Citation Nr: 1310974 Decision Date: 04/02/13 Archive Date: 04/11/13 DOCKET NO. 07-28 065 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to service connection for acne. 3. Entitlement to an initial rating in excess of 30 percent for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD F. Yankey, Counsel INTRODUCTION The Veteran served on active duty from August 1999 to August 2005. This case comes before the Board of Veterans' Appeals (Board) on appeal of a June 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California, which in pertinent part granted service connection for PTSD, rated as 30 percent, effective August 23, 2005, and denied service connection for a bilateral knee strain and a skin condition. In September 2011, the Veteran failed to appear, without explanation, for a Board hearing. He has not requested that the hearing be rescheduled. Therefore, his request for a hearing is considered withdrawn. See C.F.R. §20.702(d) (2012). In March 2012, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. The Board notes that in a February 2013 rating decision, the RO granted service connection for a chronic lumbar strain. This was a full grant of the benefit sought with regard to that issue. Grantham v. Brown, 114 F .3d 1156 (Fed. Cir. 1997). The issue of entitlement to service connection for a left knee 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. FINDINGS OF FACT 1. A skin disability was not found on examination for entrance onto active duty. 2. Clear and unmistakable evidence does not show that the Veteran had a skin disability prior to his enlistment into active service. 3. A current skin disability was present in service, and has been related to service by competent medical and lay witness evidence. 4. For the period prior to March 9, 2010, the impairment from the Veteran's PTSD more nearly approximates occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks than occupational and social impairment with reduced reliability and productivity. 5. For the period beginning March 9, 2010, the impairment from the Veteran's PTSD most nearly approximates occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The Veteran's acne was incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1111, 1153 (West 2002); 38 C.F.R. § 3.303 (2012). 2. For the period prior to March 9, 2010, the schedular 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. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 3. For the period beginning March 9, 2010, the schedular criteria for a disability rating of 50 percent for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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. 2012) 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). Under the VCAA, 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). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In a March 2006 letter, issued prior to the adjudication of the claims, the Veteran was provided with the notice required under § 5103. The Board notes that, even though the letter requested a response within 60 days, it also expressly notified the Veteran that he had one year to submit the requested information and/or evidence, in compliance with 38 U.S.C.A. § 5103(b) (evidence must be received by the Secretary within one year from the date notice is sent). The Veteran has substantiated his status as a Veteran and the second, third and fourth elements of Dingess notice are satisfied by the March 2006 letter. However, the Veteran did not receive notice about the evidence needed to establish an effective date. Since the claim is being denied, no rating is being given and no effective date is being set. The failure to provide notice on the effective date element of the claim is harmless. Smith v. Shinseki, No. 08-1667 (Aug. 17, 2010). The increased rating claim arises from disagreement with the initial rating following the grant of service connection. The courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required; and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The United States Court of Appeals for Veterans Claims (Court) has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as an effective date) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). Where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Id. The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103S; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when it is necessary to make a decision on the claim. 38 C.F.R. § 3.1599(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records, and VA and private treatment records. Additionally, the Veteran was provided an appropriate VA examination in May 2012 for his skin disability, and appropriate VA examinations in April 2006 and March 2010 for his psychiatric disability. In addition, the Board remanded the claim in March 2012 so that a VA dermatological examination and opinion could be obtained, and to attempt to obtain clinical records of psychiatric treatment the Veteran had received from the Ventura Vet Center. The requested examination was conducted in May 2012, and an opinion was provided in conjunction with that examination. Furthermore, all available records from the Ventura Vet Center were submitted in April 2012. The remand instructions were thereby complied with. Stegall v. West, 11 Vet. App. 268 (1998). In sum, the Board concludes that any errors in the notice and the development of the claims by the originating agency were not prejudicial to the Veteran. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The condition at issue is not a "chronic disease" listed under 38 C.F.R. § 3.303(a); therefore, 38 C.F.R. § 3.303(b) does not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. Feb. 2013). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). A Veteran is presumed to have been in sound condition when enrolled for service, except for any disease or injury noted at the time of enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). The regulations provide expressly that the term "noted" denotes "[o]nly such conditions as are recorded in examination reports," 38 C.F.R. § 3.304(b), and that "[h]istory of pre- service existence of conditions recorded at the time of examination does not constitute a notation of such conditions." Id at (b)(1); 38 U.S.C.A. §§ 1111, 1137. Generally, a preexisting injury or disease will be considered to have been aggravated by active service where there was an increase in disability during such service, unless there is a specific finding that the increase in disability was due to the natural progress of the disease; however, aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 U.S.C.A. § 1153 (West 2002); 38 C.F.R. § 3.306 (2012). If the disorder becomes worse during service and then improves due to in- service treatment to the point that it was no more disabling than it was at entrance into service, the disorder is not presumed to have been aggravated by service. Verdon v. Brown, 8 Vet. App. 529 (1996). Every Veteran shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence or medical judgment is such as to warrant a finding that the disease or injury existed before acceptance and enrollment, and was not aggravated by such service. 38 U.S.C.A. § 1111. In order to rebut the presumption of sound condition under 38 U.S.C. § 1111, the government must show by clear and unmistakable evidence both that the disease or injury existed prior to service, and that the disease or injury was not aggravated by service. Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). To satisfy the second requirement for rebutting the presumption of soundness, the government must rebut a statutory presumption of aggravation by showing, by clear and unmistakable evidence, either that (1) there was no increase in disability during service, or (2) any increase in disability was "due to the natural progression" of the condition. Joyce v. Nicholson, 443 F.3d 845, 847 (Fed. Cir. 2006). The clear and unmistakable evidentiary standard applies to the burden to rebut the presumption, but this standard does not require the absence of conflicting evidence. Kent v. Principi, 389 F.3d 1380, 1383 (Fed. Cir. 2004). If the presumption of soundness is not rebutted, the claim is one for service connection rather than compensation based on aggravation. Wagner. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Analysis The Veteran contends that he has a skin disability, namely acne, related to his active military service. Service treatment records, are negative for any evidence of acne or any other skin disability prior to or during military service, or at the time of the Veteran's discharge. The presumption of soundness is therefore for application. 38 U.S.C.A. §§ 1111, 1137; 38 C.F.R. § 3.304(b) (2012). The Veteran has reported that he had acne prior to his military service. However, the Veteran also reported that his acne had completely resolved by the time of his enlistment. Furthermore, there are no clinical records available verifying his subjective reports, and no evidence of any pre-service treatment for acne. Accordingly, the Board finds that the evidence does not clearly and unmistakably show that the Veteran's acne pre-existed service, and the presumption of soundness is not rebutted. If the presumption of soundness is not rebutted, the claim becomes one for ordinary service connection. Wagner v. Principi. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (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 present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Service treatment records, which do not contain an induction examination, are negative for any evidence of acne or any other skin disability. The Veteran was afforded a VA examination in April 2006, four months after his discharge, in response to his claim for service connection. He reported a three-year history of skin problems, and complained of constant itching, shedding and crusting, in areas exposed to the sun, including the face and neck. The examiner diagnosed acne, but he did not give an opinion on the etiology of the condition. In response to the Board's March 2012 remand, the Veteran was afforded another VA skin examination in May 2012. The Veteran reported that he had acne prior to going into the military, which was treated with Accutane, and completely resolved, but redeveloped in Iraq, and since that time, he has suffered from persistent pustular eruptions on his face, neck, chest and back. The examiner's diagnosis was acne or chloracne, and opined that the condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. His rationale was that the Veteran had acne prior to his military service, and the natural progression of the disease is for recurrences. While the Board does not find that this opinion is sufficient to rebut the presumption of soundness, it does acknowledge that manifestations of the Veteran's current acne occurred during active service. The Board also notes that the Veteran is competent to report his experience and symptoms in service and thereafter, although he is not competent to provide a diagnosis or an etiological opinion. While lay persons are generally not competent to offer evidence which requires medical knowledge, such as opinions regarding medical causation or a diagnosis, they may provide competent testimony as to visible symptoms and manifestations of a disorder. Jones v. Brown, 7 Vet. App. 134, 137 (1994); Layno v. Brown, 6 Vet. App. 465, 469 (1994); Barr v. Nicholson, 21 Vet. App. 303 (2007); Buchanan v. Nicolson, 451 F.3d 1331 (Fed. Cir. 2006); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). A Veteran can attest to factual matters of which he or she had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The United States Court of Appeals for the Federal Circuit has held that lay evidence is one type of evidence that must be considered and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); see also Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, the Board finds that the Veteran is competent to report that he had problems with his skin in service and that his current skin problems are of the same appearance as the problems he experience in service. Based on the foregoing, the Board finds that the Veteran's acne has been linked to service both by his own statements and the opinion of the most recent VA examiner. Consequently, the Board finds that service connection for the Veteran's acne is warranted. Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). The Veteran's entire history is to be considered when making a disability determination. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board has considered whether a "staged" rating is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. A 30 percent rating is warranted for the Veteran's PTSD if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted for PTSD if it is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Codes 9411. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is based on a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). Scores ranging from 31 to 40 reflect "Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school)." Id. A score of 41 to 50 is indicated where there are "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job)." Id. A score of 51-60 is appropriate where there are, "Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." Id. A score of 61-70 is indicated when there are, "Some mild symptoms (e.g., depressed mood and mild insomnia OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning 'pretty well,' has some meaningful interpersonal relationships." Id. In accordance with 38 C.F.R. §§ 4.1, 4.2 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to this disability. Period prior to March 9, 2010 The evidence indicates that for the period prior to March 9, 2010, the social and industrial impairment from the Veteran's PTSD most nearly approximates the occupational and social impairment with reduced reliability and productivity contemplated by the assigned evaluation of 30 percent. During an April 2006 VA examination, the Veteran reported symptoms of poor sleep; emotional detachment; severe anxiety attacks; paranoia; nightmares; avoidance of any crowds and triggers; hypervigilance; anger; rage; mistrust; anhedonia; social isolation; diminished interest in participation in significant activities or social events; restricted affect; hyper-startle response; and depression. The examiner noted that the Veteran was employed and having no documented difficulties getting along with co-workers. He also noted that the Veteran's judgment and insight were intact, and that there were no thought disorders or cognitive deficits. The Veteran also reported that he had recently begun therapy. He diagnosed PTSD, and assigned a GAF score of 70. In a June 2006 rating decision, the RO granted service connection for PTSD. An evaluation of 30 percent was awarded, effective August 23, 2005. The Veteran has appealed this initial rating. Private treatment records show that on evaluation in June 2006, the Veteran complained of relationship issues, stemming from his bad experience with his ex-wife; difficulty finding employment; sleep disturbance; avoidance behavior; bad dreams; and intrusive recollections of war. In June 2007, he complained of vocational problems, family problems, intrusive recollections, nightmares, and sleep difficulties. He was diagnosed with PTSD, and advised to continue with counseling. VA outpatient treatment records show that on evaluation in December 2009, the Veteran complained of nightly nightmares; intrusive memories of war; easy startle response; hypervigilance; mistrust of others and paranoia (causing him to keep a loaded gun); social isolation; panic attacks; depression and anhedonia (with symptoms lasting sometimes for a month); low energy; sleep disturbance; concentration problems; short-term memory problems; increased irritability; and fleeting suicidal ideation with vague plans. He denied symptoms of obsessive/compulsive disorder, generalized anxiety disorder, panic disorder with agoraphobia, and social or health anxiety. He also denied ever taking any psychotropic medications or being hospitalized for psychiatric reasons, or being suicidal. He reported private therapy for his PTSD for one year, which he claimed did not help. The Veteran reported that he had been working as an operator at an oil refinery company for three years. He also reported that he had divorced in 2006, but had been dating someone else for three years. He also mentioned his six-year old son and his girlfriend's five-year old son, whom he considered his own. Mental status examination was essentially normal, except for depressed mood, and the Veteran's reports of memory impairment, which was not formally tested at that time. The Veteran was diagnosed with PTSD, and assigned a GAF score of 62. During VA outpatient treatment in January 2010, the Veteran complained of re-experiencing symptoms; avoidance behavior; hyperarousal; low energy and motivation; increased anger outbursts and irritability; mood swings; anhedonia; impaired short-term memory; and social isolation. He was also prescribed Paroxetine for sleep and anxiety at that time. He denied thoughts of self-harm or harming others, mood lability, increase impulsivity, audio or visual hallucinations, problems with sleep or appetite, or any other depressive, anxiety, psychotic or hypomanic/manic symptoms or behavior. He also denied symptoms consistent with obsessive/compulsive disorder, generalized anxiety disorder, panic disorder with agoraphobia, and social or health anxiety. The Veteran's affect was slightly anxious, but otherwise, mental status examination was essentially normal. He was diagnosed again with PTSD, and assigned a GAF score of 62. The medical evidence of record shows that, on examination, the Veteran displayed symptoms of disturbances of motivation and mood, and was diagnosed with depression. He has also reported impairment of short-term memory, and difficulty in establishing and maintaining effective social relationships, particularly with women, following his divorce in 2006. These symptoms are contemplated by a 50 percent rating for PTSD. However, there is no evidence that the Veteran has displayed symptoms such as flattened affect; circumstantial, circumlocutory or stereotyped speech; difficulty in establishing effective work relationships, or difficulty in understanding complex commands, throughout the evaluation period. In this regard, the Veteran reported vocational problems during private treatment in 2006 and 2007, but this was related to his inability to find employment, not to an inability to establish relationships once employed. Furthermore, the April 2006 VA examiner noted that the Veteran was employed and having no documented difficulties getting along with co-workers. He was also noted during VA outpatient treatment in 2010 to have been employed for the past three years. The Board also notes that although the Veteran reported panic attacks, he did not report that they occurred as often as once per week. He also demonstrated impaired abstract thinking, in that he reported fleeting suicidal thoughts, but he indicated on more than one occasion that he would never follow through on this because of his children. In addition, although he reported problems with relationships, he was noted during this period to be in a supportive relationship and to be successfully caring for his young children. Furthermore, the Board finds that the Veteran has exhibited more symptoms reflective of a 30 percent rating such as depressed mood; anxiety; suspiciousness (inability to trust); panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss, and he has still been generally functioning satisfactorily. In addition, the Veteran has consistently been assigned GAF scores between 62 and 70. The scores are indicative of mild impairment, and are not indicative of more impairment than that contemplated by the assigned rating of 30 percent. In summary, the Board concludes that prior to March 9, 2010, the social and occupational impairment from the Veteran's PTSD more nearly approximates the criteria for a 30 percent evaluation than the criteria for a 50 percent or higher evaluation. Period beginning March 9, 2010 For the period beginning March 9, 2010, the evidence shows that the social and industrial impairment from the Veteran's PTSD most nearly approximates the occupational and social impairment with reduced reliability and productivity contemplated by an evaluation of 50 percent. The Veteran was afforded his most recent VA psychiatric examination in March 2010. At that time, he complained of sleep problems and sleep deprivation; paranoia; some hypervigilance; anxiety attacks; recurring nightmares; irritability; social isolation, in that he had only a few friends; strained relationships with family and friends, due to his attitude; avoidance behavior; distrust of others; impatience; memory problems, in that he would forget to complete household tasks; and obsessive/compulsive issues surrounding safety, i.e. frequent checking of fire extinguishers and door locks, checking his children "after they go to sleep to make sure they are breathing," keeping a weapon with him at all times, and sleeping "with a gun under his pillow or nearby." He also reported that he was working as a technologist, and that he was annoyed with his co-workers because they did not understand safety issues. He had not established a relationship with his supervisor. On mental status examination, he displayed a disturbance of motivation and mood, in that he was depressed, withdrawn, anxious, and had a flattened affect. He also demonstrated impaired attention and focus. He had trouble with serial 7 tasks and reported feeling like he was in a dream-like state all the time. He reported having trouble retaining information and losing focus easily, possibly due to sleep problems. Panic attacks were reported, as occurring more than once per week, and the Veteran endorsed signs of suspiciousness, in that he was extremely cautious and frequently on alert. He also reported feeling defeated and experiencing little joy in activities. There were no reports or evidence of delusions or hallucinations. However, obsessional rituals were present, severe enough to interfere with routine activities. There was moderate memory impairment, in that he had problems with retention of highly learned material and forgot to complete tasks. Suicidal and homicidal ideation was absent. The examiner diagnosed PTSD and Panic Disorder with Agoraphobia, and noted that the diagnoses were related and the secondary diagnosis represented a progression of the primary diagnosis because the Veteran had not been able to adequately cope with symptoms of PTSD and his condition had worsened. He was assigned a GAF score of 60. The examiner also concluded that the Veteran occasionally had some interference in performing activities of daily living because he had difficulty dealing with crowds and avoided shopping, as a result. He also concluded that the Veteran had difficulty establishing and maintaining effective work/school and social relationships because he sometimes needed to withdraw from contact with others and preferred to stay by himself. In addition, he concluded that the Veteran had difficulty maintaining effective family role functioning because he sometimes had to force himself to play with his children and was easily irritated by them. He noted that the Veteran did not have any difficulty with recreation or leisurely pursuits, and that he did not appear to pose any threat of danger or injury to himself or others. VA outpatient treatment records from the Santa Maria Community Based Outpatient Clinic dated from 2010 to 2011, which are available in Virtual VA, have also been reviewed. These records do not show psychiatric treatment after March 2010. In essence, the evidence shows that the Veteran's PTSD has been productive of symptoms that are listed in the 30 percent, 50 percent, and 70 percent levels. The symptoms themselves, however, are not the determinative factor; rather, it is the resulting social and occupational impairment that is paramount. After examining all the evidence, the Board concludes that the resulting social and occupational impairment is most consistent with the occupational and social impairment with reduced reliability and productivity required for a 50 percent evaluation, but without either the deficiencies in most areas required for the 70 percent rating or total occupational and social impairment required for a 100 percent rating. In this regard, the Board notes that as noted above, during his March 2010 VA examination, the Veteran reported symptoms such as panic attacks more than once per week, and impairment of short and long-term memory. He also demonstrated impaired judgment, in the form of paranoia, hypervigilance, and distrust of others. In addition, his obsessive/compulsive issues surrounding safety are evidence of impaired abstract thinking. The Veteran also demonstrated disturbances of motivation and mood, in that he was withdrawn, anxious, experiencing panic attacks more than once per week, displayed a flattened affect, and was noted to suffer from depression, with episodes occurring at least twice per month, and lasting from 7-14 days. Furthermore, the evidence shows that the Veteran has demonstrated some difficulty establishing and maintaining effective work and social relationships. In this regard, although he was working at the time of the March 2010 examination, he reported that he was annoyed with his co-workers, and had not established a relationship with his supervisor. Furthermore, the examiner concluded that the Veteran had difficulty establishing and maintaining effective work/school and social relationships because he sometimes needed to withdraw from contact with others and preferred to stay by himself. In addition, he concluded that the Veteran had difficulty maintaining effective family role functioning because he sometimes had to force himself to play with his children and was easily irritated by them. In determining that a rating in excess of 50 percent is not in order, the Board notes that the Veteran has not demonstrated suicidal ideation during this period; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; neglect of personal appearance and hygiene; gross impairment in thought processes or communication; grossly inappropriate behavior; persistent delusions or hallucinations; intermittent ability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives, own occupation, or name. Furthermore, although the Veteran has demonstrated consistent depression and reported panic attacks more than once per week, the evidence does not show that these symptoms have affected his ability to function independently, appropriately and effectively. Furthermore, although he has demonstrated some impaired impulse control, in that he has endorsed unprovoked irritability, and he has reported carrying a gun; there is no evidence of persistent danger of hurting self or others and no evidence of any periods violence perpetrated against himself or others. In fact, the March 2010 examiner concluded that he did not appear to pose any threat of danger or injury to himself or others. The Board also finds that although the evidence shows that the Veteran has had some difficulty establishing and maintaining effective work and social relationships, he is not totally unable to do so. In this regard, as noted above, he was working during the March 2010 examination, and although he reported being annoyed by his co-workers, there is no evidence that he was ever fired from a job, due to his PTSD symptoms. The record also shows that on VA examination and during VA outpatient treatment, the Veteran has consistently received GAF scores of no less than 60; indicative of only moderate symptoms, and on objective examination, there was no data suggesting that the Veteran's PTSD impairment was more than moderate. In summary, for the reasons and bases expressed above, the Board has concluded that the evidence supports assignment of a rating of 50 percent, but no higher for the Veteran's PTSD from March 9, 2010. Extra-schedular consideration Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1) (2012). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, 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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The Veteran's disability, as discussed above, is manifested by symptomatology causing occupational and social impairment. Such impairment is contemplated by the rating criteria. Hence, referral for consideration of an extraschedular rating is not warranted. Total Rating for Compensation Based on Individual Unemployability (TDIU) The Court has held that TDIU is an element of all claims for an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU is granted where a Veteran's service connected disabilities are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16 (2012). Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) (2012) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In this case, the evidence does not show that the Veteran's PTSD has caused unemployability. The April 2006 VA examiner noted that the Veteran's PTSD caused distress or impairment in social or occupational or other areas of function, but there is no objective evidence of such impairment in the record. In this regard, the Veteran reported difficulty finding employment, but he did not report that it was due to his PTSD symptomatology. The March 2010 VA examination report shows that the Veteran, although having difficulty with concentration and focus, irritable mood and getting along with co-workers, was gainfully employed. The Veteran did report having problems with his co-workers, but this was because he thought that they did not understand safety. There is no evidence that the Veteran lost this or any other position as a result of his PTSD. There is also o evidence showing that the Veteran has not been able to obtain employment due to his PTSD. Because there is no evidence of unemployability, further consideration of entitlement to TDIU is not required. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). ORDER Service connection for acne is granted. An initial rating of 50 percent, but not greater, for PTSD is granted from March 9, 2010, subject to the criteria applicable to the payment of monetary benefits. REMAND Unfortunately, another remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record on which to decide the Veteran's claim so that he is afforded every possible consideration. The Veteran contends that he has a current left knee disability related to an injury during active duty. The Veteran was afforded a VA examination in May 2012, in response to his claim for service connection. On physical examination, he was able to flex the left knee 125 degrees, with pain beginning at 115 degrees, and extension was normal. The examiner also noted that the Veteran had additional limitation of motion of the left knee and lower leg, following repetitive-use testing, due to less movement and pain on movement. The examiner noted that there was no evidence of degenerative or traumatic arthritis documented on X-ray. However, he did indicate that the Veteran had "shin splints" or medial tibial stress syndrome in both knees. See May 2011 VA examination report. The examiner opined that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. His rationale was that there was a normal knee examination and X-rays. As noted, although the X-rays of the Veteran's left knee were normal, there was evidence on examination of limitation of motion of the left knee and medial tibial stress syndrome in both knees. Accordingly, the Board finds that the Veteran's left knee examination was not normal, and the May 2011 examiner's negative opinion is inadequate for rating purposes because it is not based upon accurate facts. Once VA undertakes to provide an examination it is obligated to insure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). To be adequate, an examination must take into account an accurate history. Nieves-Rodriguez v. Nicholson, 22 Vet. App. 295 (2008). VA regulations provide that where an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. 38 C.F.R. § 4.2 (2012). Where the Board makes a decision based on an examination report which does not contain sufficient detail, remand is required "for compliance with the duty to assist by conducting a thorough and contemporaneous medical examination." Goss v. Brown, 9 Vet. App. 109, 114 (1996); Stanton v. Brown, 5 Vet. App. 563, 569 (1993). On remand, and addendum to the May 2012 examination report must be obtained so that the examiner may provide an etiology opinion for any currently diagnosed left knee disability. The appellant is hereby notified that it is his responsibility to report for any examination and to cooperate in the development of the case, and that the consequences of his failure to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158 and 3.655 (2012). Accordingly, the case is REMANDED for the following action: 1. Return the claims folder to the examiner who provided the May 2012 VA opinion. The examiner should review the claims folder again, and acknowledge such review in the VA examination report or in an addendum. After reviewing the record, the examiner should provide an opinion as to whether it is it is as likely as not (50 percent probability or more) that any currently diagnosed left knee disability is etiologically related to his active service. If no left knee disability is diagnosed, the examiner should reconcile that conclusion with the diagnoses of record, including the left knee strain diagnosed on VA examination in April 2006 and the "shin splints" or medial tibial stress syndrome, diagnosed on examination in May 2012. A detailed rationale, including pertinent findings from the record, should be provided for all opinions and conclusions expressed. The examiner is advised that the Veteran is competent to report injuries and symptoms and that his reports must be considered in formulating the requested opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and whether there is additional evidence that would permit the opinion to be provided. If the May 2012 examiner is not available, another qualified medical professional should review the claims file and provide the necessary opinion. If another examination is needed, it should be provided. 2. The RO should arrange for any further development suggested by any additional evidence received. The RO should then readjudicate the remaining claim on appeal. If the claim remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matter or matters 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. 2012). ______________________________________________ Michael J. Skaltsounis Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs