Citation Nr: 1340977 Decision Date: 12/12/13 Archive Date: 12/20/13 DOCKET NO. 10-43 400 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to an increased rating (evaluation) in excess of 10 percent for joint pains of the knees due to an undiagnosed illness (formerly evaluated as joints pain of shoulders and knees as due to an undiagnosed illness) (hereinafter "bilateral knee disabilities" or "right and left knee disabilities"). 2. Entitlement to an increased rating (evaluation) in excess of 10 percent for fatigue as due to an undiagnosed illness. 3. Entitlement to an increased rating (evaluation) in excess of 30 percent for dysthymic disorder with anxiety disorder, not otherwise specified (NOS) (hereinafter "acquired psychiatric disorders"). 4. Entitlement to an increased rating (evaluation) in excess of 30 percent for headaches as due to an undiagnosed illness. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran (Appellant); Veteran's Friend ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from February 1966 to February 1969. This appeal comes to the Board of Veterans' Appeals (Board) from a November 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island. In an October 2010 substantive appeal (VA Form 9), the Veteran requested a Board hearing by live videoconference. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in June 2013. A transcript of the hearing is of record. Upon implementation of this decision, additional actions will be required by the RO to adjust the code sheet use of diagnostic codes, the use of names of the knee disabilities to clarify the disabilities the Veteran currently has, and to associate the correct ratings with each disability. As will be explained below, below, the RO will need to place a separate rating for both the right and left knee reflecting that each knee is in receipt of a separate 10 percent rating, assigned for pain and noncompensable limitation of motion, as analogous to arthritis (Diagnostic Code 8863-5003) on the code sheet. At the June 2013 Board hearing, the Veteran and his representative appear to have asserted that the matter of entitlement to evaluations in excess of 10 percent for the service-connected right and left shoulder disabilities is currently before the Board. However, in a January 2012 rating decision, the RO assigned separate evaluations of 10 percent each for degenerative changes of the left and right shoulder (formerly evaluated as joint pains of shoulders and knees as due to an undiagnosed illness). The Veteran did not file a timely notice of disagreement, did not submit any new or material evidence with respect to the claims of entitlement to increased ratings for the service-connected shoulder disabilities within the applicable one-year period, and has not filed a new claim for increased ratings of the disabilities. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103 (2013). As such, the issue of entitlement to increased ratings in excess of 10 percent for the Veteran's service-connected right and left shoulder disabilities are not currently in appellate status, and these issues are not before the Board. In reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. The issue of an increased rating (evaluation) in excess of 30 percent for headaches as due to an undiagnosed illness is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. For the entire rating period, the Veteran's bilateral knee disabilities have been manifested by symptoms of painful motion and excess fatigability that are productive of noncompensable limitation of motion. 2. For the entire rating period, the Veteran's bilateral knee disabilities have not been manifested by ankylosis, recurrent subluxation or lateral instability, dislocated or removal of semilunar cartilage, malunion or non-union of the tibia and fibula with loose motion requiring a brace, or genu recurvatum. 3. For the entire rating period, the Veteran's fatigue has been manifested by symptoms of debilitating fatigue, nonexudative pharyngitis, generalized muscle aches or weakness of the neck and back, fatigue lasting 24 hours or longer after exercise, daily headaches, migratory joint pains in the knees, shoulders, and wrists, neuropsychological symptoms, and sleep disturbance characterized by nightmares and tossing and turning, and cognitive impairment of poor attention, inability to concentrate, forgetfulness, and confusion at times, which are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level. 4. For the entire rating period, the Veteran's fatigue has not been manifested by debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms that are nearly constant and restrict routine daily activities to at least 50 percent of the pre-illness level, or that wax and wane, resulting in periods of incapacitation of at least four but less than six weeks total duration per year. 5. The Veteran's acquired psychiatric disorders have been manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as depressed mood; decreased energy; excessive worry; short and long term memory impairment; excessive worry; nightmares; flashbacks; chronic sleep impairment; loss of interest in activities; some social isolation; poor concentration; flat affect; feelings of worthlessness and hopelessness; tearfulness; anxiety; and disturbances in motivation and mood. 6. In June 2013, before a decision by the Board was issued on the claim, the Veteran expressed his desire to withdraw his appeal for a TDIU. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 10 percent, but no higher, for a right knee disability have been met for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 8863-5003 (2013). 2. The criteria for a disability rating of 10 percent, but no higher, for a left knee disability have been met for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 8863-5003 (2013). 3. Resolving reasonable doubt in favor of the Veteran, the criteria for an increased rating of 20 percent, but no higher, for fatigue have been met for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.88b, Diagnostic Code 8863-6354 (2013). 4. Resolving reasonable doubt in favor of the Veteran, the criteria for an increased rating of 50 percent for dysthymic disorder with anxiety disorder, NOS, have been have been met for the entire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7105 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9433, 20.204 (2013). 5. The appeal with regard to a TDIU has been withdrawn. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.204 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). With regard to the claim for a TDIU, the withdrawal of this claim is decided as a matter of law; therefore, no discussion of the duties to notify and assist with respect to this issue is necessary. With regard to the claim for an increased rating for acquired psychiatric disorders, the Board is granting a higher disability rating of 50 percent for the entire appeal period. At the June 2013 hearing, the Veteran and his representative stipulated that a grant of such benefits would fully satisfy the appeal for an increased rating; therefore, this decision constitutes a full grant of the benefits sought on appeal on the issue of an increased rating for acquired psychiatric disorders and no further discussion regarding VCAA notice or assistance duties is required with regard to this issue. Additionally, the issue of an increased rating for headaches is being remanded for further evidentiary development. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In a claim for an increased rating, the VCAA requires only generic notice as to 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, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). With regard to the Veteran's claims for increased ratings for fatigue and bilateral knee disabilities, the RO provided notice to the Veteran in August 2009, prior to the initial adjudication of the claim in November 2009. The Veteran was notified of the evidence not of record that was necessary to substantiate the claims, as well as of VA and the Veteran's respective duties for obtaining evidence. The August 2009 notice letter also informed the Veteran how disability ratings and effective dates are assigned. Thus, the Board concludes that VA satisfied its duties to notify the Veteran. VA satisfied its duty to assist the Veteran in the development of his claim. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, service personnel records, VA treatment records, VA examination reports, a copy of the June 2013 Board hearing, and lay statements. Second, VA satisfied its duty to obtain a medical opinion when required. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). With regard to the claims for increased ratings for bilateral knee disabilities and fatigue, the Veteran was provided with VA examinations (the reports of which have been associated with the claims file) in September 2009 and November 2011. The Board finds the VA examinations were thorough and adequate and provides a sound basis upon which to base a decision with regard to the Veteran's appeal for increased ratings in excess of 10 percent for left and right knee disabilities and for an increased rating in excess of 10 percent for fatigue. The VA examiners personally interviewed and examined the Veteran, fully reviewed all medical evidence of record, and specifically addressed the symptoms listed in the relevant criteria in the potentially applicable diagnostic codes. At the June 2013 Board hearing, the Veteran contended that his bilateral knee disabilities and fatigue had increased in severity since the September 2009 VA examinations. For the bilateral knee disabilities, the Veteran did not assert that the left and right knee disabilities were manifested by ankylosis, recurrent subluxation or lateral instability, dislocated or removal of semilunar cartilage, malunion or non-union of the tibia and fibula with loose motion requiring a brace, or genu recurvatum, assertions that, if substantiated, might have entitled the Veteran to higher or separate ratings for his knee disabilities. Rather the Veteran asserted that the pain associated with his bilateral knee disabilities have increased in severity. Thus, the Board finds the request for a new VA examination, in the context of only general assertions of worsening of the bilateral knee disabilities, does not assert any worsening for which a new VA examination could show findings that a higher rating are met, as additional painful motion that is not productive of compensable limitation of motion, ankylosis, recurrent subluxation or lateral instability, dislocated or removal of semilunar cartilage, malunion or non-union of the tibia and fibula with loose motion requiring a brace, or genu recurvatum would still warrant 10 percent ratings under Diagnostic Code 5003. Additionally, while the Veteran contended he had worsened since the September 2009 VA examination, the Board notes that the Veteran was afforded a subsequent examination for the bilateral knee disabilities in November 2011. Additionally, the Veteran has not asserted that the service-connected fatigue has been manifested by debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms, which are nearly constant and restrict routine daily activities to at least 50 percent of the pre-illness level or; which wax and wane, resulting in periods of incapacitation of at least four but less than six weeks total duration per year. Rather, the Veteran has asserted general worsening in severity of his fatigue. Additionally, while the Veteran contended he had worsened since the September 2009 VA examination, the Board notes that the Veteran was afforded a subsequent examination for fatigue in November 2011. Thus, the Board finds that the Board finds the request for a new VA examination, in the context of only general assertions of worsening of fatigue, does not assert any worsening for which another VA examination could show findings that a higher rating are met. The Veteran testified at a hearing before the Board in June 2013 before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the VLJ noted the basis of the prior determinations and noted the elements of the claims for increased ratings for fatigue, acquired psychiatric disorder, and bilateral knee disabilities that were lacking to substantiate the claim for benefits. In addition, the Veterans Law Judge addressed the Veteran's fatigue, acquired psychiatric disorder, and bilateral knee disabilities and sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim through specific pertinent questioning. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) nor has identified any prejudice in the conduct of the Veterans Law Judge. By contrast, the hearing focused on the elements necessary to substantiate the claim. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Disability Rating Criteria Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2013). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1 (2013). Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2013). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Where, as here, entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern, including the appropriateness of staged ratings whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. The Board has considered whether a staged rating is warranted; however, as the Board will discuss in more detail below, the Board finds that staged ratings for the Veteran's bilateral knee disabilities, fatigue, or acquired psychiatric disorders is not appropriate in this case. In rendering a decision on appeal the Board must also 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. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Increased Ratings for Right and Left Knee Disabilities The Veteran is in receipt of a 10 percent disability rating for joint pains of the knees under Diagnostic Code 8863-5003, as being analogous to arthritis with painful motion that manifests to a noncompensable (less than 10 percent) degree. 38 C.F.R. § 4.71a. This case involves a potentially confusing procedural history and, for this reason, additional procedural explanation is required to understand the right and left knee disability issues currently on appeal. Historically, the RO granted service connection for joint pains of both shoulders and knees as due to an undiagnosed illness in an October 1998 rating decision and assigned a 10 percent initial disability rating (made effective from November 1994) under Diagnostic Code 8850-5003. The Veteran submitted a claim for an increased rating of joint pains of the shoulders and knees in July 2009. Following development, the RO issued a rating decision in November 2009 continuing the 10 percent disability rating for joint pains of shoulder and knees as due to an undiagnosed illness. In January 2012, the RO issued a rating decision assigning separate 10 percent disability ratings (effective November 2011) for degenerative changes of the left and right shoulder and continued the separate 10 percent rating for joint pains of knees due to an undiagnosed illness (formerly evaluated as joint pains of shoulders and knees). As discussed below, the Board finds that separate disability ratings of 10 percent, but no higher, as analogous to arthritis, should be assigned to both the left and right knees. Degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Notes (1) and (2) under Diagnostic Code 5003 provides the following: Note (1) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Notes (1) and (2). The Diagnostic Codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 and 5261. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a noncompensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. Id. For disabilities of the musculoskeletal system, the Board also considers whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Id. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may cause a functional loss, pain itself does not constitute functional loss. Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Veteran contends that his bilateral knee disabilities have increased in severity, making him entitled to an increased disability rating. In a November 2011 written statement, the Veteran reported taking medication for pain since he returned from the Gulf War in 1991. At the June 2013 Board hearing, the Veteran reported that his bilateral knee disabilities have affected his ability to work, but that he has not missed days because of his knee joint pains as he tries to work through the pain. The Veteran reported that the joint pains in his knees affect his daily activities such as mowing the lawn and household chores. The Veteran reported that his bilateral knee pain comes and goes and that he cannot be on his knees. The Veteran reported that the amount of joint pain he experiences in his knees is related to the amount of work he does. Having reviewed the evidence of record, both lay and medical, the Board finds that the Veteran's left and right knee disabilities have more nearly approximated the criteria for separate 10 percent disability ratings, but not higher, through the entire appeal period under Diagnostic Code 5003 as analogous to arthritis with painful, but noncompensable, limitation of motion. Throughout the entire rating period on appeal, the Veteran's right and left knee disabilities have been manifested by symptoms of painful motion and excess fatigability that are productive of noncompensable limitation of motion as required for 10 percent ratings under Diagnostic Code 5003. 38 C.F.R. § 4.71a. An April 2008 VA treatment record notes the Veteran's report of joint pain in his knees. A September 2010 VA treatment record notes that the Veteran is taking ibuprofen for pain and inflammation. In September 2009, the Veteran underwent a VA examination. The examination report notes that the Veteran developed bilateral knee pain with range of motion. The Veteran denied redness, swelling, locking, or buckling, but did report some cracking with range of motion. The VA examination report notes that the Veteran reported no flare-ups of his knee disabilities. The report indicates that the Veteran is right side dominant. The VA examination report notes that, upon physical examination, there was no deformity, swelling, crepitus, effusion, erythema, joint laxity or tenderness of either knee. Objective range of motion testing found decreased range of motion with flexion to 135 degrees and extension to 0 degrees, bilaterally. The VA examiner noted pain throughout range of motion in both knees. Upon repetition, no weakness, fatigue, or lack of endurance was noted, but pain bilaterally throughout range of motion was noted. The Veteran's knees were found clinically normal based on x-rays. In November 2011, the Veteran underwent a VA knee and lower leg examination. The Veteran reported that his knee pain had a gradual onset, denying any initial injury. The Veteran reported that his knees throb and that he has pulsating pain, but denied taking any medication for his knee pain. The Veteran reported experiencing flare-ups and that the throbbing in his knees prevents him from moving. The VA examination report notes a diagnosis of knee strain/sprain with a 1992 date of diagnosis. The report notes that the Veteran has not had physical therapy, injections, or surgeries on his knees. Imaging studies conducted during the November 2011 VA examination note no documented arthritis or patellar subluxation in either knee. Objective range of motion testing in November 2011 found decreased range of motion in the Veteran's right knee with flexion to 90 degrees, with objective evidence of painful motion at 90 degrees, and extension to 0 degrees, with no objective evidence of painful motion. Upon repetition, right knee flexion was to 100 degrees and extension was to 0 degrees. Objective range of motion testing found decreased range of motion in the Veteran's left knee with flexion to 110 degrees, with objective evidence of painful motion at 110 degrees, and extension to 0 degrees, with no objective evidence of painful motion. Upon repetition, objective range of motion testing found no additional loss in degree in either flexion or extension of the left knee. With regard to functional loss and impairment, less movement than normal, excess fatigability, and pain on movement were noted in both knees. The VA examination report notes no tenderness or pain to palpation for the joint line or soft tissues of either knee. Anterior, posterior, and medial-lateral instability were noted as normal for both knees. The VA examination report notes no evidence or history of recurrent patellar subluxation or dislocation for either knee. The report notes no tibial or fibular impairment or meniscal conditions of either knee. The VA examination report notes that the Veteran does not use any assistive devices for his knees. Based on the evidence above, the Board finds that the Veteran's left and right knee disabilities have more nearly approximated the criteria for separate 10 percent disability ratings, but not higher, through the entire appeal period under Diagnostic Code 5003 as analogous to arthritis with painful, but noncompensable, limitation of motion. Specifically, the Board finds that the Veteran's right and left knee disabilities have been productive of painful motion and excess fatigability, with noncompensable limitation of flexion or extension for the entire rating period, even with considerations of additional limitations due to pain and reported flare ups of the knee disabilities. The Veteran has not endorsed, and the evidence does not otherwise show, that additional limitation of motion due to pain and excess fatigability, including during flare ups meets, the level of a compensable limitation (e.g., limited to 45 degrees in flexion or 10 degrees in extension). 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. See DeLuca; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. The Board has applied of 38 C.F.R. §§ 4.40 and 4.45 and DeLuca, supra for the entire appeal period in reaching its finding that the Veteran has limitation of motion to a noncompensable degree with consideration of additional limitations of motion due to pain. Although the September 2009 and November 2011 VA examinations reports note that the Veteran experienced pain, such findings do not provide for a higher disability rating than 10 percent for either knee in this case. Even considering the additional motion limitation upon repetition to 100 degrees with pain limiting flexion for the right knee evidenced at in the November 2011 VA treatment records, the degree of impairment does not warrant a higher evaluation than 10 percent based on limitation of motion. See VAOPGCPREC 9-98 (motion of a joint effectively ends where pain begins). Such ranges of motion are not compensable under Diagnostic Codes 5260 or 5261. 38 C.F.R. § 4.71a. In this regard, as noted above, the Veteran had near full range of motion in both knees during the appeal period even with consideration of pain that limits motion. The range of motion for extension in both knees has been consistently 0 degrees in both VA examinations, which does not warrant a compensable rating based on extension. See 38 C.F.R. § 4.71a, DC 5261. The range of motion for flexion was 135 degrees, both initially and upon repetition, for both knees at the September 2009 VA examination, and 90 degrees initially and 100 degrees upon repetition for the right knee and 110 degrees, both initially and upon repetition for the left knee, at the November 2011 VA examination. None of the range of motion measurements warrants a compensable rating based on flexion. See id., Diagnostic Code 5260. The Board finds that the multiple range of motion tests highly probative evidence that the Veteran has not experienced limitation of flexion to such a compensable degree in either knee. Additionally, the Veteran has not alleged that he has limitation of flexion to 30 degrees to warrant a rating in excess of 10 percent for either knee. During the entire appeal period, the limitation of motion in either knee did not more nearly approximate extension limited to 15 degrees or more, or flexion limited to 30 degrees or less, as needed for a 20 percent evaluation, even with consideration of the additional limitation due to pain. The evidence also does not show compensable limitation of motion of extension (10 degrees) and limitation of motion of flexion (45 degrees) to warrant separate compensable ratings for both limitation of extension and limitation of flexion. See VAOPGCPREC 09-04 (separate ratings may be awarded for compensable limitation of flexion and limitation of extension of the same knee joint). Therefore, a higher disability rating in excess of 10 percent is not warranted under Diagnostic Codes 5260 or 5261 for limitation of extension and flexion for either knee. 38 C.F.R. § 4.71a. Thus, the evidence demonstrates entitlement to separate 10 percent evaluations, but no higher, for painful motion of the right and left knees as analogous to arthritis under Diagnostic Code 5003 throughout the rating period on appeal. The Board also finds that no other higher or separate rating is warranted under any of the other diagnostic codes pertaining to the knee. For point of explanation, ankylosis is "[s]tiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint." Dinsay v. Brown, 9 Vet. App. 79, 81 (1996) (quoting from Stedman's Medical Dictionary 87 (25th ed. 1990)). There is no lay or medical evidence of ankylosis, recurrent subluxation or lateral instability, semilunar, dislocated cartilage with frequent episodes of "locking," pain, and effusion into the joint, impairment of the tibia and fibula by malunion or nonunion, genu recurvatum, or history of removal of semilunar cartilage. There is no lay or medical evidence that the Veteran has underwent knee joint replacement surgery. Both the September 2009 and November 2011 VA examination reports note that no instability was present in either knee. Therefore, the criteria of Diagnostic Codes 5055, 5256, 5257, 5258, 5259, 5262 and 5263 do not apply. 38 C.F.R. § 4.71a. Finally, the November 2011 VA examination report notes that the Veteran has no scars related to his bilateral knee disabilities; therefore, the Veteran is not entitled to a separate compensable rating under Diagnostic Codes 7800 through 7805. 38 C.F.R. § 4.118. Based on the above evidence, the Board finds that the Veteran's left and right knee disabilities have more nearly approximated the criteria for separate 10 percent disability ratings, but not higher, through the entire appeal period under Diagnostic Code 5003 as analogous to arthritis with painful, but noncompensable, limitation of motion. For the entire period on appeal, the Veteran's left and right knee disabilities have been manifested by painful motion and excess fatigability that is productive of noncompensable limitation of motion that more nearly approximates a 10 percent rating under Diagnostic Code 5003. Assignment of staged ratings has been considered, but found not to be applicable in this case. 38 C.F.R. §§ 4.3, 4.7. Increased Rating for Fatigue The Veteran is in receipt of a 10 percent disability rating for fatigue under Diagnostic Code 8863-6354, which provides ratings for chronic fatigue syndrome (CFS) consisting of debilitating fatigue, cognitive impairments (such as inability to concentrate, forgetfulness, confusion), or a combination of other signs and symptoms. 38 C.F.R. § 4.88b. A 10 percent rating is assigned for signs and symptoms of CFS that wax and wane but result in periods of incapacitation of at least one but less than two weeks total duration per year or the symptoms are controlled by continuous medication. Id. A 20 percent rating is assigned for signs and symptoms of CFS that are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level, or signs and symptoms that wax and wane, resulting in periods of incapacitation of at least two but less than four weeks total duration per year. Id. A 40 percent rating is assigned for signs and symptoms of CFS that are nearly constant and restrict routine daily activities to 50 to 75 percent of the pre-illness level, or the signs and symptoms wax and wane, resulting in periods of incapacitation of at least four but less than six weeks total duration per year. Id. A 60 percent rating is assigned for signs and symptoms of CFS that are nearly constant and restrict routine daily activities to less than 50 percent of the pre-illness level, or signs and symptoms that wax and wane, resulting in periods of incapacitation of at least six weeks total duration per year. Id. A 100 percent rating is assigned for signs and symptoms of CFS that are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. Id. A Note to Diagnostic Code 6354 provides that, for the purpose of rating CFS, the condition will be considered incapacitating only while it requires bed rest and treatment by a physician. Id. The Veteran contends that his symptoms of fatigue warrant an increased disability rating. In a November 2009 written statement, the Veteran reported symptoms of fatigue that are nearly constant and restrict routine daily activities. The Veteran contended that his fatigue shows signs and symptoms resulting in periods of incapacitation many times per year. In a November 2010 written statement, the Veteran stated that he believes his fatigue problems are related to his multiple chemical sensitivity syndrome. At the June 2013 Board hearing, the Veteran reported working as an operating engineer and operating heavy equipment for a living. The Veteran reported a constant feeling of fatigue that restricts his daily routine. The Veteran reported having trouble driving to and from work. The Veteran reported times when he has almost fallen asleep operating a piece of equipment at work. He reported that he has to get out of the machine and walk around to try to get alert. The Veteran's friend testified that it appears the Veteran's fatigue has increased over the years and that the Veteran does not attend the meetings he used to. Having reviewed the evidence of record, both lay and medical, the Board finds that the Veteran's fatigue has more nearly approximated the criteria for a 20 percent disability rating, but not higher, through the entire appeal period under Diagnostic Code 6354, as analogous to chronic fatigue syndrome. Throughout the entire rating period on appeal, the Veteran's fatigue been manifested by symptoms of debilitating fatigue, nonexudative pharyngitis, generalized muscle aches or weakness of the neck and back, fatigue lasting 24 hours or longer after exercise, daily headaches, migratory joint pains in the knees, shoulders, and wrists, neuropsychological symptoms, and sleep disturbance characterized by nightmares and tossing and turning; and, cognitive impairment of poor attention, inability to concentrate, forgetfulness, and confusion at times, which are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level, as required for a 20 percent rating under Diagnostic Code 6354. 