Citation Nr: 1237108 Decision Date: 10/25/12 Archive Date: 11/09/12 DOCKET NO. 11-00 670 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a lumbar spine disability. 2. Entitlement to an initial rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Katie K. Molter, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1951 to September 1953. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision by the RO which denied entitlement to service connection for a lumbar spine disability and granted service-connection for PTSD, assigning a 30 percent disability evaluation, effective June 24, 2009. The Veteran has timely appealed those issues. A review of the Virtual VA paperless claims processing system reveals VA outpatient treatment records relevant to the Veteran's claim for a rating in excess of 30 percent for service-connected PTSD. Those records have been reviewed and considered. The Veteran and his spouse testified at an August 2012 Travel Board hearing. A copy of the transcript from that hearing has been reviewed and associated with the Veteran's claims file. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to service connection for a lumbar spine disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT Since service connection, the Veteran's PTSD has been productive of such symptomatology as nightmares, depressed mood, anxiety, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened affect, disturbances in motivation and mood, and occasional suicidal ideation with no intent or plan. CONCLUSION OF LAW The criteria for a disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.126(a), 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2011) defined VA's duty to assist a veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Pelegrini v. Principi (Pelegrini), 18 Vet. App. 112, 120-21 (2004), see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA's notice requirements apply to all five elements of a service- connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. The VCAA-compliance notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case the RO). Id.; Pelegrini v. Principi, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F. 3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. The RO's August and December 2009 notice letters described the evidence necessary to substantiate a claim for service connection, and met all of the requirements noted above, including informing the Veteran to provide any evidence in his possession that pertains to the claim, consistent with the law in effect at that time. This notification would also apply to the "downstream" issue of entitlement to an earlier initial disability rating and effective date. See VAOPGCPREC 8-03. In addition, these letters provided notice as to how disability ratings and effective dates are assigned and the type of evidence that impacts these types of determinations, consistent with the United States Court of Appeals for Veterans Claims (Court) decision in Dingess. Moreover, the record shows that the Veteran was represented by a Veteran's Service Organization and its counsel throughout the adjudication of the claims. Overton v. Nicholson, 20 Vet. App. 427 (2006). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter decided herein on appeal. Pertinent medical evidence associated with the claims file consists of the Veteran's service treatment records, post-service treatment records, and the report of VA examinations. Also of record and considered in connection with the appeal are various written statements provided by the Veteran and his testimony (as well as his spouses) from the August 2012 Board hearing. Thus, the Board finds that all necessary notification and development action on this claim has been accomplished. II. Legal Criteria Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings apply under a particular diagnostic code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1 (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in Fenderson, the Court noted an important distinction between an appeal involving a Veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection to consider the appropriateness of "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). When it is not possible to separate the effects of the service- connected disability from a nonservice-connected condition, such signs and symptoms must be attributed to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). Psychiatric examinations frequently include assignment of a GAF score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (adopted by VA at 38 C.F.R. §§ 4.125 and 4.126 (2008)), a GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). The evidence as described above reveals GAF scores given by VA examiners and outpatient specialists ranging between 35 and 55. However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). 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 peer or coworkers). The Board notes that 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), while a GAF score of 31 to 40 indicates major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score of 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). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). The Veteran's PTSD is currently evaluated as 30 percent disabling under Diagnostic Code 9411. The Board notes that psychiatric disabilities other than eating disorders are actually rated pursuant to the criteria of a General Rating Formula. See 38 C.F.R. § 4.130. Under the formula, a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. III. Medical Background The Veteran has alleged that his service-connected PTSD should be rated higher than his current 30 percent rating. A July 2008 mental health outpatient consult report shows that the Veteran was seen for an initial psychiatric evaluation. The Veteran report increased nightmares, flashbacks, intrusive thoughts, hypervigilance, excessive startle reflex since his return from Korea (much worse over the past year), significant depression and anxiety, and flashbacks that have become more frequent. The Veteran was tearful during the interview and had difficulty answering questions at times. His wife was noted to be very supportive. The Veteran reported being on the front lines for 6 of his 11 month tour and saw many comrades die. His activity has been much less over the past several years due to health problems and several surgeries. He feels he has more time to think because he cannot do thing he used to (gardening, fish, and hunt). The Veteran reported thoughts of self-harm for the past 12-18 months. He stated he "got so down because of everything that is wrong with my health." The last incident was 2-3 months ago. He stated that he never wanted to think about that again and he never did have a plan. He had fleeting thoughts that were not sustained. The Veteran reported being married for 57 years and having two adult children with whom he has good relationships with. He retired from working in textiles. He reported sleeping a total of 6 hours that was restorative. His sleep was also noted to be combative (his wife stated that he calls out in his sleep) and restless-he reported bad dreams. The Veteran stated that the nightmares are about what happened in Korea and the older he gets, the worse it gets. He stated that he has nightmares about 3-4 times a week with increasing frequency over the past year. He also reported flashbacks and intrusive thoughts. His appetite has been unchanged and his energy appropriate. The Veteran appeared well groomed with appropriate hygiene. His behavior was appropriate and he was fully oriented. His attitude was cooperative, pleasant, and polite. His mood was "not good."His affect was full-range and congruent. His speech was spontaneous and was at a normal rate, amount, and flow. His tone was well-modulated. The Veteran's thought processes/content were logical, goal-directed. No delusions, obsessions, or phobias were elicited during the interview. There was no evidence of sensory disturbance. The Veteran's remote, recent, and immediate memory were all intact. There was no current suicidal ideation and the Veteran denied homicidal ideation. Insight was intact and reliability was good. The Veteran was diagnosed with depression, rule out PTSD, and assigned a GAF score of 55. A June 2009 mental health nurse practitioner note shows that the Veteran reported continued symptoms of nightmares, flashbacks, intrusive thoughts, hypervigilace, and excessive startle reflex. The Veteran stated that the symptoms have been present since his return from Korea but because progressively worse since retirement in 1995. Significant depression and anxiety were noted; he rated them as 7/10. The Veteran was tearful during the interview and had difficulty answering questions at times. His affect was sad and reported having fleeting thoughts of self-harm for the past 12-18 months. Last occurrence was approximately 2 months with no plan. The Veteran stated that he would never harm himself because of his family. He reported sleeping approximately 6 hours a night. The Veteran's wife stated that he calls out in his sleep and has combative sleep. It was also noted to be fragmented and restless. The Veteran was diagnosed with PTSD and assigned a GAF score of 45. A July 2009 VA mental health nurse practitioner note shows that the Veteran reported nightmares, flashbacks, intrusive thoughts, hypervigilvance, and excessive startle reflex. He rated his depression as a 7/10. There were no tearful episodes during the interview. His affect was sad. He was alert and cooperative. No current suicidal or homicidal ideation. Sleep remains fragmented and combative. The Veteran's insight and judgment were intact and his reliability was good. He was diagnosed with PTSD and assigned a GAF score of 45. An August 2009 VA examination report shows that the Veteran stated that the older he gets, the worse his emotional difficulties have become. The Veteran began crying and cried throughout the entire examination. He stated that he has a difficulty maintaining sleep. He reported getting about 6-7 hours of sleep per night and stated that he will wake up when he is having nightmares. He reported having nightmares several times a week about war episodes. He has night sweats and yells out in his sleep. He denied flashback symptoms but stated that he does see Koreans in his room when he wakes up from nightmares. The Veteran reported intrusive thoughts every day. He denied difficulty with socialization and stated that he goes to church frequently. He is able to go to stores and like to go to restaurants (he does not because his wife does not care for them). He reported difficulty with anger control and stated that he blows up easily. He also reported generalized anxiety and dysphoria. The Veteran also reported startle to noise and stated that he avoids programs about war. The Veteran reported working for 39 years in quality control in a textile mill. He stated that he was early retired in July 1995 because they were cutting back. He stated that he did well at his job. The Veteran also reported being married to the same woman, his wife, for 58 years. He described their relationship as good. At the time of the examination, the Veteran was alert, oriented to personal information, and place. Temporal orientation was also normal. Insight was adequate. Affect was blunted and tearful. Response latencies were normal. He demonstrated adequate attention and was not distractible. Spontaneous speech was fluent, grammatic, and free of paraphasias. Immediate, recent, and remote memory were all within normal limits. During the interview, the Veteran was noted to be logical and goal directed. He reported dysphoria. He cried frequently and was feeling guilt. He reported intermittent suicidal ideation, but has no plan or intent. He denied passive thoughts of death and homicidal ideation or plan. There was no evidence of disorder in thought process or content. He made good eye contact. There was no pressured speech, grandiosity, irritability, or restlessness noted. The examiner diagnosed the Veteran with PTSD, chronic, moderate, and assigned a GAF score of 55. The examiner stated that the Veteran was currently experiencing a mild to moderate degree of impairment in social functioning, and there would be mild to moderate degree of impairment in occupational functioning. His overall level of impairment was noted to be mild to moderate. An October 2010 VA examination report shows that the Veteran reported that he continues to have nightmares two times per week. He stated when he is able to sleep his sleep is sporadic, nonrestorative, and disrupted. He reported that he experiences night sweats and restlessness. He has intrusive thoughts on most days unless he makes a significant effort to keep himself busy. He is hypervigilant and watchful. He feels that when he goes out that someone is going to attack him. He stated that this is a newly developed symptom and has not been prevalent before but he states he feels this way every time he goes out. He has concentration problems due to intrusive thoughts. The Veteran reported trying to keep himself busy to avoid thinking about his other symptoms. He avoids movies about Vietnam and about anything related to fighting. He experiences loss of control, is depressed, and frequently tearful. He is relatively isolated and withdrawn from others. The Veteran stated that he has experiences suicidal ideations but has never made a plan or attempt to harm himself. There have been no significant post military stressors and no significant remission of his symptoms. The Veteran has never been hospitalized in a psychiatric facility. He reported currently living with his wife of 59 years. He states that he has two adult sons with whom he is very close. Upon mental status examination, the Veteran was appropriately dressed. Eye contact was good and he appeared his documented age. He was cooperative and behaved appropriately. Attention and concentration were within normal limits. Thought process was linear and devoid of delusional content. Insight and judgment were adequately developed. Affect and mood was depressed. He was quite tearful during the examination. The Veteran was diagnosed with PTSD and assigned a GAF score of 50. The examiner stated that despite consistent treatment he continues to experience symptoms of PTSD which are resulting in significant impairment in his social and occupational functioning. A December 2011 VA examination report shows that the examiner indicated that the Veteran was suffering from total occupational and social impairment. The Veteran reported living with his wife of 60 years. He also reported being retired from a machine plant. He retired in July of 1995 and is not employed in any capacity. The Veteran reported that his PTSD symptoms are getting a lot worse. He says that they have increased significantly in the last year. He has been having flashbacks every day. He reports he no longer sleeps at night. He has been having suicidal thoughts but says he will not act on these because of his family. At the December 2011 VA examination, the Veteran reported symptoms of depressed mood, anxiety, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, flattened affect, disturbances in motivation and mood, difficulty in adapting to stressful circumstances, including work or a work like setting, and suicidal ideation. The examiner stated that it was her opinion that the Veteran's PTSD was severe and worsening significantly. She stated that his PTSD renders him unable to secure and maintain substantially gainful employment or either a physical or sedentary nature. A May 2012 physician's note shows that he is well but has occasional depression due to wife's illness and flashbacks of torture he experienced during the Korean War. He now asks for counseling. Is adamant that he would never harm self as he knows his family needs him and that harm self is deeply counter to his religious beliefs. A June 2012 psychiatry consult note shows that the Veteran stated that he has been unable to live a normal life without constantly reliving the battle experiences. He stated that he has had nightmares about the war almost every night, and also has flashbacks everyday continuously about the things he saw and experienced. He stated that he had problems trying to work at his job because of flashbacks, feelings of paranoia. The Veteran stated that he has not been able to have a normal family life and go places with his wife and children due to the anxiety and lack of trust for people. The Veteran reported that he is and has been hyperviligent, is not able to be around a lot of people, cannot tolerate a lot of stimulation and confusion because he has anxiety and panic attacks. He states that during his sleep, he yells and fights in his sleep. This has not gotten better through the years and states that as he gets older, thy symptoms become worse. The Veteran stated that even now if he hears something outside or inside of his home, he becomes fearful of what might happen and always gets up at night and goes out to check the perimeter of his property. Even at his present age, the memories and thoughts of what he endured and experienced causes him to have extreme anxiety, depressed mood and have a poor quality of life. He stated that he continues to feel the pain, sorrow, and suffering he endured when fighting for our country in Korea. The doctor stated that the Veteran's symptoms are more likely than not due to the severe conditions he experienced when he was in the Korean War. Upon mental status examination, the Veteran was dressed casually and appropriate. He had good hygiene. He was fully oriented to person, place, time, and situation. Behavior was calm and cooperative. There was no abnormal psychomotor activity. Speech is spontaneous and normal in rate, rhythm, and volume. Mood was described as "depressed." Affect was congruent with mood; thought process was linear and goal-directed. Thought content was without any overt symptoms of psychosis. He denied auditory/visual hallucinations. The Veteran did not voice any suicidal or homicidal ideation. His impulse control, judgment and insight were good. The Veteran diagnosed with PTSD and assigned a GAF score of 35. A July 2012 mental health medication management note shows that the Veteran reported that he is getting along well with family and friends, is active in the community and attends church. The Veteran stated that his sleep is "pretty good and sleeping longer." He reported that his appetite is good; energy is "no good, sluggish". He stated that his concentration is "not good" and states short term memory has gotten worse." He stated that his mood today is "good at this time, but not good times." The Veteran denied A/V hallucinations, reports that when he wakes up at night he "hears things at night." He denied suicidal or homicidal ideation stating," I am not suicidal; "I have had fleeting thoughts about death in the past." The Veteran stated that his stressors include: "caring for his wife who has dementia." My wife is OK during the day, but is harder to deal with in the afternoon and at night." He stated that his symptoms PTSD have gotten worse and that the older he gets, the worse his nightmares are and has more anxiety." Upon mental status examination, the Veteran was casually and appropriately dressed. He was fully oriented to person, place, time, and situation. His behavior was calm and cooperative. There was no abnormal psychomotor activity. Speech was spontaneous and normal in rate, tone, and volume. The Veteran's mood today was "good" and affect was congruent with his mood. His thought process was linear and goal-directed. Thought content was without any overt symptoms of psychosis and denied auditory/visual hallucinations. Veteran denies suicidal or homicidal ideation. His memory short term/long term are intact. Impulse control was good as well as judgment and insight. The Veteran was diagnosed with PTSD but no GAF score was assigned. The Veteran and his spouse testified at an August 2012 Board hearing regarding the Veteran's PTSD symptoms. The Veteran testified to poor sleep and feeling anxious upon waking. He also testified to lacking in motivation and not trusting people. The Veteran testified that he lashes out verbally and physically. He reported symptoms of moodiness, flashbacks, auditory and visual hallucinations, problems with short term memory, and guilt. A September 2012 mental health medication management note shows that the Veteran stated that his sleep is "pretty good and sleeping longer." He reported his appetite was good, energy was reported as "not good". Veteran reported that his concentration "not real good" and states short term memory has gotten worse" He stated that his mood today is "has been down, short temper, real bad so everybody tells me." "I get aggravated easily; I don't know how to explain it." The Veteran denied A/V Hallucinations, states that he ears noises at times and has fear that someone is outside when I go to get the paper." He reported that when he wakes up at night he "hears things at night." He denied SI/HI," I am not suicidal, "I have had fleeting thoughts about death in the past." The Veteran stated that his stressors include: "caring for his wife who has bad dementia at times." My wife's dementia is progressively getting worse, but is harder to deal with in the afternoon and at night." He stated that his symptoms PTSD have gotten worse. He further indicated that the older he gets, the worse his nightmares are and has more anxiety. Upon mental status examination, the Veteran was casually and appropriately dressed. He was fully oriented to person, place, time, and situation. His behavior was calm and cooperative. There was no abnormal psychomotor activity. Speech was spontaneous and normal in rate, tone, and volume. The Veteran's mood today is "good" and affect was congruent with his mood. His thought process was linear and goal- directed. The Veteran's thought content was without any overt symptoms of psychosis and denied auditory/visual hallucinations. He denied suicidal or homicidal ideation. The Veteran's memory short term/long term were intact. Impulse control was good and Veteran's judgment and insight were good. The Veteran was diagnosed with PTSD; a GAF score was not assigned. IV. Analysis The Board has considered the evidence of record in light of the criteria noted above and finds that the criteria for a disability rating in excess of 30 percent is not warranted. After a careful and considered review of the record, the evidence shows that the Veteran's symptoms, as described above, have not caused occupational impairment such that the Veteran has reduced reliability and productivity. At most his PTSD has caused occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. It is significant to note that the Veteran reported working in quality control for textiles for 39 years and only retired because the company was making cutbacks. At a June 2012 VA appointment, the Veteran stated that he had problems trying to work at his job because of flashbacks, feelings of paranoia. However, this was the first and only mention of the Veteran reporting that his PTSD symptoms affected his occupation (when he was working) in anyway. In a previous encounter at the VA, the Veteran had reported that he stated that he did well at his job (See August 2009 VA examination report). The Board has considered the statement made by the December 2011 VA examiner who stated that his PTSD renders him unable to secure and maintain substantially gainful employment or either a physical or sedentary nature. However, the examiner did not provide a rationale or basis for that opinion. Considering the Veteran's overall symptoms and manifestation of his PTSD since service connection, the Board finds that the evidence of record demonstrates that the 30 percent rating more than takes into accounts and considers the Veteran's report of occupational impairment. With regards to the degree to which the Veteran's PTSD symptoms cause social impairment, the Board finds that the Veteran's symptoms have caused very little social impairment, if any. The record shows that the Veteran has been married to the same woman for over 60 years; he has always described their relationship as good. In addition, the Veteran has two sons with whom he also has good relationships with. The Veteran has stated that he goes to church and that although he can no longer hunt, fish, and garden to his physical limitations, he enjoyed those activities for many years. The Veteran also stated that he likes to go out to eat but does not because he wife prefers not to. There is no evidence that the Veteran's PTSD symptoms have caused a difficulty in establishing and maintaining effective social relationships as evidenced by the fact that the Veteran appears to have maintained and established effective and productive relationships with his family. In this instance, the Board finds the Veteran's disability does not warrant a rating in excess of 30 percent. Based upon these findings, and following a full review of the record, the Board determines that the preponderance of the evidence is against a finding that the Veteran's disability should be rated in excess of 30 percent. Since grant of service connection, the Veteran's PTSD has been no more than 30 percent disabling, therefore the requirements for a rating of 50, 70, or a 100 percent have not been met. As the Board finds that the record presents no basis for an assignment of more than a 30 percent rating for PTSD, there is no basis for staged ratings of the disability pursuant to Fenderson and Hart. Fenderson, 12 Vet. App. at 126; Hart, 21 Vet. App. at 509-10. Extra-schedular Consideration An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluations are not inadequate. In this regard the Board acknowledges the opinion of the December 2011 VA examiner who found the Veteran to be unable to establish and maintain employment because of his service-connected PTSD. However, the other evidence of record, including that examination report does not support that conclusion and the examiner did not provide a rationale for that opinion. Furthermore, evaluations in excess of the assigned are provided for certain manifestations of the service-connected disabilities at issue, but the medical evidence reflects that those manifestations are not present in this case. Accordingly, extraschedular referral is not in order here. In reaching the above determinations, the Board acknowledges that the VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). ORDER Entitlement to an initial rating in excess of 30 percent for service-connected PTSD is denied. REMAND With respect to the Veteran's claim for service connection, the Board has determined that the Veteran should be afforded a VA examination in order for a medical nexus opinion. The Veteran has alleged that currently suffers from a low back disability as a result of receiving several spinal epidurals in preparation for pilonidal cyst surgery while serving on active duty. The Veteran further has alleged that he had to have surgery on his back in 1993 and still has problems to this day. Service treatment records show that the Veteran underwent surgery in 1952 and 1954 for a pilonidal cyst. A 1952 operative report shows that the Veteran was administered spinal anesthesia. A June 1954 operative report indicates that the pilondial cyst and sinus, recurrent was treated, operated, and cured. A December 2011 VA General Medical Examination report shows that the Veteran has been diagnosed with lumbar degenerative disc disease and spondylosis. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Given that there is evidence of a current disability and evidence establishing that the Veteran did receive a spinal injection during active military service, the Board has determined that a medical opinion should be obtained to address the Veteran's contention that the in-service spinal injection has caused the Veteran's current low back disability. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). Expedited handling is requested.) 1. Schedule the Veteran for a VA examination in order to determine the nature and etiology of any current lumbar spine disorder found, to include all orthopedic and neurological manifestations. The entire claims file, to include a complete copy of the REMAND must be made available to the examiner designated to examine the Veteran, and the examination report should include discussion of the Veteran's documented medical history and assertions. All appropriate tests and studies (to include x-rays and neurological studies (if needed) should be accomplished (with all results made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. After examining the Veteran and reviewing the relevant evidence in the claims file, the examiner should clearly identify any lumbar spine disorder found on examination. With respect to each diagnosed disorder, the VA examiner should offer an opinion, consistent with sound medical principles, as to whether it is at least as likely as not (50 percent or greater probability) that such disorder had its onset during the Veteran's period of active duty. In rendering the requested opinion, the examiner should specifically consider and discuss the Veteran's contention that his current spine disorder(s) are casually related to the in-service spinal epidural the Veteran received in connection with his pilondial cyst operation, all relevant medical records, to specifically include the 1952 and 1952 operative reports of the Veteran's pilondial cyst. A complete rationale should be given for all opinions and conclusions. 2. After completion of the above and any additional notice or development deemed necessary, readjudicate the claims on appeal. If any determination remains unfavorable to the Veteran, he and his representative should be provided with a supplemental statement of the case and be afforded an opportunity to respond before the case is returned to the Board for further appellate review, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs