Citation Nr: 1334325 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 07-34 711A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE 1. Entitlement to a disability rating in excess of 10 percent for a right knee disorder. 2. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Paralyzed Veterans of America, Inc. ATTORNEY FOR THE BOARD Russell P. Veldenz, Counsel INTRODUCTION The Veteran served on active duty from July 1968 to September 1970 and from October 1970 to July 1989. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in April 2006 of a Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The claims file was subsequently transferred to the RO in Montgomery, Alabama. In December 2010, the Board remanded the case to the RO for additional development. As the requested development has been completed to the extent permitted by the cooperation of the Veteran, no further action is necessary to comply with the Board's remand directives under Stegall v. West, 11 Vet. App. 268, 271 (1998). See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACT 1. The Veteran's service-connected right knee patellofemoral syndrome with degenerative joint disease is manifested by flexion limited to 115 degrees with pain, but with no additional functional loss due to pain, fatigue, weakness, incoordination, or lack of endurance with repetitive use; there also was no evidence of recurrent subluxation or lateral instability. 2. The Veteran's service-connected PTSD with anxiety and depression is shown to be productive of a disability picture that more nearly approximates that of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; his disability picture is without evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short- and long-term memory, impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. CONCLUSION OF LAW 1. The criteria for a rating in excess of 10 percent for right knee patellofemoral syndrome with degenerative joint disease have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.655, 4.1, 4.2, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5257, 5260, 5261 (2013). 2. The criteria for the assignment of a rating higher than 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.159, 3.655, 4.1, 4.2, 4.10, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006). In a claim for increase, the VCAA notice requirements are the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting Veteran-specific notice as to effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The RO provided pre-adjudication VCAA notice by letters, dated in November 2005 and March 2006. The notice included the type of evidence needed to substantiate the claims for increase, namely, evidence that the symptoms had increased. The Veteran was notified that VA would obtain service treatment records, VA records, and records from other Federal agencies, and that he could submit other records not in the custody of a Federal agency, such as private medical records or with his authorization VA would obtain any non-Federal records on his behalf. The notice included the provisions for the effective date of a claim and for the degree of disability assignable. As for content of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (38 C.F.R. § 3.159 notice); of Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim); and of Vazquez-Flores v. Peake, 580 F.3d 1270 (Fed. Cir. 2009) (evidence demonstrating a worsening or increase in severity of a disability and the effect that worsening has on employment). Further VCAA notice is not required. Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim. The RO has obtained service treatment records, VA records, reports from a private medical caregiver, and afforded the Veteran VA examinations in February and September 2006. The reports of the VA examinations included a review of the Veteran's medical history, including his service treatment records, an interview and an examination of the Veteran, as well as sufficient findings to rate disability. Therefore, the Board concludes that the VA examination is adequate. 38 C.F.R. § 4.2; see Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As noted above, the Board remanded the Veteran's claims in December 2010. The Board directed VA to ask the Veteran to identify any medical providers or mental health providers who have treated the Veteran for his PTSD and right knee. In addition, the Veteran was to be scheduled for new VA examinations to ascertain the degree of disability currently associated with his service-connected disorders. Updated VA records have been associated with the file. As to private healthcare providers, VA sent a letter to the Veteran in December 2010 requesting he identify any health care providers who treated the Veteran for either his PTSD or his right knee disability. To date the Veteran has not responded. VA examinations were scheduled in March 2011 with notice sent to his last known address of record. The Veteran did not report for the examinations. His service representative argues the letter was sent after the appointment