38 C.F.R. § 4.88b. VA treatment records from April 2008 through September 2010 reflect that the Veteran has continually presented with complaints of fatigue. An April 2008 VA treatment record notes that the Veteran reported persistent fatigue. The Veteran reported feeling constantly sleepy during the day. An August 2008 VA treatment record notes that the Veteran previously took liquid Ephedra when it was available over the counter and he has tried with Provigil in the past, but that the Veteran was not currently using any medications to manage his fatigue. September and October 2008 VA treatment records note that the Veteran reported being fatigued and that the Veteran presented with physical symptoms of fatigue. A December 2008 VA treatment record notes that the Veteran tried Ephedra and Provigil in the past for his fatigue, but that he is not currently taking medication for fatigue. A September 2010 VA treatment record notes that the Veteran reported falling asleep sometimes during the day and feeling very fatigued. In September 2009, the Veteran underwent a VA examination. The Veteran reported feeling tired all the time. The VA examination report noted that the Veteran works forty hours a week. The Veteran reported that it felt like he was going to fall asleep while operating his equipment at work. The Veteran reported missing no days from work due to illness. In November 2011, the Veteran underwent a VA examination for chronic fatigue syndrome. The VA examination report notes that the Veteran was diagnosed with chronic fatigue syndrome in 1994. The examination report, while describing the Veteran's medical history, notes that the Veteran had a history of debilitating fatigue that reduced the Veteran's daily activity level to less than 50 percent of the pre-illness level for six months or longer. The VA examination report indicates that continuous medication is not required for the Veteran's chronic fatigue syndrome and the Veteran's symptoms are not controlled by continuous medication. The VA examination report notes that the Veteran has the following findings, signs and symptoms attributable to chronic fatigue syndrome: debilitating fatigue; nonexudative pharyngitis; generalized muscle aches or weakness of the neck and back; fatigue lasting 24 hours or longer after exercise; daily headaches; migratory joint pains in the knees, shoulders, and wrists; neuropsychological symptoms; and, sleep disturbance characterized by nightmares and tossing and turning. The November 2011 VA examination report notes that the Veteran has cognitive impairment attributable to chronic fatigue syndrome of: poor attention; inability to concentrate; forgetfulness (poor memory per the Veteran); and confusion at times. The VA examination report notes that the Veteran's symptoms are nearly constant, but do not result in periods of incapacitation. The VA examiner opined that the Veteran's symptoms due to chronic fatigue syndrome restrict routine daily activities by less than 25 percent of the pre-illness level. The VA examiner noted that the Veteran is an operating engineer and is able to work 40 hours per a week. Based on the evidence above, the Board finds that the Veteran's fatigue has more nearly approximated the criteria for a 20 percent disability rating, but not higher, through the entire appeal period under Diagnostic Code 6354 as analogous to chronic fatigue syndrome. The Board finds that the Veteran has consistently reported and sought VA treatment for feelings of fatigue, manifested by a combination of debilitating fatigue, cognitive impairments, and other signs and symptoms that are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level. Specifically, the Veteran's fatigue been manifested by symptoms of debilitating fatigue, nonexudative pharyngitis, generalized muscle aches or weakness of the neck and back, fatigue lasting 24 hours or longer after exercise, daily headaches, migratory joint pains in the knees, shoulders, and wrists, neuropsychological symptoms, and sleep disturbance characterized by nightmares and tossing and turning; as well as, cognitive impairments of poor attention, inability to concentrate, forgetfulness, and confusion at times. Thus, the evidence demonstrates entitlement to a 20 percent evaluation, but no higher, for fatigue as analogous to chronic fatigue syndrome under Diagnostic Code 6354 throughout the rating period on appeal. 38 C.F.R. §§ 4.3, 4.7. Additionally, having reviewed the evidence of record, both lay and medical, the Board finds that the criteria for a disability rating in excess of 20 percent for the Veteran's service-connected fatigue have not been met or more nearly approximated for any part of the rating period on appeal, as the evidence does not show symptoms that are nearly constant and restrict routine daily activities to 50 to 75 percent of the pre-illness level, or; which wax and wane, resulting in period of incapacitation of at least four but less than six weeks total duration per year. 38 C.F.R. § 4.88b. In a November 2009 written statement, the Veteran contended that his symptoms of fatigue are nearly constant and restrict routine daily activities. At the June 2013 Board hearing, the Veteran reported constant feelings of fatigue that restrict his daily routine, having trouble driving to and from work, and also falling asleep while operating equipment at work. However, these contentions from the Veteran do not demonstrate that the Veteran's daily activities are restricted to the level of 50 to 75 percent. The September 2009 and November 2011 VA examination reports note that the Veteran works 40 hours a week as an operating engineer. At the June 2013 Board hearing, the Veteran reported working as an operating engineer and operating heavy equipment for a living. The Board notes that the November 2011 VA examination report indicates, under medical history, that the Veteran has debilitating fatigue that reduced daily activity level to less than 50 percent of the pre-illness level for over six months. This is the criteria for a diagnosis of chronic fatigue syndrome for VA purposes. See 38 C.F.R. § 4.88a. This notation was also listed in the section of the VA examination report entitled "medical history." The VA examination report goes on the list the signs and symptoms associated with the Veteran's fatigue and then provides an opinion that the Veteran's service-connected chronic fatigue syndrome symptoms restrict routine daily activities by less than 25 percent of the pre-illness level (i.e., more than 75 percent of the pre-illness level of activities are not restricted). The Board finds that the first notation in the VA examination report as to the level of reduced daily activity was a notation of the Veteran's history made in relation to how a diagnosis of chronic fatigue syndrome was first established for the Veteran, and does the reflect an assessment as to the current level of symptomatology. Finally, the Board finds that the evidence of record does not demonstrate that the Veteran had any incapacitating episodes which required bed rest and treatment by a physician for periods from four to less than six weeks. Id. While, in a November 2009 written statement, the Veteran contended that his fatigue shows signs and symptoms resulting in periods of incapacitation many times per year, the Board finds this contention is outweighed by the other, more probative, evidence of record. The November 2011 VA examination report specifically notes that the Veteran's symptoms due to chronic fatigue syndrome do not result in periods of incapacitation. Additionally, there is no evidence in the record that the Veteran has required bed rest and treatment by a physician as required by VA regulations. See id., Note (1). Nor has the Veteran alleged how the length and duration of his claimed incapacitating episodes. As such, the Board finds that the evidence of record does not show incapacitating episodes that required bed rest and treatment by a physician for periods from four to less than six weeks. Therefore, resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran's fatigue more nearly approximates the criteria for a 20 percent disability rating, but no higher, for the entire appeal period under Diagnostic Code 6354. Throughout the entire rating period on appeal, the Veteran's fatigue been manifested by debilitating fatigue, cognitive impairments, and other signs and symptoms that are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level. 38 C.F.R. § 4.88b. Assignment of staged ratings has been considered, but found not to be applicable in this case. 38 C.F.R. §§ 4.3, 4.7. Increased Rating for Acquired Psychiatric Disorders The Veteran is in receipt of a 30 percent disability rating for acquired psychiatric disorders under Diagnostic Code 9433, which is rated under the general rating formula for mental disorders. See 38 C.F.R. § 4.130. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is assigned for 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. Id. A 70 percent disability rating is assigned for 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 that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned 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; and memory loss for names of close relatives, or for the veteran's own occupation or name. Id. The use of the term "such as" in the general rating formula for mental disorders 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 symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disorder, and the effect of those symptoms on his/her social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (2013), the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that VA "intended the General Rating Formula to provide a regulatory framework for placing veterans on a disability spectrum based upon their objectively observable symptoms." The Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Within the DSM-IV, one factor for consideration is the Global Assessment Functioning (GAF) score, which is a scale ranging from 1 to 100 and reflecting "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). However, while the rating schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). DSM-IV at 46-47. GAF scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. Id. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). Id. GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which is at times illogical, obscure, or irrelevant) or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood (e.g., a depressed patient who avoids friends, neglects family, and is unable to do work). Id. The Veteran contends that his acquired psychiatric disabilities have worsened; thus, he asserts he is entitled to an increased disability rating. Specifically, in a November 2009 written statement, the Veteran contended that his psychiatric symptoms warrant a 50 percent disability rating. The Veteran contended that he has symptoms of panic attacks, agitation, feelings of inadequacy, serious depression, and short and long-term memory impairment. In a September 2009 written statement, the Veteran reported feeling detached from others, his surroundings, and activities. In a February 2010 written statement, the Veteran reported always feeling extremely depressed, irritable, tearful, and has a difficulty concentrating. The Veteran stated that he does not have any friends, but does have some acquaintances. In a November 2010 written statement, the Veteran reported that depression and panic attacks bother him every day and that he has anger. The Veteran stated that he believes that, if he lives alone, he will not bother anyone with his mental health issues. The Veteran reported that his mental problems have built up over the years specifically that his dysthymic disorder has worsened over time. In a February 2011 written statement, the Veteran asserted that he has fear that he may be harmed in some way when people are behind him or when driving a vehicle. The Veteran reported feeling that he needs to be alone and that his war illnesses have hurt his relationships, specifically with his spouse. After a review of all the evidence, lay and medical, the Board finds that, for the entire appeal period, the Veteran's acquired psychiatric disorders have been characterized by occupational and social impairment with reduced reliability and productivity more nearly approximating the criteria for a 50 percent disability rating, but no higher, under Diagnostic Code 9433. 38 C.F.R. § 4.130. The Veteran's acquired psychiatric disorders have been manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as depressed mood; decreased energy; excessive worry; short and long term memory impairment; excessive worry; nightmares; flashbacks; chronic sleep impairment; loss of interest in activities; some social isolation; poor concentration; flat affect; feelings of worthlessness and hopelessness; tearfulness; anxiety; and, disturbances in motivation and mood. An April 2008 VA treatment report reflects that the Veteran reported depression, decreased energy, excessive worrying, and tearfulness. A September 2008 VA treatment record indicates that the Veteran reported that he had experienced short term memory loss since service separation. The Veteran reported a lack of interest in activities. The treatment record indicates that the Veteran's depressive symptoms have worsened for the past three years. The examiner assigned a GAF score of 55. November and December 2008 VA treatment records note that the Veteran was assigned a GAF score of 65. January 2009 VA treatment records note that the Veteran reported nightmares two to three times per week. The Veteran was assigned GAF score of 65. The treatment record notes that the Veteran had been experiencing marital problems, contributing to his depressive symptoms. A February 2009 VA treatment record notes that the Veteran denied impairment in sleep, appetite, or lack of interest in activities, but reported experiencing nightmares. The Veteran was assigned a GAF score of 61. In September 2009, the Veteran underwent a VA examination. The Veteran reported feeling very depressed and wanting to be alone a lot. The VA examination report notes the Veteran's affect as one of mild sadness. The Veteran denied any irritability, tearfulness, manic symptoms, or panic attacks. The Veteran reported being close to his sisters and mother and having approximately fifty or more friends. The Veteran was assigned a GAF score of 60. The VA examiner opined that the Veteran's current symptoms of depression were vague and minimal. A December 2009 VA treatment record notes that the Veteran endorsed low mood, low energy, inability to fall asleep at night for more than one hour, loss of interest in activities, and anhedonia. The treatment record notes that the Veteran had some symptoms of anxiety with the Veteran reporting palpitations and increased sweating for a few minutes. The Veteran denied any avoidance, but endorsed being somewhat socially isolated. The treatment record notes the Veteran was assigned a GAF score of 60 to 65. The record indicates that the Veteran's mood and affected was depressed and, while the Veteran's memory was grossly intact, he did have some memory trouble. A January 2010 VA treatment record notes the Veteran was assigned a GAF score of 60. The Veteran reported his depressive symptoms had worsened including having low energy, poor concentration, and poor sleep. The Veteran reported nightmares and flashbacks several times a week. The treatment record notes that the Veteran's mood was depressed and his affect flat. A subsequent January 2010 VA treatment record notes that the Veteran was assigned a GAF score of 62. The treatment record indicates that the Veteran's affect was somewhat flat. A February 2010 VA treatment record notes that the Veteran was assigned a GAF score of 64. The Veteran reported feeling better, but still quite depressed and that he lacked energy and concentration. The treatment record notes that the Veteran's affect was slightly less flat. A March 2010 VA treatment record notes that the Veteran was assigned a GAF score of 62. An April 2010 VA treatment record notes the Veteran was assigned a GAF score of 65. In May 2010, the Veteran underwent a VA examination. The Veteran reported distancing himself from his spouse and feeling that he needs to be alone. The Veteran reported being isolated in his personal life. The Veteran reported being irritable all the time, difficulty sleeping, and always being sad. The Veteran endorsed the following symptoms during the previous two weeks: depressed mood; some loss of interest or pleasure in usual activities; insomnia; loss of energy/fatigue; feelings of worthlessness; tearfulness; hopelessness; difficulty making decisions; and thoughts that life is not worth living. The Veteran reported that his depressive symptoms have interfered with his daily life in terms of being social and interacting with people. The May 2010 VA examiner noted that the Veteran's psychiatric symptoms mild to moderately affected his family role, relationships, and quality of life. The VA examination report notes that Veteran had a dysthymic mood and short and long term memory impairment. The VA examination report notes that the Veteran has mild to moderate psychiatric symptoms that are chronic, continuous, and intermittent. The Veteran was assigned a GAF score of 57. A May 2010 VA treatment record notes that the Veteran was assigned a GAF score of 65. The record indicates that the Veteran seemed to not establish close relationships and often had feelings of abandonment. The VA treatment record notes that the Veteran's relationship with his spouse was deteriorating. A July 2010 VA treatment record notes that the Veteran was assigned a GAF score of 65. The Veteran reported that his sleep, concentration, and energy level had been improving with medication. An August 2010 VA treatment record notes that the Veteran was assigned a GAF score of 65. The treatment record indicates the Veteran reported nightmares occurring once every two weeks as well as flashbacks. A September 2010 VA treatment records notes the Veteran was assigned a GAF score of 65. The record notes that the Veteran reported being very angry with the current relationship with his spouse. The Veteran reported having nightmares twice a week and flashbacks three times a week. In November 2011, the Veteran underwent a VA mental disorders examination. The examination report notes Axis I diagnoses of anxiety disorder, NOS, and dysthymic disorder. The Veteran reported that he continues to live with his wife, brother-in-law, and step-grandson, but that the marital conflict between him and his wife had continued. The Veteran reported feeling that he should never have remarried and instead that he should live alone and not be a burden on others. The VA examiner noted that the Veteran had symptoms of depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The VA examiner assigned a GAF score of 60. The VA examiner opined that the Veteran's psychiatric symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The VA examiner noted that the nature, frequency, and severity of the Veteran's psychiatric symptoms continued to meet the DSM-IV criteria for anxiety disorder, NOS, and dysthymic disorder and that, although there had been slight improvement, the Veteran's symptoms remained at approximately the same level as was indicated in the May 2010 VA examination. The VA examiner noted that the Veteran's overall mental health functioning falls in the range of moderate to mild symptomatology. Based on the foregoing, the Board finds that, for the entire initial rating period, the Veteran's acquired psychiatric disorders have been characterized by symptoms of depressed mood, decreased energy, excessive worry, short and long term memory impairment, excessive worry, nightmares, flashbacks, chronic sleep impairment, loss of interest in activities, some social isolation, poor concentration, flat affect, feelings of worthlessness and hopelessness, tearfulness, anxiety, and disturbances in motivation and mood, many symptoms of which are associated with the 50 percent rating. 38 C.F.R. § 4.130. Assignment of staged ratings has been considered, but found not to be applicable in this case. The Board finds that, throughout the entire rating period, the Veteran's acquired psychiatric disorder symptoms result in occupational and social impairment with reduced reliability and productivity, which more nearly approximates the criteria for a 50 percent disability rating under Diagnostic Code 9433. 38 C.F.R. §§ 4.3, 4.7. The appeal for an increased rating for acquired psychiatric disorders is fully granted in this Board decision. At the June 2013 Board hearing, the Veteran specifically indicated that a 50 percent disability rating would satisfy the appeal as to this issue. See Hearing transcript p. 2. In a November 2009 written statement, the Veteran contended that he has occupational and social impairment with reduced reliability and productivity, the criteria for a 50 percent disability rating under Diagnostic Code 9433, as well as specifically contending that he was entitled to a 50 percent disability rating. 38 C.F.R. § 4.130. Thus, this grant of a 50 percent disability rating is a full grant of the benefits sought on appeal as to this issue. Such a full grant of benefits sought, coupled with express indication that the rating percentage sought fully satisfies the appeal, is distinguished from a case where a veteran does not express satisfaction with a partial increased rating during an appeal that is less than the maximum schedular rating. See A.B. v. Brown, 6 Vet. App. 35, 39 (1993) (recognizing that a claimant may limit the claim or appeal to the issue of entitlement to a particular disability rating which is less than the maximum allowed by law for a particular service-connected disability). The Board finds the Veteran's wavier of the remaining aspects of the appeal for an increased rating for acquired psychiatric disorders in excess of the 50 percent granted was knowing and intelligent, was made with representation and in the presence of his representative, and was supported by the Veteran's testimony and the evidence of record. Because a 50 percent increased disability rating for acquired psychiatric disorders is granted for the entire period of this appeal, the Veteran has limited this appeal in both extent and time by withdrawing the aspects of the appeal that encompassed an increased rating in excess of 50 percent. See 38 C.F.R. § 20.204 (2013) (providing that an appellant may withdraw an issue at any time before the Board issues a final decision). For these reasons, any questions of an increased disability rating in excess of 50 percent are rendered moot with no remaining questions of law or fact to decide. See 38 U.S.C.A. § 7104 (West 2002); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law is dispositive, the claim must be denied due to a lack of legal merit). In summary, the Board finds that the service-connected acquired psychiatric disorders more closely approximates the criteria for a 50 percent rating under Diagnostic Code 9433 for the entire appeal period; therefore, the appeal is fully granted. 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted for the service-connected left and right knee disabilities, fatigue, or acquired psychiatric disorders. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's bilateral knee disabilities are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's left and right knee disabilities have been manifested by symptoms of painful motion and excess fatigability that is productive of noncompensable limitation of motion. The schedular rating criteria specifically provide ratings for such noncompensable limitation of motion due to painful arthritis (Diagnostic Code 5003, 38 C.F.R. § 4.59); and contemplate ratings based on limitation of motion (Diagnostic Codes 5260, 5261), including motion limited to orthopedic factors such as pain and excess fatigability (38 C.F.R. §§ 4.40, 4.45, DeLuca). In this case, comparing the Veteran's disability level and symptomatology of the left and right knee disabilities to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule and the assigned rating is, therefore, adequate. With regard to the service-connected fatigue, the Board finds that the symptomatology and impairment caused by the Veteran's fatigue are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The Veteran's fatigue has been manifested by symptoms of debilitating fatigue, nonexudative pharyngitis, generalized muscle aches or weakness of the neck and back, fatigue lasting 24 hours or longer after exercise, daily headaches, migratory joint pains in the knees, shoulders, and wrists, neuropsychological symptoms, and sleep disturbance characterized by nightmares and tossing and turning; and, cognitive impairment of poor attention, inability to concentrate, forgetfulness, and confusion at times, which are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level. The schedular rating criteria specifically provide ratings for based on debilitating fatigue, cognitive impairments and other signs and symptoms. In this case, comparing the Veteran's disability level and symptomatology of the service-connected fatigue to the rating schedule, the degree of disability throughout the entire period under consideration is contemplated by the rating schedule and the assigned rating is, therefore, adequate. With regard to the service-connected acquired psychiatric disorders, the Board finds that the symptomatology and impairment caused by the Veteran's psychiatric disorders are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provide for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's acquired psychiatric disorders has been manifested by as depressed mood; decreased energy; excessive worry; short and long term memory impairment; excessive worry; nightmares; flashbacks; chronic sleep impairment; loss of interest in activities; some social isolation; poor concentration; flat affect; feelings of worthlessness and hopelessness; tearfulness; anxiety; and, disturbances in motivation and mood. These symptoms are part of the schedular rating criteria. The level of occupational and social impairment is explicitly part of the schedular rating criteria. The GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Moreover, all the Veteran's psychiatric symptomatology is contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan at 443. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the left and right knee disabilities, fatigue, or acquired psychiatric disorders, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Finally, the question of whether an inferred claim for a total disability rating based on individual unemployability (TDIU) has been raised under Rice v. Shinseki, 22 Vet. App. 447 (2009) is moot. As discussed below, the Veteran has withdrawn his appeal for a TDIU. For these reasons, any questions of an extraschedular disability rating are also rendered moot, with no remaining questions of law or fact to decide. See 38 U.S.C.A. § 7104. Withdrawal of TDIU Claim Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. A substantive appeal may be withdrawn in writing or on record at a hearing at any time before the Board promulgates a decision. Withdrawal may be made by the veteran or by his or her authorized representative. 38 C.F.R. § 20.204. During his June 2013 hearing, before a final decision was promulgated by the Board, the Veteran notified the Board that he wished to withdraw his appeal as to the TDIU claim. Hence, there remain no allegations of errors of fact or law for appellate consideration as to this matter. Accordingly, given this action by the Veteran the Board does not have jurisdiction to review the appeal further as to this issue. ORDER An increased disability rating of 10 percent for right knee disability, but no higher, is granted. An increased disability rating of 10 percent for left knee disability, but no higher, is granted. An increased disability rating of 20 percent for headaches, but no higher, is granted. An increased disability rating of 50 percent for acquired psychiatric disorders, but no higher, is granted. The claim for entitlement to a TDIU has been withdrawn. REMAND Increased Rating for Headaches The Veteran has previously been provided VA examinations for his service-connected headaches in September 2009 and November 2011. At the June 2013 Board hearing, the Veteran asserted that his headaches had worsened since his last VA examination. The Veteran reported experiencing daily, incapacitation headaches. The Veteran reported prostrating attacks during which he almost passes out because of his headaches and the headaches sometimes cause him to vomit. The Veteran stated that his heads hurt more, last longer, and are more frequent since his previous VA examination. The Veteran reported losing a couple of years of work in a 15 year span or a couple of days a month because of his headaches. The Veteran reported having to go home early a number of times because of headaches. Having reviewed the evidence of record, the Board finds that there is a duty to schedule another VA examination to assist in determining the current severity of the service-connected headaches. VA's General Counsel has interpreted that, when a veteran asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. See VAOPGCPREC 11-95; see also, e.g., Caffrey v. Brown, 6 Vet. App. 377, 381 (1995); Green v. Derwinski, 1 Vet. App. 121, 124 (1991); 38 C.F.R. § 3.327 (2013). In this instance, as the evidence suggests an increase in the severity of the Veteran's headaches since the most recent VA examination, the Board finds that another examination is appropriate. At the June 2013 Board hearing, the Veteran asserted that he had to repeatedly leave work early because of his service-connected headaches and that his headaches are productive of severe economic inadaptability. The Veteran has asserted that his pay stubs and employment records would indicate that he often has missed work and worked a reduced number of hours because of his headaches. On remand, VA should obtain records of this employment history and tell the Veteran he can obtain and submit these records that he has indicated may substantiate the increased rating claim by showing incapacitating episodes and economic inadaptability such as time lost from work due to headaches. Accordingly, the issue of an increased rating for headaches is REMANDED for the following action: 1. The AOJ should ask the Veteran to identify employers that the Veteran has worked for throughout the appeal period. The AOJ should task the Veteran to submit such employment, pay, and leave records. The AOJ should attempt to obtain records relating to missed time due to headaches, including pay stubs and employment records, from each employer the Veteran identifies that might have available records. If records are unavailable, the AOJ should have the employer so indicate. 2. Then, schedule the Veteran for a VA examination. The examiner is requested to review the records and should specifically provide an opinion as to the current nature and severity of the Veteran's headaches. The VA examiner should comment on the functional limitations caused by the migraine headaches, including the frequency, duration, and symptomatology experienced during prostrating attacks. The rationale for any opinion expressed should be set forth. 3. Then, readjudicate the issue of an increased rating for headaches. If the claim remains denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. The Veteran has the right to submit additional evidence and argument on the matter 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. 2013). ______________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs