may proceed with adjudication of a claim if errors in the timing or content of the notice are, as in this case, not prejudicial to the claimant. Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Mayfield v. Nicholson, 19 Vet. App. 103 (2005); see also Pelegrini, 18 Vet. App. at 121. A letter was sent to the Veteran in June 2006 that informed her of the requirements needed to establish entitlement to an increased evaluation. A letter was sent to the Veteran in July 2009 that informed her of the requirements needed to establish entitlement to TDIU.. Additionally, the matters were readjudicated following completion of VCAA notice, including in supplemental statements of the case. In accordance with the requirements of VCAA, the June 2006 and July 2009 letters informed the Veteran what evidence and information she was responsible for obtaining and the evidence that was considered VA's responsibility to obtain. No additional private medical evidence was subsequently added to the claims files. The Veteran was also informed in these letters about effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VA has a duty to assist the claimant in obtaining evidence necessary to substantiate a claim. VCAA also requires VA to provide a medical examination when such an examination is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159. Relevant VA examinations are of record, with the most recent dated in March 2011 and December 2012. 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 Board finds that the March 2011 and December 2012 VA examinations are adequate, as they provide the symptomatology of the service-connected disabilities at issue. Accordingly, there is adequate medical evidence of record to make a determination on the issues on appeal and VA's duty to assist with respect to obtaining a VA examination in this case has been met. 38 C.F.R. § 3.159(c)(4). The Board concludes that all available evidence that is pertinent to the claims decided herein has been obtained and that there is sufficient medical evidence on file on which to make a decision on the claims. The Veteran has been given ample opportunity to present evidence and argument in support of her claims. The Board additionally finds that general due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2013). Analysis of the Claims The Veteran contends that the service-connected disabilities at issue are more severe than currently evaluated. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule). 38 C.F.R. Part 4 (2013). The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2013). Separate diagnostic codes identify the various disabilities. In considering the severity of a disability it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, see Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991), where service connection has already been established, and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Where the Veteran is appealing the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the evaluation to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. See Butts v. Brown, 5 Vet. App. 532 (1993). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Pertinent to a claim for an increased rating, lay testimony is competent when it describes symptoms, which supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see Proscelle v. Derwinski, 2 Vet. App. 629 (1992) (holding that, in general, for the need for a VA examination to arise, a claimant would only need submit his competent testimony that symptoms, reasonably construed as related to the service-connected disability, have increased in severity since the last evaluation.). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). Increased Rating Claims PTSD An October 2006 rating decision granted service connection for PTSD and assigned a 10 percent rating from January 24, 1997 to October 21, 2004 and a 30 percent rating effective October 22, 2004. A February 2009 rating decision granted an earlier effective date for a 30 percent rating for PTSD of October 14, 2004. A January 2013 Decision Review Officer's decision granted a 50 percent rating for PTSD effective March 4, 2011 and a 70 percent rating effective December 3, 2012. Under the rating schedule, a 10 percent rating is assignable for psychiatric disability when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). A 30 percent evaluation is assignable for psychiatric disability 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, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent evaluation is assignable for psychiatric disability when there is 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 (for example, 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. Id. A 70 percent evaluation is assignable for psychiatric disability when there is 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); inability to establish and maintain effective relationships. Id. A 100 percent evaluation for psychiatric disability is assignable with 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; memory loss for names of close relatives, own occupation, or own name. Id. The global assessment of functioning (GAF) score reflects the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score of 31 to 40 involves 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 score of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 is defined as 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 61 to 70 is defined as mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household) but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF of 71 to 80 is assigned when symptoms, if present, are transient and are expected reactions to psychosocial stressors (e.g., difficulty concentrating after family argument), with no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). See QUICK REFERENCE TO THE DIAGNOSTIC CRITERIA FROM DSM-IV, 46-7 (1994). Black Hawk-Grundy Mental Health Clinic records dated through June 1997 reveal that the Veteran was receiving outpatient therapy once or twice a month. She was upset in January 1997 because she felt that she was being harassed by a collection agency due to some money she owed. She reported one bad panic attack in June 1997; she also reported continued flashbacks and feelings of anger related to her sexual assaults in service. The Veteran complained on VA psychiatric evaluation in July 1997 of anhedonia, poor sleep, poor concentration, poor memory, low energy and low motivation. Her medical records were not available for review. She was taking medication for anxiety. She had not worked since 1990, when she said that she had stopped working due to back problems. She reported a history of a suicide attempt by alcohol ingestion approximately four years prior to the examination. On mental status evaluation, the Veteran was oriented and alert; she had good grooming and hygiene. Her mood was considered low; her affect was appropriate her speech was logical and goal directed. She denied suicidal and homicidal ideations, and there was no evidence of delusions or hallucinations. Insight and judgment were intact. It was noted that the Veteran was crying throughout the end of the interview. The diagnoses were history of PTSD; history of alcohol abuse, in remission; and history of polysubstance abuse, in sustained full remission. Her GAF score was 60, with 55 over the last year. According to a July 1997 statement from G. F. Haban, Ph. D., the Veteran was seen for follow-up due to reports of increased stress and depression. The Veteran denied suicidal or homicidal ideation, denied symptoms suggestive of a formal thought disorder, and denied alcohol or drug abuse. Her sleep and appetite were variable. She felt that she was coping well with her stress. Private treatment reports from Cedar Falls Counseling Associates and from Black Hawk-Grundy Mental Health Clinic, dated through July 2004 are also on file. The Veteran was tearful at the beginning of her therapy session in August 1997; she was having difficulty coping, which included fear of going outside because she was afraid of her neighbor's dogs. She continued to have flashbacks and stayed mostly at home. She was very angry with men. It was reported in November 1997 that the Veteran was to be transferred to a male therapist because he was an expert in PTSD and because it was felt that she should see a male to help ease her fear of men. It was noted on a Black Hawk clinical assessment in July 2000 that the Veteran woke up angry but was coping. She felt that her medications were working. On mental status evaluation, the Veteran's speech was clear and coherent, her affect was appropriate, she was fully oriented, her thought process and reasoning were normal, and she denied suicidal or homicidal ideations. She had decreased appetite and had lost 16 pounds recently. She also had low energy and low to medium motivation. The diagnoses were PTSD; alcohol abuse, in remission; dysthymia; obsessive-compulsive personality traits. Her GAF score was 62. Problems with anxiety and flashbacks were reported in Black Hawk records for September 2002. August 2004 statements from friends of the Veteran, including her roommate of ten years, reveal that the Veteran has had problems with anxiety attacks, panic attacks, headaches, and nightmares for many years. According to her roommate, she has screamed out at night related to nightmares about being sexually assaulted. The roommate's statement also refers to the Veteran's fear of men. A VA psychiatric evaluation was conducted in October 2004, which included review of the claims folder. The Veteran was described as frail and underweight; she complained of physical pain and psychological distress. She made good eye contact and spoke fluently with some tendency to tangentiality, over-elaborating minor points in some cases and needing to be redirected. She was considered a moderately reliable historian, as she was reasonably consistent in her account. She appeared anxious and depressed. Her speech was considered mostly logical and related, with no indication of hallucinations, delusions, or a formal thought disorder. No obsessions or compulsive rituals were elicited. She was fully oriented with mostly adequate memory and concentration, although she had a tendency to vagueness and forgetting dates. A moderate sleep disturbance was noted. She also had an eating problem, primarily skipping meals because of low energy and pain. The diagnoses were PTSD/military sexual trauma (subject to verification); major depressive disorder; and borderline personality disorder. Her GAF score was 44. It was noted that the Veteran's PTSD symptomatology accounted for approximately one-third of the social and industrial impairment reflected by the GAF score. The Veteran noted on VA psychiatric evaluation in February 2010 that she felt like she could not breath several times a week, which lasted from ten minutes to an hour. Although she felt lonely; overall, she said that she was doing fairly well. Her general appearance was described as clean; her affect was full; her speech and thought process were unremarkable; her mood was anxious, good, and dysphoric; she was oriented; she had difficulty sleeping if she did not take her medication; she had suicidal ideation; and her remote memory was mildly impaired. After review of the evidence in the temporary file, to include the October 2004 evaluation, and examination of the Veteran, the diagnoses were PTSD, chronic; and dysthymic disorder. Her GAF score was 67. It was noted that her symptoms of PTSD included intrusive thoughts, nightmares, hypervigilance, depressed mood, insomnia, and decreased concentration. The examiner noted that the Veteran's symptoms had improved since the 2004 evaluation. According to the examiner, there was occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks due to PTSD but with generally satisfactory functioning. The Veteran's PTSD did not render it impossible for an average person to follow substantially gainful employment and did not prevent her from being employed. VA treatment reports for 2010 reveal a GAF score of 51 in April 2010 and of 71 in August 2010. When examined by VA in March 4, 2011, the Veteran was oriented. It was noted that the claims files were reviewed. She was taking medication for her psychiatric problems, which she said made her drowsy; she had a hard time getting going in the morning. She complained of depression, crying spells, mood liability/irritability, anhedonia, reduced energy, and intermittent hopelessness. She thought that her physical status and her anxiety were worse since her last evaluation. She did not want to be around men and was considered socially impaired. Her symptoms included obsessive/ritualistic behavior, such as checking doors and locks and her burglar alarm; mild to moderate panic attacks when she left the house; and mildly impaired recent memory. She only got approximately 2-4 hours sleep a night and had problems with nightmares of her rape. On mental status examination, her appearance was clean but mildly disheveled; her speech was spontaneous and coherent; her affect was constricted and her mood was anxious; she was easily distracted; and she had delusions of guilt. She was fully oriented. Her thought content was preoccupied with one or two topics, phobias, depersonalization, and paranoid ideation. The diagnoses were PTSD, chronic; history of chronic dysthymic disorder; and history of alcohol abuse, in remission. Her GAF score was 55. According to the examiner, there was reduced reliability and productivity due to PTSD symptoms. The Veteran was considered employable but there were some challenges because she was fearful around men and had problems with panic attacks when she left her house. She was noted to be a master's level trained counselor, was intelligent, and could express herself well. VA treatment reports reveal GAF scores of 64 in December 2011, 61 in March and May 2012, 35 and 40 in November 2012, and 40 in December 2012 and January 2013. It was noted on November 19, 2012, when her GAF was 35, that the Veteran was having problems with anger, anxiety, and issues related to her sexuality. It was reported on VA psychiatric evaluation in December 2012 that the Veteran continued to meet the diagnostic criteria for PTSD. She had mood liability, intermittent depression, reduced memory/concentration, sleep disturbances, anxiety, and panic attacks. The level of identified psychiatric disability was noted to be significant and serious. The diagnoses were PTSD, chronic; history of alcohol dependence, in sustained full remission. The GAF score was 43. Also on file is a September 2013 psychiatric evaluation from B. Center, M.D., a psychiatrist, who had reviewed the Veteran's medical records and interviewed her. According to Dr. Center, the Veteran has chronic PTSD that began during her military service and has prevented her from working since at least June 1990. Dr. Center reported that, prior to June 1990, the medical records show that the Veteran was involved in conflicts with coworkers and experienced memory problems that contributed to her no longer being able to maintain employment following surgery. It was noted that her psychiatric condition exacerbates her physical complaints of lumbar pain and urgency. Her PTSD symptomatology included social isolation, fear of men, tearfulness, anxiety, difficulty concentrating, tangential thought processing and speech, paranoid thoughts, anger outbursts, and suicidal ideation. Her PTSD appeared to have occurred after her sexual assaults in service. She met all of the criteria for a diagnosis of PTSD: She has been exposed to multiple traumatic events of sexual trauma during service; her response includes intense fear, helplessness and anger and feelings of guilt consistent with those reported by many female victims of rape; she has ongoing intrusive recollections regarding the distressing events, as well as ongoing recurrent trauma-related nightmares and poor sleep; she has intense psychological distress with any exposure to internal or external cues symbolizing these events; she engages in extensive avoidance to prevent thoughts, feelings or conversations presented to her associated with this trauma; she avoids any circumstances, including activities, places, or people, that could potentially cause her to recall these events; she shows extremely diminished interest or participation in activities; and she has symptoms of significant hyper-arousal with difficulty falling or staying asleep, outbursts of anger, hypervigilance, difficulty concentrating, and difficulty functioning. She is able to go to treatment at the VA for her PTSD and medical conditions but otherwise isolates herself. She has had both inpatient and outpatient care and continues to be maintained on psychotropic medications. The diagnoses were PTSD, chronic, severe; history of depression; and alcohol abuse, in sustained full remission. The GAF score was 38. Dr. Center concluded that the Veteran suffered from a severe, chronic and disabling psychiatric condition characterized by symptoms consistent with PTSD, which has prevented her from working since June 1990. A Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002); however, as the Court held in Mauerhan, without the examples noted in the rating criteria, differentiating a 50 percent evaluation from a 70 percent evaluation would be extremely ambiguous. The Board is to consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. If the evidence demonstrates that a Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating should be assigned. Id. The Board finds that the psychiatric findings prior to VA evaluation in October 2004 do not show disability equivalent to more than a 10 percent evaluation, as her GAF score on evaluation in July 1997 was 60 and she indicated when seen by Dr. Haban in July 1997 that she was coping well with her stress. When treated by Black Hawk-Grundy Mental Health Clinic in July 2000, she felt that her medications were working and her GAF score was 62, which indicates mild symptomatology. With respect to the period from October 14, 2004 through March 3, 2011, the psychiatric findings are equivalent in severity to the findings for the assignment of a 30 percent rating. Although there is a GAF score of 44 on evaluation in October 2004, the examiner indicated that about one-third of the score was due to PTSD symptoms. In fact, her speech was considered mostly logical and related, with no indication of hallucinations, delusions, or a formal thought disorder. She was fully oriented with mostly adequate memory and concentration. When evaluated in February 2010, she said that she was doing fairly well, and her GAF score was 67, indicative of mild symptomatology. The examiner concluded that there was occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks due to PTSD but with generally satisfactory functioning. A GAF score of 71 was noted in August 2010. The psychiatric symptomatology for the period beginning on VA evaluation on March 4, 2011 is most equivalent in severity to the symptomatology for a 70 percent rating. The Veteran noted on examination in March 2011 that her anxiety had gotten worse since her last evaluation; and it was noted that her symptoms included obsessive/ritualistic behavior, mild to moderate panic attacks when she left the house, and mildly impaired recent memory. She only got approximately 2-4 hours sleep a night. Additionally, her appearance was mildly disheveled, her affect was constricted; her mood was anxious; she was easily distracted; she had delusions of guilt; and her thought content was preoccupied. Although GAF scores from March 2011 to May 2012 varied from 55 to 64, they were 35 to 43 from November 2012 to January 2013 and when examined in September 2013, which means that symptomatology was at least serious and, when 40 or less, involves some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A rating in excess of 70 percent is not warranted during the appeal period through December 2, 2012, because the evidence does not show the equivalent of 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; memory loss for names of close relatives, own occupation, or own name. In fact, the above evidence does not show any of these symptoms. Although the September 2013 private evaluation report attests to the severity of the Veteran's PTSD, this evaluation is primarily a report on the Veteran's current psychiatric condition, for which she is already assigned a 70 percent rating. This report does not provide evidence of symptomatology prior to December 3, 2012, which is the period at issue, indicative of symptomatology resulting in total and occupational impairment. In other words, despite the Veteran's significant symptomatology, which includes anxiety, depression, social isolation, difficulty sleeping, anger, decreased concentration, there is no evidence of findings such as gross impairment in thought processes or communication, persistent delusions or hallucinations, disorientation to time or place, or significant memory loss. Chronic Low Back Strain The Veteran was granted service connection for chronic low back strain disability in an October 1997 rating decision and assigned a 10 percent evaluation effective January 24, 1997. A February 2009 rating decision granted a 20 percent evaluation for the low back disability, effective November 30, 1999. A February 2013 Decision Review Officer's decision granted a 40 percent rating for chronic low back strain effective December 3, 2012. 38 C.F.R. § 4.40 notes that disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40 (2013). 38 C.F.R. § 4.45 provides that factors of disability involving a joint reside in reductions of its normal excursion of movements in different planes of motion and therefore, inquiry will be directed to such considerations as weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); excess fatigability; and incoordination (impaired ability to execute skilled movements smoothly). 38 C.F.R. § 4.45 (2013). The Court has held that when a Diagnostic Code provides for compensation based upon limitation of motion, the provisions of 38 C.F.R. §§ 4.40 and 4.45 must also be considered, and that examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain "on use or due to flare-ups." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Ankylosis is "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Colayong v. West, 12 Vet App 524 (1999) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONALRY (28TH Ed. 1994) at 86). During the pendency of this appeal, regulatory changes amended the rating criteria for evaluating intervertebral disc syndrome effective on September 23, 2002. See 67 Fed. Reg. 54,345-54,349 (2002). Effective September 26, 2003, VA revised the criteria for diagnosing and evaluating the spine. See 68 Fed. Reg. 51454-51458 (2003). VA's General Counsel, in a precedent opinion, has held that when a new regulation is issued while a claim is pending before VA, unless clearly specified otherwise, VA must apply the new provision to the claim from the effective date of the change as long as the application would not produce retroactive effects. VAOPGCPREC 7-03; 69 Fed. Reg. 25179 (2003). The amended versions may only be applied as of their effective date and, before that time, only the former version of the regulation may be applied. VAOPGCPREC 3-00; 65 Fed. Reg. 33422 (2000). The RO has provided the Veteran with the schedular criteria under both the old criteria in the VA Schedule for Rating Disabilities and the current regulations. Therefore, there is no prejudice to the Veteran for the Board to apply both the old and new regulatory provisions. See Bernard v. Brown, 4 Vet. App. 384 (1993). Diagnostic Code 5010, which is used to rate arthritis due to trauma, provides that traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2013). Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. In the absence of limitation of motion, a 20 percent rating is warranted with x-ray evidence of involvement of 2 or more major joints, or 2 or more minor joint groups, with occasional incapacitating exacerbations. Id. A 10 percent rating is warranted for x- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Id. Prior to September 26, 2003, a 40 percent evaluation was assigned for severe limitation of motion of the lumbar spine; a 20 percent rating was assigned for moderate limitation of motion of the lumbar spine; and a 10 percent rating was assigned for slight limitation of motion of the lumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code 5292 (2002). The words such as "mild," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6 (2002). According to 38 C.F.R. Section 4.71a, Diagnostic Code 5293, prior to September 26, 2003, a 60 percent evaluation may be assigned when there is evidence of intervertebral disc syndrome with incapacitating episodes having a total duration of at least six weeks during the past twelve months; and a 40 percent evaluation is assigned when the incapacitating symptom episodes last at least four weeks, but less than six weeks. This remained essentially unchanged in the revisions effective on September 26, 2003. In June 2004, a correction was published to reinsert material that was inadvertently omitted from the initial publication of the 2003 revision. 69 Fed. Reg. 32449 (2003). Note (1) states that for purposes of evaluations under Diagnostic Code 5293, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. "Chronic orthopedic and neurologic manifestations" means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. Note (2) states that when evaluating the disability on the basis of chronic manifestations, evaluate the orthopedic disabilities using evaluation criteria for the most appropriate orthopedic diagnostic code or codes. Neurologic disabilities are to be evaluated separately using evaluation criteria for the most appropriate neurologic diagnostic code or codes. Note (3) provides that if the intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are distinct, evaluate each segment on the basis of chronic orthopedic and neurologic manifestations or incapacitating episodes, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2003). Diagnostic Code 5294 provided that ratings for sacro-iliac injury and weakness were to be rated under the criteria for Diagnostic Code 5295. 38 C.F.R. § 4.71a, Diagnostic Code 5293 (2003). Under Diagnostic Code 5295 prior to September 26, 2003, a 40 percent rating was assigned for severe lumbosacral strain, with listing of whole spine to opposite side, positive Goldthwaite's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion; a 20 percent rating was assigned with muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position; a 10 percent rating was assigned for characteristic pain on motion; and a 0 percent rating was assigned with slight subjective symptoms only. 38 C.F.R. § 4.71a, Diagnostic Code 5295 (2003). Under the revised rating criteria beginning on September 26, 2003, involving the general rating formula for diseases or injuries of the spine, a 100 percent evaluation is assigned for unfavorable ankylosis of the entire spine; a 50 percent evaluation is assigned when there is unfavorable ankylosis of the entire thoracolumbar spine; a 40 percent evaluation is assigned for forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the thoracolumbar spine; a 20 percent evaluation is assigned when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, or the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or with muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; and a 10 percent evaluation is assigned when forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees, or the combined range of motion of the thoracolumbar spine is greater than 120 degrees but not greater than 235 degrees, or with muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour. 38 C.F.R. § 4.71a, Diagnostic Codes 5235 to 5243 (2013). The notes to the revised rating formula for diseases and injuries to the spine state that any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be rated separately, under an appropriate diagnostic code. 38 C.F.R. § 4.71a, Note (1) (2013). For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Id. at Note (2) (2013). Each range of motion measurement is rounded to the nearest five degrees. Id. at Note (4) (2013). Intervertebral disc syndrome (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § 4.25 (combined ratings table) (2013). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 10 percent rating is awarded for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is awarded for disability with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is assigned for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months. A maximum 60 percent rating is warranted when there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. Note 1 provides that for the purposes of evaluations under Diagnostic Code 5293, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. "Chronic orthopedic and neurological manifestations" means orthopedic and neurologic signs and symptoms resulting from intervertebral disc syndrome that are present constantly, or nearly so. 38 C.F.R. § 4.71a (2013). Private treatment reports dated prior to July 1997 reveal that the Veteran complained of severe low back pain in January 1997. When evaluated by VA in July 1997, the Veteran complained of radiating low back pain. X-rays showed mild anterior lipping of L2, L3, and L5, with lumbarization of S1. Private treatment records for 1998 reveal the impression in June 1998 of severe pain involving the upper and lower back. A bulging disc at L5 was noted in September 1998. It was reported in October 1998 that the Veteran's back had improved significantly with therapies. According to a September 1998 report from F. Manshadi, M.D., the pertinent diagnoses were acute intractable low back pain with radicular symptoms, possibly related to lumbar disc disease or muscular strain; and history of fibromyalgia. When examined by VA in November 1999, the Veteran complained of chronic low back pain that was aggravated by walking, climbing stairs, twisting, or prolonged sitting. She noted some pain radiation to the legs, greater on the left. She walked with the aid of a crutch; without the crutch, she walked with a right-sided limp. Back flexion was limited to 55 degrees, with a pulling sensation in the lumbar region; extension was to 10 degrees with pain; and lateral bending was to 15 degrees bilaterally. There was no spasm, but exquisite point tenderness was reported. Straight leg raising was positive bilaterally, greater on the right; reflexes were absent in the right ankle. The impressions were chronic low back pain with bilateral lumbar radiculopathies; and history and physical findings at least likely consistent with fibromyalgia. According to a June 2003 statement from Ebert Chiropractic Clinic, the best estimate was that the Veteran had been seen in the early 1980's for neck and back pain. The Veteran complained on VA neurological evaluation in November 2004 of headaches, neck pain, and low back pain with radiation. She had difficulty getting out of bed, with significant morning stiffness and muscle spasms; and she used a lumbar support and a cane. She was taking medication for pain. It was noted that muscle mass, tone and strength were symmetric with strength of 5/5, bilaterally, in the upper and lower extremities; strength testing caused shaking of the extremity being tested. Passive range of motion included forward flexion to 55 degrees, extension to 10 degrees, lateral flexion to 15 degrees on each side, and rotation to 10 degrees bilaterally; the Veteran complained of pain at 15 degrees of flexion, at 1 degree of extension, at 5 degrees of lateral bending to either side, and at 5 degrees of rotation to either side. The examiner noted that range of motion testing was unreliable due to the Veteran's reporting of "constant pain" and that the Veteran's natural range of motion during the evaluation was better than during formal testing. X-rays of the low back showed minimal degenerative changes. Chronic low back pain was diagnosed. The examiner noted that the Veteran's lower extremity symptoms were not consistent with any identifiable lumbar radiculopathy. The Veteran complained on VA evaluation in March 2007 of daily back spasms, pain on motion, and tenderness. Range of motion included flexion to 75 degrees, with pain beginning at 55 degrees; extension to 10 degrees, with pain; lateral bending to 25 degrees on the right, with pain, and to 20 degrees on the left, with pain; and bilateral rotation to 17 degrees, with pain. There was additional loss of lateral bending of 5 degrees on the right and 2 degrees on the left on repetitive use. The Veteran reported severe flare-ups every 1-2 months. There was objective evidence of spasm. She used a cane to walk and could walk 1/2 block. The diagnosis was strain of the lumbosacral spine. The condition was considered to affect most daily activities. Also on file are October 2007 lay statements on the nature and severity of the Veteran's low back disability. The Veteran complained on VA evaluation in February 2010 of progressive back pain, spasm, weakness, stiffness, fatigue, and pain radiation. She noted incapacitating episodes 2-3 times a month for a day or so. She was unable to walk more than a few yards. On physical examination, her gait was considered normal. There were no spasms, atrophy, guarding, pain on motion, or weakness. Range of motion included flexion to 100 degrees, extension to 20 degrees, lateral bending to 20 degrees on each side, and rotation to 15 degrees bilaterally. There was no additional limitation on repetitive testing. X-rays and an MRI of the lumbar spine showed minimal degenerative changes. Chronic low back pain was diagnosed. There was no significant occupational effect; there was a moderate effect on exercise and chores but no effect on other daily activities. The examiner concluded that she was not totally disabled by any of her medical conditions but should not lift over 25 pounds or stand for over 30 minutes and should avoid repetitive bending or twisting. The Veteran complained on VA back evaluation in March 2011 of multiple symptoms. She had pain with motion and was only able to walk 1/4 mile. Range of motion included flexion to 95 degrees, extension to 25 degrees, lateral bending to 35 degrees to each side, and rotation to 25 degrees on the left and to 30 degrees on the right. There was no objective evidence of pain on active range of motion and no additional limitation on repetitive motion. Motor, sensory, and reflex testing was normal. X-rays of the low back showed mild multilevel degenerative changes. The diagnoses were lumbar back strain, mild; and vertebral osteoarthritis. Range of motion on VA evaluation in December 2012 included flexion of 30 degrees, with pain beginning at 5 degrees; extension of 10 degrees, with pain beginning at 0 degrees; lateral bending of 10 degrees on each side, with pain beginning at 10 degrees; and rotation of 15 degrees bilaterally, with pain beginning at 15 degrees. After repetitive testing, flexion was to 15 degrees, extension was to 5 degrees, lateral bending was to 10 degrees to each side, and rotation was to 10 degrees bilaterally. After repetitive motion, there was less movement than normal, weakened movement, excess fatigability, pain on movement, and interference with sitting, standing and/or weight bearing. Strength testing was 4/5 in the lower extremities. Sensory testing was decreased in each lower leg/ankle and in each foot/toes. There was no evidence of radiculopathy. The Veteran used a cane to ambulate. The diagnoses were chronic low back pain and degenerative disc disease of the lumbar spine. The Veteran's low back condition impacted on her ability to work. She said that her pain has gotten worse over the past two years and that she could not garden or clean out the cat box due to back pain. She quit shooting pool, playing darts, and bicycling years ago. A rating in excess of 10 percent is not warranted for low back disability prior to November 30, 1999 because, despite complained of severe back pain, there is no information on range of motion and it was reported in October 1998 that the Veteran's back had improved significantly with therapies. The evidence does not show muscle spasm on extreme forward bending and loss of lateral spine motion, unilateral, in standing position, which warrants a 20 percent rating for lumbar strain under the schedular criteria in effect prior to November 1999. A rating in excess of 20 percent is not warranted for low back disability prior to December 3, 2012. The medical evidence prior to September 26, 2003 does not reveal more than moderate limitation of motion of the lumbosacral spine, as flexion was to 55 degrees, extension was to 10 degrees, and lateral flexion was to 15 degrees to either side on VA evaluation in November 1999. The evidence does not show listing of the spine to the opposite side or marked limitation of forward bending in the standing position. Although there was additional loss of motion on VA evaluation in November 2004, the examiner concluded that the range of motion findings were unreliable, as the Veteran's natural range of motion during the evaluation was better than during formal testing. When examined by VA in February 2010, range of motion included flexion to 100 degrees, extension to 20 degrees, lateral bending to 20 degrees on each side, and rotation to 15 degrees bilaterally. There was no additional limitation on repetitive testing. Moreover, when examined in March 2011, range of motion included flexion to 95 degrees, extension to 25 degrees, lateral bending to 35 degrees to each side, and rotation to 25 degrees on the left and to 30 degrees on the right. There was no objective evidence of pain on active range of motion and no additional limitation on repetitive motion. Additionally, as there has not been any medical evidence of incapacitating episodes requiring bed rest prescribed by a physician and treatment by a physician due to intervertebral disc syndrome, a rating based on incapacitating episodes is not warranted. An increased evaluation can also be assigned for a back disability involving loss of motion when there is additional functional impairment. However, consideration of pain and functional loss is required only with respect to those Diagnostic Codes where the basis for rating is limitation of motion. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). There is no basis for a rating higher than the maximum schedular rating for additional limitation of motion due to pain or functional loss. See VAOPGCPREC 36-97, 63 Fed. Reg. 31262 (1998); Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Because the 40 percent rating assigned effective December 3, 2012 is the maximum schedular rating for lumbar strain not caused by ankylosis, it must be determined whether a higher rating is warranted for loss of motion prior to December 3, 2012. Range of motion testing in November 2004 was considered unreliable. There was no additional impairment on repetitive testing in February 2010 and March 2011. Although there was an additional loss of lateral bending of 5 degrees on the right and 2 degrees on the left on repetitive use on evaluation in March 2007, this is not severe enough to warrant a higher evaluation under the rating schedule. Consequently, a higher rating is not warranted for service-connected low back disability during the appeal period under the provisions of 38 C.F.R. §§ 4.40, 4.45. See also Deluca v. Brown, 8 Vet. App. 202 (1995). Urinary Urgency and Incontinence The Veteran was granted service connection for urinary urgency and incontinence in a July 2007 rating decision, which assigned a 20 percent evaluation effective March 9, 2007. A June 2010 rating decision granted a 60 percent evaluation effective February 22, 2010. The Veteran's urinary urgency and incontinence is related to her low back disability and is evaluated under Diagnostic Code 7517, which pertains to injuries of the bladder, and provides that such disabilities should be evaluated based on the criteria pertinent to voiding dysfunction, to include urine leakage, urinary frequency, or obstructive voiding. 38 C.F.R. §§ 4.115(a), (b), Diagnostic Code 7517 (2013). A 20 percent rating is assigned for urinary incontinence when the wearing of absorbent materials is required and when the absorbent materials must be changed less than 2 times per day. Urinary incontinence requiring the wearing of absorbent materials that must be changed 2 to 4 times per day is assigned a 40 percent rating. Urinary incontinence requiring the use of an appliance or the wearing of absorbent materials that must be changed more than 4 times per day is assigned a 60 percent rating. 38 C.F.R. § 4.115a. A 60 percent rating is warranted for renal dysfunction when there is constant albuminuria with some edema; or definite decrease in kidney function; or hypertension at least 40 percent disabling under Diagnostic Code 7101. An 80 percent rating requires persistent edema and albuminuria with blood urea nitrogen (BUN) 40 to 80 mg%; or, creatinine 4 to 8mg%; or, generalized poor health characterized by lethargy, weakness, anorexia, weight loss, or limitation of exertion. A 100 percent rating requires regular dialysis, or precluding more than sedentary activity from one of the following: persistent edema and albuminuria; or blood urea nitrogen more than 80mg%; or, creatinine more than 8mg%; or, markedly decreased function of kidney or other organ systems, especially cardiovascular. 38 C.F.R. § 4.115a. The Veteran complained on VA spine evaluation in March 2007 of increased low back pain with urinary urgency and occasional incontinence. She had had five instances of incontinence in her life; she did not wear pads. On VA genitourinary evaluation in February 2010, the Veteran complained of nausea, back pain, urgency, and incontinence. She said that she wore absorbent material that must be changed more than four times a day. The examiner reported a normal bladder examination and no blood in the urine. The diagnosis was urinary incontinence by history. The Veteran complained on VA evaluation in March 2011 of progressive urinary incontinence, worse when her back pain is worse. She reported urgency and weak or intermittent stream, with daytime voiding intervals of less than an hour and three voidings per night. Although she indicated that she voided 3-4 times an hour, the examiner noted that she had been in the examination room for more than an hour without having to void. She said that she used absorbent material when out of her house and at home during the day when she thought she needed to and sometimes at night if she thought she needed to. Used up to three pads a day. She said that she bought her first box of pads, with 80 pads, about a month earlier and had approximately 30-40 pads left. The diagnosis was intermittent stress incontinence. The Veteran reported on VA evaluation in December 2012 that she required absorbent material that needed to be changed 2-4 times a day and that her urgency had worsened over the past few months. She said that she had worn diapers for three years. The only evidence of urinary urgency and incontinence prior to VA evaluation in February 2010 is the March 2007 VA spine evaluation notation of increased low back pain with urinary urgency and occasional incontinence. The Veteran said that she had had five instances of incontinence in her life and that she did not wear pads. Because the wearing of absorbent materials was not required prior to February 2010, an evaluation in excess of 20 percent for urinary urgency and incontinence is not warranted. With respect to whether a rating in excess of 60 percent is warranted for urinary urgency and incontinence since February 22, 2010, the Board notes that this is the maximum schedular rating assigned for a voiding dysfunction. Other potentially relevant criteria have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The only criteria under 38 C.F.R. § 4.115(a) which provides for an evaluation in excess of 60 percent pertains to renal dysfunction; however, as VA examination in February 2010 reported a normal bladder examination with no blood in the urine, and the evaluations in March 2011 and December 2012 do not show any renal dysfunction, there is no evidence that the Veteran's urinary urgency and incontinence results in renal dysfunction. Thus, there is no applicable criteria which may avail the Veteran's claim for a rating in excess of 60 percent since February 22, 2010. PID The Veteran was granted service connection for PID by rating decision in November 2003, which assigned a 30 percent evaluation effective April 27, 1993, a 100 percent evaluation effective May 4, 1993, and a 50 percent evaluation effective September 1, 1993. Under Diagnostic Code 7617, a 100 percent evaluation is assigned for three months after the complete removal of the uterus and both ovaries. A 50 percent evaluation is assigned thereafter. See 38 C.F.R. § 4.116, Diagnostic Code 7617 (2013). The case should be reviewed for entitlement to special monthly compensation (SMC) under 38 C.F.R. § 3.350. See 38 C.F.R. § 4.116, footnote (1) (2013). On VA gynecological evaluation in February 2010, it was noted that the Veteran had had a total abdominal hysterectomy with bilateral salpingo-oopherectomy (TAHBSO). No residuals of the surgery were found. On VA gynecological evaluation in March 2011, a PAP smear was negative. The diagnosis was surgically absent uterus and ovaries, with otherwise normal pelvic examination. It was noted that the condition had no effect on occupation or daily activities. On VA gynecological evaluation in December 2012, it was noted that the Veteran had had a hysterectomy in 1983 due to dysfunctional uterine bleeding. The diagnosis was dysfunctional uterine bleeding, status post TAHBSO. The evidence of record indicates that the Veteran had a complete removal of her uterus and both ovaries in 1983 due to bleeding. According to Diagnostic Code 7617, a 50 percent rating is warranted beginning three months after the complete removal of the uterus and both ovaries. As such, the current 50 percent rating is the correct rating under Diagnostic Code 7617 for the entire period on appeal. Consequently, a rating in excess of 50 percent is not warranted at any time during the appeal period. As noted above, where a service-connected disability is rated under Diagnostic Code 7617, consideration must be given to SMC for the anatomical loss or loss of use of a creative organ. In this case, SMC for the Veteran's hysterectomy with bilateral salpingo-oophorectomy has been granted. The Board has also considered the remaining gynecological diagnostic codes to determine whether the Veteran may receive an increased initial rating for her hysterectomy under any other diagnostic code. However, there is no evidence that the Veteran has any other gynecological symptoms to warrant an evaluation in excess of 50 percent under Diagnostic Codes 7610-7612 or 7623-7628 for her hysterectomy. See 38 C.F.R. § 4.116, Diagnostic Codes 7610-7612, 7623-7628 (2012). Additionally, as her uterus, fallopian tubes, and ovaries have all been removed, she cannot receive an increased rating under Diagnostic Codes 7613-7615 or 7618-7622, relating to diseases and injuries of the uterus, fallopian tube, and ovary and removal of just the uterus or ovaries. See 38 C.F.R. § 4.116, Diagnostic Codes 7613-7615, 7618-7622 (2013). Additional Considerations The Board has taken the lay statements on file into consideration in this case. The Veteran is competent to report the symptoms related to her service-connected disabilities, and the lay statements on file, which relate to the Veteran's PTSD and low back, are competent with respect to what other people have observed about the Veteran's symptomatology. The lay statements are credible to the extent that they involve observable symptoms, such as musculoskeletal pain or psychiatric problems. The Veteran's complaints have been considered in this case and have resulted in an increased rating for PTSD and a grant of TDIU beginning on March 4, 2011; however, with respect to the other ratings, evaluations for VA purposes have not shown the severity required for a higher rating for the disabilities at issue, as discussed above. The Board has also considered whether any of the disabilities at issue should be referred to the Chief Benefits Director or the Director, Compensation and Pension Service for consideration of an extraschedular evaluation under 38 C.F.R. § 3.321. In Thun v. Peake, 22 Vet. App. 111 (2008), the U.S. Court of Appeals for Veterans Claims (Court) clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. Either the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. The schedular evaluations in this case are adequate. A rating in excess of that assigned is provided in the rating schedule for each of the service-connected disabilities at issue, as noted above, but the medical evidence reflects that each disability does not show the symptomatology warranting a higher rating. See 38 C.F.R. § 4.1 (2012). In other words, the symptoms for the Veteran's PTSD, chronic low back strain, urinary disability, and PIV are accounted for by the assigned schedular ratings. The record does not reflect (or suggest) any symptoms/impairment of the disability not encompassed by the schedular criteria. There is also no evidence of frequent periods of hospitalization due to any service-connected disability. Consequently, the Board finds that the criteria for referral for the assignment of an extraschedular evaluation for PTSD, chronic low back strain, urinary urgency and incontinence, and PID during the appeal period pursuant to 38 C.F.R. § 3.321(b)(1) are not met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). TDIU The Veteran seeks a TDIU rating prior to December 3, 2012 because her service-connected disabilities have prevented her from obtaining and maintaining substantially gainful employment since she had to stop working in 1990. Total disability is considered to exist when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from securing or following a substantially gainful occupation consistent with his education and occupational experience. 38 C.F.R. § 4.16. TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retention of substantially gainful employment. 