Citation Nr: 1804633 Decision Date: 01/24/18 Archive Date: 02/05/18 DOCKET NO. 15-09 521 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for service connection for degenerative disc disease, lumbar spine, with radiculopathy (lumbar spine disability). 2. Whether new and material evidence has been received to reopen a claim for service connection for right knee status post-surgery (right knee disability). 3. Whether new and material evidence has been received to reopen a claim for service connection for left knee arthritis status post-surgery (left knee disability). 4. Entitlement to service connection for lumbar spine disability. 5. Entitlement to service connection for right knee disability. 6. Entitlement to service connection for left knee disability. 7. Entitlement to an initial rating in excess of 30 percent for other specified trauma and stressor-related disorder. REPRESENTATION Appellant represented by: George T. Sink, Attorney ATTORNEY FOR THE BOARD Michael Sanford, Counsel INTRODUCTION The Veteran served on active duty from January 1963 to January 1966, and from January 1991 to May 1991. This appeal to the Board of Veterans' Appeals (Board) arose from two rating decisions of the Columbia RO. In a July 2013 rating decision, the RO, inter alia, denied requests to reopen previously denied claims for service connection for right knee and lumbar spine disabilities. A notice of disagreement (NOD) was received in August 2013. A statement of the case (SOC) was issued in March 2015, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in March 2015. Additionally, a May 2015 rating decision continued the 30 percent rating for other specified trauma and stressor-related disorder, and denied a request to reopen a previously denied claim for service connection for left knee disability. The Veteran filed an NOD in May 2016. An SOC was issued in June 2017, and the Veteran filed a substantive appeal also in June 2017. However, with respect to the higher rating claim, as explained in more detail below, the Board finds that the period under consideration in connection that claim extends from a November 2014 rating decision in which the RO awarded service connection, and assigned the initial rating for the psychiatric disability. As regards characterization of the service connection claims, the Board notes that, regardless of the RO's actions, the Board has a legal duty under 38 U.S.C.A. §§ 5108 and 7104 to address the question of whether new and material evidence has been received to reopen a previously denied claim for service connection. That matter goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim on a de novo basis. See Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). As the Board must first decide whether new and material evidence to reopen the claim has been received-and, in view of the Board's favorable decision on the request to reopen-the Board has characterized the appeal as now encompassing the requests to reopen and the de novo claims, as set forth on the title page. Also, because the higher rating claim emanates from the Veteran's disagreement with the initial rating assigned following the award of service connection, the Board has characterized the claim in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disabilities). As for the matter of representation, the Veteran was previously represented by Disabled American Veterans (as reflected in a VA Form 21-22, Appointment of Veterans Service Organization as Claimant's Representative, filed in July 2013), and subsequently, The American Legion (as reflected in a VA Form 21-22 filed in July 2016). In May 2016, he appointed private attorney George T. Sink (as reflected in a VA Form 21-22a, Appointment of Individual as Claimant's Representative). The Board has recognized the change in representation. In May 2017, the Board remanded the appeal in order to fulfill the Veteran's request for a video conference hearing. In a June 2017 letter, the Veteran, through his representative, requested to withdraw his request for a video conference hearing. See 38 C.F.R. § 20.704(e) (2017). Also in June 2017, the Veteran submitted additional evidence directly to the Board, accompanied by a waiver of local consideration. See 38 C.F.R. § 20.1304(c) (2017). While the Veteran previously had a paper claims file, this appeal is now fully being processed utilizing the paperless, electronic Veterans Benefits Management System (VBMS) and Virtual VA (Legacy Content Manager) claims processing systems. Also, this appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2) (2012) and 38 C.F.R. § 20.900(c) (2017). As a final preliminary matter, the Board notes that the matter of the Veteran's entitlement to a total disability rating based upon individual unemployablity (TDIU) may be considered a component of a rating claim when such is expressly raised by the Veteran or reasonably raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, however, the evidence submitted by the Veteran's attorney in June 2017 does not suggest that the Veteran is unable to engage in substantially gainful employment due solely to the service-connected psychiatric disability, the rating for which is on appeal. Rather, the attorney argues that the Veteran's occupational functioning is also impacted by his service-connected residuals of cold weather injury of both hands. As such, the Board finds that entitlement to a TDIU solely due to the Veteran's other specified trauma and stressor-related disorder has not been raised in connection with the current claim for higher rating; but, rather, the matter of entitlement to a TDIU based on multiple disabilities has been raised. Although the matter of entitlement to TDIU was initially adjudicated in a November 2014 rating decision, the Veteran did not thereafter initiate an appeal, and any further communication regarding his entitlement to a TDIU was not received until December 2016. As such, this matter is not properly before the Board, and is referred to the AOJ for appropriate action. See 38 C.F.R. § 19.9 (2017). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate each claim herein decided has been accomplished. 2. In an April 2005 rating decision, the RO denied service connection for lumbar spine disability, right knee disability, and left knee disability; although notified of the denial in an April 2005 letter, the Veteran did not initiate an appeal, and no pertinent exception to finality applies. 3. New evidence added to the record since the April 2005 denial relates to an unestablished fact necessary to substantiate the claims of service connection for lumbar spine disability, right knee disability, and left knee disability, and, when considered along with other evidence of record, provides a reasonable possibility of substantiating the claims. 4. The Veteran has a current diagnosis of spondylosis and stenosis of the lumbar spine, and the collective lay and medical evidence indicates that there is as likely as not a medical relationship between the diagnosed lower back condition and service. 5. The Veteran has a current diagnosis of degenerative arthritis of the right knee, and the collective lay and medical evidence indicates that there is as likely as not a medical relationship between the diagnosed right knee condition and service. 6. The Veteran has a current diagnosis of degenerative arthritis of the left knee, and the collective lay and medical evidence indicates that there is as likely as not a medical relationship between the diagnosed left knee condition and service. 7. Since the August 14, 2014 effective date of the award of service connection for other specified trauma and stressor-related disorder, the Veteran's psychiatric symptoms have included anger and irritability, nightmares, hypervigilance, avoidance, depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, obsessional rituals which interfere with routine activities, impaired impulse control, difficulty in adapting to stressful circumstances, and suicidal ideation; collectively, these symptoms of the type and extent, frequency and/or severity (as appropriate) that suggest occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSIONS OF LAW 1. The April 2005 rating decision in which the RO denied service connection for lumbar spine disability, right knee disability, and left knee disability is final. 38 U.S.C. § 7105 (b) (2012); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2017). 2. As pertinent evidence received since the April 2005 denial is new and material, the criteria for reopening the claims for service connection for lumbar spine disability, right knee disability, and left knee disability are met. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156 (2017). 3. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for a low back disability, diagnosed as spondylosis and stenosis of the lumbar spine, are met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317 (2017). 4. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for a right knee disability, diagnosed as degenerative arthritis of the right knee, are met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317 (2017). 5. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for a left knee disability, diagnosed as degenerative arthritis of the left knee, are met. 38 U.S.C. §§ 1110, 1112, 1113, 1117, 1131 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317 (2017). 6. Resolving all reasonable doubt in the Veteran's favor, the criteria for an initial 70 percent, but no higher, rating for other specified trauma and stressor-related disorder, from August 14, 2014, are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (2012 & Supp. 2015), sets forth VA's duties to notify and assist claimants in substantiating claims for VA benefits. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b). In order to satisfy its duty to notify the claimant under the VCAA, the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Regarding the claim for higher rating for other specified trauma and stressor-related disorder, the Veteran's appeal rose rises from his disagreement with the initial evaluation and effective date assigned following the grant of service connection. Courts have held that, once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i) (2017) (no duty to provide VCAA notice upon receipt of a notice of disagreement). Therefore, no further notice is needed under VCAA regarding this issue. However, the SOC The record also reflects that, consistent with applicable duty-to-assist provisions, VA has made reasonable efforts to develop the claim herein decided, to include obtaining or assisting in obtaining all relevant records and other evidence pertinent to this matter. Pertinent medical evidence associated with the claims file consists of VA treatment records, private evaluation reports, and VA examination reports. Also of record and considered in connection with the claims are various written statements by the Veteran and his attorney. Finally, the Board finds that the RO substantially complied with May 2017 remand orders. As noted in the Introduction, the Board remanded the appeal so that the AOJ could schedule the Veteran for a video conference hearing. In a July 2017 letter, the Veteran withdrew his previous request for a hearing. Consequently, no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with). In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran has been notified and made aware of the evidence needed to substantiate the claims herein decided, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Requests to Reopen At the time of the prior denial and currently, service connection may be granted for disability resulting from an injury or disease contracted in the line of duty, or for aggravation of a preexisting injury or disease contracted in the line of duty in the active military, naval or air service. 38 U.S.C. § 1131 (2012); 38 C.F.R. § 3.303 (2017). The record reflects the RO initially denied the Veteran service connection for disabilities of the right and left knees and lumbar spine in April 2005. The RO apparently denied the claim based on lack of in-service injury or illness. The evidence then of record consisted of the Veteran's service treatment records. The RO notified the Veteran of the denials in a letter also dated in April 2005. However, the Veteran did not initiate an appeal of this decision by filing an NOD within one year. See 38 C.F.R. §§ 20.200, 20.201 (2005, 2017). Also, no new and material evidence for any of the claims was associated with the claims file within one of year the denials, and no additional service records . Also, no Therefore, the April 2005 rating decision is final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. However, under pertinent legal authority, VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of the Veteran. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Regarding petitions to reopen filed on and after August 29, 2001, 38 C.F.R. § 3.156(a) defines 'new' evidence as evidence not previously submitted to agency decision makers and 'material' evidence as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). In determining whether new and material evidence has been received, VA must initially decide whether evidence received since the prior final denial is, in fact, new. This analysis is undertaken by comparing the newly received evidence with the evidence previously of record. After evidence is determined to be new, the next question is whether it is material. The provisions of 38 U.S.C. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-83 (1996). Furthermore, for purposes of the "new and material" analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-13 (1992). With regard to the previously denied claims for disabilities of the knees and lumbar spine, new evidence includes statements from the Veteran and a fellow soldier regarding the onset of his symptoms, military personnel records, and a private positive opinion. Where VA has previously denied a claim because one element of service connection is missing, the case must be reopened when evidence potentially fulfilling the missing element is submitted. See Molloy v. Brown, 9 Vet. App. 513 (1996). Further, the United States Court of Appeals for Veterans Claims (Court) has interpreted the language of 38 C.F.R. § 3.156 (a) as creating a low threshold, viewing the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Id. Given the "low threshold" standard of Shade, and presuming the credibility of the evidence (See Justus, 3 Vet. App. at 513.), the Board finds that the above-described evidence additional evidence received since the April 2005 denial was not previously before VA adjudicators, and is not cumulative or duplicative of evidence; the evidence is also relevant to the question of the etiology of currently claimed lumbar spine and knee disabilities, and thus, provides a reasonable possibility that the claims will be allowed. As such, this evidence is new and material within the meaning of 38 C.F.R. § 3.156(a),. Under these circumstances, the Board concludes that the criteria for reopening the previously denied claims for service connection for lumbar spine disability, right knee disability, and left knee disability are met. III. Service Connection The Veteran contends that his currently manifested disabilities of the lumbar spine and bilateral knees resulted from his parachute jump duties during active service. Additionally, the Veteran and a fellow soldier specifically asserted that the Veteran injured his low back and one of his knees after completing a jump while stationed in the Dominican Republic. He maintains that he was treated in the field for both problems. See, e.g., July 2013 statement in support of claim; see also September 2013 buddy statement. Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.303, 3.304 (2017). Regulations provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). In addition, certain chronic diseases, such as arthritis, may be presumed to have been incurred during service if they become manifested to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). However, presumptive service connection may alternatively be established by way of continuity of symptomatology under 38 C.F.R. § 3.303 (b). Continuity of symptomatology may be shown by demonstrating "(1) that a condition was 'noted' during service or any applicable presumption period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology." Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); see also Davidson v. Shinseki, 581 F.3d 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue to be addressed by the Board"). However, the Federal Circuit held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic in 38 C.F.R. § 3.309(a), such as arthritis. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In deciding whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Briefly summarized, the Veteran served on active duty from January 1963 to January 1966, and from January 1991 to May 1991. His DD Form 214 reflects, inter alia, that he was awarded the Parachute Badge. His personnel records document that the Veteran performed jumps on 21 separate dates between July 1963 and November 1965, including in the Dominican Republic in June 1965. The Veteran's STRs from his first period of active duty, from January 1963 to January 1966, do not document any complaints or treatment for lumbar spine either knee. However, the report of a November 1979 periodic evaluation for reserve service indicated that the Veteran had a 3 centimeter scar on the medial right knee. Additionally, the report of a July 1986 periodic examination conducted during a period of reserve service reflected a history of complaint of right knee pain in July 1984. X-rays revealed degenerative arthritis and some loose bodies. During the Veteran's second period of active duty, a March 1991 STR reflected a complaint of low back pain down to the left leg. The Veteran also had a history of some symptoms in the right leg in the past. The examiner noted that a CT scan the previous year showed a "slight bulging disc." Post service, the evidence reflects diagnoses of degenerative arthritis of the right and left knees, as well as spondylosis and stenosis of the lumbar spine. See, e.g., May 2015 VA examination report; see also May 2014 VA examination report. As current disabilities have been demonstrated, the dispositive issue on appeal concerns whether the Veteran's currently diagnosed disabilities of the knees and lumbar spine results from his parachute duties during active service. The record includes medical opinions for and against these claims. On May 2014 VA examination, the Veteran reported that he had a total of 35 jumps. He had two training jumps in Dominican Republic in 1965. He hurt his back and the right knee on the first jump and taken to a medic in the field. He was given an ice pack, pain shot, and symptoms improved. His back felt better by the second jump. The examiner opined that the right knee disability and low back disability were less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner reasoned that medical records relating to any right knee or back injury on active duty from parachuting or other activity at Fort Bragg, Fort Benning, or in Dominican Republic could not be located. There is no correlation between the March 1991 finding and any parachute jump or any injury. In 1991, he would have been age 51 and this could be a normal progression of his back unrelated to any traumatic incident. Therefore, since data was not available to corroborate the history, the examiner opined that it is less likely as not that the Veteran has a lumbar spine disability or right knee disability related to multiple parachute jumps in service. On May 2015 VA examination of the left knee, the Veteran reported a gradual onset of left knee pain in 1977. He underwent a left knee replacement in 2002. Pain in the knees was constant. The examiner opined that the claimed left knee disability, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury or illness. The examiner reasoned that there were no complaints of left knee pain during his first period of active duty service. Prior to second period of active duty service, the Veteran was noted to have left knee arthritis. He continued with history of left knee condition noted on physicals by providers, but the Veteran reported no problems with knees on histories. A November 2015 opinion from the Veteran's private treating physician indicates that the Veteran had been treated in their clinic for bilateral knee osteoarthritis status post left total knee arthroplasty and chronic low back pain with a history of lumbar spondylosis and spinal stenosis status post-surgical intervention. The physician opined that it is at least as likely as not that his past military service, to include parachute jumps made as a paratrooper, caused the degenerative arthritis in both of those areas. The observed degenerative changes in both the knees and low back are consistent with the degenerative changes seen in patients who have been exposed to repetitive high-impact activities similar to parachute jumping. On March 2017 VA examination of the left knee, the examiner opined that it is less likely as not that the Veteran's current left knee condition was caused by or related to active service. The examiner reasoned that the Veteran was initially diagnosed and treated for a left knee condition in 1986 and diagnosed with arthritis in 1990. This was essentially 20 years after he was released from active service in 1966. Review of STRs did not show any left knee complaint, diagnosis or treatment during his entire tour of active duty. If his left knee condition was directly due to his jumps between 1963 and 1966, symptoms of a left knee condition would have manifested a few months or years after his release, not 20 years later in 1986. It was also initially reported through a buddy statement that the Veteran injured his left knee on a parachute jump during service, but the Veteran corrected this information himself during a VA examination, stating it was his right knee and not his left knee that was injured during this jump. In weighing conflicting medical evidence and opinions, the Board may favor the opinion of one competent medical expert over another. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) and Owens v. Brown, 7 Vet. App. 429, 433 (1995). A medical opinion or examination report must contain (1) a clear conclusion, (2) be based on supporting data, and (3) set forth a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Based on the foregoing, the Board finds that the evidence is at least in equipoise as to whether the Veteran's currently diagnosed degenerative arthritis of the bilateral knees, as well as the spondylosis and stenosis of the lumbar spine, are due to parachute jumps during service. The Board acknowledges the negative VA opinions of record. However, considering the medical opinion rendered in November 2015, which was based on consideration of all evidence of record, including the Veteran's lay statements, the Board finds the November 2015 opinion to be the most probative. To that end, the treating physician explained that the physical picture of the Veteran's knees and low back is consistent with types of degenerative changes seen in patients exposed to high-impact activities similar to parachute jumping. This physical picture led the treating physician to conclude that the Veteran's disabilities were at least as likely as not related to service, to include parachute jumps made as a paratrooper. The Board finds this opinion probative as the physician offered a clear opinion which is supported by a cogent and appropriate rationale. With regard to the VA opinions, they appear to rely largely on the fact that there were no complaints of knee or back pain during the Veteran's first period of active duty. Indeed, the May 2014 VA examiner stated that since there was no data available to corroborate the Veteran's reported history, it was less likely than not that the Veteran's lumbar spine or right knee disabilities were related to multiple parachute jumps in service. Further, the March 2017 VA examiner stated that there were no noted left knee injuries in service and, if the Veteran's left knee disability was related to service, such would have been shown during service or shortly thereafter. The Board notes, however, that the absence of documented treatment in service is not fatal to a service connection claim. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Given that the Veteran's personnel records confirm that he completed numerous parachute jumps throughout his first period of active duty, the Board finds it to be reasonable that the Veteran suffered injuries to his lumbar spine and knees during service. Finally, as regards the May 2015 VA opinion, the examiner opined that the left knee disability clearly and unmistakably preexisted service and was not aggravated beyond its natural progression by service. However, this opinion finds that the left knee disability preexisted the Veteran's second period of active service. As explained above, the Veteran contends that the left knee disability, along with the right knee and low back disabilities, is related to his parachute jumps as a paratrooper during his first period of service. Thus, the relevant inquiry is whether the disabilities are related to his first period of service, not whether they preexisted his second period of service. Indeed, if the disabilities were incurred during the first period of service, they would obviously preexist the second period of service. As such, the May 2015 VA opinion is not relevant on the question of whether the Veteran's disabilities are related to his first period of service and therefore of no probative value. Accordingly, the Board finds that the evidence is, at the very least, relatively evenly balanced on the questions of whether the Veteran's disabilities of the bilateral knees and lumbar spine were caused by his multiple parachute jumps during service. Notably, an "absolutely accurate" determination of etiology is not a condition precedent to granting service connection, nor is "definite" or "obvious" etiology. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. See also 38 U.S.C. § 5107(b); Gilbert, supra. Given the above, and with resolution of all reasonable doubt in the Veteran's favor, service connection for spondylosis and stenosis of the lumbar spine, and for degenerative arthritis of the right and left knees is warranted. IV. Higher Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where 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. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the appeal emanates from a request for higher rating following the award of service connection, evaluation of the medical evidence pertinent to the original claim, and consideration of the appropriateness of staged rating (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The ratings for the Veteran's psychiatric disability have been assigned under Diagnostic Code 9411. However, psychiatric disabilities other than eating disorders are actually rated pursuant to the criteria of a General Rating Formula. See 38 C.F.R. § 4.130. Under the General Rating Formula, a 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 30 percent rating is warranted for occupation and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactory, 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 warranted 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 per week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted 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 intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (2017). As the United States Court of Appeals for the Federal Circuit has explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas"-i.e., "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. When evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126 (a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126 (b). Historically, psychiatric examinations frequently included assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation 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). The Board notes that the revised DSM-5, which among other things, eliminates GAF scores, applies to cases certified to the Board after August 4, 2014. See 79 Fed. Reg. 45,093 (Aug. 4, 2014). Historically, in a November 2014 rating decision, the RO granted service connection for other specified trauma and stressor-related disorder, and assigned a 30 percent rating effective August 14, 2014. In a February 2015 statement, the Veteran requested an increase in his disability with attached additional medical documentation of the symptoms of his disability. The RO treated this statement as a claim for increase. The Board notes that, although current VA regulations require claimants to file a notice of disagreement by using a specific form provided by VA, prior to March 24, 2015, VA regulations provided that a written communication from a claimant or his representative expressing dissatisfaction or disagreement with an adjudicative determination by the AOJ and a desire to contest the result constituted a notice of disagreement. Compare 38 C.F.R. § 20.201 (2016), with 38 C.F.R. § 20.201 (2014); see also 79 Fed. Reg. 57660 (Sept. 25, 2014) (amending 38 C.F.R. § 20.201 ). As the statement and attached medical evidence was received prior to March 24, 2015, the prior version of 38 C.F.R. § 20.201 applies, and the Veteran's February 2015 statement constitutes a valid NOD with the initial rating assigned in the November 2014 rating decision. In August 2014, the Veteran filed a claim for service connection for post-traumatic stress disorder (PTSD). An October 2014 Charleston Vet Center note indicates that the Veteran reported intrusive thoughts, avoidance of activities that remind him of his traumatic experiences, forgetfulness, anger, sleep problems, loss of interest in activities, isolation, being uncomfortable around others, restricted emotions, difficulty with anger, being on guard and being easily startled. He reported having suicidal and homicidal thoughts without a plan. He reported a previous suicide attempt after the Gulf War. An October 2014 Vet Center group counseling note indicated that the group discussed issues relating to anger. The Veteran participated in the group but was anxious and visibly nervous when sharing his information. On November 2014 VA PTSD examination, the examiner diagnosed other specified trauma and stressor-related disorder. The examiner found that the Veteran's symptoms of depressed mood, anxiety, chronic sleep impairment, and mild memory loss 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 examiner observed that the Veteran appeared well-groomed, was cooperative with the examiner, and exhibited normal speech. His mood was euthymic, his affect was normal range. He was fully oriented, and no hallucinations were noted. Impulse control, insight and judgment were good. Abstract thinking was intact. A January 2015 letter from a Vet Center therapist indicated that the Veteran had been an active client and participated in group therapy regularly. The Veteran reported difficulty with memory; he frequently forgot what he was supposed to do around his home, including locking his doors. He was also unable to make good decisions regarding finances. He reported having mood swings and anger outbursts. He experienced behaviors that were out of character for him, including shoplifting and using bad judgment at a part time job, resulting in losing the job. He also reported having panic attacks weekly as well as being unable to establish effective relations. In a group setting, the Veteran had mostly a flat affect. He shared information when directly asked but did not participate easily with others. He appeared nervous in the group setting. In a January 2015 letter, the Veteran's spouse indicated that the Veteran's judgment was impaired. He was arrested for shoplifting on the Air Force base. He got fired from his part time job for using poor judgment. He lost his temper with her and felt he should not be questioned about his actions or behavior. His decision-making skills were getting worse. He made poor financial decisions. He was very moody and depressed most of the time. He seemed to forget things around the house that he is supposed to do. He forgot to lock doors but declared that he did, so she usually checked behind him to make sure things were secure. On March 2015 VA examination, the Veteran reported that he and his wife were celebrating their 50th wedding anniversary the following month, and they planned to take a trip to celebrate. He continued to be close with his adult daughter, wife, and grandchildren. He reported irritability and snapping at his wife. He stated that his anxiety also made it difficult for him to speak in front of crowds at church. His mood was "relatively good, though it goes in and out." He reported some isolation from others and stayed busy with yard work to manage his anxiety. He golfed twice a week "when the weather is nice," enjoyed going to high school football games, and went to church weekly. He continued to see his four very close military friends once a week. Since his last examination, the Veteran began working a part time janitorial job 10 hours per week, cleaning up offices. He stated, "I like it. It gives me something to do. It gives me an opportunity to get out of the house." He denied work problems. He continued to be retired from his full time work. The examiner found that the Veteran's symptoms of depressed mood, anxiety, chronic sleep impairment, and mild memory loss 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. In a June 2015 Vet Center letter, a readjustment counseling therapist indicated that the Veteran continued to have difficulty establishing relationships in the social and occupational setting. He seemed to have a worsening of symptoms and disturbance of motivation and mood. He had times of intense anger, unprovoked irritability with periods of violence, and difficulty in adapting to stressful situations. He shared that his anger and impaired judgment had negatively affected his marriage. He continued to suffer from intrusive memories and sleep disturbances. He displayed avoidant type behavior, remained hypervigilant for danger, startled easily, and felt he must be on guard all the time, finding it very difficult to trust others. He still had a reduction in quantity and frequency of interpersonal relationships outside the family and a need for more time alone. He reported staying to himself other than keeping medical appointments or working at night alone. The Veteran's intense anger, flattened affect, depressed mood, emotional numbing, and difficulty adapting to stressful situations interfered with his ability to obtain satisfaction from life and function effectively. Due to significant problems related to his symptoms, he recognized the need for treatment and has consistently followed all treatment recommendations since December 2013. He appeared to have a guarded prognosis. A January 2016 VA mental health note indicated that the Veteran sought individual counseling. He reported for several years he had been struggling with intrusive memories, frequent nightmares, hypervigilance, hyperstartle, and avoidance of reminders, thoughts and feelings about experiences during the Dominican Crisis of the mid 60's. He also reported a long history of social anxiety. After his retirement, trauma-related symptoms became more frequent and severe. He felt detached from others, more irritable and inflexible. He was fighting with his wife and had decreased sex drive. He reported difficulty maintaining attention and short term memory loss. Sleep had also worsened. He had difficulty with wanting to stay up to check house and often did not fall asleep until after midnight and then is up early, is fatigued, and fell asleep during the day. He was feeling down more frequently, does not enjoy activities and he used to enjoy. He also admitted to a history of shoplifting. He was caught at the exchange 1-2 years ago, jailed, and barred from base for a year. He initially minimized this, but then admitted he continued to shoplift regularly; small things like coffee and a paper. His primary care provider started citalopram 2-3 weeks ago. He noted some improvement. He felt a little calmer and a little less irritable. On mental status examination (MSE), the Veteran appeared alert, was dressed appropriately, and had good grooming and hygiene. His behavior was cooperative. His speech was normal. There was no suicidal or homicidal ideation. There were no signs of hallucinations or delusions. Thought processes were largely linear, logical, and somewhat concrete. He was fully oriented, and attention/concentration was intact. His judgment was limited and his insight was poor. The examiner made a DSM-5 diagnosis of PTSD. A February 2016 VA mental health note indicated that the Veteran stopped both citalopram and bupropion shortly after his last appointment, because he felt flushed and unbalanced. He continued to struggle with difficulty falling asleep several nights a week, and nightmares 6 to 8 times a month. He felt calm about half the days in a month and anxious the other half. It was most bothersome when he had to get up in front of people for church or talk in front of new people. He did have periods of about a day at time when he felt sad and isolated himself and continued to have periods of irritability. He had cut down drinking to a couple servings on weekends only. He denied shoplifting since last appointment and emphasized he rarely did it and was "scared straight" by jail time. On MSE, the Veteran was alert and fully oriented, and was dressed appropriately with good grooming and hygiene. His mood was anxious and his affect was appropriate. Mild paranoia was noted. There were no signs of hallucinations or delusions. Attention/concentration was intact and judgment and insight were limited. A May 2016 VA mental health note indicated that the Veteran continued buspirone and low dose citalopram and reported symptoms had improved since his last appointment. He was able to speak in front of church members with only mild distress. He even recovered after making a mistake. Overall, he felt calmer and his mood was good. He continued to have difficulty falling asleep and woke early, sometimes due to a nightmare. He often napped during the day. MSE was similar to February 2016, except mood was euthymic, and no paranoia was noted. A June 2016 VA mental health note indicated that the Veteran had continued citalopram, buspirone, and melatonin and reported that his symptoms had worsened. With the increase in citalopram, he was calm, but felt fatigued and had difficulty with motivation during the day. He normally liked to play golf twice a week, but felt that he was not going more frequently. He still felt anxious and got a stammer when talking to people he did not know or when speaking to a group. MSE was similar to May 2016. A July 2016 VA mental health note indicates that the Veteran was having ongoing anxiety and distress when speaking in front of other people. He recounted two recent incidents where he was delivering a message to a large group and he made some mistakes. MSE was similar to June 2016. An August 2016 VA mental health note reflects that the Veteran reported difficulty with sleep and nightmares. He was easily startled. He avoided visiting sick people or attending funerals. In 2005, he lost most of his life's savings when his funds were invested into the stock market. He became depressed and angry at that time and reported homicidal ideation towards his investor that eventually subsided. He had to go back to work after being retired for several years. He had still not recovered financially and this affected his mood and ability to do a lot of activities that he would enjoy. MSE was similar to July 2016, except that insight and judgment were noted to be good. A September 2016 VA mental health note indicates that the Veteran reported symptoms of avoidance, irritability, and anxiety in social situations. The Veteran stated he initially began to seek treatment due to difficulty sleeping (including nightmares and staying up to avoid nightmares), forgetfulness, and anxiety when speaking to groups. He expressed recurrent memories that cause distress of the event he experienced in the Dominican Republic. Because this does not seem to affect him daily, he was somewhat ambivalent about treatment. The Veteran reported anxiety when speaking to groups which he occasionally had to do with various leadership positions he was in. He also reported a disturbing image that arose whenever he had to go to a funeral. MSE was similar to July 2016. An October 2016 VA mental health note reflects that the primary focus of the treatment was for adjustment issues. MSE was similar to July 2016, except insight and judgment were noted to be fair, his mood was dysphoric, and his affect was restricted. A December 2016 VA mental health note indicates that the Veteran stopped Citalopram and Buspirone a month ago, but he continued melatonin. He reported since his last appointment symptoms had improved. He felt the Citalopram was decreasing his motivation and Buspirone was causing him to feel more "hyper" and irritable. Since stopping medication, he was getting out and doing more activities with American Legion and church, but his wife complained he was gone so much. When he was home he preferred to keep to himself. This caused frequent conflict with his wife. He denied suicidal ideation, but sometimes he became overwhelmed and hopeless. On MSE, the Veteran's behavior was confrontational. His mood was irritable, and his affect was full range. Insight and judgment were limited. On December 2016 VA examination, the examiner noted that there had been no significant changes in the Veteran's social/marital/family circumstances since the prior examination. He resided at home with his wife. His adult son, who was disabled with multiple sclerosis, lived nearby, and the Veteran visited him frequently. His daughter and her two young children lived in another city, and the Veteran and his wife saw them at least once a month. He attended church regularly including Sunday morning worship services, monthly men's group, and Bible study. He was a trustee in the church. He got together with a group of about four military buddies regularly; they tried to meet at least once a week but cannot always make this possible. He used to enjoy playing golf with a group, but lately his physical problems made it too difficult for him to swing a club, so he often simply rode in the cart. He had a good relationship with his wife but felt that he did not pay as much attention to her as he ought to. The Veteran reported that his physical health problems made it impossible for him to keep performing his janitorial work, and he quit about a year ago. He had no plans to resume working. The Veteran participated in individual and group counseling at the Vet Center up until about 6 months ago, and then he began receiving outpatient mental health services from the VA. He saw his outpatient counselor once a month, and he had prescriptions for buspirone and citalopram. He was continuing to have social anxiety which made it difficult for him to speak in front of a group of people, for example at church. He reported that he used to consider himself to be an upbeat and cheerful individual, but he felt that now he tended to be irritable and easily upset. He was frustrated about his declining health, although he recognized that it is a byproduct of aging. Symptoms included depressed mood, anxiety, chronic sleep impairment, and disturbances of motivation and mood. The examiner observed that the Veteran was appropriately dressed, neatly groomed, and alert and well oriented. His speech was normal. He denied current or recent homicidal or suicidal ideation, bizarre or delusional beliefs, or morbid preoccupations. In January 2017, the Veteran and his spouse submitted separate affidavits in support of his claim. The Veteran stated that he suffered from bouts of depression and loneliness. He had issues with anger, maintaining relationships with people, severe memory and concentration issues, and suicidal thoughts. He was a First Vice Commander of the American Legion, and he had problems with other members because of his anger and mood swings. The members tried to vote him out of his position because of how inappropriate he could be when dealing with them. He became easily irritated by people, and had trouble expressing his thoughts, that he ended up just yelling and cursing at the other members. He was also a leader at his Church. The members all thought he was inappropriate because they said he was mean and belligerent to them. They thought he is too tough on everyone he worked with. The frustration and anger he felt when dealing with them was not healthy. At home, he was in a bad mood a lot of the time. His wife was constantly asking him what was wrong. Mostly, he thought about his life and how his depression hurt him. He tried to deal with his depression himself because talking to other people angered him. When he felt this way he had no energy and just wanted to be alone. He did not work well with others. He could not maintain a good relationship with the people he worked with. He was threatened to be fired at his last job because he was yelling at people a lot. The Veteran further reported that he was very particular about where his things were placed. He has set spots for all his possessions and when someone moved them it really upset him. He was obsessive about making sure everything is in its proper place and that things are done in a precise way. A couple of years ago his grandson came over and wanted to use his new remote control helicopter. His grandson was not listening to him on how to fly it, and he crashed the helicopter into his wall and caused some damage. He got so mad that he called his grandson a bad name. He could not even control himself around the people he loved. He also had memory and concentration problems. He had problems remembering the name of some of his family members. I would forget where he was going when in the car. His wife was always reminding him to change his clothes or take a shower. Sometimes he went two or three days without showering. He used to take pride in making sure he was clean. Now he did not have the motivation to keep himself up. He would get thoughts of ending things because life was too much sometimes. He did not like to play golf with his friends anymore. The Veteran's spouse stated that the Veteran had really changed over the last several years. His mental condition had been getting progressively worse. He was irritable all the time. He did realize how angry and mean he was, but everyone saw it, and it makes things tough for her. He said mean things and refused to apologize. His anger could be uncontrollable. He was always verbally abusive, but sometimes he pushed her. His mood swings scared her. She was most scared when he took a pistol they had locked up out and kept it close to him after they had gotten into an argument. She felt threatened, and told her daughter to come up and check on her. Her daughter was worried for her mother after talking with the Veteran. Her daughter took the gun and refused to bring it back. Her daughter worried about bringing her kids around. At church, the Veteran was overly bossy and not nice to people. He did not care who he upset. His memory and concentration were horrible. He had gone downhill a lot recently. He forgot her name and the name of their kids and grandkids. She would get scared when he drove because she did not feel safe. He lost his concentration quickly and she feared he would cause an accident. His poor concentration led him to have poor judgment. They now have to worry about money because he made such poor financial decisions. He was unreliable. He had a part time job last year and she thinks he got fired from it. He would not admit what actually happened. The Veteran's wife also reported that the Veteran had no motivation or drive. He even lost interest in golfing, which he loved. She was a constantly telling him to change his clothes and take a shower because he would go days without bathing. She had to be careful about how she approached these things with him. She saw him having conversations with himself. When she confronted him, he made up a story, but she knew he was talking to someone who was not there. She saw him walking around the house all the time, moving things. He would come back around and get upset that his stuff got moved by someone. He was convinced that someone was coming in and messing with his stuff. In a February 2017 addendum, the December 2016 VA examiner noted that the Veteran's anxiety and fatigue made it difficult for him to form relationships and to persist on tasks. He was easily distracted and became discouraged easily. Based on the consideration of the above-cited evidence, including the VA examination reports, VA treatment records, and the lay statements of record, the Board finds that, with resolution of all reasonable doubt in the Veteran's favor, the e collective lay and medical evidence of record indicates that an initial 70 percent rating for the Veteran's psychiatric disability is warranted from the August 14, 2014 effective date of the award of service connection). The above-cited evidence indicates that the Veteran has had suicidal ideations, obsessional rituals which interfere with routine activities, impaired impulse control, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, and an increasing inability to maintain effective relationships. Collectively, the evidence reflects that the Veteran's psychiatric symptoms are of the type and extent, frequency or severity (as appropriate), to suggest occupational and social impairment with deficiencies in most areas. Consequently, the Board has resolved reasonable doubt in the Veteran's favor in determining that the 70 percent rating is warranted from the August 14, 2014 effective date of the award of service connection. However, at no point has the Veteran manifested total occupational and social impairment. Although the Veteran and his spouse recently reported that the Veteran forgot the names of his relatives, he has not exhibited 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), or disorientation to time or place. The Board notes that even though the Veteran indicated experiencing suicidal ideation, at no time during the period under consideration in this appeal did the Veteran express an intent to act, indicating no persistent danger of the Veteran harming himself. Thus, the Board finds that, at no pertinent point has the Veteran manifested symptoms of the type, and extent, frequency, and/or severity (as appropriate) contemplated by the maximum, 100 percent schedular rating. The above determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point since the claim was filed on August 14, 2014 has the Veteran's psychiatric disability been shown to present so exceptional or so unusual a picture as to render the applicable criteria inadequate, and to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding on the part of the AOJ or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for this disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule does not contemplate the claimant's level of disability and symptomatology, and is found inadequate, the AOJ 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" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321 (b)(1). If so, 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 extra-schedular rating. Thun, 22 Vet. App. at 111. In this case, the Board finds that schedular criteria are adequate to rate the Veteran's psychiatric disability at all pertinent points. As discussed above, the Veteran's predominant psychiatric symptoms impact his overall social and occupational functioning, and a comparison between the Veteran's symptoms and the criteria of the rating schedule indicates that the rating criteria reasonably describe his level of impairment. In this regard, all of the Veteran's psychiatric symptomatology is contemplated by the rating criteria, to include those symptoms, such as nightmares, which are not specifically enumerated. See Mauerhan, supra. Notably, there is no evidence or allegation that the schedular criteria are inadequate to rate the disability. For all of the foregoing reasons, the Board finds that, resolving all reasonable doubt in the Veteran's favor, the evidence supports assignment of an initial, 70 percent rating for other specified trauma and stressor-related disorder from the August 14, 2014 effective date of the award of service connection); but that the preponderance of the evidence is against assignment of the maximum 100 percent rating for the disability at any pertinent point. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53-56. ORDER As new and material evidence to reopen the claim for service connection for lumbar spine disability has been received, to this limited extent, the appeal as to this matter is granted. As new and material evidence to reopen the claim for service connection for right knee disability has been received, to this limited extent, the appeal as to this matter is granted. As new and material evidence to reopen the claim for service connection for left knee disability has been received, to this limited extent, the appeal as to this matter is granted. Service connection for spondylosis and stenosis of the lumbar spine is granted. Service connection for degenerative arthritis of the right knee is granted. Service connection for degenerative arthritis of the left knee is granted. An initial 70 percent rating for other specified trauma and stressor-related disorder, from August 14, 2014, is granted, subject to the legal authority governing the payment of VA compensation. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs