Citation Nr: 0000876 Decision Date: 01/12/00 Archive Date: 01/27/00 DOCKET NO. 96-06 007 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for low back disability secondary to residuals of a left ankle sprain. 2. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for bilateral knee disabilities. 3. Entitlement to a disability evaluation in excess of 30 percent for post-traumatic stress disorder from June 17, 1992. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD William W. Berg, Counsel INTRODUCTION The veteran served on active duty from July 1971 to March 1973. When this matter was previously before the Board of Veterans' Appeals (Board) in July 1997, it was remanded to the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. Following the requested development, the service-connected evaluation for post-traumatic stress disorder was increased to 30 percent disabling, effective from the date of receipt of the claim for service connection on June 17, 1992. The matter was then returned to the Board for final appellate consideration. In a written argument dated in December 1999, the veteran's representative has seemingly raised the issues of entitlement to increased ratings for service-connected left ankle disability and for service-connected skin disability. However, this is not entirely clear. If the veteran wishes to pursue these matters, he should contact the regional office. FINDINGS OF FACT 1. Service connection is in effect for residuals of a left ankle sprain, currently rated 20 percent disabling. 2. No competent evidence has been submitted to show that the service-connected left ankle disability caused or aggravated any current low back disability. 3. A rating decision dated in November 1991 denied the veteran's application to reopen his claim of entitlement to service connection for bilateral knee disabilities secondary to service-connected left ankle disability. 4. The veteran was notified of this determination in December 1991, but he did not initiate an appeal. 5. The evidence added to the record since the prior final rating decision is not wholly cumulative and, when considered in connection with evidence previously assembled, is so significant that it must be considered in order to fairly decide the merits of the claim for secondary service connection for bilateral knee disabilities. 6. It is not shown that the veteran acquired bilateral knee disabilities as a consequence of his service-connected left ankle disorder. 7. The veteran's original claim for service connection for post-traumatic stress disorder was received on June 17, 1992. 8. The service-connected psychiatric disorder is productive of no more than definite social and industrial impairment; during the course of this appeal, the veteran's post- traumatic stress disorder has been manifested by some nightmares, intrusive recollections, disturbed sleep, startle response, anxiety and depression, impaired insight, intermittent anger, social isolation and intermittent fear of crowds. 9. The veteran's Global Assessment of Functioning has ranged between 85 and 70, and he is gainfully employed. CONCLUSIONS OF LAW 1. The claim for service connection for low back disability secondary to service-connected left ankle disability is not well grounded. 38 U.S.C.A. §§ 1110, 5107(a) (West 1991); 38 C.F.R. § 3.310(a) (1999). 2. Evidence added to the record since the November 1991 rating determination denying the veteran's application to reopen his claim for service connection for bilateral knee disabilities secondary to service-connected left ankle disability is new and material, and the claim for that benefit is reopened. 38 U.S.C.A. § 5108 (West 1991); 38 C.F.R. § 3.156(a) (1999). 3. The veteran's bilateral knee disabilities are not due to or the proximate result of service-connected left ankle disability. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. § 3.310(a) (1999). 4. The criteria for a disability evaluation in excess of 30 percent for post-traumatic stress disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.132, Diagnostic Code 9411 (effective prior to November 7, 1996). 5. The criteria for a disability evaluation in excess of 30 percent for post-traumatic stress disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (effective November 7, 1996). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS A. Low back disability Service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, 38 C.F.R. § 3.310(a). However, a claim for secondary service connection must be well grounded. Wallin v. West, 11 Vet. App. 509, 512 (1998); Libertine v. Brown, 9 Vet. App. 521, 522 (1996); Jones v. Brown, 7 Vet. App. 134, 137 (1994). A well-grounded service connection claim generally requires medical evidence of a current disability; medical or, in certain circumstances, lay evidence of inservice incurrence or aggravation of a disease or injury; and medical evidence of a nexus between an inservice injury or disease and a current disability. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 524 U.S. 940 (1998); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). With respect to secondary service connection claims, there must be competent medical evidence indicating an etiologic link between the service-connected disability on the one hand the disability for which secondary service connection is sought on the other. See Wallin v. West, 11 Vet. App. at 512-13. If a claim is not well grounded, the appeal must fail with respect to it, and there is no duty to assist the claimant further in the development of facts pertinent to the claim. Struck v. Brown, 9 Vet. App. 145, 156 (1996). The service medical records are completely negative for complaints or findings referable to a low back disability. The veteran does not contend otherwise; rather, he maintains that an altered gait caused by his service-connected left ankle disability has led to the development of low back disability for which service connection should be granted on a secondary basis. However, a review of the entire evidence of record does not support this contention. Although the medical evidence of record since the veteran's separation from service is relatively extensive, the earliest indication of any low back complaints is in September 1975 - two and a half years following separation - when arthralgia involving the right sacroiliac joint was suspected. However, X-rays of the dorsal and lumbar spine in October 1976 were negative. Although he complained of low back pain when examined by VA in October 1991, low back disability was not diagnosed. The veteran's original claim for service connection for low back disability secondary to service-connected left ankle disability was raised at his hearing before a hearing officer at the RO in September 1993. However, he has not submitted any competent medical evidence to show that he acquired low back disability as a consequence of his service-connected left ankle disorder. Although he has asserted that an etiologic relationship is present, the veteran as a lay person is not competent to render such an opinion, as this requires medical expertise. Robinette v. Brown, 8 Vet. App. 69, 74 (1995); Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Although more recent medical evidence suggests the existence of some form of low back disability, its precise nature is not clear. When seen at a VA outpatient clinic in June 1992, he had positive straight leg raising at 45 degrees bilaterally. X-rays of the lumbar spine on a fee-basis orthopedic examination in February 1996 were interpreted as unremarkable. The orthopedic examiner indicated that there were signs consistent with symptom magnification and that the veteran gave a "submaximal" effort during objective clinical examination. Thus, there was some limitation of motion of the back in several planes of excursion, but very minimal effort was noted or perceived. The diagnosis was complaints of low back pain with no radicular findings but with suboptimal range of motion testing noted. The examiner commented that he saw nothing specific in the veteran's history or physical examination to suggest that his current symptom complex was related to his service-connected left ankle injury. In rendering the foregoing opinion, the examiner remarked that the veteran had done many years of labor following service and had had a lifelong history of smoking and drinking that just as easily could be contributing to his current symptom complex. This statement is somewhat equivocal, possibly suggesting that the evidence is in equipoise thus warranting a grant of the claimed benefit. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). However, the Board is of the opinion that the examiner's opinion, seen in its full context, is in fact against the claimed etiologic relationship. The opinion noted in italics above is unequivocal and is based on an elicited history and clinical findings. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Black v. Brown, 5 Vet. App. 177, 180 (1993); Sklar v. Brown, 5 Vet. App. 140, 146 (1993) (generally, an etiologic opinion must be supported by clinical data). There is, moreover, no competent opinion or other evidence that the service-connected left ankle disability chronically worsened any current low back disability such as to warrant secondary service connection on the basis of aggravation. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (when aggravation of a nonservice-connected condition is proximately due to or the result of a service-connected disability, the veteran shall be compensated for the degree of disability, but only that degree, over and above the degree of disability existing prior to the aggravation). Although there the record contains some evidence that the veteran has, on occasion, favored his right lower extremity as the apparent result of his service-connected left ankle disability, the fact remains that he has submitted no competent medical evidence to attribute any current low back disability to the service-connected left ankle disorder. In these circumstances, the claim for secondary service connection for low back disability is not well grounded and must be denied. See Epps v. Gober, 126 F.3d at 1468; Edenfield v. Brown, 8 Vet. App. 384 (1995). B. Bilateral knee disabilities The record indicates that the veteran's bilateral knee disabilities consist of degenerative joint disease of both knees that has been visualized on X-ray examination. The record shows that the veteran's claim for secondary service connection for bilateral knee disabilities was denied by the Board in a decision dated in December 1985. The Board found that bilateral knee degenerative disease was initially shown several years following the veteran's separation from service and that the medical evidence of record did not demonstrate that bilateral knee degenerative disease was causally or etiologically related to service-connected residuals of a left ankle sprain. A rating decision dated in November 1991 denied the veteran's application to reopen a claim for service connection for bilateral degenerative changes, and the veteran was so informed the following month. However, he did not initiate a timely appeal, and the November 1991 rating decision became final. 38 U.S.C.A. § 7105 (West 1991); 38 C.F.R. §§ 3.104(a), 20.302, 20.1103 (1999). However, a claim will be reopened if new and material evidence has been submitted since the last final disallowance of the claim on any basis. 38 U.S.C.A. § 5108; 38 C.F.R. §§ 3.156(a), 20.1105 (1999); Manio v. Derwinski, 1 Vet. App. 140, 145 (1991); Smith v. West, 12 Vet. App. 312, 314 (1999). What constitutes new and material evidence to reopen a previously and finally denied claim is defined in 38 C.F.R. § 3.156(a). Under that regulation, new and material evidence means: evidence not previously submitted to agency decision-makers which bears directly and substantially upon the specific matter under consideration, which is neither cumulative nor redundant, and which by itself or in connection with evidence previously assembled is so significant that it must be considered in order to fairly decide the merits of the claim. The veteran subsequently filed an application to reopen his claim for service connection for bilateral knee disabilities secondary to service-connected left ankle disability, and evidence has been received in support of the application. The evidence of record before the rating board in November 1991 included service medical records that are negative for complaints or findings of bilateral knee disabilities. The veteran essentially contends that he has degenerative changes in both knees due to the alteration of his gait due to his service-connected left ankle disability. This was his contention prior to the rating decision of November 1991, and it is his contention now. The evidence previously of record shows that the veteran's earliest knee complaints were in 1984, some eleven years following his separation from service. In a letter dated in September 1984, J. Richard Jackson, M.D., the veteran's treating physician, stated that he had examined the veteran for complaints of pain in both knees and that he was found to have an elevated uric acid level that required him to take medication. The veteran stated that after standing for more than two hours, his knees began to hurt with pain up into his thighs. He also complained of stiffness in his knees in the early morning. However, he had normal range of motion of the knees. There was swelling of the right knee. The examiner found a mild effusion of the bursa that did not restrict motion. The veteran was unable to stand for more than two hours at a time, and walking up stairs of more than one flight would also be prohibited. Dr. Jackson added, in a handwritten note, that the veteran's right knee was made worse because of his easily sprainable left ankle. He stated that the veteran had to walk "with extra pressure on his right ankle to compensate for the weakness of the left ankle." When examined by VA in January of 1985, X-rays revealed degenerative changes bilaterally in the knees, and the pertinent diagnosis was degenerative disease of both knees, possibly secondary to the left ankle disability. On VA examination in October 1991, X-rays were interpreted by the radiologist as showing no significant osteophytes in the knees. On clinical examination of the knees, there was tenderness and pain on manipulation of both knees. There was genu valgum of both knees, as well as generalized tenderness and significant laxity of the knees. However, an opinion relating the knee disorders to the service-connected left ankle disability was not offered. Evidence added to the record since the November 1991 rating denial includes several statements by lay witnesses to the effect that the veteran complained of pain in his right knee and walked with a limp. A registered nurse for VA noted that the veteran favored his right leg and complained of pain in his right knee when she served as his supervisor from 1983 to 1984. A VA fee-basis orthopedic examination in July 1992, however, showed no antalgic gait or limp and no instability in the veteran's gait. The examiner stated that the veteran showed signs suggestive of symptom magnification where he would assume a somewhat rigid posture with any attempted manipulations of the lower extremity. The examiner stated that this was "completely non-physiologic". The diagnoses included arthralgia of the right knee associated with patellofemoral osteoarthritis, and subjective painful left ankle with history of previous ligamentous injury. A VA rehabilitation medicine service consultation in December 1992 culminated in an impression of "right knee and left ankle pain secondary to old injury." Private medical reports for the period from September 1975 to November 1985 were received in September 1993. It was noted in November 1985 that the veteran had been seeing Dr. Jackson for about a year and a half for right knee complaints and that he had been treated for gout with Coblenemid. When seen on November 6, 1985, the veteran was limping rather severely. A fee-basis orthopedic examination in February 1996 included X-rays of the right knee that were interpreted as unremarkable. It was again found - by a different examiner - that there were positive signs of symptom magnification. In addition, it was reported that the veteran was a "fairly poor historian" and was not too specific regarding his complaints. An examination disclosed minimal limitation of motion of both knees. The pertinent diagnosis was decreased range of motion in the right knee and left ankle with some degenerative changes noted. The examiner remarked that following service, the veteran had done many years of labor and also had a history of smoking and drinking. The examiner stated that there was nothing specific in his evaluation to suggest that his current knee symptoms were any more related to his service-connected "time" than they were to his time in the private sector or to the expected degenerative changes brought on by his lifestyle. Following the July 1997 remand, the RO wrote to the veteran and requested information that was requested by the Board in its remand. The RO did so in July 1997 and again in February 1998. There is no indication that the veteran did not receive these letters, but no response was received from the veteran to either letter. Nevertheless, the evidence added to the record since the November 1991 rating decision, considered as a whole, is not wholly cumulative or redundant and provides a more complete picture of the circumstances surrounding the origin of the veteran's claimed disability. Elkins v. West, 12 Vet. App. 209, 214 (1999). As such, the new evidence is sufficiently significant to the issue in this case that it must be considered in order to fairly decide the merits of this claim. The additional evidence is therefore new and material, and the claim must be reopened. See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). Even though new and material evidence has been submitted, there remains for consideration whether the reopened claim is well grounded. Elkins v. West, 12 Vet. App. at 218-19. Although the evidence of record, considered on the whole, is not without some indication of left ankle disability contributing to the development of bilateral knee disabilities, this evidence is sufficient only to render the claim well grounded because it is only sufficient to show that the claim for secondary service connection is plausible. However, this is not enough. It does not follow that a well- grounded claim, when considered on the merits, should now be allowed. See Epps v. Gober, 126 F.3d at 1469 (a well- grounded claim under 38 U.S.C.A. § 5107(a), is not necessarily a claim that will ultimately be deemed allowable under § 5107(b)). Despite occasional evidence of a limp and of bilateral knee complaints, the Board concludes that the preponderance of the evidence is against the claim for secondary service connection. 38 U.S.C.A. § 5107(b). The opinion of the VA examiner in January 1985 raised only the possibility of an etiological link between the service-connected left ankle disability and the bilateral knee disorders. See Alemany v. Brown, 9 Vet. App. 513, 519 (1996); Watai v. Brown, 9 Vet. App. 441, 443-44 (1996); Lathan v. Brown, 7 Vet. App. 359, 366 (1995). The more recent evidence of record, especially the examinations by orthopedic specialists, have found no etiologic relationship between the service-connected left ankle disorder and the bilateral knee disorders. Rather, the orthopedic examiners have indicated that the veteran's manual labor following service is a more convincing explanation for the development of his relatively minimal bilateral degenerative changes of the knees. Moreover, the fee-basis examiners have not found an altered gait on clinical examination. However, they have found that the veteran tends to exaggerate his symptoms and to render a suboptimal effort on range of motion testing. Although the language in which the recent orthopedic opinion is couched is somewhat equivocal, the intent seems clear; that is, that there is no etiologic relationship between the bilateral knee disabilities on the one hand and the service-connected left ankle disability on the other. The only contrary opinion entitled to any significant weight was that rendered by Dr. Jackson in September 1984 (which pertained only to the right knee). However, subsequent examinations, including those conducted by orthopedists, have found no such relationship. These examinations were far more complete; they included complaints, history, diagnostic tests, findings, and diagnoses. The etiologic opinions based thereon are, in the Board's judgment, entitled to greater weight. See Bloom v. West, 12 Vet. App. at 187; Black v. Brown, 5 Vet. App. at 180; Sklar v. Brown, 5 Vet. App. at 146. It follows that service connection for bilateral knee disabilities secondary to service-connected left ankle disability is not warranted and must be denied. C. Increased rating As a preliminary matter, the Board finds that the veteran's claim for an increased rating is plausible and thus well grounded within the meaning of 38 U.S.C.A. § 5107(a); see Proscelle v. Derwinski, 2 Vet. App. 629 (1992) (a claim of entitlement to an increased evaluation for a service- connected disability generally is a well-grounded claim). The Board is satisfied that all relevant evidence has been obtained with respect to this claim and that no further assistance to the veteran is required in order to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The record shows that the veteran's original claim for service connection for post-traumatic stress disorder was received in June 1992 and was initially denied by the RO. However, the veteran appealed, and in a decision dated in July 1997, the Board granted service connection for post- traumatic stress disorder. In a rating decision dated in August 1997, a 10 percent evaluation was assigned under Diagnostic Code 9411, effective from June 17, 1992, the date of receipt of the original claim for service connection. The veteran disagreed with this evaluation, and a rating decision dated in September 1999 increased the rating to 30 percent disabling, effective from the same date. The RO rated the service-connected psychiatric disability under both the old and the new rating criteria, which were provided to the veteran and his representative in a statement of the case issued in September 1999. The veteran's claim for a higher evaluation for post- traumatic stress disorder is an original claim that was placed in appellate status by his disagreement with the initial rating award. Furthermore, as held in AB v. Brown, 6 Vet. App. 35, 38 (1993), "on a claim for an original or an increased rating, the claimant will generally be presumed to be seeking the maximum benefit allowed by law and regulation. . . . " The distinction between an original rating and a claim for an increased rating may be important, however, in terms of determining the evidence that can be used to decide whether the original rating on appeal was erroneous and in identifying the underlying notice of disagreement and whether VA has issued a statement of the case or supplemental statement of the case. In these circumstances, the rule in Francisco v. Brown, 7 Vet. App. 55, 58 (1994) ("Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance"), is not applicable to the assignment of an initial rating for a disability following an initial award of service connection for that disability. Rather, at the time of an initial rating, separate ratings may be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Although the criteria for rating psychiatric disabilities changed during the prosecution of this claim, it does not follow that the veteran is entitled to an increased rating, as it is not shown that either version of the rating criteria is more favorable to the facts of his case. See Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). Factual Background When initially evaluated in the VA mental hygiene clinic in July 1992, veteran reported that he was easily irritable and became uptight, tense, anxious, and would lose his temper easily. His insight was absent. He stated that he drank 10 to 12 beers a week, sometimes more. On VA examination in November 1992, it was reported that the veteran had nightmares two or three times a week about the race riot aboard the USS KITTY HAWK, the ship on which he served in the waters off Vietnam. He said that anytime he saw or heard violence or a riot on television, radio or in a movie, he became worse. He had intrusive thoughts about his experience in Vietnam and said that he avoided recollections and tried to be calm and relaxed. He reported that he avoided television or radio news about violence, war or riots. He said that he had flashbacks about his experience aboard ship twice a week or so. He said that following Vietnam, he was never on a ship. He stated that he socialized with his neighbor but avoided crowds because he became nervous. He reported that he watched people around him and displayed hypervigilant behavior. He said that he had difficulty sleeping and would sleep only two or three hours at a time. He claimed that he did not have a bad temper and tried to be friendly with people. He said that he jumped when he heard a harsh noise. However, he had no feelings of depression. The veteran stated that he was hit in the back by an assailant during the race riot aboard his ship, a riot that he claimed caused many deaths and injuries. He said that he was on watch when the incident occurred and that equipment had to be moved from one area of the ship to another to prevent damage and theft of equipment. He said that the riot lasted 13 to 14 hours and that after it was quelled, many received disciplinary action and were discharged. There were many more incidents that occurred. He said that the situation was life threatening and caused him to have nightmares, anxiety, and fear. A mental status examination was positive for some anxiety and some impairment of the veteran's insight into his condition. He said that he was scared of a group of Black people but that he had no paranoid delusion. He said that he started to have nightmares in service. His memory was good, and he was competent. The diagnosis on Axis I was moderate post- traumatic stress disorder. His Global Assessment of Functioning (GAF) on Axis V was 75 currently and 75 in the previous year. On VA psychiatric examination in March 1996, the veteran stated that he graduated from high school in 1968 and went to college, where he took business administration but did not finish the course. He volunteered for service after he left college. He denied any use of alcohol or illegal substances while in school. He repeated his contentions regarding his service aboard the KITTY HAWK off Vietnam during the Vietnam War, including the race riot aboard ship in October 1972. He claimed that about 5,000 men were embarked in KITTY HAWK and that about one-third of them fought in the riot. Following separation from service, he went to work at a job in a machine shop for a year, then worked for a tool and die company for about four to five years. He then worked at the Waco, Texas, VA Medical Center as a nursing assistant for four years. He said that he had worked at the Post Office from 1984 to the present. He stated that he worked from four in the morning to 12:30 p.m. and that he liked what he was doing. He reported that he was in a mail box shop and that there were few people around. He stated that he hated working with a lot of people. He admitted to drinking about two beers a day. He denied the use of illegal substances. Although he used to go to the mental hygiene clinic, he stopped. He said that the doctor released him. He was not on any psychiatric medications. On mental status examination, it was noted that the veteran walked with a limp and was anxious. He admitted to being depressed at times but would not hurt or harm himself. He had no delusions or paranoid ideation, except when he was in a crowd, especially with Black people. He had some insight into his problem, and his judgment was fair. The mental status examination was in other respects essentially unremarkable, including testing of his cognitive ability. He was competent to handle VA funds. The diagnosis on Axis I was "post-traumatic stress disorder, delayed, milder". The Global Assessment of Functioning on Axis V was 85 currently and 85 in the previous year. On VA psychiatric examination in February 1999, it was reported that the record had been reviewed. The veteran reported that he did not take any psychotropic medications or attend any therapy sessions as an outpatient for post- traumatic stress disorder. He reported that he continued to be employed by the Postal Service as a building mechanic. He said that he remained agitated and indicated that he was angry, with feelings of being discriminated against at his job. He had constant conflicts with his supervisors and had been counseled regarding his abuse of sick leave. He did not feel comfortable at work, and if the stress level got too high, he went home. He did not like to be around crowds and tried to schedule his work to be alone. He reported an impaired social life. He did not like to go out, especially at night, and did not go shopping at malls or to the movies. He reported that he had recently begun attending church but did so irregularly. He did not socialize with friends and rented movies for entertainment. His subjective complaints included a constant sense of feeling uneasy. He reported that he felt as though he was being stared at critically by others when in a crowd. He stated feeling as though he were going to be attacked or harmed, especially by Blacks. He felt especially paranoid, suspicious and guarded around Blacks whom he did not know or was not familiar with. On mental status examination, the veteran's mood was dysphoric. Subjectively, he placed his depression at 10/10 on examination but at 4/10 usually. He explained that he had just found out that his mother had terminal brain cancer. Subjectively, he placed his anxiety at 6/10, which was the case usually. He admitted to hearing someone call his name four to five times a week. He was not delusional but was quite hypervigilant when in situations where he feared for his safety. He reported having a generalized distrust and hatred of Blacks whom he did not know. He was oriented in three spheres, and his insight and judgment were generally fair. He reported vague thoughts of self-harm by shooting himself but denied any suicidal intentions or gestures. He also reported wanting to kill Blacks, especially when he witnessed them being disrespectful to Whites, but he denied homicidal attempts. He said that he had a routinized lifestyle but not obsessively so. He stated that he had panic attacks at least once a day that lasted from half an hour to two hours, especially when he was stressed at work. He reported getting three to four hours of sleep each night but that it was broken and that he did not wake rested. He said that he had nightmares about being on a ship and of the riot aboard ship at least once a week. He claimed that he had on occasion awakened choking his wife. He said that he had flashbacks to the riot at least every other day. He denied alcohol, drug use, or legal charges. He was competent to handle VA funds. The diagnosis on Axis I were post- traumatic stress disorder, chronic; dysthymic disorder; and adjustment disorder with mixed emotional features. The Global Assessment of Functioning on Axis V was 70 currently, with a GAF score of 70 in the previous year. He was encouraged to consider medication for depression and to seek therapy for his post-traumatic stress disorder. The examiner remarked that the veteran's ability to work was affected by his depression and post-traumatic stress disorder. There was a comfort level at work that he did not enjoy outside of work, in that he was familiar with his coworkers and did not feel as intimidated or threatened by them physically. However, his depression caused him to work at a reduced efficiency, to be irritable, and to hide his feelings of being discriminated against and feeling that others were denigrating him. Analysis Under the rating formula for neurotic disorders in effect prior to November 7, 1996, a 30 percent evaluation is for application when there is definite impairment in the ability to establish or maintain effective and wholesome relationships with people, and when psychoneurotic symptoms result in such reduction in initiative, flexibility, efficiency and reliability levels as to produce definite industrial impairment; a 50 percent evaluation was for application when the ability to establish or maintain effective or favorable relationships with people was considerably impaired, and by reason of the psychoneurotic symptoms, the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment; a 70 percent evaluation was warranted when the ability to establish and maintain effective or favorable relationships with people was severely impaired, and when psychoneurotic symptoms were of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. A 100 percent schedular evaluation requires that the attitudes of all contacts except the most intimate be so adversely affected as to result in virtual isolation in the community and that there be totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes (such as fantasy, confusion, panic and explosions of aggressive energy) associated with almost all daily activities resulting in a profound retreat from mature behavior; the individual must be demonstrably unable to obtain or retain employment. 38 C.F.R. § 4.132, Code 9411 (effective prior to November 7, 1996). A 30 percent evaluation under Diagnostic Code 9411, as amended, contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation under Diagnostic Code 9411, as amended, contemplates 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 under the newly revised criteria contemplates 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 worklike setting); and an inability to establish and maintain effective relationships. A 100 percent evaluation under the newly revised rating criteria requires 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, Code 9411 (effective November 7, 1996). Whether the service-connected post-traumatic stress disorder is evaluated under the new criteria or the old, the veteran's symptomatology warrants no more than the 30 percent rating currently assigned. His predominant symptoms are a distrust or fear around Black people whom he does not know, intrusive recollections and nightmares regarding the race riot aboard the KITTY HAWK, disturbed sleep, intermittent anger, and an anxious or depressed mood with depression somewhat more predominant recently. However, the veteran has not undergone very much in the way of psychotherapy, nor has he been on psychotropic medications during the course of his appeal. His memory has been intact, he has been oriented in all spheres, and his mental status has over the course of several examinations has been relatively unchanged. Moreover, the veteran has been able to maintain gainful employment with the Postal Service, albeit with some measure of workplace impairment in the form of warning letters from his supervisor. It is notable, however, that the psychiatric examiner in 1999 was of the opinion that while the veteran's ability to work was affected by his depression and post- traumatic stress disorder, there was a comfort level at work that the veteran did not enjoy outside of work because he was familiar with his coworkers and did not feel as intimidated or threatened by them physically. In other words, the veteran's industrial inadaptability as a result of his service-connected psychiatric disorder is not shown to be any more than definite. Indeed, the veteran's Global Assessment of Functioning has ranged between 70 and 85 throughout the entire course of this appeal. The Global Assessment of Functioning (GAF) is a scale reflecting the "'psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.'" Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994) (DSM-IV)). The lower GAF score is indicative of more serious impairment, but a score of 70, the score elicited on the most recent VA psychiatric examination, still shows only some mild symptoms such as depressed mood and mild insomnia, or some difficulty in social and occupational functioning. The only symptom suggestive of greater impairment than currently evaluated is the panic attacks that the veteran claims to have at least once a day lasting from half an hour to two hours. However, as noted above, the record indicates that the veteran is given to symptom magnification, and it is doubtful that the panic attacks are as frequent as claimed given his ability to maintain gainful employment. Even if the frequency claimed were objectively shown, his overall disability picture would not more nearly approximate the criteria required for the next higher evaluation under the old rating criteria or the new. 38 C.F.R. § 4.7. Although it is clear that the veteran manifests some industrial inadaptability and social isolation as a result of his service-connected post-traumatic stress disorder, this is contemplated in the 30 percent evaluation assigned. The rating schedule is designed to compensate for average impairments of earning capacity resulting from service- connected disability in civil occupations. 38 U.S.C.A. § 1155. While under the old rating criteria, poor contact with other human beings was indicative of emotional illness, social inadaptability was evaluated only as it affected industrial inadaptability. 38 C.F.R. § 4.129 (effective prior to November 7, 1996). During the course of the prosecution of this claim, the veteran's psychiatric disability picture has in fact been relatively consistent and shows that his psychiatric impairment is moderate to definite. The GAF scores assigned during the course of this appeal have shown only modest deterioration in his psychiatric state. Moreover, the Global Assessment of Functioning takes into account all psychiatric impairments. The Board therefore concludes that the preponderance of the evidence is against an evaluation in excess of 30 percent for service-connected post-traumatic stress disorder from June 17, 1992. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. at 54. ORDER Service connection for low back disability secondary to service-connected left ankle disability is denied. New and material evidence having been submitted, the application to reopen a claim of entitlement to service connection for bilateral knee disabilities secondary to service-connected left ankle disability is granted. Service connection for bilateral knee disabilities secondary to service-connected left ankle disability is denied. An increased evaluation for post-traumatic stress disorder is denied. ROBERT E. SULLIVAN Member, Board of Veterans' Appeals