38 C.F.R. § 4.16(a). The relevant issue is not whether the Veteran is unemployed or has difficulty obtaining employment, but whether the Veteran can perform the physical and mental acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). A total disability rating may be assigned, where the schedular rating is less than total, where, if there is only one disability, the disability is rated at 60 percent or more, or where, if there are two or more disabilities, at least one disability is rated 40 percent or more and there is sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). For the purposes of determining whether one 60 percent disability or one 40 percent disability exists, the following are considered one disability: 1) disabilities of both upper or lower extremities, including the application of the bilateral factor; 2) disabilities from a common etiology or a single accident; 3) disabilities affecting a single body system; 4) multiple injuries incurred in action; or 5) multiple injuries incurred as a prisoner of war. 38 C.F.R. § 4.16(a). In this case, the Veteran's service-connected disabilities have met the above requirement since October 2004. In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Relevant evidence on file indicates that the Veteran has completed four years of college and has a master's degree in counseling. She last worked full time as a family therapist in June 1990. Most of the evidence relevant to the severity of the Veteran's service-connected PTSD, chronic low back strain, urinary urgency and incontinence, and PID has been discussed above. According to the VA examiner in February 2010, the veteran indicated that she was prevented from working because of poor concentration, short-term memory problems, anxiety and possible depression, isolation, insomnia, and fear of leaving her home and of getting hostile if someone makes a pass at her. The examiner noted that the Veteran was able to concentrate throughout the more than one hour evaluation without evidence of memory problems. The examiner felt that she displayed concentration and memory because she was able to manage her own money and household, had power of attorney for her significant other before she died in 2007, was able to drive the two hours to Des Moines for medical appointments, and took care of her cats and house plants. With respect to her anxiety and her isolation, it was noted that she was making an effort to meet new people, including going to a new church and going to bars to sing karaoke. With respect to her fear of men, it was felt that while there was probably a certain number of men that she could not tolerate at one time, she was able to go to bars and to come to the hospital for the interview, which had a lot of men, without a problem. With respect to insomnia, the examiner noted that the Veteran reported that she was able to sleep well when she took her medication. The VA examiner concluded on evaluation in February 2010 that the Veteran was not totally disabled by any of her medical conditions but should not lift over 25 pounds or stand for over 30 minutes and should avoid repetitive bending or twisting. For the Veteran to prevail on her claim for TDIU, the record must reflect that she is precluded from securing or following a substantially gainful occupation consistent with her education and occupational experience. The evidence indicates that the Veteran has an advanced degree in counseling and has worked as a therapist. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether she can find employment. See Van Hoose, 4 Vet. App. at 363. Advancing age, any impairment caused by conditions that are not service-connected, and prior unemployability status must be disregarded when determining whether a veteran currently is unemployable. 38 C.F.R. § 4.16(a). The Board concludes that the Veteran's service-connected disabilities preclude employment consistent with her education and occupational experience beginning on March 4, 2011, which is the date that the Veteran's PTSD symptomatology showed an increase in severity sufficient, when considered with her other service-connected disabilities, especially her low back strain, to conclude that she was unable to obtain and maintain substantially gainful employment consistent with her education and occupational experience. TDIU is not warranted prior to March 4, 2011 because she was considered able to work in February 2010 with some physical restrictions, such as not lifting more than 25 pounds, that should not affect someone who is not performing manual labor. There is no evidence that the Veteran's PID affects her employability. While the Veteran's urinary urgency and incontinence required the use of absorbent materials, the medical evidence does not indicate that this disability otherwise affected her employability prior to March 4, 2011, as her bladder was noted to be normal on evaluation in February 2010. With respect to her low back disability, range of motion in February 2010 included flexion to 100 degrees and extension to 20 degrees; there was no objective evidence of pain on active range of motion and no additional limitation on repetitive motion. The Veteran indicated on VA evaluation in February 2010 that she was doing fairly well, and her GAF score was 67. Moreover, it was concluded on this evaluation that her PTSD did not render it impossible for an average person to follow substantially gainful employment and did not prevent her from being employed. Although the September 2013 private evaluation concludes that the Veteran's PTSD has prevented her from working since June 1990, the Board finds that the evidence as a whole does not support the conclusion that the Veteran's service-connected disabilities resulted in an inability to obtain and maintain substantially gainful employment prior to March 4, 2011. First of all, as the Veteran's original claim was not received by VA until January 1997, a rating prior to January 1997 is not available. Although there is a GAF score of 44 in October 2004, it is unclear how much of this is due to the Veteran's PTSD. Other GAF scores prior to March 2011 were 60 in July 1997 and 62 in July 2000. Both the February 2010 evaluation and the September 2013 evaluation are based on a review of the record and an interview with the Veteran. However, the February 2010 evaluation was performed during the appeal period in question and specifically addresses each of the Veteran's PTSD symptoms as it affects her employability. While the September 2013 report contains a review of the relevant evidence, it does not address the February 2010 opinion. ORDER Entitlement to an initial increased rating for PTSD prior to March 4, 2011 is denied. Entitlement to an increased initial rating of 70 percent for PTSD beginning March 4, 2011 is granted, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to an increased initial rating for chronic low back strain, rated as 10 percent disabling from January 24, 1997 to November 29, 1999 and 20 percent disabling from November 30, 1999 to December 2, 2012, is denied. Entitlement to an increased rating for urinary urgency, which is rating 20 percent disabling from March 9, 2007 to February 21, 2010 and 60 percent disabling beginning February 22, 2010, is denied. Entitlement to a rating in excess of 50 percent for PID is denied. Entitlement to TDIU prior to March 4, 2011 is denied. Entitlement to TDIU beginning March 4, 2011 is granted, subject to the controlling regulations applicable to the payment of monetary benefits. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs