Citation Nr: 1325368 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 08-16 560A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a total disability rating based on individual unemployability (TDIU). 2. Entitlement to an initial rating greater than 30 percent for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). 3. Entitlement to an initial compensable rating prior to April 29, 2008, and to an initial rating greater than 10 percent prior to July 31, 2012, and effective November 1, 2012, for left ankle arthritis. 4. Entitlement to an initial compensable rating prior to August 6, 2010, and to an initial rating greater than 10 percent effective December 1, 2010, for right ankle arthritis. REPRESENTATION Appellant represented by: John V. Tucker, attorney WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Michael T. Osborne, Counsel INTRODUCTION The Veteran had active service from November 1979 to October 1989 and additional U.S. Army Reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied, in pertinent part, the Veteran's claims of service connection for an acquired psychiatric disability, to include PTSD (which was characterized as separate service connection claims for adjustment disorder with anxiety and for PTSD), left ankle arthritis (which was characterized as left ankle sprain), and for right ankle arthritis (which was characterized as a right ankle condition). A RO hearing was held on these claims in March 2008 and a copy of the hearing transcript has been added to the record. In a May 2008 rating decision, the RO granted the Veteran's claims of service connection for an acquired psychiatric disability, to include PTSD (which was characterized as PTSD), assigning a 30 percent rating effective March 22, 2006, left ankle arthritis, assigning a zero percent rating effective March 22, 2006, and for right ankle arthritis, assigning a zero percent rating effective March 22, 2006. This matter also is on appeal from an August 2008 rating decision in which the RO denied, in pertinent part, the Veteran's TDIU claim. In a November 2009 rating decision, the RO granted service connection for an acquired psychiatric disability, to include PTSD (which was characterized as adjustment disorder with anxiety and depressed mood). The RO combined this disability with the 30 percent rating assigned for the Veteran's service-connected PTSD. Having reviewed the evidence of record, the Board finds that this issue is characterized more appropriately as stated on the title page of this decision. In February 2011 and in January 2012, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. A review of the claims file shows that there has been substantial compliance with the Board's remand directives. The Board remanded this appeal in February 2011 to schedule the Veteran for a Travel Board hearing. A Travel Board hearing was held at the RO in June 2013 before the undersigned Veterans Law Judge and a copy of the hearing transcript has been added to the record. In its January 2012 remand, the Board directed the RO/AMC to attempt to obtain the Veteran's up-to-date VA and private treatment records. These records subsequently were associated with the Veteran's claims. The Board also directed the RO/AMC to schedule the Veteran for VA examinations to determine the current nature and severity of his service-connected disabilities and to determine their impact on his employability. These examinations occurred in May and June 2012. See Stegall v. West, 11 Vet. App. 268 (1998); see also Dyment v. West, 13 Vet. App. 141 (1999) (holding that another remand is not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In a March 2011 rating decision, the RO assigned, in pertinent part, a temporary total rating effective August 6, 2010, for the Veteran's service-connected right ankle arthritis based on surgery or other treatment necessitating convalescence. A 10 percent rating was assigned effective December 1, 2010, the first day of the month following completion of convalescence. See 38 C.F.R. § 4.30 (2012). Thus, this issue is as stated on the title page of this decision. In an October 2012 rating decision, the RO assigned, in pertinent part, a temporary total rating effective July 31, 2012, for the Veteran's service-connected left ankle arthritis based on surgery or other treatment necessitating convalescence. A 10 percent rating was assigned effective November 1, 2012, the first day of the month following completion of convalescence. Id. Thus, this issue is as stated on the title page of this decision. FINDINGS OF FACT 1. Resolving all reasonable doubt in the Veteran's favor, the record evidence suggests that his service-connected disabilities preclude him from securing or maintaining substantially gainful employment. 2. The record evidence indicates that the Veteran's service-connected acquired psychiatric disability, to include PTSD, is manifested by, at worst, occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; there is no evidence of reduced reliability and productivity, deficiencies in most areas, or total occupational and social impairment. 3. The record evidence indicates that, prior to April 29, 2008, the Veteran's service-connected left ankle arthritis was not manifested by at least moderate limitation of motion of the ankle. 4. The record evidence indicates that, between April 29, 2008, and July 31, 2012, and effective November 1, 2012, the Veteran's service-connected left ankle arthritis is manifested by, at worst, moderate limitation of motion of the ankle. 5. The record evidence indicates that, prior to August 6, 2010, the Veteran's service-connected right ankle arthritis was not manifested by at least moderate limitation of motion of the ankle. 6. The record evidence indicates that, effective December 1, 2010, the Veteran's service-connected right ankle arthritis is manifested by, at worst, moderate limitation of motion of the ankle. CONCLUSIONS OF LAW 1. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.16(a) (2012). 2. The criteria for an initial rating greater than 30 percent for an acquired psychiatric disability, to include PTSD, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9411 (2012). 3. The criteria for an initial compensable rating prior to April 29, 2008, and to an initial rating greater than 10 percent prior to July 31, 2012, and effective November 1, 2012, for left ankle arthritis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5010-5271 (2012). 4. The criteria for an initial compensable rating prior to August 6, 2010, and to an initial rating greater than 10 percent effective December 1, 2010, for right ankle arthritis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5010-5271 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before assessing the merits of the appeal, VA's duties under the Veterans Claims Assistance Act of 2000 (VCAA) must be examined. The VCAA provides that VA shall apprise a claimant of the evidence necessary to substantiate his claim for benefits and that VA shall make reasonable efforts to assist a claimant in obtaining evidence unless no reasonable possibility exists that such assistance will aid in substantiating the claim. Given the favorable disposition of the action here with respect to the Veteran's TDIU claim, which is not prejudicial to him, the Board need not assess VA's compliance with the VCAA with respect to this claim. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). With respect to the Veteran's higher initial rating claims for an acquired psychiatric disability, left ankle arthritis, and for right ankle arthritis, the Board notes that these claims are "downstream" elements of the RO's grant of service connection for each of these disabilities in the currently appealed rating decision. For such downstream issues, notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159 is not required in cases where such notice was afforded for the originating issue of service connection. See VAOPGCPREC 8-2003 (Dec. 22, 2003). Courts have held that once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d. 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In May 2006, May 2008, and in January and April 2009, VA notified the Veteran of the information and evidence needed to substantiate and complete the service connection claims, including what part of that evidence he was to provide and what part VA would attempt to obtain for him. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187. With respect to the timing of the notice, the Board points out that the Court has held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the May 2006 VCAA notice was issued to the Veteran and his service representative prior to the currently appealed rating decision issued in May 2008; thus, this notice was timely. Because all of the Veteran's higher initial rating claims are being denied in this decision, any question as to the appropriate disability rating or effective date is moot. See Dingess, 19 Vet. App. at 473. And any defect in the notices provided to the Veteran and his service representative has not affected the fairness of the adjudication. See Mayfield, 444 F.3d at 1328. The Board is aware of the decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) in which the Court held that, for an increased-compensation claim, section § 5103(a) requires, at a minimum, VA notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life. Relying on the informal guidance from VA's Office of General Counsel (OGC) and a VA Fast Letter issued in June 2008 (Fast Letter 08-16; June 2, 2008), the Board finds that Vazquez-Flores is not applicable. According to OGC, because this claim concerns an appeal from an initial rating decision, VCAA notice obligations are satisfied fully once service connection has been granted. Any further notice and assistance requirements are covered by 38 U.S.C. §§ 5104(a), 7105(d)(1), and 5103A as part of the appeals process, upon the filing of a timely NOD with respect to the initial rating or effective date assigned following the grant of service connection. The Board also notes that appropriate Vazquez-Flores notice was provided to the Veteran and his service representative in May 2009. In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id., at 490-91. To the extent that Dingess requires more extensive notice as to potential downstream issues such as disability rating and effective date, because the currently appealed rating decision was fully favorable to the Veteran on the issue of service connection, and because the Veteran was fully informed of the evidence needed to substantiate his claims, the Board finds no prejudice to the Veteran in proceeding with the present decision. See also Bernard , 4 Vet. App. at 394. The Board also finds that VA has complied with the VCAA's duty to assist by aiding the Veteran in obtaining evidence and affording him the opportunity to give testimony before the RO and the Board. It appears that all known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; the Veteran has not contended otherwise. The Veteran's Virtual VA claims file has been reviewed. The Veteran's complete Social Security Administration (SSA) records also have been obtained and associated with the claims file. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. 3.103(c)(2) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the basis of the prior determination and noted the element of the claims that was lacking to substantiate the claims for benefits. The VLJ specifically noted the issues as entitlement to increased ratings for PTSD, a left ankle disability, and for a right ankle disability. The Veteran was assisted at the hearing by an accredited representative from Disabled American Veterans. The representative and the VLJ then asked questions to ascertain whether the Veteran had submitted evidence in support of his claims. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. The representative specifically asked the Veteran about any worsening of relevant symptomatology since active service. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor identified any prejudice in the conduct of the Board hearing. By contrast, the hearing focused on the element necessary to substantiate the claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of the element necessary to substantiate his claims for benefits. The Veteran's representative and the VLJ asked questions to draw out the evidence which demonstrated worsening of the Veteran's service-connected acquired psychiatric disability and bilateral ankle disabilities, the only element of the claims in question. As such, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that any error in notice provided during the Veteran's hearing constitutes harmless error. In August 2006, the National Personnel Records Center in St. Louis, Missouri (NPRC), notified VA that, with the exception of an enlistment physical examination dated in October 1979, it had no service treatment records for the Veteran. In cases where the Veteran's service treatment records (or other pertinent records, for that matter) are unavailable through no fault of the claimant, there is a heightened obligation to assist the claimant in the development of his or her case. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). VA also must provide an explanation to the appellant regarding VA's inability to obtain his or her service treatment records. Dixon v. Derwinski, 3 Vet. App. 261 (1992). The Court further has held that VA's efforts to obtain service department records shall continue until the records are obtained or unless it is reasonably certain that such records do not exist or that further efforts to obtain those records would be futile. Hayre v. West, 188 F.3d 1327 (Fed. Cir. 1999); see also McCormick v. Gober, 14 Vet. App. 39 (2000). The Board observes in this regard that the Veteran has contended strenuously that his complete service treatment records were in possession of VA many years ago when he first sought VA disability compensation (and well before he filed his currently appealed claims) at the RO in New York City, New York, and VA must have lost these records while they were in its possession. A detailed review of the claims file does not support his assertions concerning the location of his complete service treatment records. It shows instead that VA has attempted to obtain the Veteran's complete service treatment records on numerous occasions since he separated from active service in October 1989 and joined the U.S. Army Reserve. It appears that the Veteran's U.S. Army Reserve unit may have lost his complete service treatment records after they were sent to that unit by his active duty unit following his separation from active service and transfer to the U.S. Army Reserve. It also appears that the Veteran's complete service treatment records have never been in VA's possession, including at any time during the pendency of this appeal. The RO made a formal finding in September 2006 that it was reasonably certain that the Veteran's complete service treatment records do not exist and further efforts to obtain them would be futile. The Board agrees. The Veteran has been provided with VA examinations which address the current nature and severity of his service-connected acquired psychiatric disability, left ankle arthritis, and right ankle arthritis. Given that the pertinent medical history was noted by the examiners, these examination reports set forth detailed examination findings in a manner which allows for informed appellate review under applicable VA laws and regulations. Thus, the Board finds the examinations of record are adequate for rating purposes and additional examination is not necessary regarding the claims adjudicated in this decision. See also 38 C.F.R. §§ 3.326, 3.327, 4.2. In summary, VA has done everything reasonably possible to notify and to assist the Veteran and no further action is necessary to meet the requirements of the VCAA. TDIU The Veteran contends that he is entitled to a TDIU. He specifically contends that his service-connected disabilities preclude him from securing or maintaining substantially gainful employment. Law and Regulations The Veteran may be awarded a TDIU upon a showing that he is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. Consideration may be given to his level of education, special training, and previous work experience in making this determination, but not to his age or impairment caused by disabilities that are not service connected. See 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19. To qualify for a total rating for compensation purposes, the evidence must show: (1) a single disability rated as 100 percent disabling, or (2) that the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. If there is only one service-connected disability, it must be rated at least 60 percent disabling. If there is more than one disability, then at least one disability must be rated at least 40 percent disabling, and the Veteran must have a combined disability rating of at least 70 percent. Id. Factual Background The record evidence shows that, following VA PTSD examination in July 2008, the VA examiner opined, " There are no psychological reasons this Veteran is not able to obtain or maintain employment." The Veteran also denied that his current unemployment was due to the effects of his service-connected acquired psychiatric disability, to include PTSD. Following VA joints examination in July 2008, the VA examiner discussed the Veteran's employment limitations. This examiner stated that the Veteran's service-connected rupture of the long head of the right biceps brachia resulted in "no prolonged or repeated lifting and no lifting of over 30 pounds." This examiner also stated that the Veteran's service-connected lumbosacral spine disability resulted in "light or sedentary employment with no prolonged standing or repeated bending." The Veteran's service-connected bilateral knee disabilities resulted in "no prolonged walking or standing and light or sedentary employment." Following VA joints examination in August 2008, the VA examiner opined that the Veteran's service-connected rupture of the long head of the right biceps brachia, bilateral ankle disabilities, and bilateral knee disabilities "should not preclude him from sedentary occupations." The Veteran's SSA records show that he was awarded SSA disability benefits in November 2008 for cervicalgia and for affective/mood disorder. These records also consist largely of duplicate copies of the Veteran's VA outpatient treatment records and examination reports. On VA outpatient treatment in August 2011, the Veteran complained "he had a terrible summer in which he experienced poor sleep, visual hallucinations of soldiers, nightmares in which he [relived] the jump from the airplane during which he hung from a caught parachute under the plane, irritability, social isolation, and intense anger." He also complained of "a great deal of pain in his right arm and shoulder and has a knot in his bicep that prevents him from full range of motion with his arm." He recently had returned from spending the summer with his family in the Dominican Republic. The VA clinician stated, "Despite intensive group and individual therapy for PTSD, [the Veteran] continues to suffer from flashbacks, nightmares, hyperarousal, social inadequacy, and angry outbursts. These conditions render him permanently and totally disabled, and permanently and totally unemployable." This clinician noted that the Veteran last had been able to work in 2006 when he had been a taxi driver. "Since 2006 he has been unable to work due to anxiety, depression (i.e. resulting in excess sick days), low frustration tolerance (with potential for impulsive outbursts of irritability which can escalate rapidly to anger or rage), and memory and attention problems (related to psychiatric conditions, chronic pain, and psychotropic and other medication side-effects)." This clinician stated that these problems "will render [the Veteran] unable to perform job duties, keep up with job demands, and handle the interpersonal requirements of employment." In a September 2011 letter, a VA primary care physician stated that he had reviewed the Veteran's medical records "and you have stated that you have not been able to work since September of 2006 due to your Neuropathy, PTSD, Depression, and chronic medical conditions." In a February 2012 letter, a VA staff chaplain at the VA Medical Center in Tampa, Florida, stated that the Veteran had told him that SSA had determined that he was unemployable. "Further, this Veteran continues to complain of constant pain in his arm, shoulder, neck, right ankle, and feet. He spoke of his inability to focus on tasks assigned or involved in, which to, is causing [sic] him unfortunate distress and worry." On VA general medical - pension Disability Benefits Questionnaire (DBQ) in May 2012, the Veteran's complaints included left ankle laxity leading to falls and right ankle pain at the Achilles insertion and mid-foot. The VA examiner stated that he had reviewed the Veteran's VA medical treatment records. The Veteran was not a patient in a nursing home for long-term care because of disability or currently hospitalized. He also was not currently employed. X-rays of the bilateral ankles showed calcaneal posterior enthesopathy formation "with no other significant abnormality or change." The VA examiner stated that the Veteran's disabilities of the ankles, knees, and lumbar spine would not prevent him from securing or following a substantially gainful occupation. Following VA ankle conditions DBQ in May 2012, the VA examiner stated, "Due to instability of left ankle and foot pain more prominent after right ankle stabilization surgery, the Veteran needs sedentary employment to prevent falls at least until after left ankle stabilization surgery is completed and healed." Following VA PTSD DBQ in June 2012, including a review of the Veteran's claims file, his service treatment records, and post-service VA treatment records. the VA examined opined, " It cannot be determined without resorting to mere speculation whether the Veteran is unemployable." The rationale for this opinion concerning the Veteran's unemployability was: The current nature and severity of the Veteran's mental health condition, if any is unclear. Test results are highly suggestive of exaggeration, possibly for secondary gain. In addition, though some clinicians have stated that the Veteran is severely impaired and unemployable due to PTSD, others have indicated that his impairment is mild, and all have documented his fluctuating (rather than consistent and severe) course of symptoms. This examiner stated that the Veteran's earlier Global Assessment of Functioning (GAF) scores, diagnoses, and estimates of his functioning appeared to be based entirely on his subjective reports rather than on objective testing "as was done in this exam. There are also some inconsistencies in behavior and functioning that the Veteran reported in the interview today. Given his tendency to exaggerate on objective measures, his reports in the interview and to clinicians may be questionable." This examiner also stated: An important point to remember is that an individual can exaggerated psychiatric symptoms and have a coexisting psychiatric disorder[]. Individuals can also have one psychiatric disorder and be faking or exaggerating symptoms of other disorders. Likewise, individuals can have a psychiatric condition and exaggerate or fake the symptoms of that condition, the persistence of symptoms of that condition, or the impact of those symptoms on their functioning. This examiner noted that the Veteran "appear[ed] to show increased distress due to worsening medical health...and it is possible that he has a mood disorder due to a medical condition. PTSD also [is] a possibility as he reports symptoms consistent with it and has been consistently diagnosed with it in the past." This examiner concluded in June 2012: It is difficult to determine any individual's true level of functioning when there is significant exaggeration of symptoms with or without the intent to malinger. The relationship between this Veteran's reported mental health and his current occupational and social functioning is unclear and any attempt to determine his true functional impairment (social or occupational) can only be done through the use of mere speculation. Given his report of being able to engage in various social activities...he may be employable in some domains, however, this cannot be stated with any reliability. The examiner finally cited to multiple articles in the medical literature as support for her opinion concerning the Veteran's unemployability. Following VA hearing loss and tinnitus DBQ in July 2012, the VA audiologist opined that it was at least as likely as not that the Veteran's current hearing loss "would mildly to moderately impact physical and sedentary employment; however, it would not cause him to be unemployable." This audiologist also opined that it was less likely as not that the Veteran's tinnitus would "cause an impact on" his employment. The audiologist's rationale was the Veteran had reported "having difficulties keeping up with the conversations" and had been unable to use his hearing aids properly although they helped him manage his tinnitus. The Veteran testified at his June 2013 Board hearing that he had been unemployed since September 2006. See Board hearing transcript dated June 5, 2013, at pp. 9. He also testified that he had been unable to do any lifting at his last job as a taxi driver before he stopped working. Id. He testified further that his service-connected bilateral ankle disabilities, lumbosacral spine disability, bilateral knee disabilities, and acquired psychiatric disability, to include PTSD, all prevented him from being employed. Id., at pp. 13. Analysis The Board finds that the evidence is in relative equipoise as to whether the Veteran's service-connected disabilities, alone or in combination, preclude him from securing and maintaining a substantially gainful occupation, entitling him to a TDIU. The Board acknowledges initially that service connection currently is in effect for osteoarthritis of the lumbar spine, evaluated as 40 percent disabling effective August 8, 2008, rupture of the long head of the right biceps brachia, evaluated as 30 percent disabling effective June 18, 2003, an acquired psychiatric disability, to include PTSD, evaluated as 30 percent disabling effective March 22, 2006, bilateral hearing loss, evaluated as 10 percent disabling effective October 18, 1993, tinnitus, evaluated as 10 percent disabling effective November 8, 1993, bilateral knee arthritis, evaluated as 10 percent disabling in each knee effective March 22, 2006, right ankle arthritis, evaluated as 10 percent disabling effective December 1, 2010, and for left ankle arthritis, evaluated as 10 percent disabling effective November 1, 2012. The Veteran's combined disability evaluation is 90 percent effective November 1, 2012. Thus, he meets the schedular criteria for a TDIU. See 38 C.F.R. § 4.16(a) (2012). The Board also acknowledges that SSA has found the Veteran to be unemployable; however, VA is not bound by any determination reached by SSA. There is competent evidence both for and against the Veteran's TDIU claim. For example, on VA outpatient treatment in August 2011, the VA clinician stated that the Veteran's symptomatology attributable to his service-connected acquired psychiatric disability, to include PTSD (which was diagnosed as PTSD and major depressive disorder), "render[s] him permanently and totally disabled, and permanently and totally unemployable." This clinician also stated that this symptomatology "will render [the Veteran] unable to perform job duties, keep up with job demands, and handle the interpersonal requirements of employment." By contrast, the VA examiner essentially determined on VA joints examination in July 2008 that the Veteran was limited to sedentary employment. This suggests that the Veteran was not precluded from securing or maintaining substantially gainful employment. A different VA examiner determined on VA joints examination in August 2008 that the Veteran's service-connected orthopedic disabilities did not interfere with his employability. Another VA examiner made a similar determination following VA pension DBQ in May 2012. Finally, a VA audiologist opined in July 2012 that the Veteran's service-connected bilateral hearing loss and tinnitus did not preclude him from securing or maintaining substantially gainful employment. The Board notes in this regard that, in a September 2011 letter, a VA primary care physician stated that he had reviewed the Veteran's medical records "and you have stated that you have not been able to work since September of 2006 due to your Neuropathy, PTSD, Depression, and chronic medical conditions." The Court has held that the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. Wilson v. Derwinski, 2 Vet. App. 614 (1992). A bare transcription of lay history, unenhanced by additional comment by the transcriber, does not become competent medical evidence merely because the transcriber is a medical professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). The Court also has held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Thus, a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Because the September 2011 VA clinician's opinion appears to be based on what the Veteran reported to him concerning the impact of his service-connected disabilities on his employability, the Board finds that this opinion is less than probative on the issue of whether the Veteran is entitled to a TDIU. The Board also notes in this regard that the June 2012 VA PTSD examiner opined, "It cannot be determined without resorting to mere speculation whether the Veteran is unemployable." This examiner provided a comprehensive rationale for this opinion, including citations to the record evidence and relevant medical literature. This examiner noted the inconsistencies in what the Veteran had reported and what other prior clinicians had found on objective examination of the Veteran's service-connected acquired psychiatric disability. This examiner concluded that, in light of the Veteran's possible exaggeration of his symptomatology due to his service-connected acquired psychiatric disability, no reliable opinion concerning the impact of his acquired psychiatric disability, to include PTSD, on his employability could be provided without resorting to mere speculation. The Court has held that, when VA undertakes to provide a Veteran with an examination, that examination must be adequate for VA purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Court also has held that medical opinions using the "mere speculation" language, without more, generally are disfavored because they are inconclusive as to the origin of a disability. See Warren v. Brown, 6 Vet. App. 4, 6 (1993); Sklar v. Brown, 5 Vet. App. 104, 145-6 (1993). The Court has explained that opinions which contain the "mere speculation" language, without more, amount to 'nonevidence' neither for nor against the claim because service connection may not be based on speculation or remote possibility. See Bloom v. West, 12 Vet. App. 185 (1999) (holding that a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). The Court recently held in Jones v. Shinseki, 23 Vet. App. 382 (2010), that, when a medical examiner concludes that he or she is unable to provide a nexus opinion without speculation, this alone does not make the medical opinion inadequate; a medical opinion with such language may be adequate if the examiner sufficiently explains the reasons for this inability. Id. at 389-90. See also Obert v. Brown, 5 Vet. App. 30, 33 (1993) (noting that speculative opinion is not legally sufficient to establish service connection). Before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, however, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence. Cf. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (finding that a medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Furthermore, VA must ensure that any medical opinion, including one that states no conclusion can be reached without resorting to speculation, is "based on sufficient facts or data." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2009). Therefore, it must be clear from either the examiner's statements or the Board's decision that the examiner has considered "all procurable and assembled data" by obtaining all tests and records that might reasonably illuminate the medical analysis. See Daves v. Nicholson, 21 Vet. App. 46 (2007). Having reviewed the Veteran's June 2012 VA PTSD DBQ, the Board finds that the basis for the examiner's opinion that the impact of the Veteran's service-connected acquired psychiatric disability, to include PTSD, on his employability could not be determined without resorting to speculation was explained clearly in this examiner's rationale. See Stefl, 21 Vet. App. at 124. The examiner's opinion also was "based on sufficient facts or data" and, as noted, included citations to multiple articles in the relevant medical literature. See Nieves-Rodriguez, 22 Vet. App. at 295. This persuasively suggests that the June 2012 VA examiner considered "all procurable and assembled data" prior to concluding that an opinion concerning the Veteran's employability could not be provided without resorting to mere speculation. See Daves, 21 Vet. App. at 46. The Board concludes that the June 2012 VA PTSD DBQ is adequate for purposes of evaluating the Veteran's TDIU claim. See Jones, 23 Vet. App. at 382. The Board finds that there is an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim of entitlement to a TDIU. See 38 C.F.R. § 3.102. The Veteran has asserted consistently in lay statements submitted to the RO and in his June 2013 Board hearing testimony that his service-connected disabilities preclude him from employment. There are competent opinions in the voluminous record evidence from multiple VA clinicians that both support and contradict the Veteran's assertions regarding the impact of his service-connected disabilities on his employability. Resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for a TDIU have been met. Higher Initial Rating Claims The Veteran contends that his service-connected acquired psychiatric disability, left ankle arthritis, and right ankle arthritis are all more disabling than currently evaluated. Law and Regulations In general, disability evaluations are assigned by applying a schedule of ratings that represent, as far as can be determined, the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria that must be met for specific ratings. The regulations require that, in evaluating a given disability, the disability be viewed in relation to its whole recorded history. 38 C.F.R. § 4.2; see Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where, as in this case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected acquired psychiatric disability, to include PTSD, currently is evaluated as 30 percent disabling effective March 22, 2006, under 38 C.F.R. § 4.130, DC 9411 (PTSD). See 38 C.F.R. § 4.130, DC 9411 (2012). The Veteran's service-connected left ankle arthritis currently is evaluated as zero percent disabling (non-compensable) effective March 22, 2006, as 10 percent disabling effective April 29, 2008, 100 percent disabling effective July 31, 2012, and as 10 percent disabling effective November 1, 2012, by analogy to 38 C.F.R. § 4.71a, DC 5010-5271 (traumatic arthritis-limited motion of the ankle). See 38 C.F.R. § 4.71a, DC 5010-5271 (2012). The Veteran's service-connected right ankle arthritis currently is evaluated as zero percent disabling effective March 22, 2006, 100 percent disabling effective August 6, 2010, and as 10 percent disabling effective December 1, 2010, by analogy to 38 C.F.R. § 4.71a, DC 5010-5271. Id. The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2012). Disability of the musculoskeletal system is primarily the inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40 (2012). Consideration is to be given to whether there is less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse, instability of station, or interference with standing, sitting, or weight bearing. For the purpose of rating disability from arthritis, the ankle is considered a major joint. 38 C.F.R. § 4.45 (2012). VA must consider "functional loss" of a musculoskeletal disability separately from consideration under the diagnostic codes; "functional loss" may occur as a result of weakness, fatigability, incoordination or pain on motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). VA must consider any part of the musculoskeletal system that becomes painful on use to be "seriously disabled." If a Veteran has separate and distinct manifestations relating to the same injury, he should be compensated under different diagnostic codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). The evaluation, however, of the same manifestation under different diagnostic codes is to be avoided. 38 C.F.R. § 4.14 (2012). The Rating Schedule may not be employed as a vehicle for compensating a claimant twice or more for the same symptomatology, since such a result would overcompensate the claimant for the actual impairment of his earning capacity and would constitute pyramiding. See Esteban, citing Brady v. Brown, 4 Vet. App. 203 (1993). Under 38 C.F.R. §§ 4.40 and 4.45, a Veteran's pain, swelling, weakness, and excess fatigability must be considered when determining the appropriate evaluation for a disability using the limitation of motion diagnostic codes. See Johnson v. Brown, 9 Vet. App. 7, 10 (1996). The Court held in DeLuca that all complaints of pain, fatigability, etc., shall be considered when put forth by a Veteran. Therefore, consistent with DeLuca and 38 C.F.R. § 4.59, the Veteran's complaints of pain have been considered in the Board's review of the diagnostic codes for limitation of motion. As relevant to this claim, a 30 percent rating is assigned under DC 9411 for PTSD manifested by 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) 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). A 50 percent rating is assigned under DC 9411 for PTSD manifested 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 (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned under DC 9411 for PTSD manifested 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 (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), or an inability to establish and maintain effective relationships. A 100 percent rating is assigned under DC 9411 for PTSD manifested by total occupational and social impairment due to such symptoms as gross impairment in thought process 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, and memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, DC 9411 (2012). The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). As relevant to this claim, a GAF score of 51 to 60 is defined as indicating 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). A GAF score of 61 to 70 is indicative of 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. See Carpenter v. Brown, 8 Vet. App. 240, 242- 244 (1995). DC 5010 provides that traumatic arthritis, substantiated by x-ray findings, will be rated as degenerative arthritis under DC 5003. See 38 C.F.R. § 4.71a, DC 5010 (2012). A 10 percent rating is assigned under DC 5003 for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A maximum 20 percent rating is assigned under DC 5003 for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating exacerbations. See 38 C.F.R. § 4.71a, DC 5003 (2012). DC 5271 provides a 10 percent rating for moderate limitation of motion of the ankle. DC 5271 provides a maximum 20 percent rating for marked limitation of motion of the ankle. See 38 C.F.R. § 4.71a, DC 5271 (2012). Factual Background As noted, only the Veteran's October 1979 enlistment physical examination is available for review from his service treatment records from his period of active service. A review of this examination report shows that the Veteran's lower extremities and psychiatric system was normal. The Veteran denied all relevant pre-service medical history. A review of the Veteran's service treatment records from his U.S. Army Reserve (USAR) service shows that, on periodic physical examination in April 1992, clinical evaluation of the Veteran's lower extremities and psychiatric system was normal. The Veteran denied all relevant medical history. On USAR periodic physical examination in January 1996, clinical evaluation of the Veteran's lower extremities and psychiatric system was normal. The Veteran reported a history of bone, joint, or other deformity which referred to a torn biceps on the right side. He denied all other relevant medical history. The post-service evidence shows that, on VA examination in October 1993, no complaints were noted. The diagnoses included negative physical exam. On VA outpatient treatment in June 2003, the Veteran complained that "he is sad & down. He is not able to elaborate." He denied any prior psychiatric treatment. He drank a 12-pack of beer on weekends and "used drugs in the remote past, but denies abuse." He had been married 4 times and his most recent marriage had been ongoing for 2 years. His current wife was not a U.S. citizen and lived in the Dominican Republic with their 18-month-old daughter. His other marriages ended in divorce. He had a 9-year-old daughter whom he did not see and 2 other children "with whom he maintains contact." He was unemployed and had held many jobs. Mental status examination of the Veteran showed accented but fluent speech, full orientation, a mildly depressed mood, cognition within normal limits, goal oriented thought production, poor judgment and insight, no thought/mood disorder, and no suicidal or homicidal ideation. The Veteran was "[n]ot motivated for psychotherapy." His GAF score was 60, indicating moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Axis I diagnosis was rule-out bereavement. The Axis II diagnosis was personality disorder, not otherwise specified. In a July 2003 statement, the Veteran contended that his right leg was always weak, cracking and snapping "out of place," and unstable. On VA outpatient treatment in April 2005, the Veteran complained of left ankle swelling. He denied any left ankle injury. Objective examination showed mild swelling of the left ankle below the external malleolus and an adequate range of motion. The impression was left ankle swelling. In October 2005, the Veteran complained of "problems for some years" and increased nightmares relating to an in-service parachute accident in the previous 2 years. He denied any alcohol use "and says any drug use was years ago." He also denied any current suicidal or homicidal ideation. He was able to sleep adequately. He reported a good relationship with his wife. "No depressive symptoms expressed but does report nervousness, worry, problems concentrating and remembering things, and focus on negative memories. Denied any panic symptoms." The Veteran's GAF score was 60. The impressions were adjustment disorder with anxious mood, rule-out generalized anxiety disorder versus anxiety disorder, not otherwise specified, versus PTSD. In February 2006, the Veteran complained of continued left ankle pain. He reported that his left ankle sprain was "better." Physical examination was deferred. X-rays showed no fractures "but has a calcaneal spur." The impression was left ankle sprain "with air cast still with pain." In March 2006, the Veteran's complaints included intrusive memories, flashbacks, "and 'a lot of depression' associated with non-combat traumatic events he experienced while serving in airborne units and doing parachute jumps in the Army." Mental status examination of the Veteran showed he was "in hospital scrubs" and appropriately groomed with full orientation, good eye contact, normal speech, energy level within normal limits, "visibly tearful while describing traumatic deaths of military comrades," no perceptual disturbance, normal thought process, no unusual thought content, no suicidal or homicidal ideation, and fair judgment and insight. The VA clinician stated that the Veteran "does not meet the FULL diagnostic criteria for PTSD at the present time." The Veteran's GAF score was 59, indicating moderate symptoms. The Axis I diagnoses included adjustment disorder with mixed anxiety and depressed mood. In August 2006, the Veteran complained of right ankle pain and swelling. Physical examination of the right ankle showed external malleolus with mild swelling, an "adequate but painful" range of motion, and warmth when compared to the left ankle. The impression was right ankle pain "suspect probable exacerbation of gout." On VA PTSD examination in March 2008, the Veteran's complaints included a depressed mood and feeling "angry at times." The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran was married and had 2 children. His marital and family relationships were "stable." He had no social relationships but occasionally attended church "when he has gas money." He denied any history of suicide attempts or violence. He was in a "tight" financial situation and "has tried to limit his spending." Mental status examination of the Veteran showed he was neatly groomed, appropriately and casually dressed, unremarkable psychomotor activity, unremarkable speech, a depressed mood, full orientation, unremarkable thought process and thought content, no delusions or hallucinations, reported sleep impairment due to sleep apnea, no inappropriate behavior, obsessive/ritualistic behavior, panic attacks, or suicidal or homicidal ideation, good impulse control, no episodes of violence, an ability to maintain minimum personal hygiene, and normal memory. The Veteran was not employed and had been unemployed for 2-5 years because he had been unable to stay awake and his arm would hurt or fall asleep. The Veteran's GAF score was 69, indicating some mild symptoms or some difficulty in social, occupational, or school functioning but generally functioning pretty well and with some meaningful interpersonal relationships. The VA examiner stated that total occupational and social impairment due to PTSD was not present. He also stated that the Veteran's PTSD did not result in deficiencies in judgment, thinking, family relations, work, mood, or school, an occasional decrease in work efficiency or intermittent periods of an inability to perform occupational tasks, or any transient or mild PTSD symptoms that decreased work efficiency and an ability to perform occupational tasks during periods of significant stress. This examiner also stated that the Veteran's "PTSD symptoms are controlled by continuous medication." He stated further that the Veteran was able to work. The Axis I diagnosis was mild PTSD. On VA joints examination in March 2008, the Veteran's complaints included ankle pain. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran reported that he was right-hand dominant. He denied experiencing any ankle weakness, stiffness, swelling, heat or redness, instability or giving way, locking, fatigability, lack of endurance, or flare-ups of ankle pain. He did not need any assistive devices. He also denied experiencing any episodes of dislocation or recurrent subluxation or history of inflammatory arthritis. Physical examination of the bilateral ankles showed a full range of motion with no change after repetition, a normal gait and posture, no joint ankylosis, pain with motion only when attempting to run "or long walking," no fatigue, weakness, lack of endurance, additional limitation of motion following repetitive use, incoordination, instability, functional limitations on standing, indications of abnormal weightbearing, effusion, redness, or heat, or guarding of movement. Distance walking was limited. "X-rays show some arthritis in the ankles." The diagnoses included arthritis of both ankles. In statements on a June 2008 VA Form 9, the Veteran contended that his service-connected PTSD was "more critical." He specifically contended that he was depressed and felt worthless on a daily basis. He also contended that he experienced bilateral ankle swelling and was unstable while walking due to worsening of his service-connected bilateral ankle disabilities. On VA PTSD examination in July 2008, the Veteran's complaints included social isolation, feelings of worthlessness, poor sleep (secondary to sleep apnea), and feeling helpless and hopeless. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran stated that "his relationship with his wife [w]as okay but she becomes frustrated at times." He had an "excellent" relationship with his 3 children and a good relationship with 1 brother but not another brother and "no changes since the last evaluation." He had been married to his wife for 7 years. "He reported having no friends, but then he then reported having two friends...that he talks to about every 1-2 months. He stated, 'They are like my brothers.'" There was no history of suicide attempts or violence and "[n]o significant changes in social functioning" since his most recent VA examination. Mental status examination of the Veteran in July 2008 showed he was neatly groomed, appropriate and casually dressed, unremarkable psychomotor activity and speech, a "good" mood, intact attention, full orientation, unremarkable thought process and thought content, no delusions or hallucinations, reported sleep impairment due to sleep apnea, no inappropriate behavior, obsessive/ritualistic behavior, panic attacks, suicidal or homicidal thoughts, good impulse control, no episodes of violence, an ability to maintain minimum personal hygiene, no problems with activities of daily living, and normal memory. The VA examiner stated that total occupational and social impairment due to PTSD was not present. He also stated that the Veteran's PTSD did not result in deficiencies in judgment, thinking, family relations, work, mood, or school, an occasional decrease in work efficiency or intermittent periods of an inability to perform occupational tasks, or any transient or mild PTSD symptoms that decreased work efficiency and an ability to perform occupational tasks during periods of significant stress. This examiner also stated that the Veteran's "PTSD symptoms are controlled by continuous medication. PTSD symptoms are not severe enough to interfere with occupational and social functioning." The Veteran's GAF score was 69. The Axis I diagnosis was chronic PTSD. On VA examination in August 2008, the Veteran's complaints included intermittent bilateral ankle pain since active service. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran stated that he was right-hand dominant. He used 1 cane occasionally for walking. He denied any constitutional symptoms of arthritis, no incapacitating episodes of arthritis, and no functional limitations on standing. The Veteran was able to walk more than 1/4 mile but less than 1 mile. He also denied experiencing any ankle giving way, instability, stiffness, weakness, episodes of dislocation or subluxation, locking, effusion, flare-ups, or inflammation. Range of motion testing of the right ankle showed dorsiflexion to 20 degrees without pain or limitation of motion on repetitive use and plantar flexion to 40 degrees without pain or limitation of motion on repetitive use. Range of motion testing of the left ankle showed dorsiflexion to 5 degrees with pain throughout but no limitation of motion on repetitive use and plantar flexion to 40 degrees without pain or limitation of motion on repetitive use. Physical examination showed no loss of a bone or part of a bone, inflammatory arthritis, or joint ankylosis. "X-rays of the ankles are normal except for a small heel spur which doesn't bother him." The diagnoses included a normal right ankle and mild osteoarthritis of the left ankle. On VA outpatient treatment in September 2008, it was noted that the Veteran had a positive screen for major depressive disorder. The impressions included depression with a note that the Veteran denied any current suicidal or homicidal ideation and verbally contracted for safety. In October 2008, the Veteran's complaints included "periods of depression related to physical complaints of right shoulder/bicep pain," poor sleep, "1-2 nightmares per month, hearing the voice of his jumpmaster, which he notes to be an improvement as he was previously having more frequent nightmares," feeling stressed 3-4 days a week, occasional passive suicidal ideation "but able to redirect thoughts with good impulse control." Mental status examination of the Veteran showed he was casually dressed with good grooming and hygiene, full orientation, no psychomotor retardation or agitation, involuntary or abnormal movements, a coherent, logical goal directed thought process without flight of ideas or looseness of associations, tangentiality, or circumstantiality, normal speech, passive thoughts of suicidal ideation "but able to redirect thoughts with good impulse control," no homicidal ideation, no hallucinations or "delusional constructs, and did appear to be responding to internal stimuli," and good judgment and insight. The Veteran's GAF score was 65, indicating some mild symptoms. The impressions included chronic PTSD. In December 2008, the Veteran's complaints included continuing depression "and that he has had a difficult time adjusting to physical ailments." He also complained of 3-4 nightmares per month and suicidal ideation "as recently as last week" but none currently. He also reported that "he sometimes sees some of his dead friends." The VA clinician stated that the Veteran had no symptoms "consistent with mania or hypomania." The Veteran reported that he was in a "great" marriage and had been married for 7 years to his third wife. He had a good relationship with a daughter from his first marriage and his younger son and daughter who lived with him and his wife. He stopped drinking and smoking 1 1/2 months earlier although he had been drinking a 6-pack of beer "on weekends in a social setting." Mental status examination of the Veteran showed he was appropriately dressed and groomed with good eye contact, ambulating with a walking cane, relevant, coherent, and goal-directed speech "with no evidence of psychotic thought form or content, but focused on physical ailments," no suicidal or homicidal ideation, no hallucinations, not responding to internal stimuli, full orientation, grossly intact memory and cognition, and intact insight and judgment. The VA examiner stated, " Although the [Veteran] reports symptoms in all of the PTSD clusters, his symptoms are infrequent and do not seem to be significant enough to limit his daily functioning." The Veteran's GAF score was 60. The Axis I diagnoses were depressive disorder, not otherwise specified (rule-out depressive disorder due to general medical condition versus pain disorder associated with both psychological factors and a general medical condition), and PTSD by history. The Veteran was advised to discontinue Zoloft and start taking Prozac. In March 2009, the Veteran and his wife reported "that he had been doing better [and is] more calm. He continues to think of the soldiers he has lost, and continues to hear them calling him 'SGT Winter.'" Mental status examination of the Veteran showed he was appropriately dressed and groomed with good eye contact, an irritable affect, relevant, coherent, and goal-directed speech "with no evidence of psychotic thought form or content, still focused on physical ailments," no suicidal or homicidal ideation, no hallucinations, not responding to internal stimuli, full orientation, grossly intact memory and cognition, and intact insight and judgment. The Axis I diagnoses were depressive disorder, not otherwise specified (rule-out depressive disorder due to general medical condition versus pain disorder associated with both psychological factors and a general medical condition), and PTSD by history. In April 2009, the Veteran complained that "[h]e often hears noises at night, and feels like somebody is coming up the stairs of his townhouse. He has grabbed his knife and checked every room and close in his house to find that nobody is there and everything is in order." He had been "sleeping with a large knife underneath his mattress for 6-7 months." He also complained of nightmares "and continues to feel like people are calling him or tapping him in the back." Mental status examination of the Veteran showed he was appropriately dressed and groom with good eye contact, ambulating with a walking cane, a "stressed" mood, relevant, coherent, and goal directed speech "with no evidence of psychotic thought form or content," "somatically preoccupied" with physical complaints, no suicidal or homicidal ideation, no hallucinations, no responses to internal stimuli, full orientation, grossly intact memory and cognition, and intact insight and judgment. The Axis I diagnoses were unchanged from March 2009. The Veteran was advised to continue taking Prozac 60 mg by mouth daily and begin a trial of prazosin 1-2 mg by mouth every night. On May 12, 2009, the Veteran's complaints included "that he continues to hear noises of people coming upstairs, which causes him to get stressed out at night." He stated "that there are spirits in the house." He reported sleeping better on medication "and does not recall having dreams." Mental status examination of the Veteran showed he was appropriately dressed and groomed with good eye contact, ambulating with the assistance of a walking cane, relevant, coherent, and goal directed speech "with no evidence of psychotic thought form or content," no suicidal or homicidal ideation, no hallucinations, was not "responding to internal stimuli," full orientation, grossly intact memory and cognition, and intact insight and judgment. The Axis I diagnoses were unchanged from April 2009. On May 20, 2009, the Veteran's complaints included a history of falls due to right ankle buckling. He used a cane for ambulation. He was independent in his activities of daily living. Physical examination showed a slow, antalgic gait and right ankle pain. The assessment included a note that the Veteran was "at increased risk for falls due to chronic pain...[in the] right ankle." The Veteran was advised to use his cane when needed "when experiencing pain. Use in left hand to unload joints on the right." In July 2009, the Veteran's complaints included continuing hallucinations. He reported that "even his son told him he's seen a shadow coming into the bathroom." He also reported that, while in the Dominican Republic on a recent trip, he "blew up at his wife and her family over money issues." Mental status examination of the Veteran and the Axis I diagnoses were unchanged from May 2009. In August 2009, the Veteran's complaints included continued daytime irritability. Mental status examination of the Veteran was unchanged from July 2009. "He is somatically preoccupied today (about his R biceps)." The Axis I diagnoses also were unchanged from July 2009. In September 2009, the Veteran's complaints included bilateral ankle sprains, right greater than left. Physical examination showed a full range of motion in the bilateral ankles and right ankle edema. The impressions included ankle sprain, right greater than left. The Veteran was advised to use a crutch to avoid weight bearing for 2 weeks and warm water soaks with Epsom salt. In October 2009, the Veteran complained of irritability and was "focused on pain again, this time in his ankles." The Veteran reported that prazosin "helps his irritability 'a little.'" Mental status examination of the Veteran showed he was appropriately dressed and groomed with good eye contact, ambulating with the assistance of a walking cane, relevant, coherent, and goal directed speech "with no evidence of psychotic thought form or content," no suicidal or homicidal ideation, no hallucinations, was not "responding to internal stimuli," full orientation, grossly intact memory and cognition, and intact insight and judgment. "He is somatically preoccupied today (about his ankles)." The Axis I diagnoses were unchanged from August 2009. In November 2009, the Veteran's complaints included constant bilateral ankle sprains because "he feels unstable when walking. States his pain is located mostly to his midfoot and the sides of his ankle[s]." Physical examination showed pain on palpation to the dorsal aspect of the midfoot near the cuneiforms-metacarpal bases, lateral malleolus, and distal peroneus brevis tendon in the right foot, no erythema or increased warmth, and mild edema in the lateral malleolus of the right ankle. X-rays showed increased soft tissue swelling in the lateral malleolus and peroneus brevis tendon to the right foot, "extensive osteopenia with subchondral sclerosis to midfoot suggestive of post traumatic arthritis," and no acute ankle fractures or dislocations. The assessment included post-traumatic ankle arthritis and possible peroneal tear due to chronic inversion ankle sprains. In December 2009, the Veteran complained of right lateral ankle pain. He had stability using compression stockings and an ankle brace but "still feels intense pain on the side of his foot" that was not relieved with non-steroidal anti-inflammatory medication. He walked with a cane "due to pain in ankle and knee." Physical examination of the right ankle showed pain on palpation of lateral malleolus and distal peroneus brevis tendon from posterior malleolus to styloid process insertion of the right foot, no erythema or increased warmth, mild edema to the lateral malleolus right ankle. An MRI was reviewed and showed peroneal tendonopathy with synovitis in tendon sheath, no acute tears or dislocations, retinaculum degenerative changes, and ATF ligament chronic degenerative changes. The clinician's impression was chronic inversion ankle sprains right foot. The VA clinician discussed surgical options with the Veteran of lateral ankle stabilization/retinacular repair "since he has exhausted all conservative measures." In February 2010, the Veteran stated that "he became very 'shaky' and 'nervous'" while driving over a bridge the day before his outpatient treatment visit. "He ran into the side of the bridge nearest the water and damaged the rim of the wheel on his van. He was not injured, nor was another car involved. He was able to drive the car off the bridge and stopped to calm himself down. He was then able to drive himself home without incident...He drove to the VA today without incident. He states that he has been sleeping better with the increase in the prazosin and the addition of Risperdal. He states he has been going to sleep around 10:30 at night but awakens at 2:00 a.m. and cannot get back to sleep. He has not seen any of the images around him that he previously reported, but he does hear sounds that sound like people walking up the stairs of his house. He states that he asks his wife [if] she hears them, but she reports that she does not. He denies suicidal or homicidal ideation." Mental status examination of the Veteran showed he was cleanly groomed with rapidly paced speech "particularly when describing the incident in his van on the bridge," somewhat circumstantial, no evidence of psychotic thought processes, no hallucinations, adequate judgment, fair insight, full orientation, grossly intact recent and remote memory, and no cognitive impairment. The Veteran was advised to increase his risperidone to 2 mg at bedtime. The impressions were severe major depressive disorder with psychotic features and PTSD. In March 2010, the Veteran complained that he experienced frequent right ankle sprains and his right ankle was unstable even wearing an ankle brace. A history of frequent right ankle sprains was noted. Physical examination showed pain on palpation at the ATF ligament, mild increased inversion without subluxing of peroneals, no focal edema along tendon sheath palpable, and no pain with inversion. The impression was right chronic lateral ankle sprains. In June 2010, the Veteran complained of continued nightmares "and nighttime visions of dark shadows. He often hears someone calling him by his name and military rank." He also complained of being "stressed today because his son broke his arm when he tried to jump from his dresser to his bed." He was "pleased with his participation in" a group therapy "and feels he is getting a great deal of support and understanding." The Veteran stated that "[h]e feels more hopeful about the future and denies suicidal or homicidal ideation." Mental status examination of the Veteran showed he was cleanly groomed, ambulatory with a cane and an antalgic gait, with clear, moderately paced, and logical speech, no evidence of psychotic thought process, no hallucinations, adequate judgment, fair insight, full orientation, grossly intact memory, and no cognitive impairment. The impressions were major depressive disorder and PTSD. On VA pre-operative visit on August 2, 2010, the Veteran complained that his right ankle rolled over constantly and also complained of chronic right ankle pain and swelling. He denied any prior right ankle surgery. "At this time [the Veteran] would like to have his ankle surgically repaired so he does not sprain it continuously." Physical examination showed an ankle joint range of motion within normal limits without crepitation, subtalar joint within normal limits, "no increase in isolated inversion," increased supination of the right foot, pain on palpation around the anterior talofibular (ATF) ligament, no edema, intact peroneal tendons without evidence of subluxation, 5/5 motor strength in all major muscle groups of the bilateral lower extremities, and an intact protective threshold. A magnetic resonance imaging (MRI) scan from 2009 was reviewed and showed a severe sprain or partial tear of the ATF ligament. The clinician's assessment was chronic right ankle instability. On VA outpatient treatment on August 4, 2010, the Veteran stated that "the medication that kept him stable and alert while he was away seems to be making him drowsy. He is wondering if it might could [sic] be decreased at this point since he is doing so much better." He had not had any alcohol for 32 days. He also denied any hallucinations or suicidal or homicidal ideation. Mental status examination of the Veteran showed he was cleanly groomed with clear, moderately paced, and logical speech, no evidence of psychotic thought processes, adequate judgment, fair insight, full orientation, grossly intact memory, and no cognitive impairment. The impression was major depressive disorder. The Veteran had right ankle stabilization surgery on August 6, 2010. On VA outpatient treatment on December 3, 2010, the Veteran's complaints included right ankle pain which he rated as 6/10 on a pain scale and right ankle dysfunction because "it fails" and twists while walking. Objective examination showed a limited range of motion in the right ankle. The assessment included chronic ankle pain. On December 9, 2010, the Veteran's complaints included visual hallucinations. "He states that he could see from his bedroom into his living room and initially thought that it was the shadow of people walking outside his condo throwing a shadow from the streetlight, but he went to check on this several times, and no one was walking outside." He also stated that he was "sleeping well and denies suicidal or homicidal ideation." Mental status examination of the Veteran showed he was cleanly groomed with clear, moderately paced, and logical speech, no evidence of psychotic thought processes, no hallucinations, adequate judgment, fair insight, full orientation, grossly intact memory, and no cognitive impairment. The impressions were major depressive disorder and PTSD. On December 29, 2010, the Veteran complained of "a clicking in the outside of his [right] ankle" which was not painful. Objective examination showed a well healed right ankle surgical incision, minimal edema in the posterior lateral malleolus, and no pain on palpation of the surgical scar. Range of motion testing of the right ankle showed it was stable with no increased laxity or crepitus and no subluxation of tendons. The assessment was status-post right lateral ankle stabilization. The Veteran was advised "to continue regular activity and regular shoegear at home and no further treatment is necessary" because he was not experiencing post-surgical right ankle pain. In January 2011, it was noted that the Veteran was "without complaints today." It also was noted that he originally had complained of right ankle pain and swelling status-post lateral ankle stabilization surgery more than 16 weeks earlier. The Veteran had participated in regular physical therapy sessions "and has noted steady progress with decrease in pain and swelling." He rated his pain on a pain scale as 2/10 at best, 5/10 at worst, and 3/10 currently (with 1/10 being the least pain and 10/10 being the worst imaginable pain). The Veteran was instructed "to continue regular activity and regular shoegear at home and no further treatment is necessary. [He] currently [is] not experiencing post surgical pain." Objective examination showed his posture was within functional limits, bilateral ankle plantar flexion within normal limits, left ankle dorsiflexion within normal limits, right ankle dorsiflexion to 2 degrees, 5/5 strength of the bilateral lower extremities, "some sensation deficits related to neuropathy," normal ligament stability, no gross foot deformity, foot alignment within functional limits, an improved gait pattern, no gross gait deformity. It was noted that the Veteran "has been cleared by podiatry to resume normal activities." In June 2011, the Veteran stated that "he is doing well. He states that he has been feeling over sedated on his med[ications] and has decreased them somewhat on his own. He is not having disturbed sleep, hallucinations or nightmares. He will be going to the Dominican Republic for two months this summer where his wife will have surgery. He is looking forward to being with his family. He is sleeping well with no nightmares, he has lost weight and feels generally good. Denies suicidal or homicidal ideation." Mental status examination of the Veteran showed he was cleanly groomed, clear, moderately paced, and logical speech, no evidence of psychotic thought processes, no suicidal or homicidal ideation, adequate judgment, fair insight, full orientation, grossly intact memory, and no cognitive impairment. The Veteran was advised to decrease his fluoxetine to 20 mg a day, decrease his prazosin to 1 mg at bedtime, and to decrease his risperidone to 1 mg at bedtime. The impressions were PTSD and major depressive disorder. In August 2011, the Veteran complained that "he had a terrible summer in which he experienced poor sleep, visual hallucinations of soldiers, nightmares in which he relieved [sic] the jump from the airplane during which he hung from a caught parachute under the plane, irritability, social isolation, and intense anger." He recently had returned from spending several months in the Dominican Republic with his family "while his wife recovered from surgery performed there." The VA clinician stated that, since he had begun treating the Veteran in February 2010, "we have managed to get his symptoms under control with an antipsychotic medication, antidepressants, and an alpha-1 blocker for the extreme nightmares and night terrors. He suffers from persistent, severe major depressive disorder, and chronic severe PTSD." The Veteran's PTSD symptomatology included flashbacks, nightmares, hyperarousal, social inadequacy, and anger outbursts. Mental status examination of the Veteran showed he was cleanly groomed, clear, moderately paced, and logical speech, no evidence of psychotic thought processes, no hallucinations, no suicidal or homicidal thoughts, fair judgment and insight, full orientation, grossly intact memory, and no cognitive impairment. The impressions were PTSD and major depressive disorder. In November 2011, the Veteran complained that he was "very tired and has a headache. States that he woke up at 4:00 a.m. this morning because 'the smell of death' woke him up. He states that he dreamed he was getting up to come to this appointment and his van was full of dead bodies and body parts. He states he has not had a dream like this in a while and was very disturbed by it. He continues to cope with severe chronic pain." The Veteran also reported that "he is coping as best he can and denies that he is depressed every day. He denies suicidal or homicidal ideation." Mental status examination of the Veteran showed he was cleanly groomed, ambulatory with an antalgic gait and assisted by a cane; fatigued, clear, moderately paced, and logical speech, no evidence of psychotic thought processes, no hallucinations, adequate judgment, fair insight, full orientation, grossly intact memory, and no cognitive impairment. The Veteran was advised to increase his prazosin to 4 mg at bedtime. The impressions were PTSD and major depressive disorder with psychotic features. On February 15, 2012, the Veteran complained that "his sleep has become more restless and he has experienced an exacerbation of his PTSD symptoms. He states that he []is having nightmares of death." He reported that his symptoms had worsened since the 18-year-old son of a former neighbor had committed suicide by hanging himself. The Veteran "keeps seeing and hearing the boy." He also reported that "his main problems are with getting to sleep and resting comfortably." He denied any suicidal or homicidal ideation. Mental status examination of the Veteran was unchanged from August 2011. The impressions were PTSD and severe major depressive disorder with psychotic features. On February 28, 2012, the Veteran's complaints included repeated left ankle sprain and shooting pain in the right ankle "due to neuropathy." The Veteran wanted his left ankle surgically corrected. Physical examination showed he ambulated without assistance and wore diabetic shoes, left lateral malleolar swelling, no pain on palpation of the ATF ligament, calcaneofibular ligament (CFL), or sinus tarsi, and a cavus foot type. The assessment included chronic left ankle sprain and right Achilles tendinitis. It was noted that the Veteran was scheduled for left ankle stabilization surgery in July 2012. In March 2012, the Veteran's complaints included feeling depressed, overwhelmed and increasingly isolated. He denied suicidal or homicidal ideation or any hallucinations. Mental status examination of the Veteran showed he was cleanly groomed, clear, moderately paced, and logical speech, no evidence of psychotic thought processes, adequate judgment, fair insight, full orientation, grossly intact recent and remote memory, and no cognitive impairment. The impressions were PTSD and major depressive disorder. In May 2012, the Veteran stated that, on his current psychotropic medications, "he has not experienced any combat related nightmares and has not had any visual or auditory hallucinations. He plans a trip to the Dominican Republic on 6/6/12 to visit family and is looking forward to it. He denies suicidal or homicidal ideation." Mental status examination of the Veteran showed he was cleanly groomed with clear, moderately paced, and logical speech, no evidence of psychotic thought processes or hallucinations, adequate judgment; fair insight, full orientation, grossly intact memory, and no cognitive impairment. The impressions were PTSD and major depressive disorder. On VA ankle conditions DBQ later in May 2012, the Veteran's complaints included right Achilles tendon insertion pain and mid-lateral right foot pain. A history of right ankle stabilization surgery in August 2010 and left ankle stabilization surgery scheduled for July 2012 was noted. The Veteran denied that flare-ups of bilateral ankle pain impacted the function of his ankles. Range of motion testing of the right ankle showed plantar flexion to 35 degrees with objective evidence of painful motion beginning at 35 degrees and dorsiflexion to 15 degrees with objective evidence of painful motion beginning at 15 degrees. Range of motion testing of the left ankle showed plantar flexion to 40 degrees with objective evidence of painful motion beginning at 40 degrees and dorsiflexion to 20 degrees or greater with no objective evidence of painful motion. Repetitive range of motion testing showed no additional limitation of motion in either ankle. The Veteran experienced functional loss due to less movement than normal in both ankles and pain on movement in the left ankle. Physical examination showed localized tenderness or pain on palpation of the joints/soft tissue of the left ankle, 5/5 muscle strength in both ankles, no joint laxity in either ankle, no ankylosis in either ankle, no other bilateral ankle conditions, and surgical scars that were not painful or unstable and not greater than 39 square centimeters. The Veteran used a cane occasionally and a walker regularly for ambulation "for left ankle laxity and also knee and lumbar back condition. He is unable to specify which condition dominates his use of the assistive devices." There was no functional impairment in either ankle. X-rays of the bilateral ankles showed calcaneal posterior enthesophyte formations "with no other significant abnormality." The diagnoses were enthesopathy of the right ankle and tarsus and left ankle sprain. On VA PTSD DBQ in June 2012, the Veteran's complaints included depressed mood, anxiety, panic attacks weekly or less often, chronic sleep impairment, mild memory loss, suicidal ideation, and neglect of personal appearance and hygiene. The VA examiner reviewed the Veteran's claims file, including his service treatment records and post-service VA treatment records. The Veteran lived with his wife and 2 children in a rural area. He had been married for 10 years and had an "okay" relationship with his wife "and explained that he scares her when he wakes up at night." He had been married three time previously. He did not have "particularly close relationships with his family of origin. In general, he reported that he has difficulty being around people other than those who[m] he knows." He also reported enjoying the company of other Veteran in his weekly PTSD support group. He attended events with family friends, played outside with his children, and took his children to Busch Gardens "so much that he bought an annual pass." He became "quite withdrawn" for several hours up to 3-4 times a week. He also "reported recurrent thoughts of wanting to hurt himself [but] denied any suicidal intent or plan." He and his wife "have a good sex life and are affectionate." He also had not lost interest in his regular activities. He had a panic attack "once every few months." After reviewing the claims file, the VA clinician stated, "These varying opinions and reported symptom[] level make[] it difficult to assess the Veteran's actual level of impairment." Mental status examination of the Veteran in June 2012 showed he was "dressed in stained shirt and dirty shorts" with full orientation, unremarkable speech, unimpaired thought content and progression, no difficulty in understanding complex commands, no gross impairment in thought processes or communication, no hallucinations or delusions, no grossly inappropriate behavior, slightly impaired attention and concentration, slightly impaired memory, fair judgment and insight, abstract reasoning within normal limits, and no suicidal or homicidal ideation. The VA examiner stated that the Veteran was incapable of managing his financial affairs, noting: Per the Veteran's report during this [examination] and to mental health treatment providers, he struggles significantly with memory and concentration. For example, he was able to recall only 1 of 3 words stated after several minutes, reports he is often disoriented, and becomes frustrated easily with paperwork. If this report is accurate, he would likely have difficulty managing finances without the help of family members. Following psychological testing of the Veteran, the VA clinician also stated: This [Veteran's] profile is suggestive of deliberate overreporting and indicative of someone seeking to dramatize their distress and discomfort, possibly for secondary gain. Results are not considered to be a valid measure of this Veteran's current functioning and, for that reason, no further interpretation of results are warranted [sic] at this time. The Veteran's psychological testing also suggested "suspected malingering with disability claimants." The VA examiner concluded: Overall, the Veteran endorsed a high frequency of symptoms that are highly atypical in patients with genuine psychiatric or cognitive disorders, raising the suspicion of intentional production of false or grossly exaggerated symptoms as motivated by external incentive (e.g., disability benefits). As noted, the VA examiner was unable to provide a GAF score for the Veteran "without resorting to mere speculation based on exaggerated test results and inconsistencies in record and Veteran's report." The diagnoses included PTSD with a note that this diagnosis was "made by history. Due to invalid test results this diagnosis could not be confirmed during this evaluation." The Veteran also was diagnosed as having rule-out mood disorder due to his general medical condition. The VA examiner stated, " This diagnosis is made as a rule-out only due to invalid test results." On VA outpatient treatment on July 9, 2012, the Veteran stated, " I need left ankle surgery and right tendon injection." He was wearing bilateral ankle stabilization braces and used a cane. Physical examination showed 5/5 muscle strength of the bilateral lower extremities, pain on palpation of the bilateral lower extremities, and an antalgic gait. X-rays of the bilateral ankles showed calcaneal posterior enthesophyte formations and no other significant abnormality. The impressions included left lateral ankle instability. On July 10, 2012, the Veteran stated that, while on a plane flying to the Dominican Republic to visit his family, "he fell asleep on the plane and awakened suddenly, thus triggering a flashback of getting ready to parachute out of a plane. He finally realized that he was on a commercial jet with his family and oriented himself. He closed the shade on the window of the plane so he did not have to look out." The Veteran denied hallucinations and reported that "his mood has been fairly stable overall. He is somewhat anxious about his upcoming foot surgery, but is glad to have it scheduled." Mental status examination of the Veteran showed he was cleanly groomed with clear, moderately paced, and logical speech, no evidence of psychotic thought processes, no suicidal or homicidal ideation, adequate judgment; fair insight, full orientation, grossly intact recent and remote memory, and no cognitive impairment. The impressions were major depressive disorder and PTSD. The Veteran had left ankle stabilization surgery at a VA Medical Center on July 31, 2012. On VA outpatient treatment on August 13, 2012, the Veteran denied a depressed mood, nightmares or flashbacks, psychotic symptoms, or suicidal or homicidal ideation. He reported that he was "sleeping well." Mental status examination of the Veteran showed he was cleanly groomed, in a wheelchair with his left lower leg in a cast with clear, moderately paced, and logical speech, no evidence of psychotic thought processes, hallucinations, adequate judgment, fair insight, full orientation, grossly intact memory, and no cognitive impairment. The impressions were PTSD and major depressive disorder. In January 2013, the Veteran's complaints included "a great deal of anxiety, demoralization, and frustrated [sic] related to medical conditions which are worsening." It was noted that: [The Veteran] also feels that some of his self-reports have been misconstrued. His family lives in the Dominican Republic. His culture is strongly family-oriented; there are expectations regarding family that have to be honored. Once a year, he visits his family in the Dominican Republic. Flying via airlines presents a great deal of discomfort, triggering fearful feelings about being in an aircraft, and about the parachuting accident that injured him, but he endures it for the sake of his family. He accompanied his kids to Busch Gardens last year, out of family obligations to his kids, and tolerated feeling hypervigilant and very uncomfortable in a crowded place, avoiding any rides because of his physical limitations and chronic pain (and claustrophobic feelings), avoiding heights which frighten him, and just attending shows. These types of activities are something that he can only tolerate doing once in a great while, when he is having a good day, and prepares himself mentally, or with family urging. It is not something he is able to do more than on rare occasion[s]. The Veteran denied any suicidal or homicidal ideation. The assessment was mood disorder (depression with anxiety) secondary to medical problems and PTSD by history. The Veteran testified at his June 2013 Board hearing that he experienced "traumatic dreams and also suicide thoughts" and hallucinations 2-3 times per month due to his service-connected PTSD. See Board hearing transcript dated June 5, 2013, at pp. 3. He also experienced nighttime awakenings, increased anxiety, and panic attacks 2-3 times a month. Id., at pp. 4. The Veteran also testified that he wore bilateral ankle braces and was in constant pain due to his service-connected bilateral ankle disabilities. Id., at pp. 7-8. Analysis The Board finds that the preponderance of the evidence is against the Veteran's claim for an initial rating greater than 30 percent for an acquired psychiatric disability, to include PTSD. The Veteran has contended that his service-connected acquired psychiatric disability, to include PTSD, is more disabling than currently evaluated. The record evidence does not support his assertions, however. It shows instead that the Veteran's service-connected acquired psychiatric disability has been manifested by, at worst, occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks throughout the pendency of this appeal. The Board acknowledges again that the Veteran's complete service treatment records were not available for review although the available records show no complaints of or treatment for an acquired psychiatric disability during active service or while he was in the USAR. The post-service evidence shows that he has been diagnosed as having and treated for a variety of acquired psychiatric disabilities, to include PTSD, since his service separation. There is no evidence in these records of reduced reliability and productivity, deficiencies in most areas, or total occupational and social impairment due to the Veteran's service-connected acquired psychiatric disability, to include PTSD, such that a higher initial rating than 30 percent is warranted for this disability at any time during the appeal period. See 38 C.F.R. § 4.130, DC 9411 (2012). For example, no depressive or panic symptoms were noted on VA outpatient treatment in October 2005. The Veteran was diagnosed as having adjustment disorder and his GAF score of 60 reflected moderate symptoms. VA examinations in March and July 2008 indicated that the Veteran's PTSD symptoms were controlled by medication. The VA clinicians specifically found that the Veteran did not meet any of the diagnostic criteria for even a compensable disability rating. The Veteran's GAF score of 69 in March 2008 also reflected mild symptoms at worst. He had an excellent relationship with his 3 children and had been married to his current wife for 7 years. The July 2008 VA examiner found that the Veteran's PTSD symptoms did not interfere with his occupational or social functioning and diagnosed him as having chronic PTSD. Although the Veteran was switched to Prozac in December 2008, the VA clinician stated that his infrequent PTSD symptoms did not limit his daily functioning. The Veteran himself reported that he was doing better on VA outpatient treatment in March 2009. Although he complained of auditory hallucinations in April 2009, none were present on mental status evaluation and he was preoccupied with his physical complaints. His psychotropic medication was increased in February 2010 when his speech was more rapid and he was diagnosed as having severe major depressive disorder with psychotic features and PTSD. The Veteran complained of nightmares in June 2010 but there was no evidence of psychotic thought content on mental status evaluation. He also complained of visual hallucinations in December 2010 but none were present on mental status evaluation. He reported again in June 2011 that he was doing well and had decreased his psychotropic medications on his own. The VA clinician concurred with the Veteran's assessment and advised him to decrease all of his psychotropic medications following this outpatient treatment visit. It was noted that the Veteran's psychiatric symptoms were under control in August 2011. He was advised to increase his medications at bedtime in November 2011 after complaining of visual hallucinations (although none were present on mental status evaluation). Although he complained in February 2012 of nightmares related to the death of a neighbor's child, there were no changes on mental status evaluation and these nightmares were no longer present on his current medications by May 2012. Finally, on VA PTSD DBQ in June 2012, the Veteran reported that he still was married and had a good sex life with his wife, enjoyed group therapy with other Veterans, travelled to Busch Gardens with his children, and only experienced panic attacks once every few months. The June 2012 VA examiner suspected that there were secondary gain issues and malingering involved in the Veteran's presentation of what appeared to be grossly exaggerated psychiatric symptomatology. The Veteran finally reported that he was sleeping well on VA outpatient treatment in August 2012. He also has not identified or submitted any evidence demonstrating his entitlement to an initial rating greater than 30 percent for a service-connected acquired psychiatric disability, to include PTSD. In summary, the Board finds that the criteria for an initial rating greater than 30 percent for a service-connected acquired psychiatric disability, to include PTSD, have not been met. The Board also finds that the preponderance of the evidence is against the Veteran's claim for an initial compensable rating prior to April 29, 2008, and to an initial rating greater than 10 percent prior to July 31, 2012, and effective November 1, 2012, for service-connected left ankle arthritis. The Veteran has contended that his service-connected left ankle arthritis is more disabling than currently evaluated. The record evidence does not support his assertions concerning the worsening of his service-connected left ankle arthritis. It shows instead that, prior to April 29, 2008, the Veteran's service-connected left ankle arthritis was not manifested by at least moderate limitation of motion of the ankle (i.e., a 10 percent rating under DC 5010-5271). See 38 C.F.R. § 4.71a, DC 5010-5271 (2012). Although the Veteran's complete service treatment records are not available for review, neither the available records from his active service or his USAR service show any complaints of or treatment for left ankle arthritis. The post-service evidence shows that the Veteran only had mild left ankle swelling on VA outpatient treatment in April 2005. He had a sprained left ankle in a cast with pain on VA outpatient treatment in February 2006 when x-rays showed a calcaneal spur but no fracture. Finally, VA examination in March 2008 showed a full range of motion in the left ankle without limitation of motion on repetitive use. Pain was the only DeLuca factor present and it was present only on long walking. X-rays showed arthritis and the Veteran was diagnosed as having left ankle arthritis. The Veteran also has not identified or submitted any evidence demonstrating his entitlement to an initial compensable rating prior to April 29, 2008, for left ankle arthritis. In summary, the Board finds that the criteria for an initial compensable rating prior to April 29, 2008, for service-connected left ankle arthritis have not been met. The Veteran also is not entitled to an initial rating greater than 10 percent between April 30, 2008, and July 31, 2012, and effective November 1, 2012, for his service-connected left ankle arthritis. The record evidence shows that the Veteran's service-connected left ankle arthritis was manifested by, at worst, moderate limitation of motion of the ankle (i.e., a 10 percent rating under DC 5010-5271) during each of these time periods. Id. For example, he denied any constitutional symptoms of arthritis, no incapacitating episodes of arthritis, and no functional limitations on standing on VA examination in August 2008. He was able to walk more than 1/4 mile but less than 1 mile. He also denied experiencing any ankle giving way, instability, stiffness, weakness, episodes of dislocation or subluxation, locking, effusion, flare-ups, or inflammation. Range of motion testing of the left ankle showed dorsiflexion to 5 degrees with pain throughout but no limitation of motion on repetitive use and plantar flexion to 40 degrees without pain or limitation of motion on repetitive use. Physical examination showed no loss of a bone or part of a bone, inflammatory arthritis, or joint ankylosis. "X-rays of the ankles are normal except for a small heel spur which doesn't bother him." He was diagnosed as having mild osteoarthritis of the left ankle. On VA outpatient treatment in November 2009, the Veteran complained that he was "unstable when walking" due to constant ankle sprains but physical examination was focused on the right ankle. In February 2012, the Veteran's complaints included repeated left ankle sprain and he wanted his left ankle surgically corrected. Physical examination showed he ambulated without assistance and wore diabetic shoes, left lateral malleolar swelling, no pain on palpation of the ATF ligament, calcaneofibular ligament (CFL), or sinus tarsi, and a cavus foot type. The assessment included chronic left ankle sprain. VA examination in May 2012 showed left ankle plantar flexion to 40 degrees with objective evidence of painful motion beginning at 40 degrees and dorsiflexion to 20 degrees or greater with no objective evidence of painful motion and no additional limitation of motion on repetitive testing. The Veteran experienced functional loss due to less movement than normal and pain on movement in the left ankle. Physical examination showed localized tenderness or pain on palpation of the joints/soft tissue of the left ankle, 5/5 muscle strength, and no joint laxity, ankylosis, or other ankle conditions. The Veteran used a cane occasionally and a walker regularly for ambulation "for left ankle laxity and also knee and lumbar back condition. He is unable to specify which condition dominates his use of the assistive devices." There was no functional ankle impairment. X-rays showed calcaneal posterior enthesophyte formations "with no other significant abnormality." The diagnoses included left ankle sprain. On VA outpatient treatment on July 9, 2012, the Veteran requested left ankle surgery. He was wearing an ankle stabilization brace and used a cane. Physical examination showed 5/5 muscle strength, pain on palpation, and an antalgic gait. X-rays showed calcaneal posterior enthesophyte formations and no other significant abnormality. He was diagnosed as having left lateral ankle instability. There is no indication of marked limitation of motion of the left ankle in these records such that an initial rating greater than 10 percent is warranted between April 30, 2008, and July 31, 2012. The Veteran also has not identified or submitted any competent evidence demonstrating more than moderate limitation of left ankle motion during this time period. Id. Accordingly, the Board finds that the criteria for an initial rating greater than 10 percent between April 30, 2008, and July 31, 2012, for the Veteran's service-connected left ankle arthritis also are not met. The Veteran finally is not entitled to an initial rating greater than 10 percent effective November 1, 2012, for his service-connected left ankle arthritis. As noted in the Introduction, the Veteran had left ankle stabilization surgery at a VA Medical Center on July 31, 2012, and was awarded a temporary total rating based on the need for convalescence for 3 months following this surgery. See 38 C.F.R. § 4.30 (2012). The record evidence shows that, effective November 1, 2012, the Veteran's service-connected left ankle arthritis is manifested by, at worst, moderate limitation of motion of the ankle. See 38 C.F.R. § 4.71a, DC 5010-5271 (2012). The only evidence submitted in support of the Veteran's higher initial rating claim for left ankle arthritis during this time period consists of his June 2013 Board hearing testimony. The Veteran asserted that he had to wear an ankle brace and was in constant pain as a result of his service-connected left ankle arthritis. The Board finds that these complaints are contemplated within the 10 percent rating assigned effective November 1, 2012, for the Veteran's service-connected left ankle arthritis. The Veteran also has not identified or submitted any competent evidence demonstrating that he experiences marked limitation of motion of the left ankle such that an initial rating greater than 10 percent is warranted effective November 1, 2012 for his service-connected left ankle arthritis. Accordingly, the Board finds that the criteria for an initial rating greater than 10 percent effective November 1, 2012, for the Veteran's service-connected left ankle arthritis are not met. The Board finally finds that the preponderance of the evidence is against the Veteran's claim for an initial compensable rating prior to August 6, 2010, and to an initial rating greater than 10 percent effective December 1, 2010, for his service-connected right ankle arthritis. The Veteran has contended that his service-connected right ankle arthritis is more disabling than currently evaluated before and after his right ankle lateral stabilization surgery on August 6, 2010. The record evidence does not support his assertions regarding a worsening of this disability during either of the time periods at issue in this appeal. The Veteran's available service treatment records from his active service and USAR service show no complaints of or treatment for right ankle arthritis. The post-service evidence shows that, prior to August 6, 2010, the Veteran's service-connected right ankle arthritis was not manifested by at least moderate limitation of motion of the ankle such that a compensable disability rating is warranted for this time period under DC 5271. Id. For example, the Veteran complained of right ankle pain and swelling on VA outpatient treatment in August 2006. Physical examination of the right ankle showed external malleolus with mild swelling, an "adequate but painful" range of motion, and warmth. The impression was right ankle pain "suspect probable exacerbation of gout." VA examination in March 2008 showed no ankle weakness, stiffness, swelling, heat or redness, instability or giving way, locking, fatigability, lack of endurance, or flare-ups of ankle pain, episodes of dislocation or recurrent subluxation, or history of inflammatory arthritis. Physical examination showed a full range of motion in the right ankle with no change after repetition, a normal gait and posture, no joint ankylosis, pain with motion only when attempting to run "or long walking," and no fatigue, weakness, lack of endurance, additional limitation of motion following repetitive use, incoordination, instability, functional limitations on standing, indications of abnormal weightbearing, effusion, redness, or heat, or guarding of movement. Distance walking was limited. "X-rays show some arthritis in the ankles." The diagnoses included right ankle arthritis. VA examination in August 2008 showed that the Veteran's right ankle was normal and he denied any ankle giving way, instability, stiffness, weakness, episodes of dislocation or subluxation, locking, effusion, flare-ups, or inflammation. Range of motion testing of the right ankle showed dorsiflexion to 20 degrees without pain or limitation of motion on repetitive use and plantar flexion to 40 degrees without pain or limitation of motion on repetitive use. Physical examination showed no loss of a bone or part of a bone, inflammatory arthritis, or joint ankylosis, and x-rays were normal. In May 2009, the Veteran was independent in his activities of daily living although he had a slow, antalgic gait and right ankle pain and was "at increased risk for falls due to chronic pain...[in the] right ankle." He was advised to use his cane when needed "when experiencing pain. Use in left hand to unload joints on the right." In September 2009, he a full range of motion in the bilateral ankles and right ankle edema. The impressions included ankle sprain, right greater than left. He was advised to use a crutch to avoid weight bearing for 2 weeks. In November 2009, the Veteran had mild edema in the lateral malleolus of the right ankle. X-rays showed increased soft tissue swelling in the lateral malleolus and peroneus brevis tendon to the right foot, "extensive osteopenia with subchondral sclerosis to midfoot suggestive of post traumatic arthritis," and no acute ankle fracture or dislocation. The assessment included post-traumatic ankle arthritis and possible peroneal tear due to chronic inversion ankle sprain. In December 2009, the Veteran reported stability using compression stockings and an ankle brace but "still feels intense pain on the side of his foot" that was not relieved with non-steroidal anti-inflammatory medication. Physical examination of the right ankle showed pain on palpation of lateral malleolus and distal peroneus brevis tendon from posterior malleolus to styloid process insertion of the right foot, no erythema or increased warmth, and mild edema to the lateral malleolus of the right ankle. The diagnosis was chronic inversion ankle sprains of the right foot. Finally, on a pre-operative visit on August 2, 2010, 4 days prior to his right ankle stabilization surgery, his right ankle joint range of motion was within normal limits without crepitation, subtalar joint within normal limits, "no increase in isolated inversion," increased supination of the right foot, pain on palpation around the anterior talofibular (ATF) ligament, no edema, intact peroneal tendons without evidence of subluxation, 5/5 motor strength in all major muscle groups of the bilateral lower extremities, and an intact protective threshold. The diagnosis was chronic right ankle instability. This evidence does not indicate that, prior to August 6, 2010, the Veteran's service-connected right ankle arthritis was manifested by moderate limitation of motion of the right ankle such that an initial compensable rating is warranted for this time period under DC 5271. Id. The Veteran also has not identified or submitted any competent evidence demonstrating that he experiences moderate limitation of motion of the right ankle such that an initial compensable rating is warranted prior to August 6, 2010. Accordingly, the Board finds that the criteria for an initial compensable rating prior to August 6, 2010, for the Veteran's service-connected right ankle arthritis are not met. The Veteran finally is not entitled to an initial rating greater than 10 percent effective December 1, 2010, for his service-connected right ankle arthritis. As noted in the Introduction, the Veteran had right ankle stabilization surgery at a VA Medical Center on August 6, 2010, and was awarded a temporary total rating based on the need for convalescence for 3 months following this surgery. See 38 C.F.R. § 4.30 (2012). The record evidence shows that, effective December 1, 2010, the Veteran's service-connected right ankle arthritis is manifested by, at worst, moderate limitation of motion of the ankle. See 38 C.F.R. § 4.71a, DC 5010-5271 (2012). For example, on VA outpatient treatment on December 3, 2010, 2 days after the end of his period of convalescence following right ankle stabilization surgery, the Veteran rated his right ankle pain as 6/10 on a pain scale and complained of right ankle dysfunction because "it fails" and twists while walking. Objective examination showed a limited range of motion in the right ankle. The assessment included chronic ankle pain. On December 29, 2010, the Veteran's right ankle surgical incision was well healed, there was minimal edema in the posterior lateral malleolus, no pain on palpation of the surgical scar. Range of motion testing of the right ankle showed it was stable with no increased laxity or crepitus and no subluxation of tendons. The assessment was status-post right lateral ankle stabilization. The Veteran was advised "to continue regular activity and regular shoegear at home and no further treatment is necessary" because he was not experiencing post-surgical right ankle pain. In January 2011, he was "without complaints." He had participated in regular physical therapy sessions "and has noted steady progress with decrease in pain and swelling." He rated his pain on a pain scale as 2/10 at best, 5/10 at worst, and 3/10 currently (with 1/10 being the least pain and 10/10 being the worst imaginable pain). He was instructed "to continue regular activity and regular shoegear at home and no further treatment is necessary. [He] currently [is] not experiencing post surgical pain." Objective examination showed his posture was within functional limits, bilateral ankle plantar flexion within normal limits, left ankle dorsiflexion within normal limits, right ankle dorsiflexion to 2 degrees, 5/5 strength of the bilateral lower extremities, "some sensation deficits related to neuropathy," normal ligament stability, no gross foot deformity, foot alignment within functional limits, an improved gait pattern, no gross gait deformity. It was noted that the Veteran "has been cleared by podiatry to resume normal activities." In February 2012, he ambulated without assistance and was diagnosed as having right Achilles tendinitis based on his complaints of right ankle pain. On VA ankle conditions DBQ in May 2012, the Veteran denied that flare-ups of pain impacted his right ankle function. Range of motion testing of the right ankle showed plantar flexion to 35 degrees with objective evidence of painful motion beginning at 35 degrees and dorsiflexion to 15 degrees with objective evidence of painful motion beginning at 15 degrees without additional limitation of motion. The Veteran experienced functional loss due to less movement than normal. Physical examination showed no joint laxity, ankylosis, or other ankle condition, and a surgical scar that was not painful or unstable and not greater than 39 square centimeters. There was no functional impairment in the right ankle. X-rays showed calcaneal posterior enthesophyte formations "with no other significant abnormality." The diagnoses included enthesopathy of the right ankle. This evidence does not indicate that the Veteran's service-connected right ankle arthritis was manifested by marked limitation of motion of the right ankle such that an initial rating greater than 10 percent is warranted effective December 1, 2010, under DC 5271. Id. The Veteran also has not identified or submitted any competent evidence demonstrating that he experiences marked limitation of motion of the right ankle such that an initial rating greater than 10 percent is warranted effective December 1, 2010. Accordingly, the Board finds that the criteria for an initial rating greater than 10 percent effective December 1, 2010, for the Veteran's service-connected right ankle arthritis are not met. Extraschedular The Board must consider whether the Veteran is entitled to consideration for referral for the assignment of an extraschedular rating for his service-connected acquired psychiatric disability, to include PTSD, service-connected right ankle arthritis, or for his service-connected left ankle arthritis. 38 C.F.R. § 3.321; Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the Veteran or reasonably raised by the record). An extraschedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The Board finds that schedular evaluations assigned for the Veteran's service-connected acquired psychiatric disability and bilateral ankle arthritis are not inadequate in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of each of these service-connected disabilities. This is especially true because the 30 percent rating currently assigned for the Veteran's acquired psychiatric disability contemplates moderate disability and because his service-connected left ankle arthritis was not compensably disabling prior to April 29, 2008, and his service-connected right ankle arthritis was not compensably disabling prior to August 6, 2010 (as discussed above). Moreover, the evidence does not demonstrate other related factors such as marked interference with employment and frequent hospitalization. The Board also has found that the criteria for a TDIU have been met. In light of the above, the Board finds that the criteria for submission for assignment of extraschedular ratings 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 Entitlement to a TDIU is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an initial rating greater than 30 percent for an acquired psychiatric disability, to include PTSD, is denied. Entitlement to an initial compensable rating prior to April 29, 2008, and to an initial rating greater than 10 percent prior to July 31, 2012, and effective November 1, 2012, for left ankle arthritis is denied. Entitlement to an initial compensable rating prior to August 6, 2010, and to an initial rating greater than 10 percent effective December 1, 2010, for right ankle arthritis is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs