Citation Nr: 1416758 Decision Date: 04/15/14 Archive Date: 04/24/14 DOCKET NO. 13-01 465 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUE Entitlement to an initial rating higher than 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: J.G. Fausone/Legal Help for Veterans, PLLC ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty from January 1969 to August 1971. He appealed to the Board of Veterans' Appeals (Board/BVA) from a June 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) that, in relevant part, granted his claim of entitlement to service connection for PTSD and assigned an initial 30 percent rating for this disability. He wants a higher initial rating. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (When a Veteran appeals an initial rating, VA adjudicators must consider whether to "stage" the rating, meaning assign different ratings at different times since the effective date of the award if there have been occasions when the disability has been more severe than at others. This staging of the rating compensates the Veteran for this variance). FINDING OF FACT The Veteran's PTSD has been manifested by no more than 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; difficulty in establishing and maintaining effective work and social relationships. CONCLUSION OF LAW The criteria are met for a higher 50 percent initial rating, though no greater rating, for the PTSD. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000), was codified as amended at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126, and the implementing VA regulations were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA redefined VA's duties to notify and assist a Veteran in developing a pending claim for VA compensation and other benefits upon receipt of a complete or substantially complete application. The duty to notify requires that VA apprise the Veteran of the type of information and evidence needed to substantiate his claim, including of whose specific responsibility, his versus VA's, it is for obtaining the necessary supporting evidence. These VCAA notice requirements apply to all elements of a claim, including, when the claim is for service connection, the "downstream" disability rating and effective date elements. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 438 F.3d 1311 (2007). This particular claim for a higher initial rating for the PTSD is a "downstream" issue arising out of the grant of service connection for this disability. In a situation, as here, where the claim arose in the context of the Veteran trying to establish his underlying entitlement to service connection for the disability, and VA provided him the required notice concerning this underlying issue, and service connection was subsequently granted, the claim as it arose in its initial context has been substantiated, i.e., proven, so the intended purpose of the notice served. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). VA's General Counsel has clarified that no additional VCAA notice is required for a "downstream" issue, so, here, including as concerning the initial rating assigned for the disability, and that a court decision suggesting otherwise is not binding precedent. VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). Rather than issuing an additional VCAA notice letter in this situation concerning the "downstream" initial-rating claim, the provisions of 38 U.S.C.A. § 7105(d) require VA to instead issue a statement of the case (SOC) if the disagreement is not resolved. And since the RO issued an SOC addressing the downstream claim for a higher initial rating for this disability, which included citations to the applicable statutes and regulations and a discussion of the reasons and bases for not assigning a higher initial rating, no further notice is required. Goodwin v. Peake, 22 Vet. App. 128 (2008). The VCAA also requires that VA make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim, unless there is no reasonable possibility that such assistance would aid in the substantiation of the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to the claim, irrespective of whether the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). To this end, VA has obtained the Veteran's service treatment records (STRs), but also his post-service VA clinical records. Additionally, he was provided a VA examination in furtherance of his claim for a higher rating for this disability. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA findings obtained in this case from having the Veteran examined are adequate to properly rate his disability in relation to the applicable rating criteria, as the findings are predicated on a full reading of the medical records in his claims file, objective clinical evaluation, and the Veteran's personal statements and recounted history. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion has been met. 38 C.F.R. § 3.159(c)(4). There also is indication the Veteran is receiving disability benefits from the Social Security Administration (SSA). When SSA records are potentially relevant, they must be obtained. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2009). Here, though, it appears the SSA benefits the Veteran is getting are age-related as opposed to disability related, so not on account of his PTSD. As such, his SSA records need not be obtained. For these reasons and bases, the Board finds that VA has satisfied its duty to assist the Veteran with this claim. Standard of Review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of a matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2013) (reasonable doubt to be resolved in veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran 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 preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Discussion Disability evaluations are determined by the application of the Schedule for Rating Disabilities (Rating Schedule), 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. And, as already mentioned, all reasonable doubt is resolved in the Veteran's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as here, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. And if there have been times when the disability has been more severe than at others, the rating must be "staged". Fenderson, 12 Vet. App. at 125-26. The Veteran's service-connected PTSD has been rated initially as 30-percent disabling under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411. The schedular criteria, effective as of November 7, 1996, incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. §§ 4.125-4.130. The newer DSM-V has been officially released. However, 38 C.F.R. § 4.130 still explicitly refers instead to the DSM-IV. The regulation legally requires the Board to consider this earlier version of the DSM until such time as the regulation is changed. There is a regulation change in the works that would change the regulation to reference "the current version of the DSM." But it is unclear when that proposed change will be published. Regardless, in the meantime the Veterans Benefits Administration (VBA) and Veterans Health Administration (VHA) essentially have agreed that their target date for moving to DSM-V was October 1st, coinciding with the beginning of this fiscal year. It therefore is important to bear in mind that the regulation still explicitly refers to the DSM-IV, regardless of the fact that the Board may begin seeing private evidence instead referring to criteria under the succeeding DSM-V. A rating of 10 percent is warranted if there is 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. Id. A rating of 30 percent is warranted if 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, or mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. Retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A higher 70 percent rating requires occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). Whereas the highest possible schedular rating of 100 percent requires 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. 38 C.F.R. 4.130, Diagnostic Code 9411. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) scores have been considered. The GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF score of 39 to 40 indicates "some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school)." Id. A GAF score 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)." Id. A GAF score 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)." Id. As evidenced by use of the phrase "such symptoms as", the list of symptoms in the rating criteria is meant to be mere examples of symptoms that would warrant a particular evaluation, so are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. If the evidence shows the 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 will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). The Federal Circuit Court has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Although the Veteran's symptomatology is the primary consideration, the Veteran's level of impairment must be in "most areas" applicable to the relevant percentage rating criteria. Vazquez-Claudio v. Shinseki, 2012-7114 (Fed. Cir. Apr. 8, 2013). In January 2011, the Veteran had a positive depression screen. As such, VA followed up with a suicide-risk assessment. The Veteran declined treatment for symptoms of depression. He indicated that he was "getting better" and that spring was coming, when he would be able to get a job. He stated that he last had had thoughts of taking his life 10 years earlier, so in the remote past. He had no recent suicidal thoughts or plans, and he denied any suicide attempts. It was determined that he was at low risk for suicide. Vet Center treatment notes dated in January 2011 reflect that the Veteran was semi-retired and unemployed. The Veteran reported depression, anxiety, sleeplessness, anger, and short-term memory loss. The Veteran indicated that he used marijuana and drank some alcohol and stated that in the past, he drank excessively and used cocaine. The Veteran seemed anxious and tearful as well as worried about how he would pay for treatment. A Vet Center treatment record dated in mid January 2011 indicated that the Veteran was facing multiple stressors because he had been laid of two years earlier and could not find steady work since. He was also worried about some health issues. Consequently, the Veteran was worried, depressed, and angry that he had to struggle after working hard his whole life. He was afraid that he would lose his home. His mother was sick as well, and he was afraid that he was going to lose her. He denied suicidal and homicidal ideation. He stated, however, that he would consider taking his life if his mother died. He denied a plan. In late January 2011, the Veteran was visibly upset because he had to have his favorite horse euthanized. He stated that his wife and mother put him on "suicide watch" and that he gave his pistol to his son. The Veteran assured the Vet Center counselor that he would never harm himself as long as his mother, wife, and son were alive. The Veteran was tearful, and the counselor indicated that the Veteran was "having a tough time" between losing his horse, health concerns, financial difficulties to include the possibility of losing his home, and recent news that a man with whom he served had committed suicide. In February 2011, the Veteran was referred for "very serious" PTSD that was exacerbated recently due to several events to include having to euthanize a horse and a the suicide of a fellow soldier. The Veteran had not sought PTSD treatment until recent times. Instead he took Valium that he apparently had obtained from non-mental health sources and drank excessively, although he indicated that he had stopped drinking several years earlier but used marijuana to help with sleeplessness. He also avoided thoughts, feelings, and memories of PTSD-inducing stressors. The Veteran indicated that he was willing to try psychotropic medication due to anxiety, insomnia, disturbing recollections, and other PTSD symptoms. Objectively, the Veteran was pleasant and cooperative and displayed good eye contact until discussing any combat-related issues when he would start crying. His thought processes were linear and goal directed but somewhat slowed. His affect was anxious and dysphoric. He denied suicidal and homicidal ideation. The diagnosis was of PTSD with secondary insomnia and rule out mood disorder. The Veteran's GAF was assessed as between 45 and 50. The Veteran agreed to take psychotropic medication on a trial basis. A February 2011 treatment note from the Vet Center indicated that the Veteran was still very distraught, this time because another friend died. He was having more frequent thoughts of Vietnam after speaking with many of the people with whom he served due to the recent suicide of one of them. The Veteran reported anxiety and sleeplessness and was afraid that anger would get the best of him. There was no indication, according to the counselor, that the Veteran would harm anybody. The counselor opined that given the recent deaths of friends, health problems, and financial stress, the Veteran was coping better than expected. On VA PTSD examination in April 2011, the Veteran described symptoms of anxiety attacks, social avoidance, exaggerated startle response, difficulty with relationships, a lack of affection toward his wife, emotional blunting, and sleep difficulties. He also spoke of recurrent disturbing recollections, vivid nightmares, and distress at exposure to situations and events that recalled service. He had anxiety and panic attacks, and avoided stimuli associated with trauma. He isolated himself and felt estranged from others. The symptoms were constant and severe. He was avoiding previously pleasurable activities such as rodeos and indicated that his symptoms caused work problems. He reported a history of violence described as bar fights and fighting with law enforcement when arrested for a bar fight. He denied a history a suicide attempts. The Veteran denied hospitalization and emergency room visits due to psychiatric symptoms. He stated that he was taking medication for sleep but that it was only minimally helpful. The Veteran described a good relationship with his mother and sibling. He described his marriage as "fair" due to a lack of passion. The Veteran described the relationship with his children and good. The Veteran stated that he had not worked in three years because he was laid off from his job in electronics assembly due to company cut backs. The Veteran asserted that his lack of employment was unrelated to his PTSD. Objectively, the examiner observed that the Veteran was fully oriented and displayed appropriate appearance and hygiene. His behavior was appropriate, and he maintained good eye contact throughout the examination. He was visibly anxious and depressed and cried easily when discussing the deaths of friends and fellow soldiers in service. He was somewhat suspicious. Speech, concentration, and thought processes were normal. He did not have slowness of thought and did not appeal confused. Judgment was not impaired. Abstract thinking was normal. There was mild memory impairment due to forgetting names, directions, and recent events. Panic attacks occurred less than once a week. There was no evidence of obsessive compulsive behavior, delusion, hallucination, suicidal ideation, or homicidal ideation. The examiner diagnosed PTSD and alcohol abuse in full remission and assigned a GAF score of 50. A June 2011 VA psychiatry outpatient treatment note indicated that the Veteran reported that medication were helpful. On mental status examination, the Veteran was euthymic. However, he was alert, oriented, pleasant, and cooperative. He made good eye contact, and he had normal thought processes. There was no evidence of psychosis and no suicidal or homicidal ideation. The diagnosis was of PTSD with secondary insomnia. An August 2011 VA psychiatry outpatient treatment note indicated that the Veteran reported more anxiety and had worse insomnia and nightmares after helping his children move. Consequently, he was using more Valium and Xanax. The Veteran, however, felt more hopeful since seeking help for his mental health problems. On mental status examination, the Veteran appeared less dysphoric and anxious than in the past. He was alert and oriented, pleasant and cooperative, made good eye contact, and displayed normal thought processes. There was no evidence of psychosis, suicidal ideation, or homicidal ideation. The examiner diagnosed PTSD with secondary insomnia. A September 2011 VA psychiatry outpatient treatment note indicated that the Veteran reported less nightmares and better sleep with medication and felt that his mental health was better than before he began to seek treatment. On mental status examination, the Veteran was anxious. However, he was alert and oriented, pleasant and cooperative, made good eye contact, and looked more relaxed than he did previously. His thought processes were normal. There was no suicidal ideation, homicidal ideation, or evidence of psychosis. The diagnosis was of PTSD with secondary insomnia. A December 2011 VA psychiatry outpatient treatment note indicated that the Veteran complained of depression but indicated that his mental state was better than before he pursued treatment. On mental status examination, the Veteran's mood was dysphoric. However, he was oriented, pleasant, and cooperative, and made good eye contact and displayed normal thought processes. There was no suicidal ideation, homicidal ideation, or evidence of psychosis. The diagnosis was of PTSD with secondary insomnia. A February 2012 VA psychiatry outpatient treatment note indicated that the Veteran was tearful at times. His mood was dysphoric. However he was pleasant and cooperative and made good eye contact. He was alert and oriented, and there was no evidence of psychotic material or homicidal or suicidal ideation. The diagnosis was of PTSD with secondary insomnia. A March 2012 VA psychiatry outpatient treatment note indicated that psychotropic medication were helping in that the Veteran had no new symptoms. On mental status examination, the Veteran was pleasant and cooperative and displayed good eye contact. Thought processes were normal. He denied symptoms of psychosis, and he denied suicidal and homicidal plans and intentions. His mood was euthymic. The diagnosis was of PTSD with secondary insomnia. A June 2012 VA psychiatry outpatient treatment note indicated that the Veteran was dressed neatly. He appeared to be emotionally fragile and broke into tears with little or no provocation while talking about stressors in his life and his isolation. He lived on a large piece of property with his mother and wife as well as livestock and horses. The Veteran reported poor sleep and constant anxiety. He had nightmares, anger, and emotional numbing. He isolated himself intentionally for long periods and there was a significant avoidance of "triggers" to include a total avoidance of crowds, restaurants, and shopping. There had significant secondary depression. The Veteran, however, was fully oriented, had normal behavior and appearance, normal speech, and normal thought processes. Insight and memory were good, and memory was intact. His fund of knowledge was average. Affect was congruent with mood. There were no perceptual disturbances. The examiner assessed that the Veteran was at low risk for suicide and for harming others. Throughout the appeal period, the Veteran's PTSD symptoms have been in ways consistent with the criteria for a 30 percent evaluation, in other words his existing rating, in that he has been depressed and anxious and has suffered from panic attacks less than once a week, suspiciousness, chronic sleep impairment, and just relatively mild memory loss. 38 C.F.R. § 4.130, Diagnostic Code 9411. However, he also has had difficulty in establishing effective social relationships, as evidenced by his self-imposed isolation and somewhat distant relationship with his wife. So when this additional impairment is considered, it tends to indicate he is entitled to a higher initial rating of 50 percent for his PTSD, especially when all reasonable doubt concerning this is resolved in his favor. Id. See also 38 C.F.R. §§ 4.3, 4.7. He is lacking many of the symptoms commonly associated with this higher 50 percent evaluation, such as abnormal speech patterns, flattened affect, difficulty understanding complex commands, panic attacks more than once a week, impaired judgment, and symptoms like or similar to these. But this is not a preclusion to assigning this higher rating if the evidence, on the whole, shows his symptoms cause what amounts to the level of social and occupational impairment required for the higher 50 percent rating rather than just the lesser 30 percent rating. Mauerhan, supra. As already alluded to, under 38 C.F.R. § 4.7, especially when considered in combination with § 4.3 (regarding the benefit of the doubt), 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. Here, the Veteran's PTSD symptoms more nearly approximate the 50 percent evaluation because, although he is lacking most of the symptoms characteristic of a 50 percent rating, his GAF scores, on average, indicate "serious" symptoms and "serious" impairment in his social and occupational functioning. In the aggregate, then, his PTSD symptoms more nearly approximate those necessary for a 50 percent evaluation. 38 C.F.R. § 4.130, Diagnostic Code 9411. In this circumstance, the higher evaluation must be granted. 38 C.F.R. § 4.7. There has not however been occasion when his symptoms and consequent impairment have more closely approximated the requirements for an even higher 70 percent rating, much less an even greater 100 percent rating, so the Board cannot "stage" the rating. Fenderson, supra. Employability The Court has held that, if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total disability rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the Board finds that a derivative claim for a TDIU is not raised by the record. Specifically, the evidence of record fails to show that the Veteran is unemployable because of his PTSD. Indeed, he himself stated that his mental health was not the reason for his unemployment. Therefore, the Board finds that no further consideration of a TDIU is warranted. Id. Extra-schedular Consideration Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors that would render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2013). See also Fanning v. Brown, 4 Vet. App. 225, 229 (1993). The question of an extra-schedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). And although the Board may not assign an extra-schedular rating in the first instance, it must specifically adjudicate whether to refer a case for extra-schedular evaluation when the issue either is raised by the claimant or reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Here, with regards to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria found in the Rating Schedule for acquired psychiatric disorders shows that the rating criteria reasonably describe his disability level and symptomatology. His symptoms and areas of impairment are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. Vazquez-Claudio, supra. In addition, the GAF scores are incorporated as part of the schedular rating criteria, as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Indeed, even if the available schedular evaluation for this disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." So he does not satisfy the second prong of the Thun analysis, either, therefore irrespective of the first prong. See Johnson v. Shinseki, 26 Vet. App. 237, 247 (2013) (en banc). The record does not show that he has required frequent hospitalizations. To the contrary, it does not appear from the record that he has been hospitalized at all for this disability; at most there was suspicion in years past that he was a suicide risk, but it ultimately was determined that he was not, so no resultant inpatient admission, voluntary or involuntary, certainly not on a frequent or recurrent basis. Additionally, there is not shown to be evidence of "marked" interference with his employment because of this disability, meaning above and beyond that contemplated by the schedular rating assigned for this disability. 38 C.F.R. §§ 4.1, 4.15. There is nothing in the record suggesting that his PTSD has markedly interfered with his ability to perform a job in a satisfactory manner. Moreover, there is no evidence in the medical records of an exceptional or unusual clinical picture. In short, there is nothing in the record indicating this service-connected disability causes impairment in employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating, itself, is recognition that industrial capabilities are impaired). The Board therefore has determined that referral of this claim for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is unwarranted. ORDER A higher 50 rating is granted for the PTSD, subject to the statutes and regulations governing the payment of VA compensation. ____________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs