Citation Nr: 1526775 Decision Date: 06/24/15 Archive Date: 06/30/15 DOCKET NO. 11-16 836 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an effective date prior to January 10, 2011 for the grant of service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to an effective date prior to May 26, 2009 for the grant of service connection for tinnitus. 3. Entitlement to an initial rating in excess of 50 percent for service-connected PTSD. 4. Entitlement to an initial rating in excess of 10 percent for service-connected tinnitus. 5. Entitlement to service connection for diabetes mellitus type II claimed as secondary to PTSD. 6. Entitlement to service connection for hypertension claimed as secondary to PTSD. ATTORNEY FOR THE BOARD A. G. Alderman, Counsel INTRODUCTION The Veteran served on active duty from January 1984 to January 1988. This case comes before the Board of Veterans' Appeals (Board) on appeal from June 2010, January 2012, and March 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska The current record before the Board consists entirely of electronic files known as Virtual VA and the Veterans Benefits Management System (VBMS). The issues of entitlement to service connection for diabetes mellitus, type II and hypertension, both claimed as secondary to service-connected PTSD, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran's original claim for service connection for PTSD was received by VA on January 10, 2011 and there was no pending claim, formal or informal, prior thereto. 2. The Veteran's original claim for service connection for tinnitus was received by VA on May 26, 2009, and there was no pending claim, formal or informal, prior thereto. 3. The frequency, severity, and duration of psychiatric symptoms between January 10, 2011 and December 25, 2012, which included but were not limited to chronic suicidal ideation without intent; suicidal ideation with plan; suicide attempts; self-harm; and difficulty in adapting to stressful circumstances, are comparable to the criteria for a finding of occupational and social impairment with deficiencies in most areas. 4. The frequency, severity, and duration of psychiatric symptoms as of December 26, 2012, including suicidal attempts and a marked decline in the Veteran's mental health, are comparable to the criteria for a finding of total occupational and social impairment. 5. The Veteran's service-connected tinnitus is assigned a 10 percent rating, the maximum rating authorized under Diagnostic Code 6260. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to January 10, 2011, for the grant of service connection for PTSD have not been met. 38 U.S.C.A. §§ 5107, 5110 (West. 2012); 38 C.F.R. § 3.400 (2014). 2. The criteria for an effective date prior to May 26, 2009, for the grant of service connection for tinnitus have not been met. 38 U.S.C.A. §§ 5107, 5110 (West. 2014); 38 C.F.R. § 3.400 (2014). 3. The criteria for an initial 70 percent evaluation for PTSD have been met while the criteria for a 100 percent evaluation have been met from December 26, 2012. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2014). 4. The criteria for an initial evaluation in excess of 10 percent for tinnitus have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.87, Diagnostic Code 6260 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2014). Proper notice from VA must inform the Veteran of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran's claims of entitlement to increased evaluations and earlier effective dates for PTSD and tinnitus arise from his disagreement with the initial evaluations and effective dates assigned following the grant of service connection. 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). Therefore, no further notice is needed. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained service treatment records, VA treatment records, and private treatment records. The Veteran has submitted private treatment records, copies of VA treatment records, buddy statements, lay argument, and medical articles for review. The Veteran was afforded VA medical examinations for PTSD and tinnitus. The VA audiology examinations for tinnitus were conducted in December 2009 and January 2013. The December 2009 examiner did not review the claims file in conjunction with performing the VA examination; however, as it is the severity of the Veteran's tinnitus at issue, the oversight is not prejudicial to the Veteran. The Veteran was afforded another VA examination in January 2013. The examiner reviewed the claims file. Both examiners examined the Veteran and documented symptoms related to tinnitus; therefore, the Board finds that the VA examination reports are adequate for rating purposes. The Veteran had VA examinations for PTSD in April 2011, April 2012, and March 2013. The examiners reviewed the claims files, interviewed the Veteran, and provided detailed reports outlining the Veteran's PTSD symptomatology. Therefore, the Board finds that the examination reports are adequate for rating purposes. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Effective Dates Except as otherwise provided, the effective date for a grant of compensation will be the day following separation from active service or the date entitlement arose, if a claim is received within one year of separation. 38 U.S.C.A. § 5110(a) (West 2014); 38 C.F.R. § 3.400(b)(2)(i) (2014). Otherwise, the effective date of the award of an evaluation based on an original claim shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application. 38 U.S.C.A. § 5110(a). As framed under 38 C.F.R. § 3.400, the effective date of an award of compensation based on an original claim will be the date of receipt of the claim or the date entitlement arose, whichever is the later. The effective date for an award of service connection is not based on the earliest medical evidence demonstrating a causal connection, but on the date of the claim for service connection. See Lalonde v. West, 12 Vet. App. 377 (1999); see also McGrath v. Gober, 14 Vet. App. 28, 35 (2000). A specific claim in the form prescribed by the VA must be filed in order for benefits to be paid or furnished to any individual under laws administered by the VA. 38 U.S.C.A. § 5101(a) (West 2014); 38 C.F.R. § 3.151(a) (2014). Any communication or action indicating intent to apply for one or more benefits under laws administered by the VA, and identifying the benefits sought, may be considered an informal claim. 38 C.F.R. § 3.155(a) (2014). The benefit sought must be identified, though it need not be specific. See Servello v. Derwinski, 3 Vet. App. 196, 199 (1992); see also Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009). Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the claimant, it will be considered as filed as of the date of receipt of the informal claim. 38 C.F.R. § 3.155(a) (2014). If the formal claim is received after one year of its receipt, the effective date will be the date of VA's receipt of the formal application form. Jernigan v. Shinseki, 25 Vet. App. 220, 229 (2012). However, the effective date of a claim will be the date of the informal claim if VA did not send a claimant a formal application form after receiving an informal claim, as required by 38 C.F.R. § 3.155, because the one-year time limit to return the formal claim did not begin. See, e.g., Quarles v. Derwinski, 3 Vet. App. 129, 137 (1992) (cited in Jernigan, 25 Vet. App. at 225, n.5). A. PTSD The Veteran seeks an effective date prior to January 10, 2011 for service connection for PTSD, the date VA received his claim of entitlement to service connection for PTSD including depression, anxiety, and adjustment disorder. The Veteran has raised several theories of entitlement for an earlier effective date. His arguments are as follows: (1) an earlier effective date is warranted based on continuity of symptoms during and since service; (2) VA's receipt of treatment records showing mental health treatment should constitute a claim for service connection; (3) an authorization and release form submitted prior to January 10, 2011 should be considered an informal claim; (4) an earlier effective date is warranted based on a liberalizing law; and (5) VA failed in its duty to assist because he did not know he had PTSD prior to the filing of his claim but should have been informed years prior. See Notice of Disagreement, March 2012; VA Form 9, August 2012; VA 21-4138, April 2013; Statement, May 2014; and Correspondence, March 2015. First, the Veteran argues that the manifestation of his disability should determine the effective date for service connection for PTSD. He stated that he had mental health treatment during service and continuously or almost continuously since service. He believes he should be given the benefit of the doubt that his PTSD has been ongoing since service and be assigned an effective date as of the date of separation from service or an effective date of at least June 1989. See VA 21-4138, April 2013 and Correspondence, March 2015. For service connection purposes, manifestation of the disability only determines the effective date if the evidence shows that the disability manifested after the Veteran filed a claim for service connection (i.e. entitlement to the benefit sought did not arise until after the claim was filed). 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i). Effective dates assigned for service connection on an original claim, such as in the Veteran's case, are set based on the date the Veteran filed a claim or the date the condition manifested, whichever is later. Id. The Court of Appeals for Veterans Claims (Court) has held that "entitlement to benefits for a disability or disease does not arise with a medical diagnosis of the condition, but with the manifestation of the condition and the filing of a claim for benefits for the condition." DeLisio v. Shinseki, 25 Vet. App. 45, 56 (2011). Thus, despite having had mental health treatment for years and regardless of his argument of continuity of symptoms since service, the effective date is set by the date of claim as it was received after the Veteran manifested symptoms of a mental health disorder, to include PTSD. Notably, the Veteran has mentioned 38 C.F.R. § 3.303(b) in support of his claim; however, this regulation concerns entitlement to service connection and the nexus element. It does not pertain to the assignment of effective dates. Consequently, the Board finds this argument without merit. The Veteran also argues that his treatment during service and subsequent to service should be considered claims for service connection because the treatment records put VA on notice of his mental health disorder. In Ellington v. Nicholson, 22 Vet.App. 141, 145 (2007), the appellant argued two theories of entitlement to an earlier effective date for service connection for diabetes and hypertension. His first argument is not pertinent to this claim. However, Ellington's second argument is similar to the Veteran's argument herein. Ellington argued that he filed an informal claim for hypertension and diabetes when he submitted his VA Form 21-2545, a form designed to elicit information from a claimant for diagnostic purposes only. The Court found VA had no reason to assume-and the appellant had no reason to believe-that an application for benefits was being filed each time he answered a question on the form by providing current medical information. See, e.g., Brannon v. West, 12 Vet.App. 32, 34 (1998) ("[T]he Board is not required to anticipate a claim for a particular benefit where no intention to raise it was expressed." (citing Talbert v. Brown, 7 Vet.App. 352, 356-57 (1995))). To the contrary, the appellant was simply providing the information needed to conduct a thorough, contemporaneous medical examination, so that his service-connection claim for leukemia could be fully and fairly adjudicated. See Green v. Derwinski, 1 Vet.App. 121, 124 (1991) (citing Littke v. Derwinski, 1 Vet.App. 90, 92 (1990)). Id. at 145-146. In this case, the Veteran had filed numerous claims for service connection and other correspondence with VA prior to January 10, 2011. None of the claims or correspondence addressed service connection for a mental health disorder, mentioned a mental health disorder, or indicated any intent to seek compensation or treatment for a mental health disorder. At most, in the course of developing the prior claims, VA obtained VA and private treatment records pursuant to VA's duty to assist. These records included mental health treatment records. The Veteran believes that these mental health treatment records put VA on notice and should constitute a claim of entitlement to service connection for mental health disorders. However, as in Ellington, the Board finds that VA had no reason to assume-and the Veteran had no reason to believe-that an application for service connection for a mental health disorder was being filed based on the receipt of records obtained in the course of developing other non-mental health related claims. VA is not required to anticipate a claim for a particular benefit where no intention to raise it is expressed. Talbert, 7 Vet.App. at 356-57. Accordingly, the Board finds that VA's receipt of evidence showing mental health treatment prior to January 10, 2011 does not constitute correspondence from the Veteran with intent to file a claim for service connection for a mental health disorder. Thus, the Veteran's argument is without merit. The Veteran also argues that he raised the issue of entitlement to service connection for PTSD prior to January 10, 2011 in an authorization and release form submitted for VA to obtain records in support of claims. See Statement, May 2014. The Board has reviewed all authorization and release forms submitted prior to January 2011; however, none indicate an intent to obtain records relating to a mental health disorder, to include PTSD. As such, the forms do not constitute informal claims for service connection for PTSD or other mental health disorders. The Veteran has also argued that an earlier effective date is warranted under the liberalizing law statutes and regulations. 38 C.F.R. § 3.400 provides exceptions to the general rules governing assignment of effective dates in original claims for service connection. 38 C.F.R. § 3.400(p) provides an exception for liberalizing laws under 38 C.F.R. § 3.114. Under 38 C.F.R. § 3.114, where compensation is awarded pursuant to a liberalizing law, or a liberalizing VA issue approved by the Secretary or by the Secretary's direction, the effective date of such award or increase shall be fixed in accordance with the facts found, but shall not be earlier than the effective date of the act or administrative issue. For a claimant to be eligible for a retroactive payment under the provisions of this paragraph, the evidence must show that the claimant met all eligibility criteria for the liberalized benefit on the effective date of the liberalizing law or VA issue and that such eligibility existed continuously from that date to the date of claim or administrative determination of entitlement. The provisions of this paragraph are applicable to original and reopened claims as well as claims for increase. 38 C.F.R. § 3.114. The Veteran argues that he should be granted an earlier effective date based on the initial addition of PTSD to the rating schedule. He cites VA Gen. Coun. Prec. 26-97 (July 16, 1997), which clarifies that the addition of PTSD to the rating schedule in 1980 was a "liberalizing VA issue" for purposes of 38 C.F.R. § 3.114(a). However, also held in that opinion, is that an effective date prior to the date of claim cannot be assigned under section 3.114(a) unless the claimant met all eligibility criteria for the liberalized benefit on April 11, 1980, the effective date of the regulatory amendment adding the diagnostic code for PTSD, and such eligibility existed continuously from that date to the date of claim or administrative determination of entitlement. Clearly, the Veteran did not meet the eligible criteria for service connection for PTSD in April 1980 as that date was prior to his period of service. While the Veteran does not qualify under the liberalizing law that became effective in April 1980, the Board considered whether the Veteran is eligible for an earlier effective date pursuant to the amendment to the regulations governing service connection for PTSD that became effective on July 13, 2010. Effective July 13, 2010, VA amended 38 C.F.R. § 3.304(f)(3) to liberalize the evidentiary standard for establishing the required in-service stressor in certain cases. This recent regulatory change has eliminated the requirement for submitting credible supporting evidence of the claimed in-service stressor if it is related to the veteran's "fear of hostile military or terrorist activity." However, after reviewing all of the evidence, the Board finds that service connection for PTSD was granted based on a verified stressor. Service treatment records show that in April 1984, the Veteran was treated after having had a grenade explode in his left hand. In February 2012, a VA examiner opined that the Veteran's PTSD is at least as likely as not due to the trauma of a grenade detonating in his hand that occurred during combat training. Service connection was subsequently granted. In summary, the Board has considered the Veteran's argument but finds that service connection for PTSD was not granted pursuant to a liberalizing law. Thus, he is not entitled to an earlier effective date for service connection for PTSD under this argument. Finally, the Veteran argued that he could not have filed his claim earlier than January 2011 because he did not know that he had PTSD and had no reason to know of the condition. He argues that in 2003, his VA doctor should have known to evaluate him for PTSD and that his doctor failed in the duty of care by failing to inform him that he was likely suffering from PTSD. He believes that he should be made whole for the unnecessary suffering for a mental health condition that could have been treated and was not despite numerous valid PTSD evaluations and reports dated from 1987 to 2003. Again, similar to the argument above, the manifestation of the disability does not control the effective date in this matter. Regarding the lack of an accurate diagnosis of PTSD between 1987 and 2003, the Board observes that the Veteran was treated on numerous occasions for his mental health and was diagnosed with various disorders, to include but not limited to depression and attention deficit disorder. He also completed PTSD screens prior to January 10, 2011; however, he did not file a claim for any treated or diagnosed mental health disorder prior to January 10, 2011. As such, his argument is without merit. After having reviewed all of the evidence, including the Veteran's lay statements, the Board finds that prior to January 10, 2011, the Veteran did not submit any written correspondence that when read liberally, could be considered a formal or informal claim for service connection for a mental health disorder. The effective date of an award of disability compensation shall be the date of receipt of the claim or the date entitlement arose, whichever is later. While the Veteran received mental health treatment for many years prior to the filing of his claim, a formal or informal claim for service connection was not filed prior to January 10, 2011. As such, the proper effective date is the date of the receipt of the claim as it was received later than the initial treatment for a mental health disorder. The appeal is denied. B. Tinnitus The Veteran seeks an effective date for service connection for tinnitus prior to May 26, 2009. The Board observes that the Veteran did not file a claim for service connection for tinnitus within one year of separation from service. While he filed a claim for service connection for left ear hearing loss in February 1988, he did not mention tinnitus and failed to report for his VA examination which might have raised the issue of entitlement to service connection for tinnitus. He filed a claim for right ear hearing loss in October 1991 in conjunction with a notice of disagreement with a claim related to his shoulder; however, he did not indicate the presence of tinnitus or ringing of his ears during the pendency of the claim. In a May 1993 statement, he indicated that he injured his ear drum while on active duty in 1984. He described having difficulty hearing higher tones and said some sounds faded out. He did not report ringing of his ears or tinnitus. The RO denied the hearing loss claim in July 1993. Tinnitus was not addressed. A March 1995 VA treatment record indicates that the Veteran had tinnitus of the right ear for about one year; however, a claim for service connection was not filed. Treatment records dated in December 1998 show he reported a left ear ache but not ringing of the ears or tinnitus. Tinnitus is noted in June 2003 VA treatment records. At that time, the Veteran had nonspulsatile tinnitus and bilateral hearing loss after working in a night club. He did not file a claim or any other correspondence that could be considered an informal claim for service connection for tinnitus at that time. The first indication that the Veteran sought compensation for tinnitus is located in his VA Form 21-4142, Authorization and Consent Form, dated May 26, 2009. In this release form, he stated that he had tinnitus as a result of an in-service injury. On May 27, 2009, the RO telephoned the Veteran and he confirmed that he wanted to file a claim for service connection for tinnitus. Service connection for tinnitus was eventually granted and the RO assigned an effective date of May 26, 2009, the date of his informal claim for service connection. The Veteran argues that he is entitled to an effective date prior to May 26, 2009. In his substantive appeal, VA Form 9, he indicated that he filed a claim for service connection for loss of hearing due to tinnitus in 1988, within one year of separation from service. However, as noted above, the claim filed in 1988 did not mention tinnitus or ringing of the ears and the Veteran failed to report for a VA examination that might have addressed the existence of the condition. In his January 2011 notice of disagreement, he indicated that he should be granted service connection from the date medical professionals documented tinnitus in his medical records. He stated that he has complained about tinnitus since 1984. Thus, he believes he should be granted service connection for tinnitus dating back to service. "[E]ntitlement to benefits for a disability or disease does not arise with a medical diagnosis of the condition, but with the manifestation of the condition and the filing of a claim for benefits for the condition." DeLisio, 25 Vet. App. at 56. Effective dates for service connection are assigned based on the date of claim or the date entitlement arose, whichever is later. Thus, despite having documentation of tinnitus in March 1995, and even though the Veteran is competent to report having had tinnitus since service, the date of his claim is controlling in this matter as it was received later than the date entitlement arose. In summary, since the date of claim is later than the manifestation or report of symptoms, May 26, 2009 is the proper effective date for service connection for tinnitus. The claim is denied. III. Increased Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. If two evaluations are potentially applicable, the higher evaluation 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). The Board has also considered whether referral for an extraschedular rating is warranted for each increased rating claim before the Board. Generally, evaluating a disability using either the corresponding or an analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27. Because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but, nevertheless, would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2014). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of each of the Veteran's service-connected disabilities with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the applicable criteria reasonably describe the Veteran's disability level and symptomatology, the Rating Schedule contemplates then the Veteran's disability picture, the assigned schedular evaluation is, therefore, adequate, and no referral is required. A. PTSD The Veteran seeks an initial rating in excess of 50 percent for his service-connected PTSD, rated under Diagnostic Code 9411. See 38 C.F.R. § 4.132. A 100 percent rating has been assigned from March 13, 2013. He argues that he should be rated 100 percent for the entire pendency of his claim. Under DC 9411, a 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. Under DC 9411, a 70 percent evaluation is warranted where there is 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; intermittently illogical obscure, or irrelevant speech; 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); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is 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. Id. The nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. Under DSM-IV, GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging between 31 and 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be 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. Id. 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). The Board observes that the words "slight," "moderate" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. The RO granted service connection from January 10, 2011 and assigned a 50 percent rating as of that date. In February 2011, the Veteran called VA providers and reported having suicidal thoughts. He indicated that he was worried about side effects from his medication. During an April 2011 appointment, the Veteran reported depressive symptoms with significant negative self-appraisals and future orientation. The provider noted his grooming and hygiene as well as eye contact were fair. His mood was depressed and insight was fair. The diagnosis was bipolar II and ADHD by history, mild severity, with a GAF score of 55. During a June 2011 appointment, the provider observed fair grooming, hygiene, and eye contact. His mood was anxious and insight was fair. No change in diagnosis or GAF score was indicated. For the suicide risk assessment, the Veteran reported that he was not feeling hopeless about the present or future, did not have suicidal thoughts in the last week, did not use or abuse substances in the last week, and was not experiencing a moderate to severe level of stress. The Veteran had a VA examination in April 2011. The examiner reviewed the claims file and noted that the Veteran had had a diagnosis of PTSD since 1993. Also noted was a diagnosis of bipolar disorder but that the Veteran's PTSD was most likely the primary diagnosis. A GAF score of 65 was assigned. The Veteran reported having recurrent and distressing recollections and dreams of the event, including images, thoughts or perceptions and intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. He made efforts to avoid thoughts, feelings or conversations associated with the trauma and avoid activities, places or people that arouse recollections of the trauma. He also reported a feeling of detachment or estrangement from others. Noted was difficulty falling asleep and irritability or outbursts of anger. He had had these symptoms for more than one month and the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner noted depressed mood, anxiety, and chronic sleep impairment. No other symptoms were indicated. The examiner found that the symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Regarding employment, the examiner found that PTSD caused occasional decrease in work efficiency and intermittent periods of inability to perform. October 2011 VA treatment records indicate that the Veteran was sleeping better but still having depressive episodes. He was struggling with nightmares and flashbacks. The provider observed that the Veteran's grooming and hygiene were fair, his motor behavior was agitated, his facial expression worried, and his mood anxious with appropriate and variable affect. The suicide risk assessment was negative. Insight was adequate. The provider diagnosed severe PTSD and assigned a GAF of 55. An intake assessment from the Vet Center, dated February 2012, shows the Veteran reported suicidal thoughts with a plan and prior suicide attempts. He said he tried to cut his wrists in the past, and had current thoughts of suicide. His plan was to shoot himself in the head with his pistol. He took precautions so he would not have easy access to his pistol. He also reported having thoughts of killing dictators, but did not have a plan. Noted was difficulty concentrating, learning, or recalling information; significant impairment in social or occupational functioning; disturbed sleep; irritability or aggression; anxiety; depression; apathy or lack of spontaneity; affective liability; changes in personality; and slowed thinking. The provider observed impaired memory, flat and blunted affect, and fair judgment. Hallucinations, poor appetite, recent weight gain, and sleep disturbance were indicated. A subsequently dated February 2012 Vet Center treatment record indicates that the Veteran was having suicidal thoughts but without intent. He also reported a fear of sleeping on the first floor of his house. Also noted was a history of blackouts. The provider said the Veteran had no friends, did not socialize, and kept to himself. A GAF score of 50 was assigned. On February 21 and 23, 2012, the Veteran talked about how he had been having suicidal thoughts. He said he was usually able to make them go away by playing on the computer, but that the computer did not distract his thoughts over the weekend. He went so far as to press a knife onto his wrist until he felt pain. A GAF score of 51 was assigned. See Vet Center Treatment Records, February 21 and 23, 2012. On February 28, 2012, the Veteran reported having had a bad weekend due to feeling aggressive and having ruminating thoughts that he could not get rid of. He was verbally aggressive and punched the passenger seat of his car. He had a job. He discussed his continued nightmares about the in-service trauma. He became agitated during the session and tried relaxation techniques; however the techniques did not work. A GAF score of 51 was assigned. See Vet Center Treatment Record, February 28, 2012. On March 13, 2012, the Veteran reported that he visited with a friend and that they had a good time. He tried to use relaxation techniques over the weekend, but the techniques did not work. He ended up taking a pill to help him stop thinking about his situation. He did not sleep well and ended up thinking about the trauma during service. He continued to isolate from others and shop when others are not out. He had a hard time with crowds but was willing to try things to get over it. A GAF score of 51 was assigned. See Vet Center Treatment Record, March 13, 2012. A Vet Center treatment record dated March 20, 2012 indicates that the Veteran started walking in his neighborhood to accomplish the goal of becoming more social. He could only walk around his block due to the feeling of anxiety. He was working and having intermittent sleep. A GAF score of 56 was assigned. The Veteran had another VA examination in April 2012. The examiner noted the diagnosis of PTSD and observed the prior diagnoses of bipolar and ADHD in remission, as well as MDD. The Veteran reported that he lived alone and did not engage in social activities as he did not want to spend time with others. He went to the store in the middle of the night to avoid people and at work, his employer allowed him to move his work station away from other people. He indicated that after his prior examination, he took classes as part of his part-time employment. He was working at night but had had problems working during the day. He had been working since April 2011. When not at work, he kept to himself. He did not have any friends and choses to remain alone. He did yard work in the summer. The examiner observed that the Veteran appeared to be anxious. The Veteran described his mood as depressed and noted sleep problems. He said he had arguments with his boss due to sleep problems. He arranged himself to face the door and have his back to a wall. During work, he took excessive bathroom breaks because of his thoughts. The bathroom had a lock and allowed him privacy. His nightmares interfered with sleep. He said a couple of months prior, he put a knife on his wrist and pushed down until the pain hurt worse than his thoughts. He was hypervigilant and checked his home at night while carrying a knife, double locked his doors, and placed chairs against door knobs. He moved his bed to face the door and put up barriers so that he would be prepared if someone entered. The examiner observed that the Veteran became teary during the interview. Regarding substances, the Veteran consumed alcohol every night after dinner so he could sleep. The Veteran reported having recurrent and distressing recollections and dreams of the event, including images, thoughts or perceptions. He made efforts to avoid thoughts, feelings or conversations associated with the trauma and avoid activities, places or people that arouse recollections of the trauma. He also reported a feeling of detachment or estrangement from others. The examiner observed restricted range of affect. Noted was difficulty falling asleep, irritability or outbursts of anger, and hypervigilance. He had had these symptoms for more than one month and the symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner noted depressed mood, anxiety, suspiciousness, flattened affect, disturbances with motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Based on the examination, the examiner opined that the depression was a part of the symptomatology of PTSD. The examiner assigned a GAF score of 55 but noted that the Veteran's condition as described in the interview was more severe than he reported in the examination one year prior. The examiner opined that the Veteran's symptoms resulted in occupational and social impairment with reduced reliability and productivity. On April 9, 2012, the Veteran reported sleep problems. He said his friends wanted him to move to New York. He reported having flashbacks and said he saw dead people. He rationalized noises in the house, but then checked out the noise to make sure no one was in his house. He was tired of not having friends to socialize with and for support. A GAF score of 58 was assigned. On April 24, 2012, the Veteran reported that he quit his job and was planning to move to New York. A GAF of 60 was assigned. See Vet Center Treatment Record. On April 27, 2012, the Veteran was worried and anxious. He had been having suicidal thoughts over the past few days but was able to handle them. A GAF score of 61 was assigned. On May 7, 2012, the Veteran said he was doing ok. He was able to ride the train and got a job at NYU. He had problems sitting in public. He had to rearrange his room due to it feeling uncomfortable. He had been walking outside and going out with friends. He had a problem with dogs when several congregated at once. He used his coping skills and relaxation techniques to get through stressful situations. He said it was easy when he was at home, but that it was harder in public. A GAF score of 63 was assigned. See Vet Center Treatment Record, May 7, 2012. On May 15, 2012, the Veteran reported that he had been fired from his job at NYU, which upset him. He had had problems sleeping since then. He was walking and riding the train but became anxious and paranoid when people were behind him and did not pass. He was living with a friend, was doing ok, and was using his coping skills. He indicated his desire to attend vocational rehabilitation and said he was still looking for a job. A GAF score of 60 was assigned. See Vet Center Treatment Record, May 15, 2012. A Vet Center treatment record dated May 22, 2012 shows the Veteran was doing fine. However, he had problems riding trains as well as problems when walking in public due to the rudeness of others. He was not sure how to deal with it. He was going to look for a job. He reported that he hit himself one time when he got frustrated and his typing became "gibberish." He did not know why that happened when he became upset. He told himself to get off the computer, but tried to fix the problem one last time. When his attempts did not work, he hit himself. He reported that living with friend had been helpful. He used his relaxation and meditation techniques at least once a day. A GAF score of 59 was assigned. On June 7, 2012, the Veteran's provider spoke to the Veteran's new therapist. The provider noted that the Veteran moved to New York, was seeing a new therapist, and living with a friend. A GAF score of 61 was noted. On June 13, 2012, the Veteran said he had received bad news concerning his doctor, who had informed him that he could not treat the Veteran. He also reported VA's confusion over his temporary move to New York and a scheduled compensation and pension examination. The Veteran said he meditated and felt better after speaking with his provider. A GAF score of 60 was assigned. Another treatment record shows the Veteran was looking into taking classes at a community college. He was looking for a job. A GAF score of 60 was assigned. See Vet Center Treatment Record, June 19, 2012. On June 26, 2012, he reported that he was trying to enroll in courses at the local community college. A few days prior to his appointment, he became upset and repetitive distressing thoughts did not go away until he cut his hand while making a sandwich. He reported that his roommate was out of town. He had not been on a date since his last one was not what he was looking for. He considered moving from New York back to Omaha. He had difficulty controlling the intrusive thoughts from service. A GAF score of 57 was assigned. A July 2012 Vet Center treatment record shows the Veteran enrolled in classes at the local community college. He still had problems walking on crowded streets and riding on trains with a lot of people. He was invited to coffee with a potential date and declined an outing with friends to watch fireworks. The provider assigned a GAF score of 59. An October 2012 VA intake assessment shows the Veteran reported a history of approximately 20 suicide attempts, with the last occurring a year ago. The Veteran indicated that he was chronically dysthymic and was at his baseline. He was attending school and had passing grades. He endorsed self-harm, stating he hit himself on the head with his open hand last night because he could not manage intrusive thoughts. He poked a knife into his hand two months ago when he could not control his intrusive thoughts. He reported hypervigilance, flashbacks, nightmares, and reliving the event. He had one drink per night once per week. He was unemployed. The examiner observed that he had an intense stare; guarded behavior; mildly pressured speech; chronically dysphoric mood; congruent, labile, and constricted affect; circumferential though process that was overly inclusive at times and guarded at other times; and limited insight and judgment. The Veteran appeared stable and was not in crisis. He had a history of violence but had been showing restraint. He could walk away from situations where people are too close to him or annoying to him. A GAF score of 75 was assigned. In an addendum, the Veteran's VA provider observed that the Veteran's last suicide attempt was one year ago; however, he had poked a knife into his hand 2 months ago to relieve stress rather than attempt to kill himself. He also smacked his head with his hand last night. The provider said he convincingly denied any suicidal ideation at present, though it seemed there was suicidal ideation earlier in the year. The provider cited an April 2012 note by Dr. F. which indicates that the Veteran had a suicide note that he had disposed of. The VA provider did not find an imminent safety risk. The Veteran was slightly pressured and tangential during his appointment but the provider said this was due to anxiety and psychological defense mechanisms rather than bipolar disorder. In November 2012, the Veteran reported to VA providers that his last suicide attempt was a year ago and that he engaged in chronic non-suicidal self-injurious behavior. He was still in New York living with a friend. He was working towards his computer science degree and making straight 'A's. He endorsed chronic dysthymic symptoms, suicidal ideation, and chronic symptoms of PTSD, including nightmares, re-experience with intrusive thoughts, flashbacks, hyperarousal, insomnia, increased startle, and vigilance. He said he had a short fuse. He was unemployed. He had fair eye contact and was chronically dysphoric but reported doing better. His affect was congruent, mostly stable, labile only when talking about traumatic memories, reactive, and he smiled appropriately a few times. He had no current suicidal ideation, plan, or intent. His insight and judgment was fair. The provider said the Veteran seemed at baseline and did not seem to be in acute increased danger for suicidal behavior or harm to others. He appeared to be in good control of his behavior and doing relatively well compared to past years. A GAF score of 70 was assigned. VA treatment records dated December 26, 2012 show the Veteran was depressed about leaving New York. However, while there he was in two events that almost led to altercations. One event was on the subway and the other was at the VA Center. In the last 48 hours, he held a knife to the left vein on his arm and also put a knife to his carotid but did not cut. He said he did not have many hobbies or friends in the area and when "stuck inside the house", he has "suicidal tendencies." His symptoms involved nightmares of past traumas and depression. The provider observed that his behavior was restless, facial expression was sad, mood was neutral, and affect was blunted. A GAF score of "50s" was noted. See VA Treatment Record, December 26, 2012. On January 3, 2013, the Veteran reported continued sleep problems and nightmares. He said Christmas was rough. He had put a knife to his wrist and made a superficial cut to "cause pain to make the pain in my head go away." His behavior was restless, mood was depressed, and affect appropriate. Insight was adequate. A GAF score of 50 was assigned. See VA Treatment Record, January 3, 2013. On January 16, 2013, the Veteran reported loss of memories from service. He reported continued occasional suicidal thoughts; however, he denied having a plan to harm himself and reported that even though he had impulses during the past week to harm himself by cutting his arm with a knife blade, he did not act. A GAF score of 58 was assigned. The next day, the Veteran reported that he made some superficial cuts on his hand recently but denied that it was an effort to harm himself. The provider noted that his motor behavior was restless. His mood was neutral and affect constricted. A GAF score of 50 was assigned. During a January 30, 2013 appointment with VA providers, the Veteran appeared anxious and depressed. He reported that during the past week, he had become overwhelmed with thoughts of in-service trauma but that instead of cutting himself, he struck himself on the head so hard he "saw stars." See VA Treatment Record, January 30, 2013. The Veteran had chronic suicidal thoughts. He denied having a plan to take his life, and agreed to abide by his safety contract. He reported that he had consumed alcohol every day in the last week and was experiencing a moderate to severe level of stress. On February 6, 2013, the Veteran appeared depressed and anxious. He stated that he was upset with how another medical appointment went. He was having so much difficulty coping with his feelings of distress that he made cuts on his left thumb with a knife. He was eventually able to ground himself and put the knife down. The suicide risk assessment noted suicidal ideation in the last week, minimal use of alcohol in the last week, and moderate to severe levels of stress. A GAF score of 55 was assigned. During another appointment the same day, his behavior was restless, mood neutral, and affect appropriate. A GAF score of 55 was assigned. The Board has reviewed all of the evidence to determine the severity of the Veteran's PTSD between January 2011 and March 2013. Considering the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission, the Board finds that an initial rating of 70 percent for PTSD is warranted from January 2011 until December 26, 2012 based on the Veteran's symptoms, which included but were not limited to chronic suicidal ideation without intent; suicidal ideation with plan; suicide attempts; self-harm; and difficulty in adapting to stressful circumstances. The Board considered whether a total rating should be assigned for this period but observes that the Veteran's symptoms fluctuated in frequency, severity and duration and did not result in total occupational and social impairment. For example, during this period, the Veteran was proactive in his treatment. He moved to New York and lived with a friend. He took steps to obtain a job and meet new people. He attended classes and excelled academically. His GAF scores ranged from the 50s to 75, which indicate mild to moderate symptoms or difficulty in social occupational, or school functioning. Moreover, the VA examiners did not find that his symptoms caused occupational and social impairment with deficiencies in most areas much less total occupational and social functioning. Thus, the Board cannot find that his PTSD symptoms were of the frequency and severity to cause total occupational and social impairment during this period. The Board finds that a total rating is warranted as of December 26, 2012, the date the Veteran was involved in two incidents of self-harm. The Board finds that the treatment records as of this date show a marked decline in the Veteran's functioning, resulting in total occupational and social impairment. The Board has also considered whether referral for extraschedular consideration is warranted. However, the record does not show the Veteran's PTSD is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). Here, the schedular evaluation for the service-connected PTSD is adequate as the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Veteran described his symptoms of PTSD, at worst, to include chronic suicidal ideation without intent; suicidal ideation with plan; suicide attempts; self-harm; and difficulty in adapting to stressful circumstances, among other lesser symptoms. A rating of 70 percent for PTSD contemplates social and occupational impairment with symptoms such as difficulty in adapting to stressful circumstances (including work or a worklike setting), suicidal ideation, and inability to establish and maintain effective relationships. The Board finds that the rating criteria of Diagnostic Code 9411 adequately contemplate the levels of cognitive, social, and occupational impairment that are demonstrated in the evidence of record. As discussed above, there is a higher rating available under the applicable diagnostic code, but the severity of the Veteran's PTSD does not produce such manifestations. The Veteran's symptoms fluctuated in frequency, severity, and duration but did not result in total occupational and social impairment. During this period, he was proactive in his treatment. He moved to New York and lived with a friend. He took steps to obtain a job and meet new people. He attended classes and excelled academically. His GAF scores ranged from the 50s to 75, which indicate mild to moderate symptoms. Moreover, the VA examiners did not find that his symptoms caused occupational and social impairment with deficiencies in most areas much less total occupational and social functioning. There is no suggestion in the medical evidence that the rating criteria do not reasonably describe the Veteran's disability level and symptomatology. As such, referral for consideration of an extraschedular evaluation is not warranted. In summary, the Board finds that the evidence supports the assignment of an initial 70 percent schedular rating for PTSD but not higher. A 100 percent rating is warranted from December 26, 2012. To this extent, the appeal is granted. B. Tinnitus The Veteran contends that his tinnitus is more severe than contemplated by the 10 percent rating assigned. Tinnitus is evaluated pursuant to Diagnostic Code 6260, under which tinnitus, unilateral or bilateral, is assigned a 10 percent rating. 38 C.F.R. § 4.87. Diagnostic Code 6260 was revised effective June 23, 2003, to clarify existing VA practice that only a single 10 percent evaluation is assigned for tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note (2) (2014). The Board notes that the interpretation of pre-June 2003 regulations to limit the rating evaluation for tinnitus to 10 percent regardless of whether the disability was unilateral or bilateral was appealed to the Court, which found that pre-June 2003 Diagnostic Code 6260 required that VA assign dual 10-percent ratings for "bilateral" tinnitus where it was perceived as affecting both ears. Smith v. Nicholson, 19 Vet. App. 63 (2005). However, this decision was reversed by the United States Court of Appeals for the Federal Circuit (Federal Circuit). Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006). Thus, a 10 percent rating is the maximum schedular rating available for service-connected tinnitus. The Board has considered whether an extraschedular rating is warranted for tinnitus but finds that this case does not show such an exceptional disability picture that the schedular criteria for rating the disability are inadequate. The Veteran was afforded a VA examination in December 2009. He reported that his right ear tinnitus is bothersome. During his January 2013 VA examination, the Veteran reported that the dull drone in the right ear and the high-pitched ringing in the left ear interfere with being able to understand what people are saying during conversations. The tinnitus also interferes with being able to sleep. However, in this case, the evidence does not demonstrate, and the Veteran has not asserted, that there are additional symptoms or disability associated with his service-connected tinnitus that have not been adequately covered by the rating criteria for each individual condition. He has not been hospitalized for the condition. Further, the Board finds no evidence that the Veteran is unable to work or has had to miss work because of his service-connected disability. The Board concludes that referral for an extraschedular rating is not warranted. In adjudicating the Veteran's claims for increased ratings, the Board observes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran expressly refused to have the RO consider entitlement to a TDIU in April 2013. In the April 2013 statement, he said he submitted evidence related to work absences in support of his other pending claims on appeal. He has not indicated any intent to file for a TDIU since that time and in light of his April 2013 statement and express request to not have evidence of his employment status considered for entitlement to a TDIU, the Board finds that entitlement to a TDIU has not been raised. ORDER Entitlement to an effective date prior to January 10, 2011 for the grant of service connection for PTSD is denied. Entitlement to an effective date prior to May 26, 2009 for the grant of service connection for tinnitus is denied. An initial 70 percent rating for PTSD and a 100 percent rating from December 26, 2012 are granted. Entitlement to an initial rating in excess of 10 percent for service-connected tinnitus is denied. REMAND Reasons for Remand: To obtain an etiology opinion. The Veteran seeks service connection for diabetes mellitus, type II and hypertension, both claimed as secondary to service-connected PTSD. First, the Veteran claims that the VA examination conducted in April 2012 was not a thorough examination and that it is inadequate for rating purposes. See Statement, October 2012. Second, he claims that he self-medicated his PTSD with poor dietary habits which led to his diabetes mellitus, type II and hypertension. The April 2012 VA examiner provided a negative nexus opinion between PTSD and diabetes mellitus, type II and PTSD and hypertension. Subsequently, the Veteran submitted additional articles relating to PTSD's relationship to diabetes mellitus and heart conditions. A second opinion was obtained in September 2012; however, the examiner only addressed the relationship between PTSD and diabetes mellitus, type II. Further, the examiner did not consider the Veteran's lay allegations of self-medicating his PTSD with poor dietary habits which led to diabetes mellitus, type II and hypertension, or address the several articles he submitted in support of his claim. Consequently, the Board finds that the April 2012 and September 2012 VA examination reports are inadequate for rating purposes. On remand, a VA examination must be scheduled with physicians with the appropriate expertise and the physician must opine as to the relationship, if any, between PTSD and diabetes mellitus, type II, and PTSD and hypertension. The examiner must consider the Veteran's lay statements which allege that he self-medicated with food to treat his PTSD which led to his diabetes and hypertension. The examiner must also address the multiple articles submitted addressing PTSD and its relationship to diabetes mellitus, type II and other disorders. Accordingly, the case is REMANDED for the following action: 1. Obtain updated VA treatment records, if any, and associate the records with the electronic claims file. 2. Schedule the Veteran for a VA examination with a physician(s) with the appropriate expertise to determine the etiology of his diabetes mellitus, type II, and hypertension. The physician(s) must be provided access to the Veteran's electronic claims file and a copy of this remand order. The physician(s) must indicate that he or she reviewed the electronic claims file in the examination report. All necessary testing must be completed and all symptoms reported in detail. The physician(s) must provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's diabetes mellitus, type II is causally related to service or his service-connected PTSD? If not, is it at least as likely as not that his PTSD has aggravated, or worsened, his diabetes mellitus, type II? (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's hypertension is causally related to service or his service-connected PTSD? If not, is it at least as likely as not that his PTSD has aggravated, or worsened, his hypertension? In providing the opinions, the examiner must consider the Veteran's lay statement alleging that he self-treated his PTSD with poor nutrition habits which led to his diabetes mellitus and/or hypertension. The examiner must also address the numerous articles submitted that discuss PTSD and its possible link to diabetes mellitus and other disorders. The term 'at least as likely as not' does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. In the rationale, the examiner must address the articles provided by the Veteran that address his claimed heart conditions as well as the Veteran's lay statements. 3. Then, readjudicate the claims on appeal. If the benefits remain denied, issue a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs