Citation Nr: 1304499 Decision Date: 02/07/13 Archive Date: 04/10/13 Citation Nr: 1304499 Decision Date: 02/07/13 Archive Date: 02/19/13 DOCKET NO. 07-04 454 ) DATE 07 FEB 2013 ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE 1. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder prior to January 12, 2012. 2. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder beginning on January 12, 2012. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Sara Schinnerer, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1968 to July 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2006 rating action of the Department of Veterans Affairs (VA), Regional Office (RO) in New York, New York. Jurisdiction of the case has been subsequently transferred to the RO in St. Petersburg, Florida. In November 2011, the Board issued a decision that denied a disability rating in excess of 30 percent for the Veteran's posttraumatic stress disorder (PTSD). The Veteran appealed the Board's November 2011 decision to United States Court of Appeals for Veterans Claims (Court). Pursuant to an April 2012 Joint Motion for Partial Remand (JMR), the Court issued a July 2012 Order that remanded the issue of a disability rating in excess of 30 percent for the Veteran's PTSD for further action. In a September 2012 rating decision, the rating for PTSD was increased from 30 percent to 50 percent, effective January 12, 2012. As the rating for the Veteran's PTSD is less than the maximum available rating, the issue remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). The issues of entitlement to a disability rating in excess of 30 percent for service-connected PTSD prior to January 12, 2012, and in excess of 50 percent since January 12, 2012 is remanded to the RO via the Appeals Management Center in Washington, DC. ORDER TO VACATE VA regulations provide that the Board may vacate an appellate decision at any time upon the request of the Veteran or his representative, or on the Board's own motion, when there has been a denial of due process. 38 C.F.R. § 20.904(a) (2012). In February 2006, the Veteran submitted a claim for a disability rating in excess of 30 percent for his service-connected PTSD. After this claim was denied by a rating decision in April 2006, the Veteran perfected an appeal to the Board. The Board continued the 30 percent rating and denied this claim in November 2011, after which the Veteran appealed to the Court. In April 2012, based on a JMR, the Court issued an Order in July 2012 granting the JMR, and remanded the case to the Board. Accordingly, the Board's November 2011 decision is vacated herein, and a new decision on this issue will be entered as if the November 2011 decision had never been issued. REMAND In November 2011, the Board denied the Veteran's claim of entitlement to a rating in excess of 30 percent for PTSD. In a February 2008 Social Security Administration (SSA) decision, benefits were granted, in part, due to the Veteran's PTSD. The SSA decision made a finding that the Veteran had severe impairments, to include PTSD, schizoaffective disorder, and a low back syndrome. Regarding the Veteran's psychiatric disability, the SSA found that "this profile is further eroded by psychological impairments which render the claimant unable to understand, remember, and carry out work instructions, as well as respond appropriately to supervision, co-workers, and customary work pressures in a work setting." In this regard, while the SSA decision deemed the Veteran's psychiatric disability to be PTSD, as well as schizoaffective disorder, the Veteran's only service-connected psychiatric disability is PTSD. VA outpatient treatment records dated in January 2006 through January 2008 demonstrate diagnoses of PTSD, as well as schizoaffective disorder. Thus, further clarification is necessary in order to determine which symptoms are attributable to the Veteran's service-connected PTSD disability. Moreover, the Board acknowledges that in a September 2012 rating decision, the Veteran's disability rating for his PTSD was increased from 30 percent to 50 percent, effective January 12, 2012. VA outpatient treatment records dated in May 2009 through June 2012, indicates that the Veteran's service-connected PTSD may have increased in severity since the most recent December 2008 VA examination. Moreover, the evidence of record is insufficient for the Board to distinguish between symptoms of service-connected PTSD and any other diagnosed psychiatric disorders that may be present. Accordingly, the Board finds that another VA examination is necessary. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); see also Mittleider v. West, 11 Vet. App. 181, 182 (1998). In addition, the record demonstrates that the Veteran seeks ongoing treatment for his PTSD at the VA Medical Center (VAMC) at Tampa, Florida. The record contains VA outpatient treatment records to June 2012; thus, VA must obtain any VA outpatient treatment records from June 2012 to the present. See 38 C.F.R. § 3.159 (2012); Bell v. Derwinski, 2 Vet. App. 611 (1992). Finally, following the September 2011 supplemental statement of the case, additional records were added to the claims file that the RO has not considered. Therefore, the additional evidence must be considered by the RO. 38 C.F.R. §§ 19.37, 20.1304 (2012). Accordingly, the case is remanded for the following actions: 1. The RO must contact the Veteran to provide him an opportunity to identify all VA and non-VA medical providers who have treated his service-connected PTSD since June 2012. Thereafter, the RO must attempt to procure copies of all records that have not previously been obtained from identified treatment sources. Regardless of the Veteran's response, the RO must attempt to obtain and associate with the evidence of record all treatment records from the VAMC at Tampa, Florida from June 2012 to present. All attempts to secure this evidence must be documented in the claims file by the RO. If, after making reasonable efforts to obtain the identified records, the RO is unable to secure same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claims; and (d) notify the Veteran that that he is ultimately responsible for providing the evidence. The Veteran and his representative must then be given an opportunity to respond. 2. Upon completion of the above development, the Veteran must be afforded a VA psychiatric examination to determine the current severity of his service-connected PTSD. The claims file and all records on Virtual VA must be made available to the examiner, and the examiner must specify in the examination report that the claims file and Virtual VA records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. Any indicated diagnostic tests and studies must be accomplished. All pertinent symptomatology and findings must be reported in detail. The examiner must comment upon the presence or absence, frequency, and severity of the Veteran's PTSD symptoms to include: affect; speech; panic attacks; ability to understand complex commands; short- and long-term memory; judgment; abstract thinking; motivation; mood; ability to establishing and maintaining effective work and social relationships; suicidal and/or homicidal ideations; obsessional rituals; ability to function independently, appropriately, or effectively; impulse control; neglect of personal appearance and hygiene; ability to adapt to stressful circumstances; delusions or hallucinations; general behavior; persistent danger of hurting self or others; ability to perform activities of daily living; and orientation. The examiner must attempt to distinguish symptomatology which is attributable to the Veteran's service-connected PTSD and that which is attributable to any other diagnosed psychiatric disability, to include schizoaffective disorder. Specifically, the examiner must address the Veteran's complaints of auditory hallucinations documented in his VA outpatient treatment records. If the examiner cannot ascribe particular symptoms to a specific diagnosis, this must be indicated. The examiner must also enter a complete multi-axial evaluation, and assign a Global Assessment of Functioning score, together with an explanation of what the score represents in terms of his psychological, social, and occupational functioning. The examiner must provide a complete rationale for any opinion expressed, based on the examiner's clinical experience, medical expertise, and established medical principles. If an opinion cannot be made without resort to speculation, the examiner must provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. The RO must notify the Veteran that it is his responsibility to report for any examination scheduled and to cooperate in the development of his claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for a scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 4. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated with consideration of all of the evidence of record. If any benefit remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. No action is required by the Veteran until he receives further notice; however, 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). _________________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012). Citation Nr: 1142765 Decision Date: 11/21/11 Archive Date: 12/06/11 DOCKET NO. 07-04 454 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for residuals of shrapnel wound to the head with damage to the right eye. 2. Entitlement to service connection for a back disorder. 3. Entitlement to an increased evaluation in excess of 30 percent for posttraumatic stress disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1968 to July 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2006 and January 2008 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. Jurisdiction of the case has been subsequently transferred to the RO in St. Petersburg, Florida. FINDINGS OF FACT 1. The evidence of record shows residuals of shrapnel wound incurred on active duty. 2. The competent evidence of record does not show a current back disorder that is related to the Veteran's military service or to any incident therein. 3. The Veteran's posttraumatic stress disorder (PTSD) has been manifested by intrusive memories, nightmares, anxiety, flashbacks, sleep disturbance, dysphoric mood, increased startle response, and social withdrawal. CONCLUSIONS OF LAW 1. Scar over the Veteran's right eyebrow was incurred in active military duty. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2011). 2. A back disorder was not incurred in, or aggravated by, active military service. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303 (2011). 3. The criteria for an evaluation in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions under the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2011). Proper notice from VA must inform the claimant of any information and medical or lay 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The RO's July 2007, September 2008, and February 2010 letters advised the Veteran of the foregoing elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as a statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). With respect to the Dingess requirements, the RO's July 2007 letter provided the Veteran with notice of what type of information and evidence was needed to establish disability ratings, as well as notice of the type of evidence necessary to establish an effective date. In addition, the RO's September 2008 letter informed the Veteran of what evidence was required to substantiate his claim for increased disability rating and of his and VA's respective duties for obtaining evidence. The Veteran was also asked to submit evidence or information in his possession to the RO. See Vazquez-Flores v. Shinseki, 580 F. 3d 1270 (Fed. Cir. 2009). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims, including the opportunity to present pertinent evidence. In addition, the duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records, as well as his identified VA and private medical treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Pursuant to the Board's January 2010 remand, the RO attempted to obtain private treatment records from Dr. B. of W. Clinic in New York. In February and March 2010 letters, the RO requested that the Veteran complete and return a VA Form 21-4142, Authorization and Consent to Release Information, for Dr. B., to obtain all relevant treatment records, and requested the records from Dr. B. in June 2010. However, the Veteran indicated in a May 2010 letter that he was unable to obtain any medical records from Dr. B. A July 2010 response from the W. Clinic also indicated that there were no medical records relating to the Veteran available at the facility. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (finding that remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). Furthermore, VA has provided the Veteran with a VA examination to determine the etiology of any residuals of shrapnel wound to the head with damage of the right eye or any back disorder found. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). In compliance with the Board's January 2010 remand, a VA examination was conducted in July 2010. The Board finds the July 2010 VA examination adequate as it was based upon a complete review of the Veteran's claims file, clinical examination of the Veteran, and consideration of the Veteran's statements, and the VA examiner provided a written rationale for the conclusion reached. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The VA has also provided the Veteran with multiple medical examinations to determine the severity of his PTSD. 38 C.F.R § 3.159(c)(4). Although the March 2006 an December 2008 VA examiners indicated that the Veteran's claims file was not available for review, the Board finds that this does not constitute a prejudicial error. Here, an increase in the disability rating is at issue and the present level of the Veteran's service-connected disability is of primary concern. As it would not change the objective and dispositive findings made during the VA examination, review of the claims file was not required. See Snuffer v. Gober, 10 Vet. App. 400, 403-04 (1997). Importantly, in compliance with the Board's January 2010 remand, the Veteran was scheduled for a VA psychiatric examination in August 2011. However, the Veteran failed to report for the examination. In an August 2011 letter, the Veteran stated that he would not go to any more VA examinations and that his claim should be rated on the evidence of record. The duty to assist is not a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Based on the foregoing, the Board concludes that there has been substantial compliance with its January 2010 remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Finally, as there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may also be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). Generally, in order to establish service connection for the claimed disorders, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). In certain circumstances, lay evidence may also be competent to establish a medical diagnosis or medical etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). A. Residuals of Shrapnel Wound to the Head with Damage to the Right Eye The Veteran contends that he incurred a shrapnel wound to the head that resulted in right eye damage. The Veteran described that in approximately November 1969, he came under a mortar attack at Can Tho, Vietnam while on a search mission. His service treatment records are silent as to any head or right eye disorder. He reported that he had 15 stitches over his right eye, which left a three inch scar, and was legally blind in the right eye from a metal piece in the eye. His service treatment records are silent as to treatment for a shrapnel wound. However, in October 1968, the Veteran was involved in a motor vehicle accident at which time his head hit the windshield. In an October 2001 VA optometric examination report, the Veteran complained of visual changes, especially while reading. There was blurred naked vision without prescription. The diagnoses were dry eye syndrome, without symptoms, and simple hyperope/presbyope. A June 2008 VA optometry consultation report noted assessments of mild cataracts and refractive error, bilaterally. A July 2008 computerized tomography (CT) scan of the Veteran' head revealed a metallic foreign body measuring 2.7 millimeters (mm.) x 4.5 mm. x 2.0 mm. located in the supermedial aspect of the right orbit. It was noted that the foreign body did not project into the globe nor did it appear to be in contact with the major ocular vascular structures. On a December 2008 VA examination, the Veteran denied a history of vision problems. On examination, there were no signs of vision problems shown. A July 2010 VA ophthalmology consultation report noted that the Veteran had no visual complaints. The impressions were metallic foreign body in the right orbit, according CT scan secondary to shrapnel, and constricted Goldmann visual field per a previous note. However, the VA resident/physician stated that the Veteran's visual field to confrontation was absolutely full and that there was no need for further workup or treatment at that time. The Veteran was afforded a VA examination in July 2010. The VA examiner stated that the Veteran's claims file was reviewed. The Veteran reported pain, burning or stinging, dryness, fleeting foreign body sensation, and light sensitivity in the right eye, associated with sunlight exposure since his reported mortar injury in service. As to visual symptoms, he reported blurring, tunnel vision, and impaired night vision. Following a physical examination, the diagnoses were metallic foreign body in the right orbit; no right eye globe pathology secondary to the foreign body in the right orbit; meibomianitis/blephariti, bilaterally; mild cataracts, bilaterally; and significantly constricted visual field, bilaterally. The examiner noted that the right eye damage secondary to shrapnel wound had no effect on daily activities as no right eye globe (eyeball) damage was noted and that the metallic foreign body was in the orbit (space between eyeball and bony socket). The examiner further stated that the constricted visual field of both eyes could not be attributed to the foreign body in the right orbit. The examiner explained that with the exception of the metallic foreign body in the Veteran's right eye orbit, no blunt force or penetrating trauma to the right eye was found. The examiner concluded that although the occurrence of metallic foreign body in the Veteran's orbit was consistent with the reported shrapnel injury from mortar attack or inservice motor accident, taking into consideration the anatomical distinction between orbit and eyeball, there was no right eyeball, to include retina, lens, iris, and cornea, disability that was related to the Veteran's military service. The Veteran was afforded another VA examination in July 2010. The VA examiner stated that the Veteran's claims file was reviewed. The Veteran reported the history of being hit in the face, right eye, and nose by metal fragments from mortar explosion near his military compound while he was getting out of a car. He stated that he had wound scars in his forehead and right side of the head that occasionally hurt. Physical examination revealed a well-healed scar in the right eyebrow area measuring 2.0 cm x 0.2 cm. The examiner stated that the scar was superficial, with no limitation of motion or function. There was no evidence of scars in the right side of the head. The examiner opined that the scar over the Veteran's right eyebrow was related to his reported mortar injury or motor vehicle accident in service. However, the examiner stated that there was no objective evidence of scar or penetrating trauma to the right side of the head. The medical evidence of record does not show a current disorder pertaining to the Veteran's head or right eye other than the scar in the right eyebrow area. Although the Veteran reported that he had wound scars in his forehead and right side of the head that occasionally hurt, on clinical examination, only a well healed scar in the right eyebrow area was found. Specifically, the July 2010 VA examiner noted that there was no objective evidence of other scars or penetrating trauma to the right side of the head. Additionally, despite the presence of a metallic foreign body in the Veteran's right orbit, which was found be to consistent with the reported shrapnel injury from mortar attack, the July 2010 VA examiner found no right eye globe pathology secondary to the foreign body in the right orbit. The examiner explained that there was the anatomical distinction between orbit and eyeball and that there was no right eyeball, to include retina, lens, iris, and cornea, disability that could be related to the Veteran's military service. The Board finds that the Veteran is competent to attest to the factual matters of which he had first-hand knowledge, such as the history of shrapnel wound to the head and right eye as a result of a mortar attack occurred on active duty and observable symptoms since his military service. See Layno v. Brown, 6 Vet. App. 465 (1994). Further, the July 2010 VA examiner opined that the Veteran's scar over the right eyebrow was related to the Veteran's reported mortar injury or motor vehicle accident in service. Accordingly, service connection for scar over the Veteran's right eyebrow is warranted. B. Back Disorder The Veteran claims that he incurred a back disability due to a fall of 15 feet from a roof while he was serving as a carpenter in Soc Trang, Vietnam. His service personnel records show that he served in Vietnam from July 1969 to July 1970 with the 574th Supply and Service Company. The Veteran's service treatment records are negative for any back disorder. After service separation, in a September 2001 social worker note, the Veteran reported that he was able-bodied, with no disability that would prevent him from maintaining gainful employment. On an October 2001 VA psychiatry note, the Veteran stated that he had no chronic medical problems that interfered with his life. He further stated that he was not taking any prescribed medication on a regular basis and denied receiving a pension for a non-psychiatric physical disability. March 2005 VA treatment reports reflect that the Veteran complained of back pain for two days, with no trauma. He stated that he hurt his back on the job. The Veteran claimed that this back pain occurred only when he went to work. The assessment was low back pain. On an April 2005 VA psychiatric examination report, the Veteran reported a history of back strain and muscle pain in the back for a number of years, which he stated prevented him from working. On an August 2005 VA psychiatric examination report, the Veteran reported that he worked for a landscaper about a month prior to the examination but quit when his back began to hurt. He continued to complain of back pain, which he stated began a month previously. In an August 2006 VA physician note, the Veteran complained of intermittent back pain for the past year when he worked. It was noted that his work consisted of lifting 40 pound bags onto his shoulder and that he had no pain when he did not work. The assessment was chronic low back pain. A September 2006 VA treatment report noted the Veteran's complaint of mid back pain for two weeks after a fall at a train station. He stated that while he was attempting to sit down he missed the chair and fell backwards hitting his head. The diagnosis was back contusion. In a July 2007 VA primary care note, the Veteran reported low back pain after falling off roof in Vietnam. The assessment was chronic back pain. A February 2008 disability determination report from the Social Security Administration (SSA) found the Veteran disabled due to a primary diagnosis of low back pain and a secondary diagnosis of PTSD. The Veteran reported not working due to PTSD and back problem that occurred in August 1993. The Veteran was afforded a VA examination in July 2010. The Veteran reported injury to his low back when he fell off a roof while in Vietnam in 1970 and that he had chronic back pain ever since that time. He was taking muscle relaxants and nonsteroidal anti-inflammatory drugs, with good response. The diagnosis was degenerative joint disease of the lumbar spine. The examiner stated that "it is less likely as not that the back disability diagnosed [as] mild DJD [degenerative joint disease] of lumbar spine is related to [the] [V]eteran's military service." In support of this opinion, the examiner stated that the Veteran's service treatment records were silent for complaint or treatment for low back pain and that mild lumbar degenerative joint disease was most likely age-related. After reviewing the evidence of record, the Board finds that the medical evidence of record does not show that the Veteran's current low back disorder is related to military service. There is current diagnosis of degenerative joint disease of the lumbar spine. Degmetich v. Brown, 104 F.3d 1328, 1333 (Fed. Cir. 1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). The Board considered the Veteran's statements regarding continuity of his back symptomatology since military service. The Veteran's contentions regarding his in-service back injury and continuing back pain, capable for lay observation, are competent evidence of what he actually observed and was within the realm of his personal knowledge. See Layno, 6 Vet. App. at 469-70. However, his statements regarding the onset of his current back disorder are not consistent throughout the record. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that credibility may be impeached by a showing of inconsistent statements, consistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Prior to filing his present claim of service connection for a back disorder, the Veteran reported the onset of his back pain was in 2005 when he hurt his back on the job. On the August 2005 VA examination conducted in conjunction with a claim unrelated to this issue, the Veteran stated that he worked until a month previously but had to quit when his back began to hurt. Additionally, in the August 2006 VA physician note, the Veteran complained of intermittent back pain for the past year and that he got it when he worked. It was not until in July 2007 that the medical evidence of record documented the Veteran's report of the inservice back injury from falling off a roof in Vietnam. However, the Veteran reported on the February 2008 SSA disability determination report that his back problem started in August 1993. The Board therefore finds the Veteran's statements as to the onset of the current back disorder in service inconsistent and therefore not credible. Id. Moreover, there is no documentation of any back problem after the Veteran's military discharge for approximately 35 years until he complained of back pain in March 2005 as shown by medical evidence of record. This period without complaints or treatment is evidence that there has not been a continuity of symptomatology, and it weighs heavily against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991). Furthermore, the competent evidence of record does not relate the Veteran's current back disorder to his military service. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board is prohibited from substituting its own medical judgment in place of the opinions of competent medical professionals). To extent that the Veteran contends that his current back disorder was caused by military service, the Board finds that these statements as to medical causation are not competent evidence to establish service connection for a back disorder. Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). In certain unique instances lay testimony may be competent to establish medical etiology or nexus. See Jandreau, 492 F.3d at 1377; Davidson, 581 F.3d at 1316-17. However, in this case, the Board finds that the question of whether the Veteran's in-service fall injury led to his current back disorder does not lie within the range of common experience or common knowledge, but requires special experience or special knowledge in orthopedics. The diagnosis and cause of orthopedic disorders, to include a back disorder, cannot made by the Veteran as a lay person based on mere personal observation, that is, perceived by visual observation or by any other of the senses; a back disorder is not a simple medical condition that the Veteran is competent to identify. Therefore, the Board finds that the lay evidence is not competent evidence to establish the cause of his current back disorder. The evidence of record does not otherwise demonstrate that the Veteran possesses the ability, knowledge, or experience to provide a competent etiological opinion that his back disorder was the result of his military service. Espiritu, 2 Vet. App. at 494. Accordingly, the Board finds that these statements as to medical causation are not competent evidence to establish service connection for a back disorder. Id. As the Board found as a matter of fact that the Veteran's lay statements are not competent evidence to establish the origin or cause of a back disorder, the Board need not reach the question of whether or not these statements are credible. The only competent medical opinion of record as to whether the Veteran's current back disorder is related to his active service is negative to his claim. The July 2010 VA examiner rendered a diagnosis of mild degenerative joint disease of the lumbar spine and opined that it was not related to his military service. Although the examiner considered the Veteran's reported history of back injury in service, the examiner concluded that the Veteran's current back disorder was most likely age-related and not a result of his military service. In reaching the conclusion, the examiner offered a rationale that was based on a complete review of the Veteran's claims file and consistent with the other evidence of record. Upon review and consideration of the lay and medical evidence, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a back disorder. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Evaluation Service connection for PTSD was granted by a July 2003 rating decision, and a 30 percent evaluation was assigned under 38 C.F.R. § 4.130, Diagnostic Code 9411, effective September 21, 2001. In February 2006, the Veteran filed his present claim for an increased evaluation for his service-connected PTSD and the RO continued the current 30 percent evaluation in an April 2006 rating decision. The Veteran filed a timely notice of disagreement in September 2006 and perfected his appeal in January 2007. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2011). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2010). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21 (2011); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). Id. PTSD is rated as 30 percent disabling 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, weekly or less often panic attacks, chronic sleep impairment, and mild memory loss such as forgetting names, directions, recent events. 38 C.F.R. § 4.130, Diagnostic Code 9411. PTSD is rated 50 percent 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, such as retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted when there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or 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 the inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. In evaluating the evidence, the Board has considered the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See DSM-IV; Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, such as occasional truancy, or theft within the household, but generally functioning pretty well, and has some meaningful interpersonal relationships. DSM-IV at 46-47. A GAF score of 51-60 indicates moderate symptoms, such as flat affect and circumstantial speech, occasional panic attacks, or moderate difficulty in social or occupational functioning, such as few friends, conflicts with peers or co-workers. A GAF score of 41-50 shows serious symptoms, such as suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social or occupational functioning, such as no friends, unable to keep a job. DSM-IV at 46-47. A January 2006 VA psychiatry therapy report stated that the Veteran was seen for schizoaffective disorder. He lived alone and kept himself busy with carpentry. It was noted that the Veteran had no complaints with his medication and that his condition was stable. On mental status examination, the Veteran exhibited normal grooming and hygiene, average intelligence, normal memory and thought process, and fair judgment, insight, and impulse control. He denied suicidal, homicidal ideation, or violent, or hallucinations. The diagnostic impression was schizoaffective disorder, and a GAF score of 55 was assigned. In February and March 2006 VA psychiatry therapy reports, the Veteran reported that he was single, lived alone, and remained isolated. He reported having dreams at night about his combat experience in Vietnam and history of hearing voices of his friends who were with him in combat zone. It was noted that the Veteran had no complaints with his medication and that his condition was stable. On mental status examination, the Veteran exhibited normal grooming and hygiene, average intelligence, normal memory and thought process, and fair judgment, insight and impulse control. He denied suicidal, homicidal or violent ideation, or hallucinations. The diagnostic impressions were schizoaffective disorder and PTSD, and a GAF score of 55 was assigned. The Veteran was afforded a VA psychiatric examination in March 2006. The VA examiner stated that the Veteran's claims file was not available to review; however that the Veteran's VA medical records were reviewed and the examiner saw the Veteran for an examination seven months previously. The Veteran reported that he last worked in the summer of 2005 in landscaping but stopped working because of back pain. He stated that he planned to work full time as a landscaper as his back felt better. He did not attribute his unemployment for the last seven months to his psychiatric symptoms. The Veteran lived alone and watched television for recreation; took walks; and had a few friends who he saw infrequently. The Veteran was taking medication for psychiatric treatment and credited his medications with improving his sleep patterns, reducing fluctuations in mood, and allowing him to work. As to social impairment, the examiner stated that the Veteran continued to be socially withdrawn and lacked hobbies and organized activities, and avoided a committed relationship, which the examiner stated was likely due to PTSD. On mental status examination, the Veteran was casually dressed, appropriately groomed, alert, and oriented in all spheres. He made eye contact and displayed appropriate behaviors. His mood was euthymic. His affect was bland and incongruent with thought content, in that he reported auditory hallucinations without any noticeable anxiety or distress. He denied suicidal or homicidal ideation, and displayed no impairment of communication or thought process. His speech was spontaneous and was normal in rate, rhythm, and intonation; and his thinking was logical, goal oriented, without evidence of formal thought disorder. He reported questionable auditory hallucinations and denied delusions. He indicated adequate maintenance of personal hygiene and competent management of finances, diet, and other activities of daily living. He did not report panic attacks, phobias, obsessive thoughts, or rituals that interfered with functioning. He indicated normal sleep with medication. Long and short term recall was grossly intact; attention and concentration were adequate; and judgment and insight were present. With regard to the Veteran's reported of auditory hallucinations of voices of soldiers he knew in Vietnam, the examiner stated that the onset and vague nature of the reported symptoms made the experience difficult to assess; however, if the report of hallucinations was accurate, the symptom was most likely related to the previously diagnosed schizoaffective disorder, not to PTSD. The examiner further stated that the interview suggested that the Veteran was discussing memories or daydreams rather than hallucinations. The examiner assessed that the Veteran continued to report symptoms meeting DSM-IV criteria for PTSD, to include memories of his service in Vietnam, increased arousal such as occasionally disturbed sleep patterns and hypervigilance, and signs and symptoms of numbing and avoidance. The diagnosis was PTSD, and a GAF score of 60 was listed. In an April 2006 VA psychiatry therapy report, the Veteran reported having trouble sleeping and hearing voices of his friends from Vietnam. He denied command hallucination to hurt himself or others, or hearing other voices. He also denied suicidal or homicidal ideation, or manic symptoms, to include hallucinations. On mental status examination, the Veteran exhibited normal grooming and hygiene; average intelligence; normal attention and concentration, mood, affect, memory and thought process; and fair judgment, insight and impulse control. The diagnostic impression was PTSD, and a GAF score of 55 was assigned. A May 2006 VA psychiatry note stated that the Veteran came to emergency room asking for medication. His speech was goal directed; his mood was neutral; and affect was appropriate. He was not noted depressed, suicidal, or paranoid; and he denied auditory or visual hallucination. The diagnosis was schizoaffective disorder. A June 2006 VA psychiatry therapy report stated that the Veteran had no new complaints and reported stability and tolerating well with his treatment. On mental status examination, the Veteran exhibited normal grooming and hygiene; euthymic mood with full range of appropriate affect; no evidence of acute distress; average intelligence; normal attention and concentration, memory, and thought process; and fair judgment, insight and impulse control. He denied suicidal, homicidal or violent ideation, or hallucinations. The diagnostic impression was schizoaffective disorder, and a GAF score of 55 was assigned. In a July 2006 VA psychiatry therapy report, the Veteran reported living alone as he was single and that he remained isolated. He denied hearing voices, having been depressed, or any past suicidal attempts. He stated that he kept himself busy working as a carpenter. On mental status examination, the Veteran exhibited normal grooming and hygiene; average intelligence; normal memory and thought process; and fair judgment, insight, and impulse control. He denied suicidal, homicidal or violent ideation, or hallucinations. The diagnostic impressions were PTSD and schizoaffective disorder, and a GAF score of 55 was assigned. In a September 2006 VA psychiatry therapy report, the Veteran reported that he was unable to fall sleep. He denied auditory hallucinations or having been depressed. He stated that he kept himself busy working as a landscaper. On mental status examination, the Veteran exhibited normal grooming and hygiene; average intelligence; normal memory and thought process; and fair judgment, insight and impulse control. He denied suicidal, homicidal or violent ideation, or hallucinations. The diagnostic impression was and schizoaffective disorder, and a GAF score of 55 was assigned. In a September 2006 VA psychiatry note, the Veteran reported not sleeping well, as he might have run out of medication. On mental status examination, he was alert, fully oriented, and cooperative. His mood was euthymic; affect was constricted; and speech was spontaneous. There was no evidence of acute delusion or perceptual disturbance. The impression was schizoaffective disorder. An October 2006 VA psychiatry therapy report stated that the Veteran had no complaints. He denied auditory hallucinations or having been depressed. On mental status examination, the Veteran exhibited normal grooming and hygiene; average intelligence; normal memory and thought process; and fair judgment, insight and impulse control. He denied suicidal, homicidal or violent ideation, hallucinations, hopelessness, or helplessness. The diagnostic impression was schizoaffective disorder, and a GAF score of 55 was listed. In a July 2007 VA mental health note, the Veteran was seen with a chief complaint of insomnia. The Veteran reported problem sleeping in the past week and that the medication was not helpful. It was noted that the Veteran was involved in social activities and participated in leisure or recreational activities. On mental status examination, no abnormal behavior was shown. The Veteran's mood was anxious; affect was appropriate; thought process was coherent and goal driven; and thought content was appropriate. He denied hallucinations or delusion. The Veteran reported sleep disturbance and flashbacks, as well as occasionally feeling depressed and anxious. He denied suicidal thoughts or hallucinations. On a July 2007 VA psychiatry note, the Veteran complained of sleep disturbance but denied any other symptoms of depression, anxiety, or psychosis. On mental status examination, the Veteran exhibited normal grooming and hygiene; average intelligence; normal attention and concentration; memory and thought process; and fair judgment, insight and impulse control. He denied suicidal, homicidal or violent ideation, hallucinations, hopelessness or helplessness. The diagnostic impression was schizoaffective disorder. Two weeks later, the Veteran reported that he was able to sleep well on Seroquel. No acute distress was reported. An August 2007 VA psychiatry therapy report noted the Veteran's PTSD symptoms of flashbacks and that his condition remained stable with medication. On mental status examination, the Veteran exhibited normal grooming and hygiene, normal attention and concentration, average intelligence, normal memory and thought process, and fair judgment, insight and impulse control. He denied suicidal, homicidal or violent ideation, hallucinations, hopelessness, or helplessness. The diagnostic impression was schizoaffective disorder. On a January 2008 VA psychiatry mental status examination, the Veteran exhibited normal grooming and hygiene; average intelligence; normal attention and concentration, memory and thought process; and fair judgment, insight and impulse control. He denied suicidal, homicidal or violent ideation, hallucinations, hopelessness, or helplessness. The diagnostic impression was schizoaffective disorder, and a GAF score of 50 was assigned. In a June 2008 VA mental health consultation report, the Veteran complained of memory problems and increased chronic PTSD symptoms. The examiner noted that the Veteran had been stable "for quite some time" on his current medication and that the Veteran diagnosed himself as having worsening PTSD symptoms. The examiner found that that the Veteran's current problem was more of a memory problem. The Veteran reported continuing to have daily nightmares and that he had an exaggerated startle response to loud noise. No acute depression was shown. The Veteran's mood was dysphoric; chronic anxiety bothered him; and he described hearing voices of the fellows with whom he served in combat. He also reported flashbacks. The last panic attack he had was approximately two years ago. He stated that his sleep was "pretty good." No specific 'spells' or cognitive decline problems were reported. On mental status examination, the Veteran was alert, fully oriented, neatly dressed and groomed, and pleasant and cooperative. He showed normal speech and flow of thought; grossly intact memory; normal concentration, thoughts, and perceptions; euthymic mood with chronic free floating anxiety; his affect was appropriate to mood with normal range; and normal judgment and insight. No harmful thoughts or delusions were shown. The diagnoses were PTSD and depressive and anxiety disorder, not otherwise specified; and a GAF score of 60 was listed. A July 2008 VA psychiatry note stated that the Veteran was seen on follow up. He reported feeling and thinking better and more clearly. It was noted that psychotropic medication was stable and working without ill side effects. The Veteran's affect was bright with smile. No suicidal or homicidal ideation, psychosis, or cyclic mood was shown. He was casually dressed, well oriented, and comfortable. A GAF score of 65 was assigned. On a September 2008 VA psychiatry note, no acute psychiatric symptoms were shown. It was noted that the Veteran's psychiatric symptoms were stable. On mental status examination, the Veteran was alert and in no distress. He reported poor memory. Depression was not found, but dysphoric mood was shown. The Veteran denied suicidal or homicidal ideation, psychosis, or cyclic moods. His affect and eye contact were good. The Veteran underwent another VA psychiatric examination in December 2008. He was single and lived alone in a mobile home. He stated that he spoke to his brother and sisters once a month and saw his brother regularly. He also stated that he had friends and that he attended church. The Veteran reported that he was retired since 1995 as he could no longer work due to an in-service back injury. On mental status examination, the Veteran appeared clean, neatly groomed and appropriately dressed. He displayed unremarkable psychomotor activity and speech; and his attitude was cooperative, friendly, relaxed, and attentive. His affect was normal; mood was good; attention was intact; orientation was intact to all spheres; and thought process and content were unremarkable with no delusion. He understood the outcome of his behavior and that he had a problem. His intelligence was average. He reported that he slept five to six hours at night and that he had dreams that awoke him three times a week. He denied auditory hallucinations, panic attacks, or suicidal or homicidal thoughts. No inappropriate behavior, obsessive or ritualistic behavior, episode of violence, or problem with activities of daily living was shown. His extent of impulse control was good, and he was able to maintain minimum personal hygiene. His remote memory was normal; recent and immediate memory was mildly impaired. With regard to PTSD symptoms, the Veteran had recurrent recollections about his experience as a helicopter gunner, distressing dreams occurring three to four times weekly, anxiety, and avoidance of people that he did not know. He stated that he enjoyed walking but his physical condition did not allow him to golf. He denied feeling detached or anger. He stated that he was somewhat hypervigilant but not obsessive about checking. He could not stand loud noise or having anyone behind him. The examiner found that the Veteran's current problem was more of a memory problem, immediate in particular. The Veteran had nightmares occurring every other night and had an exaggerated startle response with loud noise. He reported that if it was not for his physical problems and poor concentration, which was not due to PTSD, he would still be working. He further reported that he had some avoidance issues but he was fine where he had to work with only one person. The diagnoses were PTSD, depression, and anxiety disorder, not otherwise specified. The examiner noted that medication had a positive impact on controlling the Veteran's symptoms of depression and that although he complained of anxiety and hearing his name being called, he was likely to remain stable. The examiner further noted that the Veteran's physical problems were the primary work impairment and cognitive functioning was reduced by strokes, while his PTSD impacted on his sleep and ability to relate to others appropriately. Finally, the examiner found that the Veteran's PTSD symptoms and signs did not cause total occupational and social impairment resulting deficiencies in judgment, thinking, family relations, work, mood, or school; or reduced reliability and productivity; however that there was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, with generally satisfactorily functioning in terms of routine behavior, self-care and normal conversation. After reviewing the evidence of record, the Board finds that the evidence does not support a disability rating in excess of 30 percent for the Veteran's service-connected PTSD. The GAF scores related to the Veteran's PTSD noted during the course of appeal ranged from 55, 60, and 65. The Board observes that the GAF score noted on the January 2008 VA psychiatry note was 50; however, the diagnosis associated with that GAF score was schizoaffective disorder. While the Board is precluded from differentiating between the symptomatology attributable to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so, the January 2008 VA psychiatry note provided the GAF score specifically to illustrate the severity of schizoaffective disorder, and not impairments due to PTSD. Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Moreover, the medical evidence of record does not show any of the serious symptoms contemplated for a GAF score of 41-50. The Veteran's GAF scores of 55 and 60 show moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV at 46-47. The Veteran's GAF score of 65 shows some mild symptoms, or some difficulty in social, occupational, or school functioning. DSM-IV at 46-47. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. The evidence of record demonstrates that the Veteran has reported intrusive memories, nightmares, anxiety, flashbacks, sleep disturbance, dysphoric mood, and increased startle response. The record also reflects that the Veteran was socially withdrawn and had difficulty getting along with other people. Objectively, the Veteran was neatly groomed, appropriately dressed, and fully oriented. He exhibited cooperative, friendly, relaxed, and attentive attitude; normal psychomotor activity, speech, and thought process and content; average intelligence; fair judgment, insight, and impulse control; grossly intact memory; and capability to manage financial affairs; with no evidence of delusions, obsessive or ritualistic behaviors, panic attacks, homicidal or suicidal thoughts, episodes of violence, or problem with daily living activities. Thus, the Veteran has exhibited no evidence of flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks; difficulty understanding complex commands; impaired judgment; impaired abstract thinking; 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, or effectively; spatial disorientation; and neglect of personal appearance and hygiene. See 38 C.F.R. § 4.130, Diagnostic Code 9411. In considering this disability as a whole, the Board concludes that the Veteran's PTSD is appropriately rated as 30 percent disabling. 38 C.F.R. § 4.130, Diagnostic Code 9411. The medical evidence of record shows that the only manifestations of the higher 50 percent evaluation that the Veteran experiences are impairment of short-term memory and some difficulty in establishing and maintaining effective social relationships. Id. However, the evidence of record shows that the Veteran spoke to his brother and sisters on a regular basis; had a few friends that he saw infrequently; and attended church. The July 2007 VA mental health noted that the Veteran was involved in social activities and participated in leisure or recreational activities. The Veteran reported continuing to work as a carpenter and landscaper as lately as in September 2006. While the record reflects that the Veteran is currently not working, the December 2008 VA examiner indicated that the Veteran's PTSD symptoms did not preclude employment or impair occupational functioning. In fact, the Veteran reported that he would still be working if it was not for his physical problems and poor concentration. The examiner found that the Veteran's physical problems were the primary work impairment and cognitive functioning was reduced by his stroke, while his PTSD impacted sleep and ability to relate to others appropriately. Notably, the December 2008 VA examiner found that the Veteran's PTSD signs and symptoms did not cause deficiencies in the areas of judgment, thinking, family relations, work, or mood; or reduced reliability or productivity due PTSD symptoms. See Mauerhan, 16 Vet. App. 436. Accordingly, although the evidence of record may demonstrate some of the symptomatology contemplated in a 50 percent evaluation, the Veteran's disability picture as a whole does not warrant a rating in excess of 30 percent. For the foregoing reasons, an increased evaluation for the Veteran's service-connected PTSD is not warranted. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2011). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2011). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria under the Rating Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the current 30 percent disability rating for PTSD inadequate. As noted above, the Veteran's service-connected PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411, the criteria of which is found by the Board to specifically contemplate the Veteran's level of disability and symptomatology. The Veteran's PTSD has been manifested by intrusive memories, nightmares, anxiety, flashbacks, sleep disturbance, dysphoric mood, increased startle response, and social withdrawal. Objectively, the Veteran was neatly groomed, appropriately dressed, and fully oriented. He exhibited cooperative, friendly, relaxed, and attentive attitude; normal psychomotor activity, speech, and thought process and content; average intelligence; fair judgment, insight, and impulse control; grossly intact memory; and capability to manage financial affairs; with no evidence of delusions, obsessive or ritualistic behaviors, panic attacks, homicidal or suicidal thoughts, episodes of violence, or problem with daily living activities. Occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms were shown; however, the Veteran's PTSD signs and symptoms did not result in deficiencies in the areas of judgment, thinking, family relations, work, or mood were shown, as well as reduced reliability and productivity. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the current 30 percent disability rating for his service-connected PTSD. A rating in excess of 30 percent is provided for certain manifestations of service-connected PTSD but the medical evidence of record reflects that those manifestations are not present in this case. The medical evidence does not demonstrate manifestations such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; 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, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; and neglect of personal appearance and hygiene. Id. Therefore, the currently assigned schedular evaluation is adequate and no referral is required. 38 C.F.R § 4.130, Diagnostic Code 9411; Thun, 22 Vet. App. at 115. Staged ratings have been considered. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence shows no distinct periods of time during the course of the appeal, during which the Veteran's PTSD varied to such an extent that a rating greater or lesser than 30 percent would be warranted. Thus, staged ratings are not in order. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim for an increased evaluation in excess of 30 percent for PTSD, the doctrine is not for application. Gilbert, 1 Vet. App. at 54. ORDER Service connection for a scar over the right eyebrow is granted. Service connection for a back disorder is denied. An increased evaluation in excess of 30 percent for PTSD is denied. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs