Citation Nr: 1317334 Decision Date: 05/28/13 Archive Date: 06/06/13 DOCKET NO. 94-12 701 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to a disability rating for posttraumatic stress disorder (PTSD) in excess of 30 percent prior to February 22, 2000, and in excess of 50 percent from February 22, 2000. 2. Entitlement to service connection for a right knee disorder. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) for the period prior to January 5, 2010. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from May 1986 to February 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in September 1998 and July 1999 by a Department of Veterans Affairs (VA) Regional Office (RO) that denied an increased rating for PTSD, a TDIU, and service connection for knee disabilities. In February 1998, the Veteran filed a claim seeking a TDIU. In a September 1998 rating decision, a TDIU was denied, as well as the concomitant increased rating claim for PTSD. The Veteran appealed that decision to the Board. In a July 1999 rating decision, service connection for bilateral knee disability was denied. The Veteran appealed that decision to the Board as well. The Veteran thereafter attended a Board videoconference hearing in April 2002, which was conducted by a Veterans Law Judge (Board Member) who is no longer employed by the Board. In December 2002, the Board remanded the issues on appeal for further development. In a May 2005 rating decision, service connection for dysthymic disorder/depressive disorder was denied. The Veteran appealed that decision to the Board. Following the May 2005 rating action, the Veteran requested another Board hearing. She then testified from the Muskogee, Oklahoma, RO at a Board personal hearing in October 2007. The transcripts of the referenced hearings are included in the claims folder. In an April 18, 2008 decision, the Board denied the appeal for a rating in excess of 30 percent for bilateral pes planus with bilateral plantar fasciitis and heel spurs; denied a rating in excess of 10 percent for bursitis of the left hip; granted a rating for PTSD of 30 percent for the period prior to February 22, 2000 and 50 percent for the period from February 22, 2000; denied service connection for bilateral knee disability; denied service connection for dysthymic disorder/depressive disorder; and denied TDIU. The Veteran appealed the April 2008 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2010 memorandum decision, the Court vacated the Board's April 2008 decision as to each issue, and remanded the case to the Board. The Court vacated the Board's decision in its entirety, including as to the grants of increased ratings for PTSD; however, the Board points out that the RO has already implemented the Board's grant of increased ratings for PTSD, and also that the Court is statutorily prohibited from reversing the Board's favorable findings under 38 U.S.C.A. § 7261(a)(4) (West 2002). Consequently, the Board will not disturb the grant of higher ratings for PTSD, and has recharacterized the PTSD issue accordingly. As to the issue of entitlement to a TDIU, the record reflects that in a February 2010 rating action the RO granted TDIU, but only effective from January 5, 2010. The matter of entitlement to a TDIU for the period prior to January 5, 2010 remains on appeal. In a March 2011 decision, the Board denied entitlement to a disability rating in excess of 30 percent for bilateral pes planus, and granted service connection for dysthymic disorder. A separate Board decision dated in March 2011 denied entitlement to an increased rating for the left hip bursitis. The issues of entitlement to service connection for a bilateral knee disability, entitlement to an increased rating for PTSD, and entitlement to TDIU prior to January 5, 2010 were remanded for additional development. The record indicates that the Appeals Management Center (AMC) complied with the Board's requests regarding the issue of entitlement to a higher rating for PTSD, including readjudication of the increased rating for PTSD claim. As the AMC complied with the March 2011 Remand directives, the Board will proceed to render a decision on the claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). The claim for service connection for a left knee degenerative joint disease was granted in a September 2012 rating decision. This action constitutes a full grant of the benefits sought, and the claim for service connection for a left knee disability is no longer on appellate review. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second Notice of Disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). The issue of service connection for a right knee disability remained on appeal and is discussed below. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The issues of service connection for a right knee disability and entitlement to TDIU prior to January 5, 2010 are addressed in the REMAND portion of the decision below, and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. For the period of the appeal prior to February 22, 2000, the Veteran's PTSD symptomatology was manifested by 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, chronic sleep impairment, and irritability. 2. For the period of the appeal prior to February 22, 2000, the Veteran's PTSD symptomatology was not manifested by occupational and social impairment with reduced reliability and productivity, disturbances in motivation and mood, or difficulty in establishing or maintaining effective work and social relationships. 3. For the period of the appeal from February 22, 2000, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity, disturbances in motivation and mood, and difficulty in establishing or maintaining effective work and social relationships and there was no evidence of occupational and social impairment with deficiencies in most areas of work, school, family relations, judgment, thinking, and mood. 4. For the period of the appeal from February 22, 2000, the Veteran's PTSD was not manifested by occupational and social impairment, with deficiencies in most areas. CONCLUSIONS OF LAW 1. For the rating period prior to February 22, 2000, the criteria for a disability evaluation in excess of 30 percent for the service-connected PTSD were not met or more nearly approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.130 including Diagnostic Code 9411 (2012). 2. For the rating period from February 22, 2000, the criteria for the assignment of a disability evaluation in excess of 50 percent evaluation for the service-connected PTSD were not met or more nearly approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.130 including Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Duty to Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2012). A VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. VCAA notice requirements apply to all five elements of a service connection claim (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). The Board finds that in this case VA has satisfied its duties to notify under the VCAA. The RO provided VCAA notice letters to the Veteran in April 2001, January 2003, June 2004, March 2006, June 2006, November 2007, and March 2011. The letters notified the Veteran of what information and evidence must be submitted to substantiate a claim for an increased rating. Additionally, the March 2006, June 2006, November 2007, and March 2011 letters provided the Veteran with the general criteria for the assignment of an effective date and initial rating. Although the notice was not issued before the initial rating decision on appeal, the Veteran has not been prejudiced as the claim was readjudicated in supplemental statements of the case dated in July 2006, August 2006, June 2007, and October 2012. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In June 2006, September 2010, and March 2011, the Veteran informed VA that she had no additional evidence or information to submit in support of her claims. The Board finds that all relevant evidence has been obtained with regard to the Veteran's claims, and the duty to assist requirements have been satisfied. All available service treatment records were obtained. VA treatment records dated from 1990 to 2011 are associated with the claims folder. The Veteran underwent VA examinations in August 1998, February 2000, April 2003, November 2005, December 2005, April 2006, February 2010, April 2011, and October 2012 to obtain medical evidence as to the current severity of the service-connected PTSD. These examinations were adequate because each was performed by a medical professional based on either a review of claims file or solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran, offered opinions, and provided a rationale for the opinions provided. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). For these reasons, the Board finds that the duties to notify and assist the Veteran in the claims have been met, so that no further notice or assistance to the Veteran is required. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The United States Court of Appeals for Veterans Claims (Court) has held that that provisions of 38 C.F.R. § 3.103(c)(2) impose two distinct duties on VA employees, including Board personnel, in conducting hearings: The duty to explain fully the issues and the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). At the Board hearing, the undersigned Veterans Law Judge identified the issues, sought information as to treatment to determine whether all relevant records had been obtained, and sought information as to the cause, onset, and severity of the Veteran's disabilities. Ultimately the claims were remanded for an examination and other development. The Board thereby met the duties imposed by 38 C.F.R. § 3.103(c)(2) as interpreted in Bryant. Disability Rating for PTSD Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. 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 the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating criteria for rating mental disorders provides a 100 percent rating for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of 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. A 70 percent rating requires 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. A 50 percent rating requires 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. A 30 percent 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). 38 C.F.R. § 4.130, Diagnostic Code 9411. The Court has held that Global Assessment of Functioning (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); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.), 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). Scores ranging from 41 to 50 reflect 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. Once the evidence has been assembled, it is the Board's responsibility to evaluate the evidence. 38 U.S.C.A. § 7104(a) (West 2002) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"). The VA Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. In this case, the Board has considered all the evidence of record as it bears on the ratings for the distinct time periods, and has not barred any evidence from consideration for any period, although evidence created during a particular time period may be of more probative value in assessing the severity of impairment for that time period. By way of background in this case, service connection for PTSD was granted in a September 1991 rating decision. The RO assigned a 10 percent rating at that time. The Veteran filed a claim for increased rating in November 1993, which the RO denied in a May 1994 rating decision. The Veteran appealed. In an October 1996 decision, the Board denied a disability rating in excess of 10 percent for the PTSD. In September 1998, the Veteran filed another claim for an increased rating for PTSD. In a September 1998 rating decision, entitlement to an increased rating for PTSD was denied. The Veteran perfected an appeal for this issue. In December 2002, the Board remanded this issue to the RO for further development. In a May 2005 rating decision, service connection for dysthymic disorder/depressive disorder was denied. The Veteran perfected an appeal for this issue. In an April 18, 2008 decision, the Board granted a rating of 30 percent for PTSD for the period prior to February 22, 2000; granted a rating of 50 percent for PTSD for the period from February 22, 2000; and denied service connection for dysthymic disorder/ depressive disorder. In a May 2008 rating decision, the RO implemented the Board decision and increased the Veteran's rating for PTSD to 30 percent prior to February 22, 2000 and to 50 percent from February 22, 2000. The Veteran appealed the April 2008 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a February 2010 memorandum decision, the Court vacated the Board's April 2008 decision as to each issue, and remanded the case to the Board. The Court purported to vacate the Board's decision in its entirety, including as to the grants of increased ratings for PTSD; however, the Board points out that the RO has already implemented the Board's grant of increased ratings for PTSD, and also that the Court is statutorily prohibited from reversing the Board's favorable findings under 38 U.S.C.A. § 7261(a)(4). Consequently, the Board will not disturb the grant of higher ratings for PTSD and, consistent with the Court's order, adjudicate the remaining aspect of the PTSD rating issue on appeal. In a March 2011 decision, the Board granted service connection for dysthymic disorder. The service-connected dysthymic disorder and depressive disorder was included with the service-connected PTSD. The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14 (2012), which provides that the evaluation of the same manifestation under different diagnoses are to be avoided. Rating prior to February 22, 2000 After a review of the evidence, the Board finds that, for the period of the appeal prior to February 22, 2000, the Veteran's PTSD symptomatology was manifested by 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, chronic sleep impairment, and irritability, which warrants a 30 percent disability rating under Diagnostic Code 9411. For this time period, the evidence includes GAF scores of 55 and 60, which represent moderate symptoms or moderate difficulty in social and occupational functioning that contemplates few friends and conflicts with peers or co-workers. For this period of time, the Veteran had symptoms of anger, difficulty concentrating, angry mood and affect, depression, and insomnia. The December 1993 VA examination report that indicates that the Veteran had anger when talking about all her difficulties with change of command, complained about having difficulty concentrating, mood affect showed some anger, and she had experienced some initial insomnia. The diagnosis was PTSD. A GAF score of 60 was given. VA clinical record in September 1998 indicated that the Veteran had been depressed for over one year, and she was on Prozac (20 mg.), and that she had moved to Texas from Oklahoma one year ago. She reported that she accepted a job with the Federal Aviation Administration in September 1997, but was fired from the job in February 1998. She reported that she filed an EEOC complaint against the employer for wrongful termination, and that she was attending school and working towards a Bachelors Degree in Science. Examination in September 1998 revealed that the Veteran's mood was somewhat dysphonic. The diagnosis was depressive disorder, with a GAF score of 75 which is indicative of transient symptoms and expectable reactions to psychological stressors and no more than slight impairment in social or occupational functioning. See DSM-IV. For the period of the appeal prior to February 22, 2000, the Board finds that the Veteran's PTSD symptomatology did not more closely approximate occupational and social impairment with reduced reliability and productivity, disturbances in motivation and mood, or difficulty in establishing or maintaining effective work and social relationships. The weight of the competent and credible evidence shows that the PTSD was manifested by mild to moderate and transient symptoms. The weight of the evidence shows the for this time period, the PTSD more closely approximated occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks although generally functioning satisfactorily with routine behavior, self-care, and conversation normal. Occupational and social impairment with reduced reliability and productivity and difficulty in establishing effective work and social relationships has not been shown for the time period prior to February 22, 2000. Thus, on this record, the Board finds that the evidence establishes that for this period the service-connected PTSD was not productive of more than occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks for the time period prior to February 22, 2000; therefore, a rating in excess of 30 percent for this time period is not warranted. Rating from February 22, 2000 For the time period of the appeal from February 22, 2000, the date of a VA psychiatric examination, the Board finds that the Veteran's PTSD more closely approximates occupational and social impairment with reduced reliability and productivity, disturbances in motivation and mood, and difficulty in establishing or maintaining effective work and social relationships. VA report of examination on February 22, 2000 noted that the Veteran's psychomotor activity was depressed, eye contact was occasional and she wore glasses, mood was depressed, and affect was mood congruent. The Veteran admitted to anger, but denied impulses to hurt others, and admitted to depression, but denied thoughts about suicide. The diagnosis was depressive disorder, and the examiner assigned a GAF score of 55 which is indicative of moderate impairment in occupational and social functioning. VA examination in April 2003 revealed that the Veteran did not talk spontaneously, but did answer questions, mood was depressed, and she reported some thoughts of homicide, but she did not have any plans to act it out. The Veteran reported that she often argues with others, and had recurrent and obsessive thoughts about her 1st Sergeant and what he did in the military. The diagnosis was dysthymic disorder, PTSD, and alcohol dependence, in remission. The examiner assigned a GAF score of 55. In a July 2003 addendum statement, the examiner indicated that 30 percent of her mental problems are believed to be related to her service-connected PTSD and 70 percent due to her non-service-connected dysthymia. The examiner also explained that factors other than PTSD are contributing to her dysthymia, specifically, that her alcohol dependence may make her mental disorder worse, but not permanently if successfully treated. As noted above, service connection for dysthymic disorder was granted in March 2011; therefore, symptoms and impairment associated with dysthymic disorder are being rated together with the service-connected PTSD. VA clinical record in October 28, 2005 showed difficulty sleeping and nightmares once per night from history of in-service stressor. The record also noted a history of depression. VA examination in December 2005 indicated that the Veteran had been alcohol free since 2000. The examiner commented on a 2001 letter in the record written by the Veteran and stated that it exhibited poor construction, organization, and redundancy. It demonstrated that the Veteran's intellectual functioning was not really good. The examiner noted that her claim folder was immense, but no psychiatric significance. The examiner noted the Veteran's somewhat diminished intellectual functioning and mild-to-moderate depression. The examiner indicated that the Veteran embellished her PTSD complaints. The diagnosis was PTSD. The examiner indicated that the degree of the Veteran's disability was disputable. The examiner further stated that, once the Veteran loses her current employment, she will be indeed unemployable. VA clinical record in January 2007 indicated complaints of erratic sleep, with nightmares of combat and night sweats several times per week. The diagnosis was PTSD. The Veteran testified in October 2007 that she wakes up often at night with anxiety attacks. (T. 6-7). She takes medication for her PTSD and states that she needs therapy, but is not currently receiving such care. (T. 8-9). She complained about having difficulty in relationships. (T. 9). She testified she was currently employed as a Detention Officer for the past year and was an aviator operator in Dallas the prior eight years. (T. 4-5). A VA psychiatric examination report dated in February 2010 indicates that the Veteran reported having constant symptoms of nightmares, intrusive thoughts, and flashbacks. She reported that her symptoms affected her total daily functioning and this resulted in irritability, anger outbursts, anxiety, and isolation. She reported having trouble sleeping; she had nightmares and woke up sweating. The Veteran reported that her relationship with her parents and siblings was good. She did not have a significant other. Mental status examination revealed that the Veteran's affect and mood showed a disturbance of mood and motivation. Panic attacks were present and occurred once a week. The examiner indicated that the behavioral, cognitive, social, affective, and somatic symptoms attributed to the Veteran's PTSD were as follows: trouble sleeping, anger outbursts, depressed mood, decreased energy and motivation, easy startle response, nightmares, intrusive thoughts, flashbacks, and a preference for isolation. The Axis I diagnoses were PTSD, major depressive disorder, panic disorder, and alcohol dependence in remission. The examiner stated that the Axis I diagnoses were related and the PTSD led to the development of the depressive disorder and panic disorder. The examiner noted that the PTSD symptoms were characterized by nightmares, intrusive thoughts and flashbacks and the major depressive disorder was characterized by decreased general interest, depressed mood, insomnia, and decreased energy. The examiner stated that the GAF score was 44 which is indicative of serious symptoms and serious impairment in social and occupational functioning (e.g. no friends, unable to keep a job). See DSM-IV. The examiner indicated that the Veteran had difficulty establishing and maintaining effective relationships because the Veteran preferred to isolate herself and avoid large crowds. She had difficulty maintaining effective family role functioning because the Veteran was irritable and had anger outbursts. The Veteran was afforded another VA examination in October 2012. The Axis I diagnosis was PTSD and the examiner indicated that the Veteran also had anxiety, depression, and sleep issues which were included in the PTSD diagnosis. The report indicates that the veteran had good, supportive family relationships. She had a current boyfriend and lived alone but had the support of her sister for activities such as cleaning and transportation. It was noted that the veteran was highly educated with several degrees and she liked school. It was noted that the Veteran's difficulty with interpersonal relationships, depression, and fatigue, all PTSD related, made her work activities more difficult to carry out. Her most recent job ended in January 2010 and was a quality assurance position with a juvenile detention center. The report indicates that the Veteran's PTSD symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, flattened affect, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a work like setting, and heightened irritability. The examiner opined that the Veteran's PTSD has remained stable for several years and it continued to produce moderate or considerable social and work dysfunction. The examiner indicates that the Veteran functioned well in an academic setting and with her family. She had difficulty relating to others in a work setting and to non family members in the social sphere. The examiner indicated that the Veteran's PTSD was best summarized as causing occupational and social impairment with reduced reliability and productivity. The GAF score for the PTSD was 53 which is indicative of moderate symptoms and moderate impairment in social and occupational functioning. For this time period from February 22, 2000, the evidence shows that the PTSD was assigned GAF scores that ranged from 44 to 55, which represent a range from moderate symptoms or moderate difficulty to serious symptoms and serious impairment in social and occupational functioning. For this period of time, the weight of the competent and credible evidence establishes that the Veteran had more than an occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks. The weight of the evidence shows that the PTSD more closely approximates reduced reliability and productivity due to symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, flattened affect, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a work like setting, and heightened irritability. The Board finds that, for the time period of the appeal from February 22, 2000, the service-connected PTSD more closely approximates the criteria for a 50 percent rating under Diagnostic Code 9411. The Board further finds that, for the period from February 22, 2000, the Veteran's PTSD symptomatology has not more nearly approximated occupational and social impairment with deficiencies in most areas. The weight of the competent and credible evidence shows that the PTSD causes a deficiency in work in that the Veteran had difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances including work or a work like setting. The weight of the competent and credible evidence shows that for this period the PTSD causes a deficiency in mood; however, the weight of the evidence shows that the Veteran does not have deficiencies in school, family, judgment or thinking. The VA examination reports and VA mental health treatment records show that for the entire period of the appeal, the Veteran had good judgment. There was no impairment in thought process or concentration. The weight of the evidence shows that the Veteran had a good and supportive relationship with her family, and that she liked school and had earned various degrees. For these reasons, the Board finds that the criteria for the assignment of a 70 percent rating under Diagnostic Code 9411 are not met or more nearly approximated for the time period of the appeal from February 22, 2000. The evidence establishes that the service-connected PTSD did not cause deficiencies in most areas (work, school, family relations judgment, thinking or mood), and a rating in excess of 50 percent for the PTSD is not warranted. Extraschedular Consideration The Board has considered whether an extraschedular evaluation is warranted for the PTSD. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD is have been manifested by moderate symptoms or moderate difficulty to serious symptoms and serious impairment in social and occupational functioning due to symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, flattened affect, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a work like setting, and heightened irritability. These symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). The levels of occupational and social impairment are explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the symptoms and impaired social and occupational functioning reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on daily life. In the absence of exceptional factors associated with the PTSD, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An increased rating for the service-connected PTSD, in excess of 30 percent prior to February 22, 2000, and in excess of 50 percent from February 22, 2000, is denied. REMAND The Veterans Claims Assistance Act of 2000 (VCAA) specifically provides that the duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002). In the present case, the Veteran has contended that her right knee disability was caused or aggravated by the service-connected right foot metatarsalgia, bilateral flatfeet, plantar fasciitis, heel spurs, and left hip bursitis. See the Veteran's statements dated in October 1998, July 1999, and January 2000. Disabilities that are proximately due to, or aggravated by, service-connected disease or injury, provides that any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. 38 C.F.R. § 3.310 (2012). Service connection can be granted for a disability that is aggravated by a service-connected disability and that compensation can be paid for any additional impairment resulting from the service-connected disorder. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran has been provided VA examinations in February 2000, April 2003, and July 2003 but a right knee disability was not detected, although knee pain was documented. An April 2011 VA examination report shows a diagnosis of degenerative joint disease of the right knee by x-ray. The VA examiner in April 2011 rendered an opinion that it was less likely than not that the right knee disability was caused or chronically worsened by a service-connected disability. The basis of this opinion was that there was no documented evidence of treatment of a chronic right knee condition in service or within five years of service separation and the chronicity of the right knee condition was not established in service or after service separation. The pertinent law and regulations for secondary service connection do not require evidence of a chronic disability in service or after service in order for service connection on a secondary basis to be granted; thus, it appears that the VA examiner provided a legally inadequate basis for the medical opinion, and the examination is inadequate. For this reason, the Board finds that another VA medical opinion to fully address the theory of secondary service connection is necessary. The RO should ask the VA examiner who conducted the April 2011 VA examination or a suitable replacement to prepare an addendum to the April 2011 examination report to provide an opinion as to whether the degenerative joint disease of the right knee was caused or aggravated by the service-connected right and left foot disability and the left hip disability. The RO should appropriately contact the Veteran by letter and request that she provide sufficient information and, if necessary, authorization to enable the RO to obtain any pertinent VA or non-VA clinical records showing treatment of the degenerative joint disease of the right knee. The RO should make an attempt to obtain copies any outstanding records from any identified treatment source. The issue of a TDIU rating prior to January 5, 2010 is inextricably intertwined with the issue of entitlement to service connection for a right knee disability. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). Accordingly, the issues of service connection for a right knee disability and entitlement to TDIU prior to January 5, 2010 are REMANDED for the following action: 1. The RO should ask the Veteran to identify any source of VA or non-VA medical treatment rendered for degenerative joint disease of the right knee, and request sufficient information to identify the health care providers, and, if necessary, signed authorizations to enable VA to obtain any additional evidence. If the Veteran adequately identifies any health care providers and provides the completed authorizations, the RO should request legible copies of all pertinent clinical records that have not been previously obtained and should incorporate them into the claims file. 2. The RO then should ask the VA examiner who conducted the April 2011 VA examination (or if no longer available, a suitable replacement) to prepare an addendum medical opinion on the following question: Is it as likely as not (50 percent probability or more) that degenerative joint disease of the right knee was aggravated by (permanently worsened in severity beyond a normal progression) the service-connected right and left foot disabilities and the left hip bursitis or other service-connected disability? The VA claims folder should be made available to the examiner for review in connection with the examination. The examiner should provide a rationale for all conclusions. If the VA examiner determines that he or she is unable to provide the requested medical opinion without resorting to speculation, the examiner should indicate this in the report. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, the RO should schedule the Veteran for such an examination. 3. After completing all indicated development, the RO should readjudicate the issues of service connection for a right knee disability and TDIU for the period prior to January 5, 2010 in light of all the evidence of record. If any benefit sought on appeal remains denied, then a fully responsive Supplemental Statement of the Case should be furnished to the Veteran and representative, and they should be afforded a reasonable opportunity for response. The Veteran has the right to submit additional evidence and argument on the 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). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs