Citation Nr: 1327474 Decision Date: 08/27/13 Archive Date: 09/05/13 DOCKET NO. 07-17 385 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to service connection for a prostate disorder, to include as secondary to Agent Orange exposure. 2. Entitlement to service connection for a vision disorder, to include as secondary to Agent Orange exposure. 3. Entitlement to service connection for a headache disorder, to include as secondary to Agent Orange exposure. 4. Entitlement to service connection for a respiratory disorder, to include as secondary to Agent Orange exposure. 5. Entitlement to service connection for a skin rash disorder, to include as secondary to Agent Orange exposure. 6. Entitlement to service connection for neuropathy of the hands, to include as secondary to Agent Orange exposure. 7. Entitlement to service connection for a cardiac disorder, to include as secondary to Agent Orange exposure. 8. Entitlement to service connection for a disorder manifested by fatigue, to include as secondary to Agent Orange exposure. 9. Entitlement to service connection for disorder manifested by joint aches, to include as secondary to Agent Orange exposure. 10. Whether new and material evidence has been received sufficient to reopen a claim of entitlement to service connection for a lumbar spine disorder, and if so, whether service connection is warranted. 11. Entitlement to an initial evaluation in excess of 30 percent prior to April 26, 2006 and from September 1, 2005 to June 11, 2006 for posttraumatic stress disorder (PTSD); in excess of 50 percent from June 12, 2006 to November 26, 2007 and from February 1, 2008 to February 8, 2011; and in excess of 70 percent as of February 9, 2011. 12. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and Brother in Law ATTORNEY FOR THE BOARD H. Bunker, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1969 to June 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. The Veteran and his brother in law testified before a Decision Review Officer (DRO) at the Hartford, Connecticut RO in July 2007. The Veteran also testified at a Board hearing at the RO in Hartford, Connecticut in June 2013. These transcripts have been associated with the file. The Veteran was granted entitlement to service connection for PTSD in a July 2004 rating decision and assigned an evaluation of 30 percent disability, effective December 24, 2003. During the pendency of the appeal, in an August 2005 rating decision, the RO assigned a 100 percent temporary total rating from April 26, 2005 to August 31, 2005. A 30 percent evaluation was assigned effective September 1, 2005. In a January 2007 rating decision a 50 percent evaluation was assigned, effective June 12, 2006. In a March 2008 rating decision a 100 percent temporary total rating was assigned from November 27, 2007 to January 31, 2008. Finally, in a March 2012 rating decision a 70 percent evaluation was again assigned as of February 9, 2011. The Board's analysis contemplates the schedular rating awarded for periods other than when a 100 percent rating was in effect. With respect to increased ratings, the United States Court of Appeals for Veterans Claims (Court) has held that on a claim for an original or increased rating, the appellant will generally be presumed to be seeking the maximum benefit allowed by law or regulations, and it follows that such a claim remains in controversy where less than the maximum benefit is allowed. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Additional evidence had been received at the Board. However, in an August 2012 statement the Veteran and his representative waived RO review of this evidence and therefore, Board adjudication of the current appeal may go forward without remanding the appeal for a supplemental statement of the case. See 38 C.F.R. § 20.1304(c)(2012). The case was brought before the Board in November 2010 and January 2013, at which time the claim was remanded to allow the Agency of Original Jurisdiction (AOJ) to further assist the Veteran in the development of his appeal, to include obtaining records from the Social Security Administration (SSA), associating outstanding VA treatment records with the claims file, obtaining an opinion on employability, and scheduling the Veteran for a Board hearing. The Veteran's SSA records and outstanding VA treatment records were associated with the claims file. A VA examiner provided an opinion in a February 2011 VA examination report. The Veteran had a Board hearing in June 2013. Therefore, the Board finds that there has been substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). The issues of entitlement to service connection for a vision disability, neuropathy of the bilateral hands, the reopened issue of entitlement to service connection for a lumbar spine disability, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that a prostate disorder is related to service, or is attributable to Agent Orange exposure. 2. The preponderance of the evidence is against a finding that a headache disorder is related to service, or is attributable to Agent Orange exposure. 3. The preponderance of the evidence is against a finding that a respiratory disorder is related to service, or is attributable to Agent Orange exposure. 4. The preponderance of the evidence is against a finding that a skin rash disorder is related to service, or is attributable to Agent Orange exposure. 5. The preponderance of the evidence is against a finding that a cardiac disorder is related to service, or is attributable to Agent Orange exposure. 6. The preponderance of the evidence is against a finding that a disorder manifested by fatigue is related to service, or is attributable to Agent Orange exposure. 7. The preponderance of the evidence is against a finding that a disorder manifested by joint aches is related to service, or is attributable to Agent Orange exposure. 8. A July 1971 rating decision denied the Veteran's claim of service connection for a lumbar spine disorder as the evidence of record indicated that the disability preexisted service and was not aggravated by service. The Veteran did not perfect an appeal of this decision. 9. Evidence received since the July 1971 rating decision which is neither cumulative nor redundant, raises a reasonable possibility of substantiating the claim of service connection for a lumbar spine disorder. 10. From December 24, 2003 to April 25, 2003 and from September 1, 2005 to November 26, 2007 the Veteran's PTSD was manifested by panic attacks, avoidance of activities and discussion related to service, distressing thoughts related to service, and impairment in social and occupational impairment. 11. As of February 1, 2008 the Veteran's PTSD has been manifested by depression, anxiety, suicidal ideations, and the inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. A prostate disorder was not incurred in or aggravated by active military service, and may not be presumed to have been the result of exposure to Agent Orange. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. A headache disorder was not incurred in or aggravated by active military service, and may not be presumed to have been the result of exposure to Agent Orange. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 3. A respiratory disorder was not incurred in or aggravated by active military service, and may not be presumed to have been the result of exposure to Agent Orange. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 4. A skin rash disorder was not incurred in or aggravated by active military service, and may not be presumed to have been the result of exposure to Agent Orange. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 5. A cardiac disorder was not incurred in or aggravated by active military service, and may not be presumed to have been the result of exposure to Agent Orange. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 6. A disorder manifested by fatigue was not incurred in or aggravated by active military service, and may not be presumed to have been the result of exposure to Agent Orange. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 7. A disorder manifested by joint aches was not incurred in or aggravated by active military service, and may not be presumed to have been the result of exposure to Agent Orange. 38 U.S.C.A. §§ 1110, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 8. The July 1971 rating decision which denied the Veteran's claim for service connection for a lumbar spine disorder is final. 38 U.S.C.A. § 7105 (West 2002 & Supp. 2002); 38 C.F.R. § 20.1103 (2012). 9. Evidence received since the July 1971 rating decision is new and material and the Veteran's claim for service connection for a lumbar spine disorder is reopened. 38 U.S.C.A. § 5108 (West 2002 & Supp. 2012); 38 C.F.R. § 3.156(a) (2012). 10. The criteria for an evaluation of 50 percent, but no higher, for PTSD have been met from December 24, 2003 to April 25, 2003, and from September 1, 2005 to November 26, 2007. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 11. The criteria for an evaluation of 70 percent, but no higher, for PTSD have been met as of February 1, 2008. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims folder. Although the Board has an obligation to review the entire record, the Board does not have to discuss each piece of evidence reviewed. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The notice requirements were met in this case by letters sent to the Veteran in January 2004 and July 2006. The January 2004 letter advised the Veteran of the information necessary to substantiate his claim, and of his and VA's respective obligations for obtaining specified types of evidence. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); 38 C.F.R. § 3.159(b). The July 2006 letter also advised the Veteran of how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the Veteran was not provided adequate 38 U.S.C.A. § 5103(a) notice prior to the adjudication of the claim in the July 2004 rating decision, this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claims after reading the above letter as well as the rating decision, statement of the case, and supplemental statements of the case. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Veteran has neither alleged nor proven that prejudice resulted from lack of proper VCAA notice, and therefore, the Board determines that none resulted. See Shinseki, supra. During the pendency of the appeal, the VCAA notice requirements were interpreted as follows. For an increased compensation claim, the veteran must be notified that he 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. Additionally, the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration, and their impact upon employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) (Vazquez-Flores I). The United States Court of Appeals for the Federal Circuit (Federal Circuit) subsequently held that the notice described in 38 U.S.C. § 5103(a) need not be veteran specific, i.e., it need not notify the veteran of alternative diagnostic codes, and that that the statutory scheme does not require 'daily life' evidence for proper claim adjudication. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (Vazquez-Flores II) (vacating and remanding in part Vazquez-Flores I). The notice must advise the veteran to submit evidence demonstrating the effect that the worsening of his disability has on his employment. Vazquez-Flores v. Shinseki, 24 Vet. App. 94, (2010) (Vazquez-Flores III). The Veteran was notified of these changes in October 2008. The Veteran has not alleged that VA failed to comply with the notice requirements of the VCAA, and he was afforded a meaningful opportunity to participate effectively in the processing of his claim, and has in fact provided additional arguments at every stage. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005). The Veteran's service treatment records and VA treatment records are in the file. The VA has also obtained private treatment records and associated them with the claims file. The Veteran has not indicated that there are any additional outstanding records to be obtained. The duty to assist with obtaining medical records has been satisfied. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The case of McLendon v. Nicholson, 20 Vet. App. 79 (2006), held that an examination is required when (1) there is evidence of a current disability, (2) evidence establishing an "in-service event, injury or disease," or a disease manifested in accordance with presumptive service connection regulations occurred which would support incurrence or aggravation, (3) an indication that the current disability may be related to the in-service event, and (4) insufficient evidence to decide the case. A VA examination was not provided in conjunction with the Veteran's claims for prostate, headache, respiratory, skin rash, cardiac, fatigue and joint ache disorders and, as discussed below, the evidence of record does not warrant one. See 38 C.F.R. § 3.159(c)(4). In the present case, there is no competent evidence of record to support a finding that the Veteran's claimed disorders are related to service. The Veteran himself has provided statements that his claimed disorders are related to service, to include Agent Orange exposure, and although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issues in this case, these fall outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer); see also Waters v. Shinseki, 601 F.3d 1274, 1279 (Fed. Cir. 2010) (the Veteran's conclusory lay statement is insufficient to trigger VA's duty to provide an examination with an opinion). The Veteran has not satisfied all the elements of McLendon; therefore, VA is not required to provide him with a VA examination in conjunction with his claims. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a). The Veteran was afforded multiple VA medical examinations to determine the severity of his PTSD. These opinions were rendered by medical professionals following a thorough examination and interview of the Veteran and review of the claims file. The examiners obtained an accurate history. The examiners provided a detailed explanation for the opinions that were reached. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disorder since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11-95. Therefore, the Board finds that the examination is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In light of the foregoing, all relevant facts have been adequately developed to the extent possible; no further assistance to the appellant in developing the facts pertinent to the issue on appeal is required to comply with the duty to assist. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for the claimed disorder on a direct basis, generally there must be probative evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). A presumption also exists for certain diseases associated with exposure to herbicide agents, which may be presumed to have been incurred in service even if there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307(a)(6) are met. 38 C.F.R. § 3.309(e). The term 'herbicide agent' means a chemical in an herbicide, including Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. The diseases for which service connection may be presumed to be due to an association with herbicide agents include AL amyloidosis, chloracne or other acne form disease consistent with chloracne, Type 2 diabetes, Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers, and soft-tissue sarcoma other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, mesothelioma. Service connection may be presumed for residuals of Agent Orange exposure by showing two elements. First, it must be shown that the Veteran served in the Republic of Vietnam during the Vietnam era. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6). Second, the Veteran must have been diagnosed with one of the specific diseases listed in 38 C.F.R. § 3.309(e). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a 'competent' source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. Layno v. Brown, 6 Vet. App. 465 (1994). Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. In certain instances, however, lay evidence has been found to be competent with regard to a disease with 'unique and readily identifiable features' that is 'capable of lay observation.' See, e.g., Barr v. Nicholson, 21 Vet. App. 303 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the 'authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence'). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Prostate, Headache, Respiratory, Skin Rash, Cardiac, and Fatigue Disorders Here, the Veteran has confirmed service in Vietnam during the Vietnam War era from June 1970 to June 1971 and is therefore presumed to have been exposed to herbicide agents. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6). The Veteran is arguing that his claimed disorders were caused by exposure to Agent Orange in-service. As has been noted, the Veteran is presumed to have been exposed to Agent Orange. The Board observes prostate cancer, respiratory cancer, skin conditions, such as chloracne or other acneform disease consistent with chloracne, and ischemic heart disease are on the list of diseases associated with herbicide agents. However, the Veteran has not been diagnosed with any of these specific diseases. He specifically testified in June 2013 that he had not been diagnosed with prostate cancer. There is also no evidence he has been diagnosed with a respiratory cancer. While he has complained of various skin rashes, he has not been diagnosed with chloracne or another acneform disease which is consistent with chloracne; rather he has been diagnosed with a rash and pruritus. A September 2011 rating decision also specifically denied service connection for ischemic heart disease as the Veteran had not been diagnosed with this disorder. See 38 C.F.R. § 3.309(e). Therefore, the presumption is inapplicable here for the above claimed disorders. While service connection may not be granted on a presumptive basis for the claimed disorders, the Veteran is not precluded from establishing service connection with evidence that these disabilities were incurred during service or are otherwise related to service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). As discussed below, the preponderance of the evidence is against the Veteran's claims on a direct basis and the appeal will be denied. The Board has reviewed the Veteran's service treatment records and observes the Veteran was given a medical examination at entrance to service in July 1969. He specifically denied urinary problems, headaches, chronic or frequent colds, sinusitis, hay fever, shortness of breath, chronic cough, skin diseases, or trouble sleeping. On examination, no defects were found and the Veteran was qualified for entrance to service. The Veteran only reported back pain and blunt trauma to the left eye while in service. There are no complaints for other health problems. On his June 1971 separation examination the Veteran again had no health defects or abnormalities noted. This evidence weighs against the Veteran's claim that these conditions began in service. The law also provides that even if a chronic condition is not shown during service, service connection may be established under 38 C.F.R. § 3.303(d) if the evidence shows a disease first diagnosed after service was incurred in service. The Veteran filed a claim for service connection in June 1971, the month he separated from service, for a back injury. The Veteran did not indicate at this time that he had prostate, headache, respiratory, skin, cardiac, or fatigue disorders which began in-service. This evidence, directly after the Veteran separated from service, weighs against the Veteran's claim that the current claimed disorders began in service and continued on thereafter. In a June 2003 private treatment record it was noted the Veteran had watery eyes, a runny nose, and congestion due to allergies. In July 2003 a private treatment record noted the Veteran's complaints of headaches. During allergy testing the Veteran had an allergic reaction and was transported to the hospital for further testing. Upon further testing his echocardiogram and stress test were normal. The physician determined the Veteran had a non-Q wave myocardial infarction under the stress of the epinephrine, which was given due to the allergic reaction. He had a normal heart with epinephrine induced ischemia versus coronary artery disease with non-Q wave myocardial infarction brought up by epinephrine. In August 2003 the Veteran was evaluated for rhinoconjunctivitis, asthma, and possible sleep apnea. He was diagnosed with seasonal allergic rhinoconjunctivitis and mild, intermittent, seasonal asthma. In August 2004 the Veteran was again seen by a cardiologist. The physician noted the August 2003 non-Q wave myocardial infarction, with normal coronary arteries and a normal left ventricle and ejection fraction. The Veteran reported intermitted twinges of discomfort in his chest, which were no different to those feelings prior to the epinephrine injection. On examination his electrocardiogram was normal with no diagnostic changes. In an October 2004 VA treatment record the Veteran reported that he had a rash 3 weeks earlier of the abdomen and arms which he believed was due to poison ivy. The arm rash had resolved and some rash was left on his abdomen. No diagnosis was given. In a February 2005 VA treatment record the Veteran reported a past medical history including headaches. See also August 2006 Vet Center record. In June 2005 the Veteran reported he had chronic fatigue syndrome. In a separate June 2005 VA treatment record the Veteran denied a history of a skin rash. In a January 2007 VA treatment record the Veteran reported headaches. It was noted that he had a prostate nodule which was referred to the genitourinary department. In an October 2008 treatment record from the Vet Center the Veteran reported feeling fatigued. In March 2009 the Veteran had a normal electrocardiogram with no ischemic changes. In a June 2009 VA treatment record the Veteran was seen for itching of his neck and shoulders. He was diagnosed with pruritus. In May 2010 the Veteran was seen for a chest cold and was diagnosed with acute bronchitis. In a September 2010 VA treatment record the Veteran was seen for a hand rash and productive cough. He was given calamine lotion and cough medicine. In a November 2010 VA treatment record the Veteran reported with a hand rash which had improved since the previous visit. The Veteran underwent surgery for his prostate in December 2010, having a transurethral resection of the prostate performed. In a February 2011 Vet Center record the Veteran reported that he could not control his urine. The Veteran also testified at his June 2013 Board hearing that he experienced severe migraines with vomiting and spinning. He also testified he had not been diagnosed with prostate cancer or given a specific respiratory condition diagnosis. In addition to the absence of symptomatology from service related to these conditions and an absence of medical diagnoses linking the claimed disorders to service, the evidence includes the Veteran's statements and testimony asserting continuity of symptoms with respect to the claimed disorders since active duty service. The Veteran is competent to state his current symptoms, including urinary problems, headaches, coughs, skin rashes, pain in his chest, and fatigue. While competent to discuss symptoms, the Veteran is not then competent to give himself a medical diagnosis and relate it to service. The Board has considered the Veteran statements that he has prostate, headache, respiratory, skin, cardiac, and fatigue disorders which are related to service. See e.g., December 2003 claim. As noted, although lay persons such as the Veteran are competent to provide opinions on some medical issues, see Kahana, supra. diagnosing and determining the etiology of the above claimed conditions falls outside the realm of common knowledge of a lay person. Additionally, the Veteran has offered only conclusory statements regarding the relationship between his service and prostate, headaches, respiratory, skin, cardiac, or fatigue disorders. Accordingly, the Board assigns the Veteran's statements little probative value. Accordingly, the preponderance of the evidence is against the claims for service connection on a presumptive and direct basis and the benefit of the doubt rule does not apply. See 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). The claims of entitlement to service connection for prostate, headache, respiratory, skin, cardiac, and fatigue disorders are denied. Joint Ache Disorder The Veteran is alleging that he suffers from a disorder which causes joint aches. The Board has reviewed the Veteran's service treatment records and notes that there is no evidence he complained of, or was treated for, a general disorder causing joint aches. He was cleared for separation from service with no health defects or abnormalities noted. Following separation from service the Veteran has been treated by the VA and private treatment providers for various disabilities. In a February 2005 VA treatment record the Veteran reported aches all over his body. In a February 2010 again he reported he felt achy. The examiner found no major joint deformity. There is no diagnosis in any VA or other treatment record for a diagnosis which causes joint aches. After reviewing the claims file, the Board finds that there is no competent evidence of record which shows that the Veteran has a disorder which causes joint aches. Without a current diagnosis of a disability, the Board cannot grant service connection. To prevail on the issue of service connection, a current disability must have existed on or after the date of application for that disability. See 38 U.S.C.A. § 1110; see also Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (agreeing that the requirement that a claimant have a current disability before service connection may be awarded is satisfied when a claimant has a disability at the time a VA claim is filed or during the pendency of that claim.). While the Board appreciates the Veteran's service, there is no competent evidence that he has been diagnosed with a disorder causing joint aches. The Veteran has produced no competent evidence or medical opinion in support of his claim that he suffers from such a disability, and the great weight of the evidence included in the record weighs against granting the Veteran's claim. Accordingly, the Veteran's claim for service connection must be denied. New and Material Evidence to Reopen a Claim for a Lumbar Spine Disorder Previously denied claims may be reopened with the submission of new and material evidence. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. §§ 3.156, 20.1105 (2012). "[N]ew evidence" means evidence not previously submitted to agency decision-makers, and "material evidence" means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is 'low.' Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). The Veteran's claim of entitlement to service connection for a lumbar spine disorder was denied in a July 1971 rating decision. The Veteran did not appeal this decision and it is final. 38 U.S.C.A. §§ 7103, 7266. The evidence received since the July 1971 rating decision includes VA treatment records, the Veteran's statements, and hearing testimony. The Veteran's treatment records show that he has been diagnosed with degenerative disc disease of the lumbar spine. He has also reported back pain which existed for 30 years. See e.g., April 2004 treatment record. The Veteran also testified in June 2013 that he believes his back pain was aggravated due to the heavy weight he carried in service and that he had continuous treatment for a lumbar spine disorder after separation from service. This evidence is new, as it was not previously of record at the time of the July 1971 rating decision. It is also material in that it helps to support the Veteran's claims that his lumbar spine disorder is related to service. Therefore, the claim is reopened. PTSD Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally, 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). In Fenderson v. West, 12 Vet. App. 119 (1999), the Court held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. In Fenderson, the Court also discussed the concept of the "staging" of ratings, finding that in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a Veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson at 126-28; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). Under 38 C.F.R. § 4.130, Diagnostic Code 9411, a 30 percent evaluation is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id. Under this diagnostic code, a 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereo-typed speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability evaluation is warranted when there is 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 work like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: 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 and place; memory loss for names of close relatives, own occupation, or own name. Id. As evidenced by use of the phrase "such symptoms as," followed by a list of examples, this list of symptoms in the rating criteria is meant to be mere examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). However, if the evidence shows the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the Diagnostic Code, the appropriate equivalent rating will be assigned. Mauerhan, at 443. The Federal Circuit Court has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). As discussed below, the Board finds that a 50 percent evaluation, but no higher, is warranted from December 24, 2003 to April 25, 2005 and from September 1, 2005 to November 26, 2007. The Board also finds a 70 percent evaluation, but no higher is warranted as of February 1, 2008. From December 24, 2003 to April 25, 2005 and from September 1, 2005 to November 26, 2007 The findings in the claims file indicate that the Veteran has some memory loss, and mixed mental status findings. At his March 2004 VA examination the Veteran had a goal directed thought process and normal speech. His thought content was depressed. His judgment and insight were considered fair. In an August 2004 VA treatment record the Veteran reported poor concentration and poor short-term memory. An assessment by the Vet Center in December 2004 noted the Veteran had some memory and concentration problems with poor insight and judgment. His speech was pressured at times. A January 2005 private examiner found the Veteran was oriented times three and remembered objects, with prompting. The February 2005 Vet Center assessment noted the Veteran had impaired memory problems. In the February 2007 VA examination report his insight and judgment were poor and he communicated poorly. Abnormal speech, impaired judgment, and impaired abstract thinking are taken into account with the 50 percent evaluation. In a January 2004 Vet Center assessment the Veteran reported that he attempted to block thoughts and feelings associated with combat. He reported flashbacks at his March 2004 VA examination. At this examination he also reported nightmares approximately twice a week. In a May 2006 Vet Center record the Veteran reported an increase in intrusive memories and sleep disturbances. In a September 2006 VA treatment record the Veteran reported nightmares and intrusive thoughts. See also December 2004 Vet Center assessment. In a December 2006 VA treatment record the Veteran reported feeling angry with everything. A January 2004 Vet Center assessment also noted the Veteran's reports of irritability and rage. At his March 2004 VA examination the Veteran reported that his wife had commented on his irritability. See also February 2007 VA examination report noting irritability on examination. The Vet Center assessment from December 2004 also reported that the Veteran had panic attacks throughout the week. This report also noted the Veteran was overwhelmed easily and had difficulty making decisions. A February 2005 Vet Center report indicated the Veteran had panic attacks daily. The Veteran reported feelings of depression including a depressed mood, low energy, and low motivation. See March 2004 VA examination report. In a May 2006 Vet Center record the Veteran reported increased feelings of anxiety and depression. In a July 2006 VA treatment record the Veteran reported feeling depressed and anxious. These symptoms have been taken into account with the 50 percent evaluation. With regard to social functioning, during this time period the Veteran has endorsed difficulty in establishing and maintaining effective work and social relationships. He stopped working in 2004 due to PTSD and physical problems. A January 2004 Vet Center assessment noted the Veteran avoided people, places, events, and things that evoked traumatic memories. In a December 2004 Vet Center assessment the Veteran was reported to be withdrawn and socially isolated. With encouragement he attended group therapy at the Vet Center. The Veteran reported that his wife slept in a different room. See July 2006 VA treatment record. In a May 2006 Vet Center record the Veteran reported marital issues in that he and his wife had little interaction with each other, even being home together each day. He again reported in a June 2006 Vet Center treatment record that he had limited interaction with his wife and family and feeling detached from his community. The Board finds that a 50 percent evaluation is warranted from December 24, 2003 to April 25, 2003 and from September 1, 2005 to November 26, 2007. The Board observes that a higher rating is not warranted because the competent evidence of record does not demonstrate that the Veteran's symptomatology more closely approximates a 70 percent evaluation. In this regard, although the Veteran has symptoms of irritability, there is no evidence of impaired impulse control, such as unprovoked irritability with periods of violence. The Veteran denied suicidal and homicidal ideation at his March 2004 VA examination and in August and November 2004 VA treatment records. The Board notes that the Veteran was briefly hospitalized in February 2005 due to suicidal ideations. However, following this, the Veteran reported feeling that he would be better off dead, but he also stated he had no active suicidal plan or intent at a June 2006 VA appointment. The Veteran also denied suicidal or homicidal ideations at September 2006 and December 2006 VA appointments. The Board takes into account all of the Veteran's symptoms when determining an appropriate evaluation instead of relying on one factor. While the Veteran endorsed feelings of depression and anxiety, during this time period the evidence does not show that the Veteran had near continuous panic or depressing affecting his ability to function independently, appropriately, and effectively, which could warrant a higher rating. Also during his psychological assessment the Veteran has denied hallucinations or delusions. See March 2004 VA examination report and March 2005 VA treatment record. There is also no evidence he has obsessional rituals interfering with his routine activities. The Board also acknowledges that the Veteran suffers from symptoms not covered under Diagnostic Code 9411. For instance, he has reported feelings of hypervigilance and an exaggerated startle response. See e.g., June 2006 VA treatment record. However, all of the Veteran's symptoms have been taken into account when determining the most appropriate evaluation. It is clear from the competent evidence of record that the Veteran's PTSD manifestations throughout the appeal period have consistently included panic attacks, avoidance of activities and discussion related to service, distressing thoughts related to service, and impairment in social and occupational impairment. This level of social and occupational impairment, however, is consistent with his existing 50 percent rating. Also of record are the Veteran's GAF scores. GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders contemplates that the GAF scale will be used to gauge a person's level of functioning at the time of the evaluation (i.e., the current period) because ratings of current functioning will generally reflect the need for treatment or care. The Board notes that while GAF scores are probative of the Veteran's level of impairment, they are not to be viewed outside the context of the entire record and they will not be relied upon as the sole basis for an increased rating. At his March 2004 VA examination the Veteran was assigned a GAF score of 50. In an August 2004 VA treatment record the Veteran was assigned a GAF score of 45. See also May 2004 VA treatment record. The Veteran was assigned a GAF score of 35 at his June 2005 discharge from inpatient treatment for PTSD. At his February 2007 VA examination the Veteran's GAF score was 40-45. A GAF of 31-40 is defined as exhibiting some impairment in reality testing or communication (speech is at times illogical, obscure, or irrelevant), or any major impairment in several areas, such as work or school, family relations, judgment, thinking or mood, (a depressed man that avoids friends, neglects family, and is unable to work; a child that frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41-50 is assigned for serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). The Board has taken the Veteran's GAF scores into account. Even assuming that the Veteran's GAF scores represent severe symptoms, they will not be relied upon as the sole basis for an increased disability rating. Instead, the Board must consider the entire claims file, including the private treatment records, VA examinations, and VA treatment when determining the proper rating. Taking into account all of the Veteran's PTSD symptoms discussed above, the Board finds that a 50 percent rating for PTSD is appropriate from December 24, 2003 to April 25, 2005 and from September 1, 2005 to November 26, 2007. The Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran's disability in his favor. The Board concludes that the objective medical evidence and the Veteran's statements regarding his symptomatology show disability that warrants the assignment of a 50 percent rating from December 24, 2003 to April 25, 2003 and from September 1, 2005 to November 26, 2007. See 38 C.F.R. § 4.7. In addition to the medical evidence, the Board has considered the statements of the Veteran and his family in support of his claim. The Veteran and his family, as `, are competent to report on that as to which they have personal knowledge, such as anxiety, social impairment, and irritability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 310 (2007); and 38 C.F.R. § 3.159(a)(2). Since the allegations of these particular symptoms appear to be uncontradicted, even by medical findings of record, the Board also finds them to be credible and, thus, probative. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Rucker v. Brown, 10 Vet. App. 67 (1997) (indicating his competency to make these proclamations must be distinguished from the weight and credibility of his lay testimony, which are factual determinations going to the ultimate probative value of this evidence). However, as laymen, without the appropriate medical training and expertise, the Veteran and his family are not further competent to provide a probative (persuasive) opinion on a medical matter, especially the severity of his PTSD in relation to the applicable rating criteria. An examiner, including the VA compensation examiners, takes into consideration the Veteran's subjective complaints, his social and occupational history, and the results of the objective mental status evaluation in determining the overall severity of his PTSD. This determination is multi-factorial, not just predicated on lay statements and other testimony, rather, all of the relevant medical and other evidence. The Federal Circuit Court has recognized the Board's 'authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence.' Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Resolving reasonable doubt in favor of the Veteran, the Board concludes that the evidence discussed above supports no more than a 50 percent rating for the Veteran's PTSD from December 24, 2003 to April 25, 2005 and from September 1, 2005 to November 26, 2007. 38 U.S.C.A. § 5107 (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). However, the preponderance of the evidence is against a higher evaluation. Id. As of February 1, 2008 The mental status findings in the claims file indicate the Veteran's judgment and insight as of February 1, 2008 were generally appropriate. In a December 2010 VA treatment record the Veteran had organized though process and fair to good insight. See also July 2011 VA treatment record. There has been no evidence throughout the appeal of gross impairment in the Veteran's thought process or communication which could warrant a higher rating. The Veteran was noted to have poor memory and concentration in a December 2010 VA treatment record. A statement from the Veteran's sisters in May 2008 also noted the Veteran had trouble remembering names of people, places, and birthdays. Neither the Veteran nor a VA or private treatment provider has indicated that the Veteran has memory loss so severe he cannot remember the names of his close relatives, his own occupation, or his own name, which could warrant a higher rating. The Veteran reported anxiety in a March 2012 Vet Center treatment record. See also December 2010 and November 2011 Vet Center records. In a December 2008 VA treatment record the Veteran reported flashbacks and nightmares. He reported getting 2-3 hours of uninterrupted sleep a night. In an August 2010 VA treatment record the Veteran reported falling asleep while standing up because he was having trouble sleeping at night. At his February 2011 VA examination the Veteran reported feeling low and not having anything to look forward to. The Veteran also reported depression in a November 2011 Vet Center treatment record. The Veteran reported irritability and anger, with angry outbursts in an April 2008 VA treatment record. The Veteran's sisters also provided a statement in May 2008 noting that the Veteran was irritable, angered quickly, and yelled at his children and wife. He reported getting angry, throwing things, and punching walls at home. He also reported road rage and having followed someone in his car. See February 2011 VA examination report. At his March 2012 Vet Center appointment the Veteran reported he was irritable when interacting with his children. These symptoms have been taken into account in the 70 percent evaluation. In a December 2010 VA treatment record the Veteran admitted to transient passive suicidal ideation. The Veteran also endorsed passive suicidal ideation at a January 2011 VA medical appointment; however he denied it at his February 2011 VA examination. At his July 2012 visit to the Vet Center the Veteran denied suicidal ideations, plan or intent. The Veteran also testified to constant suicidal ideations at his June 2013 Board hearing. These symptoms were taken into account with the current 70 percent evaluation. The Veteran has not shown that he is in persistent danger of hurting himself or others, which could warrant a higher evaluation. With regard to social impairment, in a May 2008 Vet Center record the Veteran reported having marital problems with his wife. See also April 2008 Vet Center record noting the Veteran's wife slept in a separate room. He stated that he had been very socially isolated and spends time in his house. He reported a recent trip to Italy with his family, but he did not like being out of the house. At his February 2011 VA examination he reported that his marriage had been bad since 2002 and that he has his wife were "passing in the night." In a December 2011 VA treatment record the Veteran reported estrangement between him and his wife and that his children sided with their mother during arguments. In a March 2012 Vet Center record the Veteran reported that he was happiest when he was at home by himself and his family was at work and school. At his June 2013 Board hearing the Veteran also testified that he sometimes stayed in his pajamas for 3-4 days at a time and did not leave the house. The inability to establish and maintain effective relationships is one symptom taken into account for a 70 percent disability rating. The Board observes that a higher rating is not warranted because the competent evidence of record does not demonstrate that the Veteran's symptomatology more closely approximates a 100 percent evaluation. In an October 2010 VA treatment record the Veteran reported seeing a face like image when he looked out the window. However, upon further examination the Veteran denied hallucinations and delusions at his February 2011 VA examination and in a July 2011 VA treatment record. The Board takes into account all factors when determining the appropriate evaluation. The Veteran had poor hygiene noted in an April 2008 Vet Center record. In a December 2010 VA treatment record the Veteran was well groomed. At his February 2011 VA examination he was poorly groomed, but his hygiene was good. Neglect of personal appearance and hygiene is a symptom taken into account for a 70 percent disability rating. The Board takes into account all the evidence of record when determining the appropriate rating, instead of relying on a single symptom. At his February 2011 VA examination the Veteran denied obsessional rituals, which could warrant a higher rating. The Board also acknowledges that the Veteran suffers from symptoms not covered under Diagnostic Code 9411. However, all of the Veteran's symptoms have been taken into account when determining the most appropriate evaluation. Also of record are the Veteran's GAF scores. The Board notes that while GAF scores are probative of the Veteran's level of impairment, they are not to be viewed outside the context of the entire record and they will not be relied upon as the sole basis for an increased rating. In a December 2010 VA treatment record the Veteran was assigned a GAF score of 45. At his February 2011 VA examination he had a GAF score of 39. A GAF of 31-40 is defined as exhibiting some impairment in reality testing or communication (speech is at times illogical, obscure, or irrelevant), or any major impairment in several areas, such as work or school, family relations, judgment, thinking or mood, (a depressed man that avoids friends, neglects family, and is unable to work; a child that frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41-50 is assigned for serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job. Taking into account the Veteran's PTSD symptoms, including social impairment, suicidal ideation, and depression, the Veteran has been assigned GAF scores corresponding with moderate and severe symptoms. The Board observes that the Veteran's depressive disorder has been rated as 70 percent disabling as of February 1, 2008. As such, the assigned GAF scores are appropriate for this time period. The Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran's disability in his favor. The Board concludes that the objective medical evidence and the Veteran's statements regarding his symptomatology show disability that warrants the assignment of a 70 percent rating as of February 1, 2008. See 38 C.F.R. § 4.7. In addition to the medical evidence, the Board has considered the Veteran's statements in support of his claim. As noted, the Veteran is competent to report on that as to which he has personal knowledge, such as anxiety, social impairment, suicidal ideation, and irritability. See Jandreau, supra; Barr, supra. The Board also finds these statements to be credible and, thus, probative. See Buchanan, supra. However, as a layman, without the appropriate medical training and expertise, the Veteran is not further competent to provide a probative opinion on a medical matter, especially the severity of his PTSD in relation to the applicable rating criteria. An examiner, including the VA compensation examiner, takes into consideration the Veteran's subjective complaints, his social and occupational history, and the results of the objective mental status evaluation in determining the overall severity of his PTSD. This determination is multi-factorial, not just predicated on lay statements and other testimony, rather, all of the relevant medical and other evidence. Overall, the Board concludes that the evidence discussed above supports no more than a 70 percent rating for the Veteran's PTSD as of February 1, 2008. In reaching its decision, the Board considered the benefit-of-the-doubt rule. However, the preponderance of the evidence is against a higher evaluation and therefore, it does not apply. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Extra-Schedular Consideration There is no evidence of exceptional or unusual circumstances to warrant referring these claims for extra-schedular consideration. 38 C.F.R. § 3.321(b)(1). The Court has clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a determination of whether the evidence presents such an exceptional disability picture that the available schedular evaluation for the service-connected disability is inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, there must be a determination of whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms". Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1). The Board finds no such evidence in this particular instance, however. The Veteran's complaints related to his PTSD are considered under the appropriate diagnostic code. His primary symptoms are depression, anxiety, and social impairment. But all of his symptoms are accounted for in the regular schedular rating criteria. According to 38 C.F.R. § 4.1, generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Indeed, in Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993), the Court reiterated this, noting the disability rating, itself, is recognition that industrial capabilities are impaired. As the assigned schedular evaluation for the service-connected PTSD is adequate, referral for an extra-schedular rating is unnecessary. Thun, supra. Furthermore, there is no evidence of any exceptional or unusual circumstances, such as frequent hospitalizations, suggesting he is not adequately compensated for this disability by the regular Rating Schedule. His evaluation and treatment for this disability has been almost entirely on an outpatient basis, not as an inpatient, much less frequent inpatient. So extra-schedular referral is not warranted under the circumstances presented. See Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). ORDER Entitlement to service connection for a prostate disorder is denied. Entitlement to service connection for a headache disorder is denied. Entitlement to service connection for a respiratory disorder is denied. Entitlement to service connection for a skin rash disorder is denied. Entitlement to service connection for a cardiac disorder is denied. Entitlement to service connection for a disorder manifested by fatigue is denied. Entitlement to service connection for disorder manifested by joint aches is denied. New and material evidence having been received, the claim of entitlement to service connection for a lumbar spine disorder is reopened; to this extent only, the appeal is granted. Entitlement to an evaluation of 50 percent, but no higher, is granted, effective December 24, 2003 to April 25, 2005 and from September 1, 2005 to November 26, 2007 for PTSD, subject to the laws and regulations governing monetary awards. Entitlement to an evaluation of 70 percent, but no higher, is granted, effective February 1, 2008 for PTSD, subject to the laws and regulations governing monetary awards. REMAND The Veteran was seen in service in July 1969 with blunt trauma to his left eye. He was noted to have a small cystic like structure. The Veteran has current diagnoses of macular changes of the left eye, and glaucoma and cataracts of the bilateral eyes. See January 2012 VA treatment record. There is no opinion of record to determine if the Veteran's current visual disorders are related to service. Accordingly, an opinion should be obtained. The Board has determined that new and material evidence has been received to reopen the Veteran's claim of entitlement to service connection for a lumbar spine disorder. The Veteran should be afforded a VA examination to determine the etiology of his lumbar spine disorder, to include an opinion regarding whether the condition pre-existed service and if so, whether the condition was worsened in service. The examiner should also comment on whether the Veteran's claimed peripheral neuropathy of the bilateral hands was caused or aggravated by the lumbar spine disorder, if determined to be related to service. As for the Veteran's claim for entitlement to a TDIU, the Court has held that all issues 'inextricably intertwined' with an issue certified for appeal are to be identified and developed prior to appellate review. See Harris v. Derwinski, 1 Vet. App. 180 (1991). As the issue of entitlement to a TDIU is impacted by the outcome of the Veteran's visual, lumbar spine and peripheral neuropathy claims, the TDIU claim is considered to be inextricably intertwined. Consequently, the claim of entitlement to a TDIU must be remanded in accordance with Harris. The AOJ should request an opinion as to whether entitlement to a TDIU is warranted based on the Veteran's service-connected disabilities. 38 C.F.R. § 4.16(a) and (b). Accordingly, the case is REMANDED for the following action: 1. Have an appropriate VA physician provide an opinion to determine if the Veteran's vision disorders are related to his military service. The entire claims file (i.e. any medical records contained in Virtual VA, CAPRI, and AMIE), to include this REMAND, must be reviewed by the examiner in conjunction with the opinion. If the examiner does not have access to Virtual VA, any relevant treatment records contained in Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should indicate on the examination report that (s)he has reviewed the folder in conjunction with the examination. The examiner should state whether it is at least as likely as not that the Veteran's visual disorders are related to service. The examiner should specifically comment on the July 1969 service treatment record noting blunt trauma to the left eye. It would be helpful if the examiner would use the following language, as may be appropriate: 'more likely than not' (meaning likelihood greater than 50%), 'at least as likely as not' (meaning likelihood of at least 50%), or 'less likely than not' or 'unlikely' (meaning that there is less than 50% likelihood). The term 'at least as likely as not' does not mean 'within the realm of medical possibility.' Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinion provided. A detailed rationale should be provided for all opinions. Conversely, if the examiner concludes that an etiological opinion cannot be provided, he or she should clearly and specifically so specify in the examination report, with an explanation as to why this is so. If further examination of the Veteran is necessary to provide the requested opinion, the Veteran should be scheduled for an additional examination. It is the Veteran's responsibility to report for any examination scheduled, and to cooperate in the development of the case; the consequences of failing to report for a VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158, 3.655 (2012). 2. Schedule the Veteran for a VA examination to determine the etiology of the Veteran's lumbar spine disorder. The entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE), to include this remand must be reviewed by the examiner in conjunction with the examination. If the examiner does not have access to Virtual VA, any relevant treatment records contained in Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. The examiner should indicate on the examination report that (s)he has reviewed the folder in conjunction with the examination. The examiner should provide the following opinions: (a) Whether there is clear and unmistakable (obvious or manifest) evidence that any current lumbar spine disorder preexisted service; (b) If so, whether there is clear and unmistakable evidence that shows lumbar spine disorder did NOT increase in severity beyond the natural progression of the disorder during service; and (c) Is it at least as likely as not that the Veteran's lumbar spine disorder is otherwise related to service? (d) If the examiner finds that the Veteran's lumbar spine disorder is related to service or that there is clear and unmistakable evidence that the lumbar spine disorder preexisted service and did not increase in severity beyond the natural progression of the disorder during service, he or she should then state whether it is at least as likely as not that the lumbar spine disorder caused OR aggravated (worsened) the Veteran's claimed neuropathy of the bilateral hands. The examiner should take into account the Veteran's June 2013 Board hearing testimony and all other relevant VA and private treatment records. The examiner should also specifically review the April 1968 letter to the draft board from the Veteran's private physician and his July 1969 in service complaints of lumbar spine pain. The supporting rationale for all opinions expressed must be provided. If the examiner is unable to provide any of the requested opinions without resorting to speculation, the examiner must provide an explanation for the basis of that determination. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). For example, no medical expert could provide the requested opinion because information from service or shortly thereafter is missing; current medical knowledge could yield many possible answers and/or opinions; the examiner lacks the expertise to render the requested opinion; or other testing is needed. 3. After completing the above directives, have an appropriate VA examiner provide an opinion as to the effects of the Veteran's service-connected disabilities on his ability to maintain employment consistent with his education and occupational experience. The entire claims file, including this REMAND, must be reviewed by the examiner in conjunction with the opinion. The examiner should confirm in the examination report that (s)he has reviewed the folder in conjunction with the examination. Based on a review of the case and the claims file, the examiner must provide an opinion as to whether the Veteran's service-connected disabilities, acting alone or together, preclude him from securing and following substantially gainful employment consistent with his education and occupational experience. The examiner should consider a June 2006 VA treatment record from a staff psychiatrist which stated that the Veteran was unemployable and an opinion from the February 2011 VA examiner who opined the Veteran could not work due to his PTSD and his physical disabilities involving his lower back. The examiner should also note that when it is not possible to separate the effects of a service-connected disability from a non-service-connected disability, 38 C.F.R. § 3.102 requires that reasonable doubt be resolved in the claimant's favor, thus attributing such signs and symptoms to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998) (emphasis added). All opinions provided must include an explanation of the bases for the opinion. If the requested opinion cannot be made without resort to speculation, the examiner must state this and specifically explain why this is so. 4. After completing the above and assigning any necessary disability evaluations, if, and only if, the Veteran does not meet the criteria for TDIU on a schedular basis, for any timeframe during the appeal period, under 38 C.F.R. § 4.16(a), refer the claim of entitlement to a TDIU on an extra-schedular basis to the Director of the Compensation and Pension Service for special consideration under 38 C.F.R. § 4.16(b). 5. After the examination has been completed, the Agency of Original Jurisdiction (AOJ) must review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 6. After completing the above, and any other development deemed necessary, the AOJ should readjudicate the claims. If the benefits sought on appeal are not granted, the Veteran and his representative should be furnished with a supplemental statement of the case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs