Citation Nr: 1319563 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 09-38 380 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to higher an initial evaluation (rating) for posttraumatic stress disorder (PTSD), in excess of 30 percent for the period from November 7, 2008 to March 1, 2013, and in excess of 10 percent beginning March 1, 2013. 2. Entitlement to service connection for a right knee strain. 3. Entitlement to service connection for sleep apnea. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from June 1979 to February 1987, and from May 2006 to September 2007. This matter comes on appeal before the Board of Veterans' Appeals (Board) from an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which, in pertinent part, granted service connection and a 30 percent initial evaluation for PTSD, effective November 7, 2008, and denied service connection for sleep apnea and a right knee strain. In a subsequent November 2012 rating decision, the Veteran's service-connected PTSD was rated 10 percent disabling for the period (stage) beginning March 1, 2013. The Board notes that the 10 percent rating stage has been developed as a "reduction" issue although it is not. A review of the record shows that the proper issue on appeal is only that of a staged initial rating, with the assignment of a 10 percent rating for this "stage" of the rating from March 1, 2013. The April 2009 rating decision granted service connection and assigned a 30 percent initial disability rating, effective November 7, 2008. The Veteran filed a timely notice of disagreement with the April 2009 initial rating decision assignment of initial rating. The RO issued a statement of the case in September 2009. The Veteran perfected the initial rating for PTSD issue in September 2009. In a May 2012 rating decision during the initial rating appeal, the RO purported to propose to reduce the evaluation. The Veteran was provided notice and an opportunity to respond before the decrease became effective. Although the November 2012 rating decision assigned a 10 percent rating stage, purportedly to implement the reduction, the Board finds that the April 2009 initial rating decision had not become final; therefore, there was no final decision from which a reduction could have been undertaken in accordance with the provisions of 38 C.F.R. § 3.105(e) (2012). Accordingly, the propriety of the November 2012 reduction is not at issue, and it is appropriate to proceed with a staged initial rating appeal. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The issues of service connection for a right knee strain and sleep apnea 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 from November 7, 2008 to March 24, 2011, the Veteran's PTSD has been recharacterized by occupational and social impairment with reduced reliability and productivity due to such symptoms as: sleep impairment, nightmares, anxiety, anger and irritability, disturbance of motivation and mood, difficulty in establishing and maintaining relationships. 2. For the period from November 7, 2008 to March 24, 2011, the Veteran's PTSD has not been characterized by 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. 3. For the period from March 24, 2011 to the present, the Veteran's PTSD has been manifested by symptoms of, nightmares, sleep impairment, irritability, and hypervigilance, which cause some occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 4. For the period from March 24, 2011 to the present, the Veteran's PTSD has not been characterized by 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, for the period from November 7, 2008 to March 24, 2011, the criteria for a higher initial rating of 50 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code 9411 (2012). 2. For the initial rating period from March 24, 2011 to March 1, 2013, the criteria for a higher initial rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code 9411 (2012). 3. Resolving reasonable doubt in the Veteran's favor, for the initial rating period beginning March 1, 2013, the criteria for a higher initial rating of 30 percent for PTSD, but no higher, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.125, 4.126(a), 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) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a timely December 2008 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate the claim as well as what information and evidence must be submitted by the Veteran and what evidence VA would obtain. The notice included provisions for disability ratings and for the effective date of the claim. Because this is an appeal that arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for PTSD, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the United States Court of Appeals for Veterans Claims (Court) have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App.112 (2007). 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date). As discussed above, although the RO purported to implement a reduction in the Veteran's PTSD rating in a November 2012 rating decision, the Board has found that there was no final decision from which a reduction could have been undertaken; as such, the propriety of the reduction is not at issue, and the Board will proceed as if this is a staged initial rating appeal. Although not required to assign a lower rating or stage during an initial rating, the Veteran was provided notice and an opportunity to respond before the decrease became effective under the procedural framework and safeguards set forth in 38 C.F.R. § 3.105 governing rating reductions. These procedures were explained to the Veteran in adequate detail in a July 2012 letter, and he was provided sufficient opportunity to present additional argument and evidence. Accordingly, the Board finds that there is no prejudice to the Veteran as he received additional notice under the provisions of 38 C.F.R. § 3.105, which is more than is required under the VCAA notice provisions. See also Hartman, 483 F.3d 1311; Dunlap, 21 Vet. App.112. Moreover, neither the Veteran nor his representative have alleged any prejudice with regard to the notice in this case; hence, further VCAA notice is not required with regard to the initial rating appeal. Regarding the duty to assist, the Board is satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes service treatment records, VA treatment records, private treatment records, and statements from the Veteran and his representative. Moreover, the Veteran was also afforded VA PTSD examinations in March 2009, March 2011, and August 2012. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the opinions and findings relating to the severity of the Veteran's PTSD obtained in this case are adequate, as the opinion is predicated on a full reading of the VA medical records in the claims file and the Veteran's statements. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). In view of the foregoing, the Board finds that VA has fulfilled its duties to notify and assist the Veteran in the claim under consideration. Adjudication of the claim at this juncture, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Disability Rating Criteria Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. 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. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. 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). 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. Fenderson, 12 Vet. App. at 126. For the reasons set forth in detail below, the Board finds that, for the period from November 7, 2008 to March 24, 2011, the Veteran's PTSD disability more nearly approximated a 50 percent disability rating, and a 30 percent rating is warranted for the period thereafter. The schedular criteria, effective as of November 7, 1996, incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. §§ 4.125, 4.130. A rating of 10 percent is warranted for PTSD if there is 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. 38 C.F.R. § 4.130. A rating of 30 percent is warranted for 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). Id. A 50 percent rating is warranted 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted if it is productive of 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 work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. A 100 percent rating is warranted for PTSD if there is 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. Id. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is 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 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV). GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). Id. GAF scores from 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, with some meaningful interpersonal relationships. Id. GAF scores ranging from 51 to 60 reflect 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. Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). DSM-IV at 46-47. GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which 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., a depressed patient who avoids friends, neglects family, and is unable to do work). Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. If the evidence shows that the veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). The U.S. Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Staged PTSD Ratings The Board notes that the staged PTSD rating is at 30 percent from November 7, 2008 to March 1, 2013, and at 10 percent disabling thereafter. Upon review of the record, the Board finds that the evidence is in relative equipoise as to whether the 50 percent criteria were met or more nearly approximated for the period from November 7, 2008 to March 24, 2011, and as to whether the 30 percent criteria are met or more nearly approximated for the period from March 1, 2013. The evidence of record includes a February 2008 VA mental health treatment note where the Veteran reported sleep impairment and trouble with concentration and short-term memory. Upon mental status examination, the Veteran reported depression at times and irritability and anger. Thought form, progression, and content were clear, coherent and goal directed. Thoughts of harm to self or others were denied. There was no evidence of hallucinations, delusions, or paranoia. The VA psychiatrist diagnosed the Veteran with PTSD and depression and assigned a GAF score of 70, indicative of mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. In a subsequent VA mental health treatment note dated October 2008, the Veteran reported symptoms sleep impairment, erratic eating, decreased energy level, and moodiness. A mental status evaluation revealed that the Veteran had good eye contact and his speech was normal. Affect was affable and bright. Thought form, progression, and content were clear, coherent and goal directed. Thoughts of harm to self or others were denied. There was no evidence of hallucinations, delusions, or paranoia. The Veteran was alert and oriented to self, date, and place. Judgment and insight were good. Complaints of difficulty with concentration and memory were noted. The VA psychiatrist diagnosed the Veteran with PTSD and depression and assigned a GAF score of 70, reflecting mild symptoms or some difficulty in social, occupational, or school functioning. See DSM-IV at 46-47. The Veteran was afforded a VA PTSD examination in March 2009. During the evaluation, the Veteran reported symptoms of intrusive memories, nightmares, distress when exposed to military reminders, hyperarousal, avoidance of crowds, loss of interest in pleasurable activities, anxiety, anger and irritability, difficulty with concentration and memory, and numbness and detachment from others. Upon mental status examination, the March 2009 VA examiner noted that the Veteran was alert, oriented, and cooperative. It was noted that the Veteran appeared somewhat depressed and affect was constricted. Thoughts were clear and goal oriented. There was no evidence of delusions, hallucination, panic, paranoia, or suicidal or homicidal ideation. Cognitive abilities were grossly intact, although the Veteran did report some difficulties with concentration and focus. The VA examiner diagnosed the Veteran with PTSD and assigned a GAF score of 55, indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV at 46-47. In a subsequent May 2009 VA mental health note, the Veteran continued to report some emotional numbing, but affect and expression were stable. The VA social worker diagnosed the Veteran with PTSD and assigned a GAF score was reported as 75, reflecting transient PTSD symptoms with no more than slight impairment in social, occupational, or school functioning. See DSM-IV at 46-47. On VA examination conducted in March 2011, the Veteran reported occasional intrusive thoughts, nervousness, sleep impairment, and avoidance of crowds. The Veteran reported that there had been "marked" improvement in his PTSD symptoms. Although the Veteran stated that he had concentration problems in the past, in March 2011 he reported that he was able to read and study well. He stated that his marriage was great, denied physical problems and reported that he had lost weight through diet and exercise. Upon mental status examination, the March 2011 VA examiner noted appropriate grooming and hygiene. Speech was clear. Affect was calm and overall mood seemed normal. Orientation was appropriate and thinking was spontaneous, logical, and productive. Relationships with pothers were good in quality and self-esteem was intact. Concentration was good and reasoning skills indicated the capacity for abstract thinking. Judgment and insight were also good. The VA examiner noted that the Veteran continued to have PTSD, but at a markedly improved level than in the past. Although the Veteran had some problems with intrusive memories, sleep disturbance, and hypervigilance, they occurred only occasionally. The VA examiner noted that these symptoms had a very mild impact on the Veteran's social relationships, mood, and activities. The VA examiner stated that the Veteran demonstrated no occupational or social impairment at the time. The prognosis was noted as good and a GAF score of 72 was assigned, reflecting transient PTSD symptoms with no more than slight impairment in social, occupational, or school functioning. See DSM-IV at 46-47. The Veteran was afforded another VA PTSD examination in August 2012, where the examiner continued the diagnosis of PTSD and provided a GAF score of 70, indicative of mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. See DSM-IV at 46-47. The VA examiner indicated that the Veteran's level of social and occupational impairment associated with PTSD was mild to transient, with decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. During the evaluation, the Veteran stated that he had several close friends and he attended his children's activities when he had time. The Veteran reported that he avoided crowds, has anger outburst, and disliked family gatherings. The Veteran was employed as a helicopter pilot in a supervisory position and reported that he was stressed by problems brought to him at work. The Veteran denied concentration or memory problems affecting his job. The Veteran also reported that he had not participated in mental health treatment for the last 18 months. The August 2012 VA examiner noted that the Veteran experiences depressed mood, anxiety, suspiciousness, panic attacks occurring weekly or less, and difficulty in establishing and maintaining effective work or social relationships. The Board notes that a mental status examination was not performed during the August 2012 VA examination. In a December 2012 statement, the Veteran reported that his PTSD disability was troublesome. Specifically, he stated: "At one time I thought I was over it [PTSD], then it returns as severe as ever. It's dishearting." Initial PTSD Rating from November 7, 2008 to March 24, 2011 Upon review of the evidence of record above, the Board finds that from November 7, 2008 to March 24, 2011, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as: sleep impairment, nightmares, anxiety, anger and irritability, disturbance of motivation and mood, difficulty in establishing and maintaining relationships, more nearly approximating a 50 percent rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. The most probative evidence of record that relates to this rating period includes the February 2008 and October 2008 VA mental health treatment note (discussed in detail above), where the Veteran reported sleep impairment, trouble with concentration, short-term memory loss, erratic eating behavior, decreased energy level, moodiness, depression, irritability and anger. The VA psychiatrists diagnosed the Veteran with PTSD and depression and assigned a GAF score of 70, indicative of mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. In the March 2009 VA examination the Veteran reported symptoms of intrusive memories, nightmares, distress when exposed to military reminders, hyperarousal, avoidance of crowds, loss of interest in pleasurable activities, anxiety, anger and irritability, difficulty with concentration and memory, and numbness and detachment from others. The Veteran stated that he felt walled off, numbed, distant and detached from others. It was noted that the Veteran appeared somewhat depressed and affect was constricted. Thoughts were clear and goal oriented. There was no evidence of delusions, hallucination, panic, paranoia, or suicidal or homicidal ideation. Cognitive abilities were grossly intact, although the Veteran did report some difficulties with concentration and focus. The VA examiner diagnosed the Veteran with PTSD and assigned a GAF score of 55, indicative of moderate symptoms or moderate difficulty in social, occupational, or school functioning. See DSM-IV at 46-47. Upon review of the evidence, The Board finds that the evidence is in relative equipoise as to whether a rating in excess of 30 percent is warranted for the period from November 7, 2008 to March 24, 2011. In this regard, the Board finds that the Veteran's PTSD disability reflected both mild to moderate symptoms and mild to moderate difficulty in social, occupational, or school functioning. For example, the Veteran suffered from sleep impairment, anxiety, and hypervigilance, which are contemplated under the criteria for a 30 percent rating. However, the Veteran's disturbance of motivation (lack of interest) and mood (depression), and difficulty in establishing and maintaining relationships (numbing and detachment from others), are specifically listed in the 50 percent rating criteria. The reported difficulties with concentration, memory, and focus are also contemplated under the 50 percent PTSD rating criteria. See 38 C.F.R. § 4.130, Diagnostic Code 9411. As for the GAF scores, they also reflect both mild to moderate symptoms and mild to moderate difficulty in social, occupational, or school functioning. For example, the February 2008, October 2008, and May 2009 VA mental health treatment notes assigned GAF scores of 70, 70, and 75, respectively, indicative of mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. The March 2009 VA examiner, however, assigned a GAF score of 55, which contemplates moderate symptoms or moderate difficulty in social, occupational, or school functioning. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that a 50 percent evaluation for PTSD is warranted for the initial rating period from November 7, 2008 to March 24, 2011. 38 C.F.R. §§ 4.3, 4.7. The Board further finds that a higher rating in excess of 50 percent is not warranted for the initial rating period from November 7, 2008 to March 24, 2011. After reviewing the evidence of record, the Board finds that, for this period, the Veteran's PTSD has not been characterized by 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. Here, the Board finds that the Veteran's PTSD symptoms do not demonstrate occupational and social impairment in most areas, such as work, school, family relations, judgment, thinking, or mood. See Vazquez-Claudio v. Shinseki, 2012-7114 (Fed. Cir. Apr. 8, 2013) (finding that although the veteran's symptomatology is the primary consideration, § 4.130 also requires an ultimate factual conclusion as to the veteran's level of impairment in "most areas"). For example, the Veteran reported having some close friends, a great relationship with his wife, and participated in his children's activities. The Veteran stated that he works in a supervisory role as a helicopter pilot. Further, although the Veteran experiences depressed mood, his symptoms are not near-continuous as contemplated by a 70 percent disability rating. The Veteran's judgment and thinking have been deemed to be within normal limits in the VA examinations of record. The Veteran has consistently denied suicidal and homicidal ideation. His speech has not been found to be illogical, obscure, or irrelevant. For these reasons, the Board finds that the weight of the evidence of record does not demonstrate that the Veteran's PTSD causes occupational and social impairment in most areas, such as work, school, family relations, judgment, thinking, or mood. Accordingly, the Board finds that a 70 percent disability evaluation is not warranted for this period. Initial PTSD Rating from March 24, 2011 to Present As discussed in detail above, the RO assigned a staged PTSD disability rating of 10 percent for the initial rating period from March 1, 2013. The 10 percent rating was based, in large part, on the March 24, 2011 VA examination report. Upon review of the evidence of record, the Board finds that a higher initial rating of 30 percent for the period from March 1, 2013 is more nearly approximated, but a rating in excess of 30 percent is not warranted for the period from March 24, 2011 to the present. In this regard, the Board finds that, for the period beginning March 24, 2011, the evidence of record demonstrated that the Veteran's PTSD disability more nearly approximates the criteria for a 30 percent rating, as it was manifested by symptoms such as: nightmares, sleep impairment, irritability, and hypervigilance, which cause some occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. For example, the evidence demonstrate that although the Veteran had concentration problems in the past, in the March 24, 2011 VA examination, he reported that he was able to read and study well. He stated that his marriage was great, denied physical problems and reported that he had lost weight through diet and exercise. Despite continuing intrusive thoughts, the Veteran stated "I don't dwell on them anymore." He further reported that intrusive thoughts only lasted 20 to 60 seconds and that he was then able to "move on." The Veteran continued to report avoiding packed rooms and large crowds; however, the Veteran noted that this now bothered him as opposed to "enraging" him. As for sleep impairment, the Veteran stated that, once he fell asleep, he was able to maintain his sleep. The Veteran credited his improvement on treatment received for anger and depression for approximately 18 months and was currently not obtaining any mental health treatment. The March 2011 VA examiner noted that the Veteran continued to have PTSD, but at a markedly improved level than in the past. Although the Veteran had some problems with intrusive memories, sleep disturbance, and hypervigilance, they occurred only occasionally and had a very mild impact on the Veteran's social relationships, mood, and activities. The VA examiner stated that the Veteran demonstrated no occupational or social impairment at the time. The prognosis was noted as good and a GAF score of 72 was assigned, reflecting transient PTSD symptoms with no more than slight impairment in social, occupational, or school functioning. See DSM-IV at 46-47. Thereafter, in a subsequent VA PTSD examination in August 2012, the Veteran stated that he had several close friends and he attended his children's activities when he had time. The Veteran was employed as a helicopter pilot in a supervisory position and reported that he was stressed by problems brought to him at work. The Veteran denied concentration or memory problems affecting his job. He also reported that he had not sought mental health treatment for the last 18 months. The August 2012 VA examiner noted symptoms of depressed mood, anxiety, suspiciousness, panic attacks occurring weekly or less, and difficulty in establishing and maintaining effective work and social relationships. The examiner assigned a GAF score of 70, indicative of mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. See DSM-IV at 46-47. The VA examiner indicated that the Veteran's level of social and occupational impairment associated with PTSD was mild to transient, with decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. As for the GAF scores, the Board notes that the March 2011 and August 2012 VA examiners assigned GAF scores of 72 and 70, respectively. The Board finds that these scores reflect mild to transient PTSD symptoms with no more than mild to slight impairment in social, occupational, or school functioning. See DSM-IV at 46-47. For these reasons, the Board finds that, for the initial rating period from March 24, 2011 to the present, the Veteran's PTSD symptoms, in addition to the assigned GAF scores of 72 and 70, and the level of social and occupational impairment, do not warrant a PTSD disability rating in excess of 30 percent. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Initial Rating Beginning March 1, 2013 The Board notes that the March 1, 2013 effective date for the 10 percent PTSD disability rating was assigned pursuant to the purported reduction provisions of 38 C.F.R. § 3.105(e) (final rating action will be taken and award will be reduced or discontinued effective the last day of the month in which a 60-day period from the date of notice to the veteran expires). As discussed in the previous sections, the April 2009 initial rating decision was not final; as such, the purported November 2012 reduction has been recharacterized as a "staged" rating for the period from March 1, 2013. Accordingly, because the March 1, 2013 effective date was based on procedural requirements, rather than the lay and medical evidence of record, the Board will assign a rating for this stage based on the evidence. For the reasons explained in the previous section, resolving reasonable doubt in the Veteran's favor, the Board finds that a 30 percent rating is warranted for the period from March 1, 2013 to the present. As analyzed in the previous section addressing the appropriate rating for the period from March 24, 2011 to the present, the Board finds that a higher rating in excess of 30 percent is also not warranted for the period beginning March 1, 2013. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether referral for an extraschedular is warranted for 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 all the symptomatology and impairment caused by the Veteran's PTSD with depressive disorder is contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, 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 has, at worst, manifested sleep impairment, nightmares, anxiety, anger and irritability, disturbance of motivation and mood, difficulty in establishing and maintaining relationships. 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 at 443. The levels of occupational and social impairment are also 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 problems reported by the Veteran are contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with an acquired psychiatric disorder, 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 initial rating of 50 percent for PTSD for the period from November 7, 2008 to March 24, 2011 is granted; a rating in excess of 30 percent from March 24, 2011 to March 1, 2013 is denied; and a rating of 30 percent beginning March 1, 2013 is granted. REMAND A remand is required in this case to ensure that there is a complete record upon which to decide the Veteran's claims for service connection for a right knee strain and sleep apnea. VA has a duty to make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the claim for the benefits sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A(a) (West 2002); 38 C.F.R. § 3.159(c), (d) (2012). Generally, 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). Service Connection for Right Knee Strain In regard to the claim for service connection for a right knee strain, the Veteran contends that his condition is due to an in-service injury to his knee. Specifically, the Veteran stated that he injured his knee in service after two or three falls climbing in and out of vehicles. The Board notes that an in-service statement of medical examination reveals that the Veteran suffered a right knee sprain during physical training in July 2005. The Veteran was afforded a VA fractures and bone disease examination in March 2009. The VA examiner diagnosed the Veteran with a right knee strain and opined that the Veteran's joint pains were not due service based on "lack of injury." The examiner stated that the Veteran's joint pain was most likely due to the aging process. The Board finds the March 2009 VA opinion to be inadequate. The VA examiner provided a nexus opinion based on the inaccurate determination that the Veteran's joint pain was not due to service because of no injury in service. This contradicts the July 2005 in-service statement of medical examination which revealed that the Veteran did suffer a right knee strain during service. Further, the VA examiner did not address the Veteran's statements regarding in-service injuries to his right knee. As such, the Board finds that the March 2009 VA examiner's opinion was based on factually inaccurate assumptions that the Veteran did not sustain a knee strain in service. For these reasons, the examination opinion was inadequate, and a new VA orthopedic (knee) examination and opinion should be obtained on remand. Service Connection for Sleep Apnea As to the Veteran's claim for service connection for sleep apnea, the Board finds that a VA examination is also warranted. Pursuant to VA's duty to assist, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4)(i) (2012). A medical examination or medical opinion may be deemed necessary where the record contains competent medical evidence of a current diagnosed disability or recurrent symptoms of a disability, establishes that the veteran suffered an event, injury or disease in service, and indicates that the claimed disability may be associated with the established event, injury or disease in service. See Id; McLendon v. Nicholson, 20 Vet App. 79, 83 (2006). The Veteran has not been afforded a VA examination to address service connection for sleep apnea. The Veteran has a current diagnosis of moderate sleep disordered breathing. See January 2008 polysomnography report from the Sleep Disorder Center. The Veteran is currently using a continuous positive airway pressure (CPAP) machine for his sleep disorder. The Veteran states that he was diagnosed with a sleep disorder in January 2008, only four months after service separation in September 2007. Although the Veteran claims that he was unaware of his sleep disorder in service (due to the inability to observe one's own sleeping patterns), he stated that his wife told him that he would stop breathing while sleeping. The Board notes that the Veteran's wife is purportedly a nurse. Although there is no statement in the record directly from the wife, the Veteran's statements regarding his wife's observations have remained consistent throughout the record. For example, in the January 2008 sleep study report from the Sleep Disorder Center, conducted only four months after service separation, and prior to the Veteran's claim for VA compensation, the Veteran reported complaints of nonrestorative sleep, as well as his wife observing snoring and breathing cessation. In a follow-up treatment note from the Sleep Disorder Center, dated March 2008, the Veteran stated that his wife was telling him that he stopped breathing while sleeping. In his December 2008 claim for service connection for sleep apnea, the Veteran reported that soon after he returned home, his wife noticed that he was having problems breathing during sleep. The Veteran reported that he would stop breathing several times during the night. In an October 2009 statement, the Veteran reported that his wife noticed that he was having problems breathing while sleeping during service while on R&R (rest and recuperation) and soon after service separation. For these reasons, a VA examination to obtain a medical nexus opinion on the question of whether current sleep apnea had its onset during service is warranted. See McLendon, 20 Vet. App. at 83. Further, the last VA treatment record is dated February 22, 2012 from the Mount Vernon VA Medical Center (VAMC). On remand, updated VA treatment records should be obtained and associated with the claims file or the Virtual VA electronic claims file. Accordingly, the claims for service connection for a right knee strain and sleep apnea are REMANDED for the following action: 1. The RO/AMC should obtain all VA treatment records from the Mount Vernon VAMC from February 22, 2012 to the present. Any documents received by VA should be associated with the record. Any negative responses should be properly documented in the record. 2. Thereafter, schedule the Veteran for a VA orthopedic (knee) examination to assist in determining the nature and etiology of his right knee disorder. The examiner is requested to offer the following opinion: Is it as likely as not that the current right knee disorder is (probability of 50 percent or greater) a result of military service, to include any knee injury in service? The examiner is asked to specifically address the July 2005 in-service statement of medical examination reflecting right knee sprain. All examination findings, along with rationale for all opinions expressed, should be set forth in the examination report. 3. Schedule the Veteran for a VA examination to assist in determining the nature and etiology of his sleep disorder. The examiner is requested to offer the following opinion: Is it as likely as not that the current sleep apnea is (probability of 50 percent or greater) a result of military service? The examiner should specifically discuss the January 2008 diagnosis of moderate sleep disordered breathing, rendered four months after service separation. The examiner is also asked to specifically discuss the Veteran's lay statements regarding his wife's observations that he stopped breathing (apneas) while sleeping during a period of R&R (rest and recuperation) and after service separation. All examination findings, along with rationale for all opinions expressed, should be set forth in the examination report. 4. After all development has been completed, the RO/AMC should readjudicate the issues of service connection for right knee strain and sleep apnea. If the benefits sought remain denied, the Veteran and his representative should be furnished a supplemental statement of the case, and be given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. 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 Veteran is advised to appear and participate in any scheduled VA examination(s), as failure to do so may result in denial of the claim(s). See 38 C.F.R. § 3.655 (2012). 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 Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board is appealable to the Court. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012). Department of Veterans Affairs