date, but the Board finds that the date at the top of the file copy of the letter advising the Veteran of the VA examinations is the date the copy was printed and associated with the file. The service representative also argues the RO did not make any follow up phone calls to the Veteran, citing to VHA Directive 2010-027 (a directive that provides policy for implementing processes and procedures for the scheduling of VA outpatient clinic appointments). It is contended that the Veteran was not contacted by phone about scheduling of his VA examination. Despite the representative's arguments, the Veteran has provided no evidence or information to indicate that he was not timely notified of the scheduled examination or that he had good cause for not reporting for it. Although there is no notation in the file that the Veteran was contacted by telephone prior to the appointment, there is a presumption of regularity of the administrative process that is only rebutted by clear and convincing evidence to the contrary. Ashley v. Derwinski, 2 Vet. App. 62, 64 (1992) (quoting United States v. Chem. Found. Ind. 272 U.S. 1, 14-15 (1926); Schoolman v. West, 12 Vet. App. 307, 310 (1999). There is no clear evidence to the contrary that VA did not follow the directive by unsuccessfully attempting to call the Veteran. Other then the assertions of the service representative, the evidence does not reflect irregularities in the way VA examinations were scheduled and the Veteran notified. The service representative's contention that there were no follow up phone calls is not the clear evidence to the contrary that would be sufficient to rebut the presumption of regularity. Instead, it is reasonable that VA did attempt to follow up with the Veteran and that the presumption that VA adhered to its own policies and procedures is not rebutted. Further, VA regulations provide that when a claimant fails to report for a scheduled medical examination without good cause, it may result in an adverse decision. 38 C.F.R. § 3.655. The Board notes that the Veteran was advised even earlier in December 2010 that an examination would be scheduled and the consequences for the failure to report without good cause shown, the claim may be decided on the evidence of record or denied. The VA's duty to assist is not a one-way street. If the Veteran wishes help, he cannot passively wait for it in those circumstances where his own actions are essential in obtaining the putative evidence. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board thus finds that the RO met the directives of the remand and duty to assist and the claims shall be decided on the evidence of record. As the Veteran has not identified any additional evidence pertinent to the claim and as there are no additional records to obtain, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations applies, assigning the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). The Veteran's Lay Evidence The Board recognizes that the evidence supporting the Veteran's claims for higher rating includes his statements as to the severity of his service connected right knee and PTSD disabilities. The Board has considered his lay statements as to both his bilateral knee disabilities and his PTSD disabilities. In evaluating a claim for an increased schedular disability rating, however, VA must consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). The Board is not free to ignore VA's duly promulgated regulations, which include the Rating Schedule. Franklin v. Brown, 5 Vet. App. 190, 193 (1993). The Board is bound by the law and is without authority to grant benefits on an equitable basis. See 38 U.S.C.A. §§ 503, 7104; Harvey v. Brown, 6 Vet. App. 416, 425 (1994). Furthermore, in rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and weight, factual determinations going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. That involves specialized knowledge or training in identifying injuries and diseases of the orthopedic or muscoskeletal system. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. No factual foundation has been established that the Veteran is otherwise qualified through specialized education, training, or experience to offer a medical diagnosis. Such competent evidence concerning the nature and extent of the Veteran's right knee disability or PTSD have been provided by the VA examiners, a private physician, and the VA medical personnel who have examined him during the current appeal period and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which this disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective testimony of increased symptomatology. Claim for an Increased Rating for the Right Knee Rating factors for a disability of the musculoskeletal system include functional loss due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40; see DeLuca v. Brown, 8 Vet. App. 202, 206 -07 (1995). With respect to joints, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; see DeLuca, 8 Vet. App at 206-07. Also with arthritis or periarticular pathology, painful motion is factor to be considered. 38 C.F.R. § 4.59. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Separate ratings for a knee disability may be assigned for limitation of flexion and for extension. VAOPGCPREC 9-04 (September 17, 2004). A separate rating may also be assigned for instability of the knee under Diagnostic Code 5257. Esteban v. Brown, 6 Vet. App. 259, 261 (1994) (laxity and loss of motion are separate and distinct disabilities) Limitation of knee flexion under Diagnostic Code 5260 is rated 10 percent with flexion limited to 45 degrees. Flexion limited to 30 degrees is rated 20 percent, and flexion limited to 15 degrees is rated 30 percent, the maximum schedular rating under that Diagnostic Code. Limitation of knee extension under Diagnostic Code 5261 is rated noncompensable or zero percent with extension limited to 5 degrees. Extension limited to 10 degrees is rated 10 percent. Extension limited to 15 degrees is rated 20 percent. Higher ratings are afforded under this Diagnostic Code for more severe limitation of extension. Subluxation or instability of the knee under Diagnostic Code 5257 is rated 10 percent for slight recurrent subluxation or lateral instability. Moderate recurrent subluxation or lateral instability is rated 20 percent. Severe recurrent subluxation or lateral instability is rated 30 percent. Normal range of knee motion is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. VAMC treatment records indicate the Veteran did complain of knee pain in April 2004. In a letter dated in January 2005, Dr. D. F. H. reported the Veteran had a service related injury to his right knee and had a torn meniscus. All treatment by Dr. H. directly related to the old service related knee injury. The Veteran has undergone meniscus resection, decompensation of a Baker's cyst, and debridement of chondromalacia. All relate to the original injury. At present, the Veteran has synovitis with swelling and in the future, the Veteran will probably need a total knee replacement. In February 2006, the Veteran was provided a VA examination. He complained of pain and throbbing in the right knee with the pain becoming sharp with a sudden move. The Veteran did not report any additional limitations of motion or function. He used a brace but there were no other assistive devices and he had not experienced any falls. He has to be careful if he squats and he cannot participate in sports such as basketball. He enjoys riding his motorcycle and works part time at UPS in a job that involves prolonged walking and heavy (over 70 pounds) lifting. The knee did not cause any occupational limitation or lost time. Upon examination there was no limitation of flexion and he had full extension bilaterally. There was no additional limitation after repetition and there was no pain upon motion. The Veteran did not have any anterior cruciate ligament, posterior cruciate ligament, or vargus/valgus instability. The Lachman and McMurray tests were negative. An X-ray demonstrated osteoarthritis. The diagnosis was osteoarthritis of the right knee with a mild functional impairment related to pain. In a letter dated in May 2006, Dr. H. noted the veteran complained of right knee pain and he followed the Veteran for years for the right knee condition. It has resulted in chronic effusion, synovitis, and progressive degenerative changes. In Dr. H's opinion, the Veteran will eventually need a total knee replacement. In July 2006, the Veteran complained to his care providers at VA that his right knee was more painful than his left and he is fatigued a lot. The physical examination did not reveal any erythema or effusion. The Veteran was provided a second VA examination in September 2006 that focused on the left knee, although the examiner examined and noted findings related to the right knee. The Veteran had a steady gait without using an assistive device. There was mild warmth and swelling and moderate tenderness in the right knee. There also was a five degree valgus deformity. The right knee range of motion was from 0 degrees to 115 degrees with what the examiner called a moderate to severe limitation due to pain. The left knee range of motion was from 0 to 120 degrees. There was no appreciable instability of the knees bilaterally. The Veteran had increased guarding and weakness of the right knee with repetition. There was no additional loss of motion. The Veteran's right knee disability does not warrant a rating higher than 10 percent at any time during the rating period for consideration on appeal. The schedular criteria for a higher evaluation contemplate knee flexion limited to 30 degrees or less. Flexion to 115 degrees with pain does not more nearly approximate or equate to flexion limited to 30 degrees, the criterion for a 20 percent rating for limitation of flexion under Diagnostic Code 5260, considering functional loss due to pain, weakness, excess fatigability, swelling, deformity, atrophy, or painful movement, under 38 C.F.R. §§ 4.40, 4.45, 4.59, and repetitive motion. While the Veteran did experience pain with flexion, the pain does not raise to the level of functional loss equating to flexion limited to 30 degrees. See Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011) (pain must affect some aspect of normal movement in order to constitute functional loss under 38 C.F.R. § 4.40). To this extent, the Board places greater weight on the objective findings of the VA examination than the Veteran's subjective complaints of pain. Extension to 0 degrees in the right knee does not more nearly approximate or equate to extension limited to 10 degrees. Therefore, a 10 percent rating for limitation of extension under Diagnostic Code 5261 is not warranted. There is no indication there would be additional functional loss due to pain, weakness, excess fatigability, swelling, deformity, atrophy, or painful movement, and repetitive motion. 38 C.F.R. §§ 4.40, 4.45, 4.59. The Veteran did not have episodes of dislocation or subluxation. There was no instability or abnormal movement. In the absence of evidence of slight recurrent subluxation or lateral instability of the knee, the criterion for a separate, 10 percent rating under Diagnostic Code 5257 were not met. In sum, throughout the rating period on appeal, the criterion for a higher rating based on limitation of flexion under Diagnostic Code 5260, in excess of 10 percent for the right knee, have not been met, nor does the disability picture more nearly approximate the schedular criteria for a higher rating for the right knee. Further, there is no evidence in the record that establishes a limitation of extension or instability of the knee warranting a separate rating under Diagnostic Codes 5261 and/or 5257. Finally, there is no evidence of other ratable pathology such as ankylosis, dislocated or removed semilunar cartilage, acquired or traumatic genu recurvatum, tibia and fibula impairment (malunion or nonunion) under Diagnostic Codes 5256, 5262, and 5263. \ There is evidence the Veteran had right knee surgery to treat a meniscus disorder. The rating schedule does provide a rating for cartilage removal (Diagnostic Code 5259), but that diagnostic code does not provide the Veteran with a higher rating as a 10 percent rating is the maximum rating allowed. Diagnostic Code 5258 provides for a 20 percent rating but there is no evidence of dislocated cartilage or episodes of locking, which is part of the criteria for Diagnostic Code 5258. In any event, the only symptom the Veteran has exhibited is pain, which is already accounted in his current rating under Diagnostic Code 5260. The evaluation of the same disability or the same manifestations under various diagnoses is not allowed. See 38 C.F.R. § 4.14 (2012). A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his [or her] earning capacity." See 38 U.S.C.A. § 1155; Brady v. Brown, 4 Vet. App. 203, 206 (1993). The assigned rating of 10 percent rating was the minimum compensable rating for a knee disability. 38 C.F.R. § 4.59; see Burton v. Shinseki, 25 Vet. App. 1, 3-4 (2011) (painful motion under 38 C.F.R. § 4.59 requires a minimum rating for the specific joint). For reasons expressed, the current evaluations more accurately reflects the actual degree of impairment shown for the right knee since the Veteran filed his claim for a higher rating, and there is no basis for staged ratings under Fenderson, supra, and/or Hart, supra. The preponderance of the evidence is against the claim for a rating higher than 10 percent for the right knee under Diagnostic Codes 5260, 5261, 5257, and the benefit-of- the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Claim for an Increased Rating for PTSD When evaluating the level of disability from a mental disorder, the rating agency shall consider the extent of social impairment, but shall not assign an evaluation based solely on the basis of social impairment. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only insofar as it affects earning capacity. 38 C.F.R. §§ 4.126, 4.130. PTSD is rated under Diagnostic Code 9411 under the General Rating Formula for Mental Disorders. The criteria for a 30 percent rating are 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). The criteria for a 50 percent rating are 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. The criteria for a 70 percent are occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships. The criteria for a 100 percent rating are total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The Global Assessment of Functioning (GAF) score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g. suicidal ideation or severe obsessional rituals), or any other serious impairment in social or occupational functioning. GAF score from 51 to 60 represents 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). While the GAF score is relevant evidence, the GAF score alone is neither statutorily nor regulatory controlling in rating a psychiatric disorder, rather the rating is determined by the application of the Rating Schedule, 38 C.F.R. Part 4, as explained above. Neither the number of symptoms, nor the type of symptoms, nor the GAF score controls in determining whether the criteria for the next higher rating have been met. It is the effect of the symptoms, rather than the presence of symptoms, pertaining to the criteria for the next higher rating, that is determinative. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Accordingly, the evidence considered in determining the level of impairment from PTSD with anxiety and depression under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). In September 2003, VAMC notes indicated the Veteran attended weekly PTSD groups and completed an anger management class. He was noted to be calm, cooperative with a mildly depressed mood. He had nightmares two to three times a week. He had poor sleep habits and low energy levels. There were no hallucinations or psychosis and he was alert and oriented. The GAF was 60. The Veteran described memory loss in February 2004, although the loss related to parts of the trauma that caused the PTSD. In March 2004, the Veteran reported he blows up at people at work and it scared the Veteran as he did not know why he did this. In April 2004, the Veteran reported anxiety attacks and depression. He also had frequent nightmares. He heard voices at night and sometimes during the day. He is afraid what might happen if he loses control. He had no job or family stresses and his wife was supportive. The Veteran reported low energy and poor sleep habits. He also asserted he lost interest in activities but the therapist noted he was a body builder and worked out. The Veteran stated he had no social life. There was no acute suicidal or homicidal ideation or thoughts. The Veteran was verbal, coherent, and logical. He was alert and oriented and there was no looseness of associations. The GAF score was 60. In May 2004, the Veteran reported he had experienced road rage. In September 2004, the Veteran felt he was doing better. He would leave a situation before getting into an altercation. He also thought his depression had improved and was able to get along with others. He was cooperative and verbal with a stable mood and appropriate affect. He had nightmares one to two times a month. He did hear things at night. He also reported flashbacks. There were no suicidal or homicidal ideation or thoughts. His appetite was okay and his sleep was fair. He still had a low energy level. His cognition, judgment, and insight were intact. It was noted he has been married for 21 years with three children and he works 20 to 22 hours a week. In December 2004, the Veteran felt really good and thought he was doing well even without taking medication (he had ran out a few weeks earlier). He reported his wife and children lived with him and were supportive. He still worked part time with UPS although he currently was not working due to left knee surgery. He was friendly, cooperative, and in a pleasant mood. There were no perception problems or paranoia. His appetite was okay and his sleep and energy levels were fair. He was alert and oriented. The GAF score was 60. In January 2005, the Veteran was worried about short term memory problems such as driving down a road and forgetting where he was going. Otherwise, the Veteran felt his life was fairly satisfying and meaningful. His only continuing stress was insomnia. The therapist advised the Veteran that short term memory waxed and waned with PTSD and the symptom would be monitored to see if it persisted or worsened. In June 2005 the Veteran reported that he looked forward to riding his bike (motorcycle) and went to a motorcycle show. He had experienced some bad days that occurred after his mother's death. He also had got angry at work but left the area and otherwise, work at UPS was good. He had stopped his medication and his wife noticed he became more irritable. He still had nightmares and one flashback a month earlier. There was no suicidal or homicidal ideation. In August 2005, as noted, the Veteran had stopped taking prescription medication but restarted two weeks earlier. The Veteran still had nightmares and heard people calling him. He reported a short temper with anyone. He isolated himself from others. He denied any family conflict. He worked about 25 hours a week for UPS and liked his job. He also enjoyed riding his motorcycle around the city, which he found relaxing. The Veteran had a mildly depressed mood with congruent affect. There were no suicidal or homicidal thoughts and his thought process was goal directed. His memory was intact. His appetite was okay and his sleep and energy levels were fair. He was alert and oriented. The GAF score was 60. In October 2005, the Veteran was mildly depressed and still had memory problems although not as bad as they had been. The therapist believed the waxing and waning of memory problems sounded as though the symptom was part of the disassociation aspect of PTSD. The Veteran had insomnia due to nightmares about Vietnam. The Veteran reported his anger surged 2 times in the prior month with an argument with his supervisor. He controls his anger for the most part with a time out. He admitted it was a bad time of the year because it was the part of the year that a number of relatives had previously died. The Veteran reported problems trying to process one stressor and it was suggested he restart group therapy. In January 2006, the Veteran stated he had done real well as of late. His wife had noticed the changes and he was happy to hear that from her. He still had periods where he did not like being bothered by others and wanted to isolate himself. He still had nightmares. The Veteran was not at work due to foot surgery but planned to return as soon as he was medically cleared to return. He was calm, cooperative with coherent and relevant speech. His mood was euthymic and affect appropriate. There was no suicidal or homicidal ideation or thoughts and his thought process was logical and goal oriented. His memory and insight was normal. The GAF score was 60. The Veteran was provided a VA mental health examination in February 2006. The Veteran had nightmares and flashbacks. These symptoms were associated with nervousness and depression but the symptoms were more frequent at sometimes than at other times. He had sleep disturbance with poor concentration every now and then. He was irritable and short tempered from time to time. He experienced guilt, anger, and feelings of isolation. For years he had tried to keep busy but the symptoms have persisted. He has been married twice and had three children. There have not been any problems with alcohol or drugs. He avoids crowds, noises, and anything that reminds him of Vietnam. Upon examination, the Veteran's speech was coherent and relevant. His mood was nervous. He experienced depression every now and then with some periods more frequent than others. His affect was constricted. He also had hyperalertness with an exaggerated startle response every now and then. His thought process was intact and there were no hallucinations or suicidal or homicidal ideation or thoughts. The Veteran was oriented and his insight and judgment were intact. The diagnosis was moderate PTSD and the GAF score was 60. Nevertheless the examiner stated the symptoms persisted and the Veteran was trying to cope. The examiner stated the Veteran lost one to two days a month from work due to PTSD. The symptoms of isolation, depression with irritability and short temper affected the Veteran socially as well. He was able to perform his activities of daily living and there was no other psychiatric diagnosis. In April 2006, the Veteran reported hearing unreal voices calling his name but the Veteran was alert, oriented, and maintained normal eye contact. His speech was coherent and relevant. His affect was congruent and there was no suicidal or homicidal ideation. The note stated the Veteran was coping effectively with current treatment but a therapist also noted that same month that the Veteran was noncompliant with his medication and stopped his PTSD classes. The Veteran kept busy around his house with chores and he forgot appointments. There were no family problems. He had a few nightmares each month. He still enjoyed riding his motorcycle. The Veteran avoided eye contact. His speech had a normal rate and rhythm and there we no hallucinations or paranoia. The Veteran reported he tended to isolate himself and was hypervigilant. His mood was mildly depressed but was no threat to himself or others. He had a good appetite, fair energy level, and slept 4-5 hours. The therapist stated the Veteran had impaired concentration and insight. His thought process was goal directed, memory intact, and he was oriented. The GAF score was 55. In June 2006, the Veteran reported needing treatment as his symptoms had intensified. He had problems with anger management and irritability. He also had flashbacks, nightmares, intrusive thoughts, and poor sleep hygiene. He maintained good eye contact with appropriate speech and behavior. He was cooperative and his thought process and memory were intact. He was oriented and had a good affect. There was no paranoia, hallucinations, or suicidal or homicidal ideation or thoughts. In April 2007, the Veteran reported feeling anxious and irritable at times but had no suicidal thoughts. A sleep study report demonstrated that the Veteran had sleep apnea. He had depression, nightmares, and had little patience with others. There was no suicidal or homicidal ideation or thoughts In November 2008, a PTSD symptom survey noted that all of the Veteran's symptoms were moderate except he felt his distance from others was extreme. In May 2010, the Veteran still complained of increased dreams and nightmares and he was not sleeping. He worried about his health. He still worked part time for UPS. He had intrusive thoughts and depression. He complained of memory problems and erectile dysfunction. He avoided eye contact and appeared evasive at times. He hears someone calling his name but there are no command hallucinations or delusional ideations. His mood was mildly depressed with a congruent affect. The Veteran had decreased motivation and energy. He did not have suicidal or homicidal ideation or thoughts. His thought process was linear and goal directed and hi memory and concentration was intact. The GAF was 65. In June 2010, the Veteran stated he was okay and felt alright. He wanted to quit work but did not want to worry about the money. He stated he loved his family but does not communicate with them. He stated he did good at work and was not angry there. He can get easily upset but controlled his anger. He reported he was sleeping alright but had a hard time remembering his dreams and a hard time with his memory. He sleeps two to three hours. He still heard his name called. He has started being nervous around people and does not have much patience around them. The Veteran did not maintain good eye contact and looked at something else for most of the session. He had a euthymic mood but flat effect. His speech was normal rate and volume and he was coherent and logical. He was somewhat guarded. He had no delusions. He was hypervigilant, and exhibited avoidance behavior. He also had intrusive thoughts and a memory deficit for recent events. His insight and judgment was adequate. The GAF score was 55. In August 2010, the Veteran stated he was okay. The nightmares and flashbacks were not as frequent. He stated he sleeps hard and when he wakes up, he finds it hard to get out of bed. He still has periods where he goes through depression but the medication helps. He stated he lacked the motivation to do anything but ride his motorcycle. He reported going to Las Vegas with friends. While they went out to gamble, he did not want to get involved. He stayed in his room and relaxed. He does enjoy being with his grandchildren. Because he wants to be left alone, his wife leaves him alone. The veteran was unable to maintain eye contact but was calm and cooperative. He interacted and participated in the therapy session. His speech was at a normal rate and volume and he was coherent and goal directed. He was somewhat guarded, hypervigilant, with reports of intrusive thoughts and memory deficits. His insight and judgment was adequate. The GAF score was 55. Analysis In evaluating the evidence, the Board concludes that the VA examination and outpatient treatment records show that the symptoms of PTSD have affected the Veteran's everyday life and his ability to function to a degree that more nearly approximates the schedular criteria for a 30 percent rating, and no higher, under Diagnostic Code 9411. The evidence shows that the psychiatric symptomatology was of such extent, severity, depth, and persistence approximates the criteria for a 30 percent schedular rating, and the record overall reflects few, if any, symptoms or severity of PTSD that typify the criteria for a 50 percent schedular rating. For instance, there is no objective evidence of 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 or inability to establish and maintain effective relationships. The record does not show that any of the foregoing symptoms or any other symptoms of the same type and degree approximating a 50 degree rating. As previously noted, the Veteran was alert and oriented and he took care of his personal appearance. Although he had some paranoid feelings and heard voices calling his names, the symptoms did not interfere with his routine activities or his ability to work. He was capable of performing activities of daily living, without any reported difficulty noted. Frequent complaints included sleep problems, social isolation, irritability, anger, memory impairment, and concentration difficulty, but the symptoms did not affect his ability to function independently. While the evidence indicates that the Veteran has irritability and anger difficulties as well as social isolation problems that have affected his functioning, he nevertheless has maintained part time employment. While more recently he has expressed a desire to quit work, he also reported that he does a good job and it may even be a source of support for the Veteran since it appears he can perform most of his duties alone and it keeps him engaged. He has reported occasional anger problems but it appears that is directed with his superiors and there are no reported problems with co-workers. When he does get angry, he has learned to remove himself from the situation. The Board also has no doubt that his PTSD affected his marriage and his relationship with his children, he is not estranged from any of them and it appears his family offers support even when he is not willing to accept interaction with them. As for symptoms associated with the diagnosis of PTSD but not listed in Diagnostic Code 9411, the symptomatology does not more nearly approximate or equate to the level of occupation and social impairment with reduced reliability and productivity required for a 50 percent rating. For example, the Veteran's sleep, memory, and concentration difficulties are not shown to prevent him from performing his activities of daily living or to maintain gainful employment. Further, his depression has not prevented him from functioning independently, appropriately, and effectively. He was able to control his impulses, and his judgment and insight were intact. Furthermore, for the relevant period for his claim for an increased claim, the pertinent record, which is primarily comprised of VA treatment records and VA examination reports, shows that the assigned GAF scores mostly ranged from 55 to 60 (indicating moderate disability), with one score of 65 (indicating mild disability). The scores have remained relatively static within the range of 55 to 60 throughout the period considered in this appeal. In any event, a disability rating depends on evaluation of all the evidence and a VA examiner's classification of the level of a psychiatric impairment by words or by a GAF score is to be considered, but is not determinative of the percentage disability rating to be assigned. 38 C.F.R. § 4.126. Further, as discussed above, the symptoms and their severity have remained relatively stable even with additional personal stressors in the Veteran's life such as health concerns. Although the Veteran has stated his symptoms have worsened, the Board notes that the Veteran's subjective complaints have remained essentially unchanged in severity when detailed beyond the Veteran's characterizations. To the extent any of the symptoms have worsened, the effect on industrial impairment, the focus of any mental health rating, remained unchanged The Board finds that the PTSD disability has not significantly changed and that a uniform evaluation is warranted for the period considered under this appeal. Accordingly, as the degree of disability has not increased following the assignment of the initial rating a single evaluation, rather than "staged ratings" is proper. Fenderson, supra; see also Hart, supra. For these reasons, for all relevant times during the period under appeal, the preponderance of the evidence is against an initial rating higher than 30 percent for PTSD, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Extraschedular Consideration Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular rating is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Comparing the Veteran's current disability levels and symptomatology to the Rating Schedule, the levels of disability are encompassed by the Rating Schedule. Higher ratings are provided for more severe conditions relating to both the right knee and PTSD. Furthermore, the Veteran has not been hospitalized for PTSD or for the right knee. While the Veteran has reported having missed some work on account of PTSD, the time periods do not appear to be extensive. He has also indicated that he has adopted strategies to deal with his symptoms and has reported his own satisfaction in his job performance. There is no evidence that he has lost time at work because of his right knee disability. In short, the evidence has not shown that there is marked interference with employment. In light of the foregoing, the assigned schedule ratings are adequate and no referral to an extraschedular rating is required under 38 C.F.R. § 3.321(b)(1). In other words, the Board finds that the rating criteria reasonably describe the Veteran's PTSD disability and symptomatology, such as anger, social isolation, and emotional distancing, and these symptoms are contemplated by the Rating Schedule under Diagnostic Code 9411, and the Veteran does not have any symptomatology not already contemplated by the Rating Schedule. The same reasoning also applies to his right knee disability and his symptom of pain is already contemplated under the diagnostic code 5260 and the Veteran does not have any symptomatology not already contemplated by the Rating Schedule. Therefore, the Board finds that a referral for an extraschedular rating is not warranted. Total Disability Base Upon Individual Unemployability During the appeal period, the Veteran has not expressly raised and the record does not reasonably raise a claim for total disability rating for compensation based on individual unemployability. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) (in a claim for increase, where the Veteran expressly raises a claim for a total disability rating on the basis of individual unemployability or the claim is reasonably raised by the record, the claim is not a separate claim, but a part of a claim for increase). As noted, although the evidence suggests that the Veteran's PTSD may have affected his employment in the performance of his duties and the severity of his PTSD symptoms have been discussed, the Veteran has secured and maintained a part-time job. Therefore, in the circumstances of this case, the Board declines to take jurisdiction over a total disability rating claim. ORDER Entitlement to a rating in excess of 10 percent for service-connected right knee patellarofemoral syndrome with degenerative joint disease is denied. Entitlement to a rating in excess of 30 percent for service-connected PTSD is denied. ____________________________________________ John Kitlas Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs