Citation Nr: 1628787 Decision Date: 07/19/16 Archive Date: 07/28/16 DOCKET NO. 08-33 604 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan THE ISSUES 1. Entitlement to a higher initial disability rating in excess of 50 percent for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression, from March 31, 2005. 2. Entitlement to a higher initial disability rating in excess of 20 percent for degenerative disc disease of the lumbar spine (hereinafter "back disability") from March 31, 2005. REPRESENTATION The Veteran is represented by: The American Legion ATTORNEY FOR THE BOARD A. Tenney, Associate Counsel INTRODUCTION The Veteran, who is the appellant, had active service from March 1968 to October 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2006 rating decision by the RO in Detroit, Michigan, which denied reopening service connection for PTSD, and a November 2006 rating decision, which granted service connection for a back disability and assigned a 20 percent initial disability rating, effective March 31, 2005 (date of claim for service connection). During the pendency of the appeal, an April 2013 rating decision granted service connection for PTSD and assigned a 50 percent initial disability rating for PTSD, effective March 31, 2005 (date of claim to reopen service connection). As the Veteran disagreed with the initial rating assigned following service connection for an acquired psychiatric disorder and the back disability, the Board has characterized the issue in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating appeals from claims for increased ratings for already service-connected disability). As higher initial ratings are available, and the Veteran is presumed to seek the maximum available benefit, the issues have remained viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a claimant is presumed to be seeking the maximum benefit under the law). FINDINGS OF FACT 1. For the entire initial rating period on appeal from March 31, 2005, the service-connected acquired psychiatric disorder has been manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as depression, anxiety, nightmares, panic attacks that occur weekly or less often, chronic sleep impairment, and difficulty establishing and maintaining effective work and social relationships. 2. For the entire initial rating period on appeal from March 31, 2005, the service-connected acquired psychiatric disorder was not characterized by occupational and social impairment with deficiencies in most areas. 3. For the entire initial rating period on appeal from March 31, 2005, the service-connected back disability has not been manifested by ankylosis, limitation of flexion to 30 degrees or less, or incapacitating episodes requiring physician ordered bed rest having a total duration of at least 4 weeks during a 12 month period. CONCLUSIONS OF LAW 1. For the entire initial rating period on appeal from March 31, 2005, the criteria for a disability rating in excess of 50 percent for an acquired psychiatric disorder have not been met or more nearly approximated. 38 C.F.R. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2015). 2. The criteria for a disability rating in excess of 20 percent for the service-connected back disability have not been met or more nearly approximated for any part of the rating period on appeal. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2015). As the rating issues on appeal arise from the Veteran's disagreement with the initial ratings following the grant of service connection, no additional notice is required regarding this downstream element of the service connection claim. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Court have similarly held that regarding the downstream element of the initial rating that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (noting that, once an initial VA decision awarding service connection and assigning a disability rating and effective date has been made, 38 U.S.C.A § 5103(a) notice is no longer required); 38 C.F.R. § 3159(b)(2) (no VCAA notice required because of filing of NOD). Regarding the duty to assist in this case, the Veteran received VA examinations in May 2005, June 2005, and February 2013. The VA examination reports are of record. To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examination reports reflect that the VA examiners reviewed the record, conducted an in-person examination, and rendered the requested opinions and rationale, including as to functional impairment. All relevant documentation, including VA treatment records, has been secured and all relevant facts have been developed. There remains no question as to the substantial completeness of the issues on appeal. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). Any duties imposed on VA, including the duties to assist and to provide notification, have been met as set forth above. Higher Initial Rating for Acquired Psychiatric Disorder Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2015). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1 (2015). Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2 (2015). Where there is a question as to which of two disability ratings shall be applied, the higher rating is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. When, after careful consideration of the evidence, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Pertinent in this case, the General Rating Formula provides that a 50 percent rating is assigned 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R § 4.130. A 70 percent rating will be assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; 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. 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). A 100 percent schedular rating contemplates 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. The use of the term "such as" in the General Rating Formula for Mental Disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disorder, and the effect of those symptoms on his/her social and work situation. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the Federal Circuit held that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." The Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale 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 DSM-IV at 32). A GAF score of 21 - 30 indicates "Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends)." A GAF score of 31 - 40 indicates "Some impairment in reality testing or communication (e.g. speech is at times illogical, obscure or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school)." 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)." 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)." A GAF score of 61-70 indicates "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." The GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See Richard, 9 Vet. App at 267; Carpenter v. Brown 8 Vet. App. 240, 243 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the rating issue. The GAF score must be considered in light of the actual symptoms of a veteran's disorder as they reflect on the degree of occupational and social impairment, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126 (a) (2015). The Veteran contends generally that the service-connected PTSD has been manifested by more severe symptoms and impairment than contemplated by the 50 percent initial disability rating assigned from March 31, 2005. See June 2016 Appellant's Brief. The Veteran underwent a VA examination in May 2005. The May 2005 VA examination report reflects the Veteran was accompanied by his sister, who reported that the Veteran experienced blackouts and was unable to think clearly. The VA examiner noted that the Veteran was uncooperative, vague, and unable to provide a reliable history. The VA examiner assessed orientation to time, person, and place and that the Veteran did not cooperate with recall testing. The May 2005 VA examiner diagnosed depressive disorder and cognitive disorder, and assigned a GAF score of 45. A June 2005 VA treatment record reflects the Veteran reported nightmares and flashbacks, and denied suicidal thoughts or hallucinations. The VA examiner assessed coherent speech, a coherent thought process, and noted that the Veteran was "insightful into his emotional and medical problems and he seems compliant with treatment." A GAF score of 51 to 60 was assigned. A January 2006 VA treatment record reflects self-reports of hypervigilance and a denial of suicidal ideation. The VA examiner assigned a GAF score of 51 to 60. October 2007 and November 2007 VA treatment records reflect the VA examiners assessed chronic PTSD and each assigned a GAF score of 50. A May 2008 VA treatment record reflects the Veteran reported "episodes of feeling scared," with the VA examiner diagnosing PTSD. A GAF score of 50 was assigned. A July 2008 VA treatment record reflects self-reports of depression and flashbacks with symptoms of PTSD "mostly under control." The Veteran denied suicidal or homicidal ideation, and the VA examiner assessed a coherent thought process and orientation to self, time, and place. The VA examiner did not discern any cognitive defects. A GAF score of 50 was assigned. A September 2008 VA treatment record reflects the Veteran reported little interest or pleasure doing things, feeling depressed, and trouble concentrating, and denied feeling bad about himself or thoughts of hurting himself. The VA examiner assessed a depressed affect and assigned a GAF score of 55. A March 2009 VA treatment record reflects the Veteran denied suicidal thoughts, plans, or intent and the presence of auditory, visual, or tactile hallucinations. The VA examiner assessed a pleasant affect and coherent/goal-directed speech and thought. A GAF score of 65 was assigned. October 2009 and January 2011 VA treatment records reflect the Veteran denied feeling down, depressed, or hopeless, as well as denying little interest or pleasure in doing things. A March 2012 VA treatment record reflects self-reports of depression and anxiety controlled by medication and that the Veteran denied suicidal or homicidal ideation. A March 2013 VA treatment record reflects the Veteran denied nightmares, being constantly on guard, watchful or easily startled, as well as denying feeling numb or detached from others, activities, or surroundings. A February 2013 VA examination report reflects the Veteran reported living with a brother, staying in touch with his three children, and social isolation. Upon examination the February 2013 VA examiner assessed a depressed mood, anxiety, panic attacks that occur weekly or less often, chronic sleep impairment, disturbances of motivation and mood, mild memory loss, difficulty establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and the inability to establish and maintain effective relationships. The February 2013 VA examiner opined that the PTSD manifested as occupational and social impairment with reduced reliability and productivity and assigned a GAF score of 50. After a review of the lay and medical evidence, the Board finds that, for the entire initial rating period on appeal from March 31, 2005, the weight of the competent and probative lay and medical evidence demonstrates that a higher initial disability rating in excess of 50 percent for service-connected acquired psychiatric disorder is not warranted as the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as depression, anxiety, nightmares, panic attacks that occur weekly or less often, chronic sleep impairment, and difficulty establishing and maintaining effective work and social relationships. Specifically, a review of the relevant lay and medical evidence, including the Veteran's lay statements, VA treatment records, and VA examination reports dated May 2005 and February 2013, does not reveal that the Veteran has experienced occupational and social impairment with deficiencies in most areas. The evidence does not show symptoms or impairment such as obsessional rituals, near continuous panic or depression affecting the ability to function independently, impaired impulse control, neglect of personal appearance or hygiene, or spatial disorientation. The May 2005 VA examination report reflects the Veteran was uncooperative, vague, and unable to provide a reliable history. The May 2005 VA examination report also indicates the Veteran was alert and oriented. A July 2008 VA treatment record reflects the Veteran reported that symptoms of PTSD were "mostly under control." The February 2013 VA examination report reflects the Veteran reported to the VA examiner that he was living with a brother and had relationships with his three sons. The February 2013 VA examination report also indicates the VA examiner did not discern suicidal ideation or persistent delusions and/or hallucinations, and opined that the PTSD manifested as occupational and social impairment with reduced reliability and productivity. A March 2013 VA treatment record reflects the Veteran denied nightmares, being constantly on guard, watchful or easily startled, and feeling numb or detached from others/activities. Further, the numerous VA treatment records, as well as the May 2005 and February 2013 VA examination reports, do not note any reports of suicidal ideation. The Board also finds that GAF scores are also compatible with a 50 percent disability rating for the service-connected PTSD. As noted above, a GAF score of 61-70 indicates mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, while a score of 51 to 60 indicates moderate difficulty in social, occupational, or school functioning, but generally functioning well and having meaningful interpersonal relationships, and a score of 41-50 indicates serious symptoms or difficulty in social, occupational, or school functioning. The GAF scores of 55 and 65 assigned by the September 2008 and March 2009 VA examiners (respectively) demonstrate mild symptoms as evidenced by the Veteran's interpersonal relationships. The GAF scores of 50, 51, and 51 to 60 assigned by various VA examiners from June 2005 to February 2013 demonstrate moderate symptoms and findings consistent with a 50 percent rating. Although a GAF score of 45 (indicative of serious symptoms) was noted in May 2005, it alone is not dispositive of the issue on appeal and must be considered in conjunction with the record as a whole, which include GAF scores of 50, 51, 51 to 60, 55, and 65. The same May 2005 VA examination report that assigned a GAF of 45 included findings of uncooperative and orientation to time, person, and place with no discernable suicidal ideation. A June 2005 VA treatment record from one month later resulted in a GAF of 51 to 60 and findings consistent with a 50 percent rating, placing the single lower GAF of 45 in context. See 38 C.F.R. § 4.1 (2015) (it is essential in the examination and rating the disability that each disability is to be viewed in relation to its history); 38 C.F.R. § 4.2 (rating specialist is charged with interpreting examination reports in light of the whole recorded history, reconciling the various reports into a consistent picture). While the evidence demonstrates suspiciousness, the evidence of record during the period on appeal does not indicate that the Veteran's PTSD manifested as impaired impulse control, such as unprovoked irritability with periods of violence or near constant panic attacks (one factor for a 70 percent disability rating under Diagnostic Code 9411). For these reasons, the weight of the competent and probative lay and medical evidence of record is against a rating in excess of 50 for service-connected acquired psychiatric disorder for the initial rating period on appeal from March 31, 2005. Because the preponderance of the evidence is against a higher initial rating, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Higher Initial Rating for Back Disability For disabilities of the musculoskeletal system, the Board also considers whether a higher disability rating is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling, and pain on movement. 38 C.F.R. § 4.45. Additionally, painful motion is an important factor of disability, and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Veteran is in receipt of a 20 percent disability rating for the back disability under Diagnostic Code 5242. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (Diagnostic Codes 5235 to 5243). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. Under the General Rating Formula, a 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine at 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. The General Formula for Diseases and Injuries of the Spine also, in pertinent part, provide the following Notes: Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V). 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 combined normal range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of the spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation; or neurological symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Under Diagnostic Code 5243 (Intervertebral Disc Syndrome), a 20 percent disability rating is assigned 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 disability rating is assigned with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a maximum 60 percent disability rating is assigned with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Diagnostic Code 5243 provides the following Notes: Note (1): 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. Note (2): If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment should be evaluated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. The Veteran contends generally that the service-connected back disability symptoms and impairment more closely resemble the criteria for a rating in excess of 20 percent. See June 2016 Appellant's Brief. Various VA treatment records for the initial rating period on appeal from March 31, 2005 reflect self-reports of chronic back pain. Specifically, a June 2005 VA examination report reflects the Veteran reported chronic lower back pain, pain as a seven to nine on the one to ten pain scale, aggravated by activities. The Veteran also reported the inability to stand for more than 30 minutes, carry more than 20 pounds, walk more than one block, or climb more than one flight of stairs. At the June 2005 VA examination, range of motion testing of the thoracolumbar spine reflected forward flexion to 60 degrees, extension to 30 degrees, bilateral flexion to 20 degrees, and bilateral rotation to 20 degrees. The VA examiner noted a normal gait, no swelling or redness of the joints, and diagnosed degenerative disc disease "not additionally limited by pain, lack of endurance, fatigue, or weakness after repetitive use." March 2009 and June 2009 VA treatment records reflect forward flexion to approximately 30 to 40 degrees, and extension to approximately five degrees. Both the March 2009 and June 2009 VA examiners noted no redness or deformity. An October 2009 VA treatment record reflects the Veteran reported chronic back pain controlled by medication. A March 2012 VA treatment record reflects self-reports of chronic back pain exacerbated by activity, and a November 2012 VA treatment record reflects the Veteran reported muscle tightness with the VA examiner assessing no swelling. The Veteran underwent another VA examination in February 2013. The February 2013 VA examination report reflects the Veteran reported daily pain, pain rated as a six on the one to ten pain scale, additional pain with prolonged standing, walking, or carrying more than ten pounds, and denied flare ups. At the February 2013 VA examination, range of motion testing of the thoracolumbar spine reflected forward flexion to 60 degrees, extension to 20 degrees, bilateral flexion to 25 degrees, and bilateral rotation to 25 degrees, each with no objective evidence of painful motion. The VA examiner assessed less movement than normal and tenderness. The VA examiner did not discern an abnormal gait, guarding, or ankylosis, and noted a normal sensory examination and no incapacitating episodes over the prior 12 months. The Board finds that the weight of the medical and lay evidence does not demonstrate that the criteria for a disability rating in excess of 20 percent for the service-connected back disability have been met or more nearly approximated for any part of the rating period on appeal as the back disability has not been manifested by ankylosis, limitation of forward flexion to 30 degrees or less, or incapacitating episodes requiring physician ordered bed rest having a total duration of at least 4 weeks during a 12 month period. Findings from the June 2005 and February 2013 VA examinations, and history and findings in the numerous VA treatment records reflecting treatment for back pain, as well as the Veteran's self-reported symptoms, are consistent with a 20 percent rating under the General Rating Formula for Diseases and Injuries of the Spine for the symptoms and level of impairment actually demonstrated by the back disability. Diagnostic Code 5242 warrants a 20 percent rating for forward flexion greater than 30 degrees, but not greater than 60 degrees. In this case, as noted at both the June 2005 and February 2013 VA examinations, the Veteran's back disability manifested as flexion to 60 degrees, including as due to pain, and VA treatment records from March 2009 and June 2009 reflect that forward flexion was measured to approximately 30 to 40 degrees. See 38 C.F.R. § 4.71a, General Rating Formula for Disease and Injuries of the Spine (DCs 5235 to 5243) (assigning a 20 percent rating, in pertinent part, for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees). A higher disability rating of 40 percent or higher for the back disability would only be warranted for forward flexion more closely approximating 30 degrees or less, favorable or unfavorable ankylosis of the entire thoracolumbar spine, and/or incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during a 12 month period, none of which is present here. As discussed above, at the June 2005 and February 2013 VA examinations, no ankylosis was observed, and, at worst, forward flexion was limited at 60 degrees. Next, the evidence of record during the appeal period does not show the Veteran had any incapacitating episodes for at least 4 weeks during a 12 month period for any period. The Board has considered the Veteran's assertion of muscle tightness (which is rated as part of the 20 percent rating criteria), and the fact VA treatment records from 2009 reflect flexion was reported at 30 to 40 degrees; however, four years later, at the February 2013 VA examination, the Veteran explicitly denied experiencing any flare-ups and forward flexion was measured to 60 degrees. For this reason, the Board does not find that flare-ups, should they occur, would limit forward flexion to 30 degrees or less. Additionally, the Board has considered whether there is additional functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40, 4.45, and 4.59. See also DeLuca. Evidence including the VA examination reports and VA treatment records indicate, at worst, forward flexion to 30 to 40 degrees and combined range of motion of 170; these degrees of functional impairment do not warrant a higher rating based on limitation of motion. The Board has also considered whether there are any objective neurologic abnormalities associated with the service-connected low back disability that warrant a separate rating. See 38 C.F.R. §§ 4.14, 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. An unappealed May 2014 rating decision denied service connection for bilateral lower extremity radiculopathy, as secondary to the service-connected back disability. The Board finds that no objective neurologic abnormalities have been asserted by the Veteran or raised by the other evidence of record since May 2014; therefore, a separate rating for neurologic abnormalities associated with the service-connected back disability is not warranted. Extraschedular Consideration The Board has also evaluated whether the acquired psychiatric disorder and back rating issues should be referred for consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2015). Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: 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 as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extra-schedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran'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. Thun v. Peake, 22 Vet. App. 111 (2008). With respect to the first prong of Thun, the evidence in this instant appeal does not establish such an exceptional disability picture as to render the schedular rating criteria inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the schedular rating criteria found in 38 C.F.R. § 4.130, Diagnostic Code 9411, reflects that the diagnostic criteria reasonably describe all the Veteran's disability level (social and occupational impairment) and symptomatology. The diagnostic criteria convey that compensable ratings will be assigned for PTSD that manifests by various levels of occupational and social impairment. The Veteran's disability picture has been shown to encompass occupational and social impairment symptoms that fall within the diagnostic criteria for a 50 percent rating for the initial rating period on appeal from March 31, 2005. From March 31, 2005 the PTSD was productive of no more than occupational and social impairment with reduced reliability and productivity due to such symptoms as chronic sleep impairment, anxiety, depression, and panic attacks that occur weekly or less often, and GAF scores of 45, 50, 51 to 60, 55, and 65. All the impairment and symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" examples or symptoms in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. In addition, the GAF scores, which are incorporated into the schedular rating criteria as part of the DSM-IV, assess the degree of overall occupational and social impairment or overall severity of symptoms. For these reasons, the Veteran's service connected PTSD has not been shown to be productive of an exceptional disability picture; therefore, the Board determines that referral for extra-schedular consideration pursuant to 38 C.F.R. § 3.21(b)(1) is not merited. With respect to the first prong of Thun, as to the back disability, the evidence in the instant appeal does not establish such an exceptional disability picture as to render the schedular criteria inadequate. The back disability has manifested primarily as non-incapacitating episodes with limited range of motion (both forward flexion and combined ranges of motion), including due to pain, and interference with standing and weight bearing. See 38 C.F.R. § 4.45 ("interference with sitting, standing, and weight-bearing are related considerations"). The schedular rating criteria (Diagnostic Code 5242) specifically contemplate such symptomatology and functional impairment. With respect to functional impairment with prolonged walking and standing, interference with standing and weight-bearing (walking necessarily involves weight-bearing) is considered as part of the schedular rating criteria under 38 C.F.R. § 4.45. To the extent that prolonged standing or walking causes incidental back pain, such pain is considered as part of the rating criteria, to include as due to orthopedic (DeLuca and 38 C.F.R. §§ 4.40, 4.45, 4.59) factors such as weakness, incoordination, and fatigability, which are incorporated into the schedular rating criteria. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); Burton v. Shinseki, 25 Vet. App. 1, 4 (2011); Sowers v. McDonald, No. 14-0217 (Vet. App. Feb. 12, 2016). Under Johnson v. McDonald 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. In this case, the Veteran has not asserted, and the evidence of record has not suggested, any such combined effect or collective impact of multiple service-connected disabilities that create such an exceptional circumstance to render the schedular rating criteria inadequate. In this case, there is neither allegation nor indication that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. The Veteran's service-connected disabilities include PTSD and the back disability. Finally, in adjudicating the current appeal for higher ratings, the Board has not overlooked the Court's holding in Rice v. Shinseki, 22 Vet. App. 447 (2009), which held that a claim for a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) may be part of an a rating issue when the TDIU claim is either expressly raised by a veteran or reasonably suggested by the record. In this case, as distinguished from the facts in Rice, a January 2016 rating decision denied a TDIU. Should the Veteran disagree with the January 2016 rating decision, he should file a notice of disagreement within one year. ORDER The appeal for a higher initial disability rating in excess of 50 percent for an acquired psychiatric disorder, to include PTSD and depression, is denied. The appeal for a higher initial disability rating in excess of 20 percent for a back disability is denied. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs