Citation Nr: 1313622 Decision Date: 04/24/13 Archive Date: 05/03/13 DOCKET NO. 10-25 165 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a bilateral knee disability. 2. Entitlement to an initial rating in excess of 10 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD M. Donohue, Counsel INTRODUCTION The Veteran served on active duty from October 1988 to May 1992 with an additional unverified period of service in the Army Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal of April 2009 and April 2010 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Although the Veteran initially requested a personal hearing with a Veterans Law Judge, he withdrew his hearing request in January 2011. His hearing request is, therefore, considered withdrawn. 38 C.F.R. § 20.704(e) (2012). FINDINGS OF FACT 1. A bilateral knee disability was not manifest during service and is not attributable to service. 2. The Veteran's PTSD has been productive of no more than occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. CONCLUSIONS OF LAW 1. Knee disability was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for an initial disability rating in excess of 10 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS After the evidence has been assembled, the Board is responsible for evaluating the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). Indeed, in Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Furthermore, the Board notes that it has reviewed all of the evidence in the claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate the issues adjudicated herein and what the evidence in the claims file shows, or fails to show, with respect to these claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). I. The Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The law and regulations also require VA to notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided to VA that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. In March 2006, the Court issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006) and held that the notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, 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. Upon receipt of an application for "service connection," therefore, VA is required to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. With respect to the Veteran's service connection claim, the record reflects that VA issued a VCAA notice letter to the Veteran in November 2008, prior to the initial adjudication of his claim. This letter informed the Veteran of what evidence was required to substantiate his claim and of his and VA's respective duties for obtaining evidence. The November 2008 letter also informed the Veteran as to the law pertaining to the assignment of a disability rating and effective date as the Court required in Dingess. With respect to the Veteran's increased rating claim, as the April 2010 rating decision granted the Veteran's claim of entitlement to service connection, such claim is now substantiated. His filing of a notice of disagreement as to the initial rating assigned in that determination does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3) (2012). Rather, the Veteran's appeal as to the initial rating assignment here triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. The December 2010 statement of the case (SOC), under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," set forth the relevant diagnostic code for rating the disability at issue, and included a description of the rating formulas for all possible schedular ratings under this diagnostic code. The Veteran was thus informed of what was needed not only to achieve the next-higher schedular rating, but also to obtain all schedular ratings above the initial evaluation that the RO assigned. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher initial rating for the service-connected disability at issue. The VCAA also provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law provides that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. An examination is deemed "necessary" if the record does not contain sufficient medical evidence for VA to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In the present appeal, the Board finds that reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claims, and that there is no reasonable possibility that further assistance would aid in substantiating such claims. In particular, the record contains the Veteran's service treatment records, excerpts of his service personnel records, his VA medical records and multiple VA examination reports. As the Board will discuss in its analysis, the Veteran was provided with two VA examinations in February 2010 and an examination in September 2012. The reports from these examinations reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate clinical examinations and rendered appropriate diagnoses consistent with the remainder of the evidence of record, and pertinent to the rating criteria. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board therefore concludes that the examinations are adequate for adjudication purposes. See 38 C.F.R. § 4.2 (2012). The Veteran and his representative have not contended otherwise. The Board observes that the Veteran has been diagnosed with bilateral knee disabilities but a medical opinion regarding the etiology of these disabilities has not been obtained. However, for reasons explained immediately below, such an examination and opinion are not necessary. Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in initial service connection claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service; and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. As will be discussed below, there is already medical evidence that the Veteran currently has a bilateral knee disability. The record is missing critical evidence of that an injury or disease occurred in service, McLendon element (2), and the Veteran's claim is being denied on that basis. The outcome of this case thus hinges on matters other than those which are amenable to VA examination and medical opinion. Specifically, resolution of the Veteran's claim hinges directly or indirectly upon whether he suffered an in-service injury or disease. In this case, as discussed in detail below, the Board finds the Veteran's statements of in-service knee injuries to be not credible. See Bardwell v. Shinseki, 24 Vet.App. 36 (2010). In the absence of evidence of in-service disease or injury, referral of this case for an opinion as to etiology would place the examining physician in the role of a fact finder. This is the Board's responsibility. In other words, any medical opinion which provided a nexus between the Veteran's claimed disability and his military service would necessarily be based solely on the Veteran's uncorroborated assertions regarding what occurred in service. The Court has held on a number of occasions that a medical opinion premised upon an unsubstantiated account of a claimant is of no probative value. See, e.g., Swann v. Brown, 5 Vet.App. 229, 233 (1993) [generally observing that a medical opinion premised upon an unsubstantiated account is of no probative value, and does not serve to verify the occurrences described]; Reonal v. Brown, 5 Vet. App. 458, 461 (1993) [the Board is not bound to accept a physician's opinion when it is based exclusively on the recitations of a claimant]. With respect to the third McLendon element, (association with service), the Court has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the Veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuing symptoms such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this regard, the competent evidence of record in the present appeal does not demonstrate an association between the Veteran's service and his diagnosed knee disabilities. The Board has carefully considered the Court's language in McLendon - that the threshold for showing this association is a low one. However, the Court's language makes it clear that there is in fact a threshold. Although the Board is cognizant that an October 2008 VA treatment record documented the Veteran's complaint of knee pain which started while the Veteran was serving in Iraq, this is clearly a transcription of the Veteran's self-reported medical history. LeShore v. Brown, 8 Vet.App. 406, 409 (1995) ('a bare transcription of a lay history is not transformed into 'competent medical evidence' merely because the transcriber happens to be a medical professional'). Indeed, as discussed below, the Veteran has also stated that his knee disability began in 2002, ten years after he separated from service. Only the Veteran's contentions provide any suggestion of such association, and the Board does not find the Veteran's contentions to rise to the level of the "indication of an association" referred to in 38 U.S.C.A. § 5103A or in McLendon. However, if a Veteran's mere contention, standing alone, that his claimed disability is related to his service is enough to satisfy the "indication of an association," then that element of 38 U.S.C.A. § 5103A is meaningless. An interpretation of a statute that renders part of the statutory language superfluous is to be avoided. See Splane v. West, 216 F.3d 1058, 1068-69 (Fed. Cir. 2000) ["canons of construction require us to give effect to the clear language of statute and avoid rendering any portions meaningless or superfluous"]. It is clear that more than a mere contention is required under McLendon. The facts of this case are different than the facts in Charles v. Principi, 16 Vet. App. 370 (2002), in which the Court held that VA erred in failing to obtain a medical nexus opinion where evidence showed acoustic trauma in service and a current diagnosis of tinnitus. Significantly, in this case, there is no credible evidence of in-service disease or injury. Thus, under these circumstances, the Board finds that a remand to obtain a medical opinion would serve no useful purpose. The Board has carefully reviewed the Veteran's statements and concludes that he has not identified further evidence not already of record. The Board has also reviewed the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has been accorded the opportunity to present evidence and argument in support of his claims. He has declined to exercise his option of a personal hearing. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and that no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claim. Essentially, all available evidence that could substantiate the claim has been obtained. There is no indication in the file that there are additional relevant records that have not yet been obtained. II. The Service Connection Claim In general, service connection may be granted for disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110; 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. See 38 C.F.R. § 3.303(d) (2012). In order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). 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). Here, the Veteran contends that he has a bilateral knee disability as a result of injuries he sustained while on active duty. Specifically, the Veteran reported during the February 2010 VA examination that he injured his knees while in Boot Camp from physical training, running, and jumping off track vehicles. The Board notes that the Veteran served in Southwest Asia from December 1990 to April 1991. However, the Veteran is not alleging that his disability is a result of combat, but rather that his disability is the result of stress imposed on his knees from running and jumping with no assertion of incurrence or aggravation during combat. As a result, the combat presumption is not for application in this case. See 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(d) (2012). The record reflects that the Veteran was diagnosed with patellofemoral syndrome of the bilateral knees during the February 2010 VA examination. Evidence of a current disability has been demonstrated. With respect to an in-service disease or injury, the Veteran's service treatment records are negative for any complaints or treatment for a knee disorder. He did not undergo a separation examination. While the Veteran waived his separation examination, the record includes a self-report of medical history that he completed shortly after his separation for service and in connection with his enlistment in the National Guard. In this August 1992 report, the Veteran denied having a "trick" or locked knee, or swollen or painful joints. The Veteran's August 1992 enlistment physical examination revealed that the Veteran's knees were normal. Phrased differently, the Veteran's knees were examined in August 1992 and a disability was not identified; rather the lower extremities were normal and he denied pertinent pathology. Rather than a silent record, there is objective and subjective evidence of no pathology in August 1992. While the Veteran is competent to report on factual matters of which he has first-hand knowledge (see Washington v. Nicholson, 19 Vet.App. 362, 368 (2005)), his recollection of in-service events is inconsistent with the evidence contained in the claims folder, including his denial of any knee problems shortly after his separation from service. As such, the Board finds that his description of in-service events unreliable, and therefore, not credible. See Curry v. Brown, 7 Vet.App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran). Moreover, the Board notes that the Veteran has provided inconsistent statements as to the date he began to experience knee problems. Specifically, while the Veteran reported to medical professionals that his knee pain began while he was on active duty, his October 2008 claim stated that his disability began in May 2002. See the February 2010 VA examination; see also an October 2008 VA treatment record. The Board also finds it significant that, while the Veteran filed a claim for VA benefits in April 2000 and June 2003, he did not mention knee problems. If he had been experiencing knee problems since May 1992, as he currently contends, it would appear only logical that he would claim such disability at that time. In essence, the Veteran's knee disability claim rests of his own contention that he experienced knee problems while in service. The Board has considered his assertion. However, in light of the Veteran's conflicting statements, his denial of any knee problems following his separation from service, the negative service treatment records, and the normal lower extremities in August 1992, the Board finds his statements to be not credible, despite his recent allegations of having continuous problems. In this case, the Board places far greater probative value on the normal contemporaneous service department records, the normal August 1992 examination, and his denial of knee problems shortly after he separated from service than it does on the more recent statements of the Veteran, made in connection with his claim for monetary benefits from the government. Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran). Such records are more reliable, in the Board's view, than the Veteran's unsupported assertions of what occurred during service. The Veteran's statements are self-serving and are unsupported by his service records. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence). Accordingly, the Board finds the Veteran's statements to be lacking in credibility and probative value. Based on the above, the Board concludes that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for patellofemoral syndrome. Although the evidence shows that the Veteran currently suffers from the disease, there is no credible evidence that he had knee problems during service. In the absence of competent and credible evidence of an in-service disease or injury, it follows that evidence of a nexus between the in-service injury and the claimed current disability is also lacking. Such is the case here. The evidence of record does not contain a competent and credible statement attempting to link the Veteran's knee disabilities to his active duty service. In fact, when the Veteran complained about bilateral knee pain in October 2010, a VA clinician "reminded him that he is 'officially' obese and that his knees are weight bearing joints." To the extent that therer is an allegation of continuity, we note that the disability is not an enumerated chronic disease and 38 C.F.R. § 3.303(b) is not applicable. To the extent that the Veteran asserts that there is relationship exists between post service development of patellofemoral syndrome and service, any such statement offered in support of his claim does not constitute competent evidence and cannot be accepted by the Board. Since, generally, laypersons are not capable of opining on matters requiring medical knowledge (such as the present case), the Board finds that the Veteran's opinion that his patellofemoral syndrome was caused by service is not competent evidence. We also note that in regard to the issue of causation, there are no Jandreau/Buchanan exceptions, beyond a remote post-service diagnosis. Indeed, the evidence of record does not indicate that the Veteran has the necessary medical training or experience to comment on complicated medial questions such as the etiology of his patellofemoral syndrome. Accordingly, the Board must conclude that the weight of the evidence is against the claim of service connection for patellofemoral syndrome. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. In conclusion, the preponderance of the evidence is against the award of service connection for patellofemoral syndrome, as credible evidence has not been presented establishing an in-service disease or injury. As a preponderance of the evidence is against the award of service connection, the benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet.App. 49, 55-57 (1991). III. Rating Claim Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran's service-connected PTSD is currently rated under 38 C.F.R. § 4.130 Diagnostic Code 9411 (Posttraumatic stress disorder). In this case, the Board has considered whether another rating code is "more appropriate" than the one used by the RO, Diagnostic Code 9411. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Upon review, Diagnostic Code 9411 is deemed by the Board to be the most appropriate primarily because it pertains specifically to the diagnosed disability in the Veteran's case (PTSD). In any event, with the exception of eating disorders, all mental disorders are rated under the same criteria in the rating schedule. Therefore, rating under another diagnostic code would not produce a different result. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 9411. PTSD is to be rated under the general rating formula for mental disorders under 38 C.F.R. § 4.130. The pertinent provisions of 38 C.F.R. § 4.130 relating to rating psychiatric disabilities read in pertinent part as follows: 100 percent - 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. 70 percent - 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 (2011). 50 percent - 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 effective work and social relationships. 30 percent - Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 10 percent - Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. In Vazquez-Claudio v. Shinseki, __ F.3d ___, No. 2012-7114 (Fed.Cir. April 8, 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." A Global Assessment of Functioning (GAF) score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 61 to 70 reflect 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, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more 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). See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV for rating purposes]. In this case, the Veteran's service-connected PTSD is currently rated as 10 percent disabling. For the reasons explained in greater detail below, the Board that a disability rating in excess of 10 percent is not warranted. As noted, the assignment of a 30 percent disability rating requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Again, the Board's inquiry is not necessarily strictly limited to the criteria found in the VA rating schedule. See Mauerhan, supra. Accordingly, the Board will first discuss the symptoms identified in the ratings criteria and will then address any other aspects of the Veteran's psychiatric symptomatology which would warrant a higher rating. Upon review, the evidence of record indicates that the Veteran experiences depression and anxiety. For example, in September 2008, the Veteran reported experiencing a depressed mood, anhedonia, decreased appetite, psychomotor retardation and decreased energy. This treatment record also documents the Veteran's complaint that he startles easily, does not like public places, is hypervigilant, and isolates himself. The record also indicates that the Veteran's PTSD symptomatology includes suspiciousness. See the September 2012 VA examination report. For example, the Veteran reported that he is distrustful of others and "watching people." He also reported that he has to "have his chair at a certain corner so he can watch everything." In September 2008 the Veteran reported that he "sleeps fitfully" and "doesn't feel rested on awakening." While the record indicates that the Veteran has been diagnosed with restless leg syndrome and sleep apnea, the Veteran's wife has reported that the Veteran will cry in his sleep. See the February 2010 VA examination report. The record does not differentiating between symptomatology attributed to his PTSD and that of his non service-connected sleep apnea and restless leg syndrome and it is well established that the Board is precluded from making such a distinction in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet.App. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet.App. 136, 140 (1996). Accordingly, the Board will attribute the Veteran's chronic sleep impairment with his service-connected PTSD. The evidence of record does not reflect, and the Veteran does not appear to allege, that his PTSD symptomatology includes panic attacks or mild memory loss. Indeed, the September 2012 VA examiner indicated that such symptoms were not present. The Board's inquiry is not necessarily limited to the criteria found in the VA rating schedule. See Mauerhan, supra. In this capacity the Board notes that in addition to the depressed mood, anxiety, and chronic sleep impairment described above, the record indicates that the Veteran also suffered from irritability, hypervigilance, difficulty concentrating, and is distrustful of others. See the September 2012 VA examination report. The Veteran also reported that he no longer coaches little league due to lack of interest. Id. Notwithstanding the presence of these symptoms, the Federal Circuit has held that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." See Vazquez-Claudio, supra. In the present case, the areas referenced by a 30 percent rating under § 4.130 are occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Upon review, however, the Board finds that the Veteran's PTSD symptomatology is adequately addressed in the currently assigned 10 percent ratings criteria which contemplate occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. Here, the record indicates that the Veteran's PTSD symptomatology does not decrease his work efficiency or ability to perform occupational tasks. For example, in October 2008, the Veteran reported that he "is attentive to [his] job and he feels liked and supported by his employer." While the Veteran reported that he was aggravated by the poor performance of the employees he supervised, there is no indication that this "aggravation" had any impact on his occupational functioning. During the February 2010 VA examination, the Veteran denied having interpersonal conflicts with his supervisors and co-workers. He stated that he is satisfied with his current work and denied having employment problems. While the February 2010 VA examiner reported that the Veteran experienced an "occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks" this conclusion is directly contradicted by the examiner's findings. Specifically, the examiner described the Veteran's PTSD symptomatology as "mild." He further noted that the Veteran has worked as a field technician for nine years and that he denied any interpersonal conflicts with his supervisors and coworkers. It was noted that the Veteran had never been fired or involuntarily terminated and was satisfied with his current work. During the examination, the Veteran denied having any problems at work and reported that that he worked primarily by himself. Moreover, contrary to the examiner's statement, the Veteran explicitly declined to state that his symptoms impacted his work because he works alone. While the February 2010 VA examiner stated that "if [the Veteran] had to work around others and/or if there were frequent or intense interactions with others, he would have difficulty as he would prefer to be alone and/or relate in a suspicious, distrusting, and guarding manner." As discussed in greater detail below, however, the record indicates that this was not an accurate statement. Moreover, at the time of the examination, the Veteran's PTSD symptomatology was not causing him any occupational impairment. In May 2010, the Veteran reported that he had been working productively and enjoyed his job. While the Veteran reported that he was continuing to have difficulty sleeping in July 2010, it was noted that this was not impacting his employment because he worked alone. In July 2010, the Veteran requested that his PTSD be reviewed because he believed it interfered with his ability to get along with others. Specifically, the Veteran stated that he is able to work on his own without any problems, but becomes anxious and easily agitated when working with others. While cognizant that the Veteran reported that he became anxious and easily agitated, there is no evidence that these symptoms resulted in any occupational impairment. Indeed, in November 2010 the Veteran apparently received a promotion and began working in sales, he reported that "things are going good." The Veteran recognized that "he becomes very irritable with people who work for him" and reported that his unit is often difficult to manage, but he relates to them as if they were troops and the employees follow his orders. It was noted that with this new position, the Veteran would have to work later but would earn a higher income. In April 2012, the Veteran reported that he has "new responsibilities at work" due to a recent "promotion and increase in pay." While the Veteran reported that his job was "demanding" there was no indication that the Veteran's PTSD symptomatology impacted his occupational functioning. After conducting a clinical examination and reviewing the Veteran's claims file, the September 2012 VA examiner stated that the Veteran's PTSD symptomatology results in occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress. During the examination, the Veteran described difficulty remembering instructions and difficulty with attention and concentration as he forgets what he reads and has to go back and read it again, but he denied difficulty adjusting to stress and change in the workplace. He also denied interpersonal conflicts with supervisors and coworkers. While cognizant that the Veteran has demonstrated many of the symptoms specified in the 30 percent rating criteria, as noted above, the presences of certain symptoms is not necessarily determinative. These symptoms must also cause the occupational and social impairment in the referenced areas. See Vazquez-Claudio, supra. After considering the evidence of record, the Veteran's symptoms more closely approximate the criteria for a 10 percent disability rating. The criteria for the next higher rating of 30 percent have not been met or approximated for any period in this appeal. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board additionally observes that the Veteran has been assigned GAF scores ranging from 51 to 69. As discussed above, a GAF score of 51 is consistent with moderate symptoms whereas a score of 69 is consistent with mild symptoms. While a GAF score of 51 is indicative of moderate symptoms, a GAF score is not the sole determinative factor in the assignment of an increased disability rating. In this capacity the Board notes that he February 2010 VA examiner has stated that the Veteran's PTSD only results in mild impairment. Further, the VA treatment records which provide a GAF score of 51, also diagnosed the Veteran with depressive disorder and alcohol abuse. Therefore, based on a review of all the evidence, the Board concludes that a disability rating in excess of 10 percent is not warranted at any time during the appeal period. Under Floyd v. Brown, 9 Vet.App. 88, 95 (1996), the Board cannot make a determination as to an extraschedular evaluation in the first instance. See also VAOPGCPREC 6-96. However, the Board can address the matter of referral of a disability to appropriate VA officials for such consideration. According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet.App. 225, 229 (1993). Under Thun v. Peake, 22 Vet.App. 111 (2008) aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the initial inquiry posed by Thun, the criteria pertaining to PTSD in the Rating Schedule focus on psychiatric symptoms which interfere with occupational and social functioning. As discussed above, such symptomatology describes the Veteran's current disability picture. Accordingly, the Board finds that the Veteran's disability picture has been contemplated by the ratings schedule. Since the available schedular evaluation adequately contemplates the Veteran's level of disability and symptomatology, the second and third questions posed by Thun become moot. Nevertheless, the Board will briefly note that the evidence in this case does not demonstrate any of the factors provided in the "governing norms" such as frequent hospitalization or marked interference with employment. See 38 C.F.R. § 3.321(b)(1). In this case, there is no indication that the Veteran has required frequent hospitalizations for his PTSD. In fact, it does not appear that the Veteran has been hospitalized at all for this disability. With respect to employment, the evidence of record indicates that the Veteran works in sales and there is no indication that this disability has caused him to miss work or creates any unusual employment impairment. See Van Hoose v. Brown, 4 Vet.App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired]. In addition, there is no evidence in the medical records of an exceptional or unusual clinical picture, or of any other reason why an extraschedular rating should be assigned. The Board therefore has determined that referral of the case for extra-schedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Service connection for a bilateral knee disability is denied. An initial disability rating in excess of 10 percent for PTSD is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs