Citation Nr: 1602492 Decision Date: 01/21/16 Archive Date: 01/28/16 DOCKET NO. 10-42 217 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to an initial rating higher than 30 percent for posttraumatic stress disorder (PTSD) prior to April 7, 2015. 2. Entitlement to a rating in excess of 10 percent for chondromalacia patella of the right knee, status post meniscus tear, with surgical repair and degenerative joint disease. 3. Entitlement to a rating in excess of 10 percent for chondromalacia patella of the left knee with degenerative joint disease. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M.H. Stubbs, Counsel INTRODUCTION The Veteran served on active duty from May 1974 to May 1977. These matters come before the Board of Veterans' Appeals (Board) from September 2009 (knees) and September 2010 (PTSD) rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In February 2013, the Board denied the claims for increased ratings for the service-connected right and left knee disabilities. The Veteran appealed the Board's denial to the United States Court of Appeals for Veterans Claims (Court). In an April 2014 Memorandum Decision, the Court vacated and remanded the Board's February 2013 decision. (The Veteran did not appeal the Board's February 2013 denial of a compensable rating for a right knee postoperative scar to the Court; as a result, this issue was deemed abandoned in the April 2014 Memorandum Decision). The claims were previously remanded by the Board in September 2014 and March 2015. The September 2014 remand directed that the Veteran be afforded a VA joints examination. The most recent remand directed the RO to obtain Social Security Administration records and schedule the Veteran for a VA psychiatric evaluation. In a July 2015 rating decision, the RO provided a 100 percent rating for PTSD, effective April 7, 2015. The Veteran indicated that he felt this rating should be in effect from 2009, so the claim for an increased rating for PTSD prior to April 7, 2015 remains on appeal. A total rating for compensation based on individual unemployability (TDIU) is an element of all appeals of an initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Court, in Bradley v. Peake, 22 Vet. App. 280 (2008), found that, although no additional disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of a TDIU predicated on a single disability (perhaps not ratable at the schedular 100 percent level) when considered together with another disability separately rated at 60 percent or more may warrant payment of special monthly compensation (SMC) under 38 U.S.C.A. § 1114(s). The Court reasoned that it might therefore benefit the Veteran to obtain or retain a TDIU rating even where a 100 percent schedular rating is already in effect. Here, however, the most recent April 2015 VA examination included that the Veteran had been employed since 2012. Additionally, there are no statements from the Veteran's representative in the December 2015 brief that the Veteran is unemployed or underemployed. At the time he initiated these claims the Veteran was employed full time as a truck driver for a North Carolina city. As such, the Board will not address a claim for TDIU at this time. The issues of entitlement to service connection for GERD, diabetes mellitus, hypertension, and arthritis, all as secondary to service-connected PTSD have been raised by the record in during the December 2015 appellate brief, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). The issue(s) of entitlement to increased ratings for bilateral knee disorders are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT Prior to April 7, 2015, the Veteran's PTSD manifested occupational and social impairment with deficiencies in most areas due to signs and symptoms including nightmares, intrusive thoughts, impaired impulse control, memory impairment, hallucinations, and thoughts of suicide. CONCLUSION OF LAW Prior to April 7, 2015, the criteria for an initial rating of 70 percent, and no greater, for the Veteran's service connected PTSD, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2014); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Board has given consideration to the VCAA, which includes an enhanced duty on the part of VA to notify a veteran of the information and evidence necessary to substantiate claims for VA benefits. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist veterans in the development of their claims. See 38 U.S.C.A. §§ 5103, 5103A. Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. See id. at 486. In the instant case, correspondence dated March and April 2009 notified the Veteran of information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. The letters additionally included notice regarding the degree of disability and effective date. The Board finds that the notice provisions of the VCAA have been fulfilled, and that no further notice is necessary. With respect to the duty to assist, VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance with 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). The Veteran's service treatment and personnel records, as well as his post-service medical treatment records have been obtained. VA attempted to obtain any SSA disability records associated with the Veteran; however, the SSA provided a response that they did not have any medical records/SSD records for the Veteran. The Veteran was afforded a VA psychiatric examination in April 2015. The examiner reviewed the Veteran's claim file, past medical history, recorded his current complaints, conducted an appropriate evaluation, and rendered an appropriate diagnosis and opinion consistent with the remainder of the evidence of record. The Board, therefore, concludes that the examination report is adequate for the purpose of rendering decisions on the current appeals. See 38 C.F.R. § 4.2; see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran and his representative have not contended otherwise. The Veteran was provided with the opportunity to testify at a hearing, but he declined this opportunity. Thus, the duties to notify and assist have been met, and the Board will proceed to a decision. Laws and Regulations Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1. Where the Veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board notes that the Veteran's service-connected PTSD is evaluated under Diagnostic Code 9411. The regulations establish a general rating formula for mental disabilities. See 38 C.F.R. § 4.130. 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. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. The Board notes that the DSM-IV has been recently updated with the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 5th Edition (2013) (DSM V). Effective March 19, 2015, VA adopted as final, without change, its' interim rule amending the portion of its Schedule for Rating Disabilities (i.e., 38 C.F.R. §§ 3.384, 4.125, 4.126, 4.127, and 4.130) dealing with mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with DSM-V. See 53 Fed. Reg. 14308 (March 19, 2015). However, the provisions of the rule only apply to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. During his period of appeal, the Veteran's PTSD symptoms have been addressed by his private doctor and the VA under the DSM-IV and DSM-V. His VA examination provided a diagnosis of PTSD under the DSM-V. The Veteran's service-connected PTSD has been evaluated as 30 percent disability rating under 38 C.F.R. § 4.130, Diagnostic Code 9411 prior to April 7, 2015, and 100 percent thereafter. The criteria for rating psychiatric disabilities other than eating disorders are contained in a General Rating Formula. Under that formula, 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 normal routine behavior, self-care, and conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Lastly, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. See 38 C.F.R. § 4.130, DC 9411. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association 's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM- IV), p. 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (Mar. 1995); 60 Fed. Reg. 43186 (1995). Factual Background and Analysis In his December 2015 appellate brief, the Veteran's representative argues that the Veteran is entitled to a 100 percent rating for PTSD from his claim date in 2009. The representative stated that the "Veteran's PTSD is the same now as it was in 2009, according to the medical records in the file. His GAF has actually improved...The 2015 VA examination and the 2009 treatment records show the same severe level of impairment. He deals with frequent audio and visual hallucinations, as well as getting lost on familiar streets." In January 2009, the Veteran initially sought treatment for his PTSD with Dr. E.W.H. of the Goldsboro Psychiatric Clinic. The private treatment records dated from January 2009 to June 2009 and January 2015 document office visits made to the facility by the Veteran. The clinic utilizes a standard pre-printed patient assessment form utilizing multiple-choice "Symptom Checklist" and "Hallucination Checklist" responses as well as "yes or no" responses. The patient assessment forms provide little to no explanations or further comments by the interviewer. It should be noted that the forms documenting the symptoms were signed by either a CNA (certified nurse aide), and only the treatment (medication) plan was signed by the psychiatrist (Dr. H.). On his initial visit, the Veteran was diagnosed with PTSD and chronic major depression. The Veteran reported that after service he worked for the City of Dunn for 17 years, and that for the prior 28 years he worked as a truck driver for the Public Works. The Veteran reported having nightmares about parachute jumps beginning in 1987. In January 2009, his PTSD symptoms included frequent nightmares, flashbacks, panic attacks four times per week, intrusive thoughts, hypervigilance, and an easy startle response. He did not tolerate people being behind him. He socialized occasionally with family but rarely with friends. He was noted to have a mildly impaired recent memory, such that he cannot remember what he reads and he gets lost when traveling. He reported anger, sadness and fear "comes upon him without his understanding why 60 percent of the time." Based on the "hallucination checklist" the Veteran heard his name called, heard cars drive up to his residence, heard noises in his house, and saw shadows out of the corner of his eye multiple times per week. Although Dr. H. condensed the January 2009 visit in his initial letter, a review of the visit shows the Veteran endorsed all of the possible options on the "hallucination checklist" and all but one of the options on the "symptoms checklist." Dr. H. noted that the Veteran felt depressed, had crying spells, angers easily, and "feels helpless and suicidal at times." Dr. H. found that the Veteran was "moderately compromised in his ability to sustain social relationships and moderate compromised in his ability to sustain work relationships." Based on the initial assessment, Dr. H. assigned the Veteran a GAF of 40. In March 2009, during an assessment with a CNA, the Veteran again endorsed all but one of the items listed in the "symptoms checklist" and all of the hallucinations on the "hallucination checklist." Notably, between January and March, the Veteran went from having no problems with his interest in things and difficult learning new things at least half the time, to a loss of his interest in things half the time and never having difficulty learning new things. His complaints that were recorded outside of the checklists were "still not getting enough sleep, knee is messed up real bad, depressed him and the economy." It is noted that this assessment was recorded as occurring in 5 minutes. Dr. H. assigned the Veteran a GAF of 35. In April 2009, the Veteran endorsed all symptoms on the "symptom checklist," except now he indicated he never had problems learning new things. He continued to have all the hallucinations on the "hallucination checklist" two to five times per week. The assessment with the CNA lasted 7 minutes, and Dr. H. then assigned a GAF of 40. By June 2009, the Veteran endorsed all of the symptoms on the "symptoms checklist" and all the hallucinations on the "hallucination checklist" except he stopped "seeing animals." The symptoms the Veteran endorsed were (the list of symptoms on the checklist): anger, sadness, and fear "out of the blue;" depressed, "energy level, interest leve, agitated, angry, can verbally described trauma pictures, words, both, feels helpless, feels hopeless, suicidal, easy to learn new things, mood swings, worry, racing thoughts, jumping thoughts, crying spells." Additionally, the forms ask about the number of times per week or month the Veteran experienced nightmares, "wakes in panic," flashbacks, average hours of sleep, night sweats, startles (yes or no), hypervigilant (yes or no), "no one behind them," intrusive thoughts (yes or no), and an option to circle how frequently they socialize, and what memory lapses they may have (options include: "room/room, misplaces, forgets told, can't read, lost driving). The Veteran denied panic attacks and reported frequently socializing with friends and family in June 2009. He noted he would misplace things and forget what he had been told. He had 6.5 hours of sleep per night on average, waking once per night. The assessment lasted 8 minutes. In October 2010, Dr. H. provided an assessment outside of the patient assessment forms. The progress note included that the Veteran's sister had died of cancer less than two months previously. The Veteran noted he was granted PTSD by the VA and assigned a 30 percent rating, which he had appeal ed. He reported weekly nightmares, flashback, and panic attacks twice a week lastly 30 minutes. He was "sleeping very poorly." Nevertheless, he was working full time driving trucks. It appears to state [handwriting] that the Veteran was "depressed all the time" and he had crying spells. His recent memory was "worse." He was assigned a GAF of 35. VA treatment records include a May 2010 record that the Veteran was still employed as a truck driver, and a May 2011 record that the Veteran was "retired." In March 2014, the Veteran tested positive for marijuana during a test his VA provider performed in conjunction with an "opioid contract" with the VA. Essentially, in order to obtain opioid medication, the VA attempts to ensure that substance abuse does not occur. As a result of the positive test, the Veteran began a substance abuse program with the VA. He reported periodic use of marijuana since age 16. He also reported using alcohol more than once per day. He reported he "retired from the city" and was receiving SSI. He reported his friends and family were supportive of him. He was assessed with a GAF of 65. He reported no intent self-harm or to harm others. He reported good relationships with his siblings and "friends/coworkers." During a group therapy session associated with the substance abuse program, the Veteran reported he was "socializing with friends, playing cards, drinking, and someone passed a joint and I took a puff." He stated he only used it because he is now retired. He stated he is feeling "happy." The record does not contain private treatment records between 2010 and 2015. On January 2015, the Veteran participated in a "returning patient assessment." It appears the clinic changed the assessment form. This time the assessment lasted 20 minutes. The form has symptoms on one side, a column with the numbers 1 through 10, a column with "daily weekly monthly" and columns with "same, better, worse." It appears the assessment showed the Veteran had broken sleep, nightmares, panic attacks up to three times a week, flashbacks, and night sweats. He denied any hallucinations. His anger, depression and memory deficiencies were the same. He maintained eye contact, was cooperative and alert. He was oriented and did not complain of memory impairment. His mood was euthymic and his affect normal. His thought content was normal. Under "insight/judgment" either Dr. H. or a CAN marked the following on the form "aware of problem/role, understands facts, draw conclusions, problem solving." As these were the all of the options, it appears his insight and judgment were adequate. This assessment included handwritten notes from Dr. H. The Veteran was noted to nap during the day, up to two hours, for a total amount of sleep between six and eight hours. His affect and mood were appropriate. His assessment was that the Veteran "needs day job." He assigned a GAF of 45. In April 2015, the Veteran was afforded a VA PTSD examination, which used the DSM-V to evaluate and diagnose the Veteran's PTSD. The examiner found the Veteran had total occupational and social impairment due to his PTSD symptoms. The Veteran described avoidance of people and places, social isolation, restricted affect, anhedonia, episodes of uncontrolled anger and guilt, depressed mood and feelings of worthlessness and guilt. He reported few friends, limited leisure time activities and a very limited social life. His flashbacks, episodes of anxiety and panic, social isolation, chronically disturbed sleep, anger, difficulty concentrating; hypervigilance, exaggerated startle response and depressed mood have had a "detrimental impact upon his ability to function in a workplace." However, the record noted he "has been employed as a truck driver since 2012." PTSD symptoms reported by the evaluator included: depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, impairment of short and long term memory, flattened affect, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, suicidal ideation, obsessional rituals interfering with routine activities, impaired impulse control, and neglect of personal appearance and hygiene. He was noted to meet the criteria for the DSM-IV and DSM-V diagnosis of chronic severe PTSD. He reported several symptoms had increased in frequency, duration and intensity since his last examination, to include his anger, sleep disturbances, social isolation, obsessive hypervigilance, and difficulty concentrating. The Board notes that the 2015 examination was the first PTSD examination provided to the Veteran. The examiner found that under the DSM-IV, the Veteran was assigned a GAF of 44, which represents "serious symptoms" and deficits in social, work and personal functioning. The examiner found that "due to the level of the symptoms discussed above, and the manner in which they disrupt the veteran's ability to relate to superiors and co-workers, and the degree to which they impair the veteran's ability to accomplish tasks, it is at least as likely as not that the veteran would be unable to secure or maintain any kind of reasonable employment at this time." Initially, the Board notes that in reviewing the 2009 private clinic notes, the patient assessment forms provided no comments or support for the assessment and did not indicate at any point whether the nightmares, flashbacks, etc., were the result of wartime experiences, as opposed to other traumatic events in the Veteran's life. The Court has held that a medical opinion that contains only data and conclusions is not entitled to any weight and a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes is derived. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The Court has held on a number of occasions that a medical opinion premised upon an unsubstantiated account is of no probative value. See e.g. Reonal v. Brown, 5 Vet. App. 458, 460 (1993); Moreau v. Brown, 9 Vet. App. 389, 395- 39 (1996); Swann v. Brown, 5 Vet. App. 229, 23 (1993). Additionally, according to regulatory authorities in North Carolina, a CNA is: Nurse Aide "Nurse Aide" means a person who is listed on the N.C. Nurse Aide I Registry and is in compliance with 42 CFR Part 483 [10A NCAC 13D .2001 (35)]. Nurse aide means any individual providing nursing or nursing-related services to residents in a skilled nursing facility who is not a licensed health professional (emphasis added), a registered dietitian, or someone who volunteers to provide such services without pay. Nurse aides do not include paid feeding assistants [42 CFR 483, Subpar t B 483.75(e); Social Security Act 1819(b) (5) (F) and 1919(b) (5) (F)]. Thus, a CNA, is not a licensed health care professional, and in some instances, can be a volunteer without pay. Therefore, the 2009 patient assessment forms in this case, were prepared by an unlicensed individual who is not required to have any mental health training. The Board notes that in adjudicating a claim the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In addition, the Board acknowledges that the Veteran is competent to give evidence about what he experiences; for example, he is competent to report that he experiences certain symptoms, such as his problems with intrusive thoughts, nightmares, and irritability. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). Here, the Board finds the Veteran's description of his PTSD symptoms to be somewhat credible. Throughout 2009, the Veteran endorsed a number of hallucinations. These hallucinations were never brought up to VA medical professionals and the Veteran continued to work as a truck driver during this period. Additionally, through the use of the patient assessment forms, it was possible to see slight changes in reported symptoms, such as whether he had difficulty learning new things or not. Similarly, although the Veteran reported to his private health care provider and to the VA examiner that he socially isolates and only interacts with his family, a 2014 group substance abuse group noted that the Veteran was socializing with friends ("drinking and playing cards"), and that his friends and family were supportive of him. While the Veteran is competent to report his PTSD symptoms, the discrepancies in reported symptoms make an assessment of the Veteran's credibility difficult. On the issues addressed in this paragraph, the Board assigned less credibility to the Veteran's statements. The Veteran contends that his PTSD is more severe than the 30 percent rating assigned prior to April 7, 2015. The Board finds that for the period prior to April 7, 2015, the Veteran's PTSD symptoms fell between the criteria for a 50 percent rating and a 70 percent rating. Regarding the criteria for a 70 percent rating, the Veteran had symptoms such as deficiencies in judgement (drinking and marijuana use) and mood (depressed and crying spells), suicidal ideation (endorsed in patient assessment forms in 2009, denied in 2014), and possibly an inability to establish and maintain effective relationships (the Veteran reported social isolation to all PTSD care providers, except when treated for substance abuse in 2014). The Veteran did not have symptoms such as spacial disorientation, obsessional rituals that interfered with routine activities, abnormal speech, impaired impulse control such as unprovoked irritability with periods of violence (no descriptions of angry outburst), neglect of personal appearance or hygiene (there were no descriptions of clothing or smell, etc.). Regarding the criteria under the 50 percent rating, the Veteran had symptoms such as panic attacks more than once a week, mild impairment of memory, impaired judgment, disturbances of motivation and mood, and difficult in establishing and maintaining effective work and social relationships. As noted above, the Veteran endorsed all of the hallucinations listed on the "hallucination checklist" in 2009. Although persistent delusions and hallucinations are listed in the criteria for a 100 percent rating, the Board is providing little probative value to the hallucination checklist findings. There is no description from the Veteran, in his own words, of any hallucinations. Additionally, even accepting the hallucinations in 2009, the totality of the Veteran's PTSD symptoms did not more nearly approximate a 100 percent rating prior to April 7, 2015. The Veteran exhibited normal behavior, he was not a persistent danger of hurting himself or others (there were no indications of suicide attempts, self-harm or violence against self or others), he was able to perform activities of daily living (he lived alone and supported himself with a full time job), he did not have disorientation to time or place (he worked full time as a truck driver), and he never had memory loss for names or his own occupation. He did not show PTSD symptoms such as the ones listed above, or others of a similar severity. GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the rating issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)). Here, prior to April 7, 2015, GAF scores from the Veteran's private psychiatrist measured from 35 to 45. A GAF score of 31 to 40 shows some impairment in reality testing or communication. A GAF score of 41 to 50 indicates serious symptoms or any serious impairment in social, occupational or school functioning. The Board notes that the hallucinations endorsed by the Veteran in 2009 are found to not be pertinent medical evidence as they were recorded by an unlicensed medical professional, and were a part of a checklist. Additionally, the Veteran was employed full time throughout this period, and although he reported social isolation, it appears he had some social contact with family and friends. In 2014, the Veteran was assigned a GAF of 65, indicating mild symptoms. The serious range GAF scores correspond to the Veteran's symptoms. Overall, the Board notes that the Veteran's PTSD symptoms, prior to April 7, 2015, more closely approximate the 50 percent rating criteria. It appears that the Veteran improved in his functioning between 2009 and 2014, based on available evidence. However, given that the private psychiatrist provided GAF scores in the serious range, and the Veteran endorsed "suicidal" on his assessment forms, the Board will resolve reasonable doubt in the Veteran's favor and finds that prior to April 7, 2015, the Veteran's PTSD warrants a 70 percent rating. The Board notes that it is unclear when the Veteran was employed during the period on appeal. It appears that he may have retired from truck driving for the city after 30 years of employment in late 2010 or 2011. However, during his VA examination in 2015, he reported he was again working as a truck driver since 2012. In addition to his PTSD symptoms generally falling between the criteria for 50 and 70 percent ratings, the Board notes that the Veteran is not entitled to a 100 percent rating prior to April 7, 2015. The Veteran was noted in 2014 to have supportive friends and family and to socialize with his friends. He was also employed full time during some part of this appeal, including his city employment that he maintained for 30 years. As such, the Board does not find that the Veteran had total occupational and social impairment during the prior to April 7, 2015. The Board must also determine whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment or frequent periods of hospitalization. Id. at 115-116. When either of those elements has been satisfied, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this case, the schedular evaluations noted above are adequate. The PTSD disability symptoms are contemplated by the schedular criteria and additional higher ratings are available. The Board has noted when the Veteran's symptoms span different ratings under the criteria. And even though the balance of his symptoms were of a moderate severity during this period, as his GAF scores indicated serious impairment, the higher 70 percent rating was assigned. The criteria under the General Rating Formula for Mental Disorders is inclusive, in that it allows for a variety of symptoms to be applied to the ratings as long as they are of a similar severity and produce a level of occupational and social impairment. The Board discussed why the Veteran's symptoms fell between the 50 and 70 percent ratings, and addressed why the Veteran's reported symptoms did not reach the next higher level of symptoms associated with an increased rating. As such, the diagnostic criteria reasonable describe and contemplate the severity and symptomatology of the Veteran's PTSD. The Veteran has had sporadic treatment for his PTSD and, although he was treated for substance abuse in 2014 as a part of his opioid contract with the VA, he has not been hospitalized in relation to his PTSD symptoms. The Board does not find that this constitutes marked interference or frequent hospitalization for the purposes of an extraschedular rating. As the rating schedules are adequate to evaluate the disabilities, referral for extraschedular consideration is not in order. ORDER Entitlement to an initial 70 percent rating, and no higher, for PTSD prior to April 7, 2015, is granted. REMAND Knees In September 2014, the Board remanded the Veteran's increased knee rating claims for additional development. The Board noted that the Court observed that VA medical records associated with the Veteran's claims file included an October 2008 treatment report at which time he reported that both knees "give away some time and he falls." Additionally, a November 2008 physical therapy treatment record indicated that the Veteran's left knee continued to buckle, causing him to stumble and fall, and that, in conjunction with his physical therapy treatment, he was issued a metal adjustable cane. Also, the Veteran's primary care provider noted in a January 2009 medical examination report that the Veteran complained that his left knee cap was "slipping." The Court found that the Board failed to address why medical evidence of record related to the Veteran's knee stability and treatment, including issuance of a cane did not warrant a higher rating or separate rating for instability thereby rendering the Board's decision inadequate. The Court maintained that while the Board concluded that the overall record weighed against finding subluxation or instability an October 2008 VA medical record reflected that both of the Veteran's knees would give way causing him to fall, and a November 2008 physical therapy record evidenced that he was issued a cane following his report of repeated "stumbles and falls" and buckling of his left knee. Under Diagnostic Code 5257, recurrent subluxation or lateral instability is evaluated as slight, moderate, or severe. As such, in September 2014, the Board ordered a new VA knees examination. In October 2014, the Veteran was afforded a VA joints examination. The examination included repeated range of motion testing, and several joint stability tests. The examiner found that the Veteran's knees had normal anterior, posterior, medial and lateral stability. Lastly, the examiner noted that "the subjective complaint of instability was less likely joint instability and more likely muscle instability as the quadriceps muscle group responsible." However, the examiner found muscle strength testing to be normal in both knees. In a December 2015 brief, the Veteran's representative voiced complaints with the October 2014 VA examination. The representative noted that although the examiner indicated that the Veteran's subjective feeling of knee instability was related to his quadriceps muscle group, the examiner did not state whether this muscle was related to the Veteran's knee injuries or surgeries. Additionally, the representative noted that the examination form listed the full extension of the knee as from 140 degrees to zero degrees, but that the examiner had listed his full extension as from zero to zero degrees. The representative stated that this was contradictory of the examiner's finding that the Veteran did not have ankylosis. Although it is apparent that the examiner was indicating the Veteran had full extension to zero degrees, the representative's question regarding the cause of the muscle impairment should be addressed. As the examination both records that the Veteran had normal muscle tone and that his quadriceps were the reason for his subjective instability, an additional VA examination is necessary. Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA joints examination to determine the current severity of his bilateral knee disabilities. The virtual claims file must be made available to and reviewed by the examiner. The examination report should specifically address the instability of the Veteran's knees given his subjective complaints of instability and falling down. The report should also address the October 2014 examiner's opinion that his subjective instability was a result of his quadriceps. The examiner should provide an opinion as to whether any diagnosed quadriceps disability or deficiency is due to the Veteran's service-connected knee disabilities. The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups (if the Veteran describes flare-ups). The examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion lost. If this is not feasible to determine without resort to speculation, the examiner must provide an explanation for why this is so. 2. Then, the AMC/RO should readjudicate the claims on the merits. If the benefit sought is not granted, the Veteran and his representative should be furnished a SSOC and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ DAIVD L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs