Citation Nr: 1728056 Decision Date: 07/18/17 Archive Date: 07/27/17 DOCKET NO. 09-15 545 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to a higher initial disability rating (or evaluation) for posttraumatic stress disorder (PTSD), in excess of 30 percent from November 1, 2006 to January 26, 2016, and in excess of 50 percent from January 26, 2016. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Tenney, Associate Counsel INTRODUCTION The Veteran, who is the appellant, had active service from August 1986 to March 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In April 2011, the Veteran testified at a hearing before the undersigned Veterans Law Judge at the RO in Roanoke, Virginia. A copy of the hearing transcript has been associated with the record. Pursuant to a settlement agreement in the case of National Org. of Veterans' Advocates, Inc. v. Secretary of Veterans Affairs, 725 F. 3d 1312 (Fed. Cir. 2013), the Board's August 2011 decision on the issue of a higher initial rating for PTSD was identified as having been potentially affected by an invalidated rule relating to the duties of the undersigned Veterans Law Judge while conducting the April 2011 Board hearing, notwithstanding that the August 2011 Board decision favorably cited to Bryant v. Shinseki, 23 Vet. App. 488 (2010), stated that the hearing officer duties applied to the Veterans Law Judge, and stated how the Veteran was aware of the evidence needed to substantiate a higher rating on appeal. In order to remedy any such potential error, the Board sent the Veteran a letter notifying him of an opportunity to receive a new hearing and/or a new decision from the Board. Subsequently, the Veteran requested to have the prior Board decision partially vacated to the extent that it did not grant a rating in excess of 30 percent for PTSD, and indicated that he wanted a new Board hearing and a new Board decision to be issued. In June 2014, the Board partially vacated the August 2011 decision only to the extent that the Board denied an initial disability rating for PTSD in excess of 30 percent, notwithstanding that the June 2014 Board decision purported to fully vacate the August 2011 Board decision. Although the June 2014 Board Order to Vacate purported to vacate the prior August 2011 Board decision even to the extent it granted a 30 percent initial disability rating for PTSD, such purported complete vacation of the August 2011 Board decision to the extent the Board granted a higher rating from 10 percent to 30 percent is void ab initio as beyond the legal authority granted by the settlement agreement in National Org. of Veterans' Advocates, Inc. v. Secretary of Veterans Affairs to "remedy any harm" or "harms caused by VA's failure to abide by its commitment to cease applying" an invalidated amendments to the Board hearing regulation. By definition, the grant of a 30 percent rating cannot constitute "harm" of any kind. As such, the May 2015 Board decision, in pertinent part, determined that the June 2014 Board decision purporting to completely vacate the Board's August 2011 decision in fact only partially vacated the Board's decision to the extent it denied an initial rating for PTSD in excess of 30 percent. The net result is that the Board's August 2011 partial grant of an initial disability rating of 30 percent (from 10 percent) was not in fact vacated by the June 2014 Board decision. Accordingly, the issue on appeal has been characterized as entitlement to a higher initial disability rating for PTSD, in excess of 30 percent from November 1, 2006 to January 26, 2016, and in excess of 50 percent from January 26, 2016, to comport with the partial grant of benefits to 30 percent provided in the August 2011 Board decision and the June 2016 rating decision, which granted a 50 percent rating effective January 26, 2016, creating the "staged" initial rating on appeal. In February 2015, at a Board videoconference hearing, the Veteran again provided testimony relevant to the appeal from the RO in Roanoke, Virginia, before the undersigned Veterans Law Judge in Washington, DC. A copy of the transcript has been associated with the record. As discussed above, the case was previously before the Board in May 2015, where the Board, in pertinent part, remanded the issue on appeal for additional development, to including providing the Veteran with a new VA examination. January 2016 and April 2016 VA examination reports have been associated with the record. As such, an additional remand to comply with the May 2015 directives is not required. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. For the entire initial rating period on appeal from November 1, 2006, the service-connected PTSD has more nearly approximated occupational and social impairment with deficiencies in most areas due to such symptoms as auditory hallucinations, mood swings, irritability and anger, intrusive thoughts, nightmares, flashbacks, sleep disturbance, social detachment and isolation, hypervigilance, suicidal ideation, and impaired impulse control with periods of violence. 2. For the entire initial rating period on appeal from November 1, 2006, the service-connected PTSD has not more nearly approximated total occupational and social impairment. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, for the entire initial rating period on appeal from November 1, 2006, the criteria for a 70 percent disability rating, and no higher, for the service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.1, 4.3, 4.7, 4.14, 4.130, Diagnostic Code 9411 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION 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) (2016). As the rating issue on appeal arises from the Veteran's disagreement with the initial rating following the grant of service connection, no additional notice is required regarding this downstream element of the service connection claims. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United States Court of Appeals for Veterans Claims (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 November 2007, February 2008, January 2016, and April 2016. 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 occupational and social 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 issue 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 the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2016). Where there is a question as to which of two disability ratings shall be applied, the higher rating 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. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, 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. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2016). Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20 (2016). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Pertinent in this case, the General Rating Formula provides that a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. 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. 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) (2016). The Veteran contends generally that the service-connected PTSD has been manifested by more severe symptoms and impairment than contemplated by the 30 percent disability rating assigned for the appeal period from November 1, 2006 to January 26, 2016, and the 50 percent disability rating assigned from January 26, 2016. Specifically, at the April 2011 Board hearing, the Veteran testified to auditory hallucinations, chronic sleep impairment, the inability to trust others, and that he was easily angered. At the May 2015 Board hearing, the Veteran testified to intrusive thoughts, sleep disturbances, irritability, anger, difficulty concentrating, hypervigilance, and exaggerated startle response, each beginning in 2006. The Veteran also testified to increased irritability and hypervigilance beginning in 2013. See May 2015 Board hearing transcript. A February 2016 statement reflects that the Veteran indicated that the symptoms and impairment of PTSD should be rated as 70 percent disabling for the entire initial rating period on appeal from November 1, 2006. A March 2015 statement reflects that the spouse wrote that she witnessed the Veteran experience chronic irritability, poor judgment, and hypervigilance. The spouse also wrote that she and the Veteran did not have a social life. An October 2006 VA treatment record reflects the VA examiner noted "severe anger." A February 2007 VA treatment record reflects that the Veteran reported intense emotional distress, suicidal and homicidal ideation, hypervigilance, irritability, anger, breaking a co-workers neck during a fight that the co-worker initiated, road rage, being charged with assault and battery after threating a police officer, and that he had recently completed a 14-month anger management program that was "completely unhelpful." A November 2007 VA examination report reflects the Veteran was evaluated as normal. The November 2007 VA examiner assessed that the Veteran was alert, oriented, and cooperative with normal affect. A February 2008 VA examination report reflects that the Veteran reported being married, increased assaultiveness after separating from his first wife, a short temper, nightmares one or two times per week, and being employed. The February 2008 VA examiner assessed orientation in all spheres, goal-directed speech and thought processes, normal behavior, good insight and judgment, and noted that the Veteran was polite and cooperative. The February 2008 VA examiner did not discern suicidal or homicidal ideation. The February 2008 VA examiner assessed mild symptoms of PTSD and opined that the Veteran did not represent a threat to himself or others. A GAF score of 55 was assigned. An August 2011 VA treatment record reflects that the Veteran reported feeling constantly on guard, watchful, or easily started, and denied nightmares, feeling numb, detached from others, or activities. An October 2013 VA treatment record reflects the Veteran reported homicidal ideation and suicidal ideation. A May 2013 VA treatment record reflects nightmares, flashbacks, recurrent/intrusive thoughts, avoidance, irritability, anger, and that the Veteran denied suicidal or homicidal ideation. An October 2013 VA treatment record reflects that symptoms of PTSD had worsened in severity, and that the Veteran denied being "physical or violent." Additional October 2013 VA treatment records reflect the Veteran reported auditory hallucinations with the VA examiner assigning a GAF score of 50. A January 2016 VA treatment record reflects that the Veteran reported sleeping with a loaded pistol under his pillow, and denied current suicidal or homicidal ideation, intent, or plan. The January 2016 VA examiner assessed hypervigilance, problems concentrating, and chronic sleep impairment. A January 2016 VA examination report reflects the VA examiner assessed depressed mood, anxiety, suspiciousness, chronic sleep impairment, suicidal ideation, and difficulty in establishing and maintaining effective work and social relationships. The January 2016 VA examiner opined that PTSD manifested as occupational and social impairment with deficiencies in most areas. An April 2016 VA examination report reflects that the Veteran reported being married three times, depression, and chronic sleep impairment. The Veteran also reported still hearing screams for help while showering, being charged with battery and assault, and denied suicidal and homicidal ideations. The April 2016 VA examiner assessed orientation in all spheres, depression, anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. The April 2016 VA examiner did not discern persistent delusions or hallucinations, grossly inappropriate behavior, or persistent danger of hurting self or others, and opined that PTSD manifested as occupational and social impairment with reduced reliability and productivity. After a review of the lay and medical evidence, the Board finds that, for the entire rating period on appeal from November 1, 2006, the severity of the Veteran's psychiatric symptoms more nearly approximate occupational and social impairment, with deficiencies in most areas, as described for a higher 70 percent rating under Diagnostic Code 9411, due to PTSD symptomatology and impairment including auditory hallucinations, mood swings, irritability and anger, intrusive thoughts, nightmares, flashbacks, sleep disturbance, social detachment and isolation, hypervigilance, suicidal ideation, and impaired impulse control with periods of violence. See 38 C.F.R. § 4.130. Specifically, the October 2006 VA treatment record reflects that the VA examiner assessed severe anger, and the February 2007 VA treatment record reflects intense emotional distress, suicidal and homicidal ideation, hypervigilance, irritability, and anger. Further, the November 2007 VA treatment record reflects that the Veteran reported breaking a co-workers neck during an fight, road rage, being charged with assault and battery after threating a police officer, and that a 14-month anger management program that was "completely unhelpful." The February 2008 VA examination report also reflects the Veteran reported increased assaultiveness, and the January 2016 VA examiner opined that PTSD manifested as occupational and social impairment with deficiencies in most areas. Further, numerous VA treatment records, as well as various lay statements from the Veteran, reflect occupational and social impairment manifested as suicidal ideation, and at the May 2015 Board hearing, the Veteran testified to intrusive thoughts, sleep disturbances, irritability, anger, difficulty concentrating, hypervigilance, and exaggerated startle response, each beginning in 2006. Accordingly, the Board finds that, after resolving all reasonable doubt in favor of the Veteran, for the rating period from November 1, 2006, the severity of the Veteran's occupational and social impairment and symptoms due to service-connected PTSD more nearly approximates the criteria a higher 70 percent disability rating. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Based on the above, the Board also finds that, for the entire initial rating period on appeal from November 1, 2006, the level of occupational and social impairment due to PTSD symptoms have not met or more nearly approximated the criteria for a higher 100 percent disability rating. See 38 C.F.R. § 4.130. For the rating period on appeal from November 1, 2006, the record does not indicate total occupational and social impairment, including no symptoms suggestive of total occupational and social impairment, such as no gross impairment in thought processes or communication, persistent delusions, 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, as required for a 100 percent disability rating under Diagnostic Code 9411. Specifically, a review of the relevant lay and medical evidence, including November 2007, February 2008, January 2016, April 2016 VA examination reports, the Veteran's lay statements, and the April 2011 and February 2015 Board hearing transcripts does not reveal that the Veteran has experienced total occupational and social impairment. In addition, while the Veteran has reported memory difficulties, as reflected in numerous VA treatment records, memory loss has specifically been attributed to a non-service-connected neurocognitive disorder. See May 2016 VA examination report; see also Mittleider v. West, 11 Vet. App. 181, 182 (1998) (stating that the Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence that does so). Further, at the February 2015 Board hearing, the Veteran testified to being employed; therefore, the evidence of record does not demonstrate total occupational impairment. Extraschedular Referral Consideration The Board has considered whether referral for an extraschedular rating would have been warranted for the acquired psychiatric disorder for any part of the rating period on appeal. 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); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances). Second, if the schedular rating 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 rate 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 VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the veteran's disability picture requires the assignment of an extraschedular rating. 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 and degree of social and occupational impairment of the acquired psychiatric disorder with the schedular rating criteria found in 38 C.F.R. § 4.130, Diagnostic Code 9411, reflects that the diagnostic criteria reasonably describe the Veteran's disability level (social and occupational impairment) and symptomatology. The diagnostic criteria convey that compensable ratings will be assigned for an acquired psychiatric disorder that manifests by various levels of occupational and social impairment. In this case, the Veteran's disability picture has been shown to encompass occupational and social impairment due to symptoms that are like or similar to the diagnostic criteria for a 70 percent rating for the entire rating period on appeal from November 1, 2006. The acquired psychiatric disorder was productive of no more than occupational and social impairment with deficiencies in most areas due to such symptoms as auditory hallucinations, mood swings, irritability and anger, intrusive thoughts, nightmares, flashbacks, sleep disturbance, social detachment and isolation, hypervigilance, suicidal ideation, and impaired impulse control with periods of violence. 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 acquired psychiatric disorder has not been shown to be productive of an exceptional disability picture; therefore, the Board determines that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.21(b)(1) is not merited. 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. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the symptoms reported by the Veteran are specifically contemplated by the criteria discussed above. In the absence of exceptional factors associated with acquired psychiatric disorder, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.21(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The other service-connected disabilities in this case are hyperpigmentation of the face, degenerative arthritis of the lumbar spine, left knee tendonitis, tinnitus, hearing loss, right hip osteoarthritis, cervical spine osteoarthritis, and a headache disability. Finally, in adjudicating the current appeal for a higher rating, 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, at the February 2015 Board hearing, the Veteran testified as to being employed; therefore, a TDIU issue has not been raised. ORDER An initial disability rating of 70 percent, but no higher, for PTSD from November 1, 2006 is granted. ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs