Citation Nr: 0814033 Decision Date: 04/29/08 Archive Date: 05/08/08 DOCKET NO. 06-10 974A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to an initial disability rating for post- traumatic stress disorder (PTSD) in excess of 30 percent from December 7, 1995 to September 10, 2003. 2. Entitlement to an initial disability rating for post- traumatic stress disorder in excess of 50 percent from September 11, 2003 to August 2, 2005. 3. Entitlement to an increased disability rating for residuals of a herniated disc, currently evaluated as 20 percent disabling. 4. Entitlement to an increased disability rating for residuals of infectious hepatitis, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD A. Hinton, Counsel INTRODUCTION The veteran served on active duty from March 1968 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office in Newark, New Jersey (RO). In a July 2004 rating decision, the RO continued a 20 percent disability rating for residuals of a herniated disc; and granted an increase in the assigned rating for residuals of infectious hepatitis from zero to 20 percent. In a September 2004 rating decision, the RO granted service connection for post-traumatic stress disorder and assigned that disability a 50 percent disability rating effective September 11, 2003. In a notice of disagreement received in May 2005, the veteran initiated an appeal as to the ratings continued or assigned in the July and September 2004 rating decisions. He also disagreed with the effective date assigned for service connection for PTSD, claiming an effective date from December 1995. Subsequently in a March 2006 rating decision, the RO granted entitlement to an effective date of December 7, 1995, for service connection for PTSD. The RO assigned a 30 percent disability rating from that date to September 10, 2003; continued the already assigned 50 percent rating from September 11, 2003 to August 2, 2005; and assigned a 100 percent rating from August 3, 2005. At the same time as that rating decision, the RO issued a statement of the case addressing the ratings for the three disabilities which are the subject to this decision. Thereafter, the veteran perfected a timely appeal as to the ratings for the three disabilities here on appeal. The veteran has made no indication that he wishes to pursue an appeal for an earlier effective date for service connection for PTSD than that assigned in the March 2006 rating decision. The veteran and his wife testified at an October 2007 Video- Conference hearing before the undersigned. The issues of entitlement to increased disability ratings for residuals of a herniated disc and for residuals of infectious hepatitis are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The evidence establishes that the veteran's PTSD has caused no more than an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks during the period from December 7, 1995 to September 10, 2003. 2. The evidence establishes that the veteran's PTSD has caused no more than reduced reliability and productivity, and difficulty in establishing and maintaining effective work and social relationships, during the period from September 11, 2003 to August 2, 2005. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 30 percent for PTSD are not met during the period from December 7, 1995 to September 10, 2003. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R . § 4.130, Diagnostic Code 9411 (2007). 2. The criteria for an initial disability rating in excess of 50 percent for PTSD are not met during the period from September 11, 2003 to August 2, 2005. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist The Veterans Claims Assistance Act (VCAA) (codified at 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2007)) imposes obligations on VA in terms of its duty to notify and assist claimants. When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2007); 38 C.F.R. § 3.159(b) (2007); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his possession that pertains to the claim. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Id. In Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that any error by VA in providing the notice required by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1) is presumed prejudicial, and that once an error is identified as to any of the four notice elements the burden shifts to VA to demonstrate that the error was not prejudicial to the appellant. During the pendency of this appeal, on March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements apply to all five elements of a service connection claim. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. This appeal arises from the veteran's disagreement with the initial evaluation following the grant of service connection for PTSD in a September 2004 rating decision. Prior to that decision, the RO provided the veteran notice appearing to satisfy VCAA notice requirements with respect to requirements for establishing entitlement to service connection. To the extent it did not, this is harmless error since service connection was granted. Courts have held that in such appeals, arising from disagreement with the initial evaluation following a grant of service connection, once service connection is granted, the claim is substantiated; thereafter 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). Moreover, the statutory notice required by the VCAA is only one part of the system of notice required and provided in the VA claim adjudication process. See Wilson v. Mansfield, No. 07-7099 (Fed. Cir. October 15, 2007). Under Wilson (citing Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), 38 U.S.C.A. § 5103(a) requires only a generic notice after the initial claim for benefits has been filed and before the initial decision; and does not apply throughout the claim adjudication process since other forms of notice-such as contained in the rating decision, statement of the case, and supplemental statement of the case-provide the claimant with notice of law applicable to the specific claim on appeal. Id. In this case, notice applicable to the specific claim on appeal was provided by the statement of the case and supplementary statements of the case. As to VA's duty to assist, VA has associated with the claims folder the veteran's private and VA treatment records, and he was afforded several formal VA examinations. The Board finds that no additional assistance is required to fulfill VA's duty to assist. 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). The Board notes that the Court has recently provided guidance concerning the notice that is necessary in increased rating claims. See Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Adequate VCAA notice in an increased rating claim must inform the claimant that he must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; and that, if an increase in disability is found, a disability rating will be determined by applying relevant Diagnostic Codes. If the claimant is rated under a Diagnostic Code that contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability, the notice letter must provide at least general notice of that requirement. The notice letter must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation. In this case, a March 2006 letter informed the veteran that he must provide, or ask the Secretary to obtain, medical or lay evidence demonstrating a worsening or increase in severity of his PTSD and the effect that worsening has on his employment and daily life. This letter also informed him to submit any pertinent evidence in his possession and provided appropriate notice with respect to the effective-date element of the claim. It also included information on how VA determines the disability rating by use of the rating schedule, and provided examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain), to include treatment records, Social Security determinations, statements from employers concerning the impact of the disability on the veteran's employment, and statements from persons concerning their observations of how the disability has affected the veteran. This letter also informed the veteran of the assistance that VA would provide to obtain evidence on his behalf. The Board does not believe that this is a case in which a noticeable worsening or increase in severity of the disability would not establish the veteran's entitlement to an increased rating. In any event, the veteran was provided the specific criteria for rating his PTSD disability in the March 2006 Statement of the Case. Additionally, the veteran has participated in the appeals process and presented testimony before the Board with particular focus on the criteria needed for a higher disability evaluation, hence he has demonstrated actual knowledge of the evidence needed to substantiate his claim. Although the veteran was not provided adequate notice until after the initial adjudication of the claim, the Board finds that there is no prejudice to the veteran in proceeding with the issuance of a final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). As explained below, the Board has determined that an increased rating is not warranted at any time throughout the veteran's appeal for PTSD. Consequently, no effective date for an increased rating will be assigned, so the failure to provide earlier notice with respect to that element of the claim was no more than harmless error. Moreover, following the provision of the required notice and the completion of all indicated development, the RO readjudicated the claim. There is no indication or reason to believe that the ultimate decision would have been different had complete VCAA notice been provided at an earlier time. In sum, the Board is satisfied that any procedural errors in the development and consideration of the claims were insignificant and non prejudicial to the veteran. Accordingly, the Board will address the merits of the claim. II. Analysis Disability evaluations are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), which are based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002). Evaluations of a service-connected disability require review of the entire medical history regarding the disability. 38 C.F.R. §§ 4.1, 4.2 . If there is a question that arises as to which evaluation to apply, the higher evaluation is for application if the disability more closely approximates the criteria for that rating; otherwise, the lower rating is for assignment. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 . The Board notes that this appeal arises from an RO decision granting of service connection with an assignment of an initial rating for the veteran's Bipolar disorder. Therefore, consideration will be given to "staged ratings" from the time that service connection was made effective; that is, different percentage ratings for different periods of time may be assigned in this case. Fenderson v. West, 12 Vet. App. 119 (1999). See also Hart v. Mansfield, No. 05-2424 (U.S. Vet. App. Nov. 19, 2007) (finding staged ratings appropriate also in cases where the appeal was not as to the initial rating assigned after service connection is established). The veteran's PTSD disorder is assigned the following "staged ratings" under 38 C.F.R. § 4.130, Diagnostic Code 9411: A 30 percent disability rating from December 7, 1995 to September 10, 2003; a 50 percent rating from September 11, 2003 to August 2, 2005; and a 100 percent rating from August 3, 2005. As a 100 percent schedular rating represents the maximum assignable under the Rating Schedule, the appeal pertains only to the first two periods since a schedular rating higher than 100 percent is not feasible. See 38 U.S.C.A. § 1114; 38 C.F.R. § 4.130, Diagnostic Code 9411. According to 38 C.F.R. § 4.126(a), a mental disorder shall be evaluated "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 examination." 38 C.F.R. § 4.126(a) (2007). The regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. Under the general rating formula, a 30 percent rating is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), 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). 38 C.F.R. § 4.130 (Diagnostic Code 9411) (2007). A 50 percent evaluation is assigned if 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 in short-term 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; or difficulty in establishing and maintaining effective work relationships. Id. A 70 evaluation is warranted when 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; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and an inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. A Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing DSM-IV. The medical evidence shows a GAF score has been assigned after the filing of the veteran's claim for an increase. The Board notes that an examiner's classification of the level of psychiatric impairment, by words or by a score, is to be considered but is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95. However, a GAF score is highly probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). A GAF score of from 31 to 40 represents some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. These symptoms include speech which is at times illogical, obscure, or irrelevant; a person who is depressed and avoids friends, neglects family, and is unable to work. A GAF score from 41 to 50 is defined as serious symptoms or any serious impairment in social, occupational, or school functioning. A GAF score from 51 to 60 represents moderate symptoms, or moderate difficulty in social or occupational functioning. A GAF score from 61 to 70 represents some mild symptoms, or some difficulty in social or occupational functioning; but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score from 71 to 75 represents transient symptoms, if present, and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school functioning. One of the first records of psychiatric symptoms associated with the present claim on appeal is shown in a November 1995 VA medical certificate showing the veteran was currently taking Methadone. The certificate contains a diagnostic impression of PTSD; substance abuse. He was referred for PTSD treatment. The report of a March 1996 VA examination for PTSD shows that the veteran reported complaints of erratic sleep patterns, with recurring dreams of Vietnam, and nightmares; isolative behavior and discomfort around people; one episode of a flashback; startle reaction with nocturnal anxiety attacks with profuse sweating. On examination, the veteran was oriented times three. His speech was clear, coherent, and goal directed. He had occasional eye contact. He was cooperative. He reported that his mood was not good because he was separated from his wife. His affect was blunted. He denied having any auditory or visual hallucinations. He had good attention span and concentration. He had reasonable insight and judgment. His intellectual functioning was average. His short term memory was intact. He denied having suicidal or homicidal ideation. The report contains a diagnosis under Axis I of PTSD; history of heroin abuse. Under Axis V, the GAF score was estimated as 75. A September 2003 private progress note shows that the veteran reported having some sleeping issues and mild depression, which had responded to Xanax. The report of an August 2004 VA examination for PTSD shows that the veteran reported he was married. He reported complaints of moderate to severe symptoms of PTSD, occurring without remission throughout the past year. He reported having distressing memories nearly daily, frequent nightmares, which usually awakened him. He described persistent avoidance of stimuli associated with trauma experienced in Vietnam. He avoided activities, places, or people that brought back memories of Vietnam. He reported that he had diminished interest in activities, and marked feelings of estrangement from others. He had difficulty feeling close to others and showing affection. He had persistent symptoms of increased arousal, and difficulty sleeping. He reported problems with concentration and with hypervigilance. The examiner noted that the veteran had not worked since over a year before, when he stopped working due to treatment for hepatitis. When he had worked, he had great problems getting along with his foreman at work, and overall he had much difficulty maintaining good work relationships. On examination, the veteran was dressed casually, but appropriately. He was apprehensive, but cooperative. He was calm, but his mood was anxious and depressed. His affect was constricted. His speech was normal, and he had no impairments in perceptions. His thought processes were intact and thought content was marred by persistent reexperiencing service trauma. He indicated intermittent wishes that he was dead but denied any intent or plan. He stated that he would not hurt himself out of concern for his wife. He had no suicide attempts and had no homicidal ideation. He was oriented times three. His short-term memory and concentration were both mildly impaired, secondary to anxiety. His remote memory appeared to be intact. His ability to think abstractly was intact. The examiner estimated that the veteran's judgment could at times be compromised by stress, and that he had moderate problems with anger control problems. The veteran had adequate insight into his psychiatric disorder. The report contains an Axis I diagnosis of PTSD, chronic. Under Axis V, the GAF score was estimated as 55. The examiner correlated this score with moderate to serious symptoms of PTSD, and great difficulty maintaining relationships. The examiner concluded with an opinion that the combination of the veteran's PTSD, plus his service- connected hepatitis, had made him unemployable for the past year. The report of an August 2005 VA examination for PTSD shows that the veteran reported having serious symptoms of PTSD for much of the previous year, without remission. He reported having intrusive, distressing memories about Vietnam nearly daily. He reported that he had difficulties sleeping, frequent nightmares of Vietnam, and that neutral stimuli easily brought back distressing memories. He had persistent avoidance of stimuli reminding him of Vietnam, and avoided talking about his experiences in Vietnam. He reported feeling estranged, isolated, and lacked interest in activities. He reported having problems with restricted range of affect, and showing affection. He had persistent symptoms of increased arousal, and difficulties with irritability, concentrating, and hypervigilance. Under the section titled occupational history, the report shows that the veteran had not worked in two and a half years. Under that section, the report notes that "overall, his PTSD symptoms alone make him unemployable." Under the section titled adult social history, the report noted in conclusion that overall, outside of his wife, the veteran was unable to maintain effective relationships. On examination, the veteran dressed casually, but appropriately. He was apprehensive, but cooperative. He was calm in his motor activity. His mood was anxious and affect was constricted. His speech was normal. There were no impairments in his perceptions and his thought process were intact. He had persistent problems with reexperiencing the trauma in service. He denied any suicidal ideation, or ideation of hurting others. He was oriented times three. His short term memory and concentration were impaired due to anxiety. His remote memory and abstract ability appeared to be intact. The examiner estimated that the veteran's judgment could become moderately compromised by stress. He had moderate to severe problems with anger control. He had adequate insight into his psychiatric problems. The report contains a diagnosis of PTSD. The GAF score was 45, solely based on the PTSD. The examiner opined that the veteran's serious symptoms made him unable to maintain work relationships, resulting in his being unemployable. A. Rating from December 7, 1995 to September 10, 2003 Based on the foregoing, the Board finds that the veteran is not entitled to an initial evaluation greater than 30 percent for his PTSD for the period from December 7, 1995 to September 10, 2003. The clinical evidence of record clearly demonstrates that during that period the veteran had symptoms of sleep impairment, isolative behavior and discomfort around people, flashbacks, and nightmares, which can be related to his PTSD. The VA medical evidence of record, as reflected in the March 1996 VA examination report, does not reflect that the veteran demonstrates the vast majority of the symptomatology needed to meet the criteria for a 50 percent rating under Diagnostic Code 9411. The medical evidence does not reflect that he has flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; or impairment in short-term and long-term memory. Moreover, he was not shown to have impaired judgment or impaired abstract thinking. While the veteran's reported work and family history may indicate some degree of disturbances of mood, or difficulty in maintaining effective work relationships, the veteran's difficulties at work and at home more appropriately approximate the criteria for the 30 percent disability rating. He was apparently still working at that time, and was separated from his wife. The symptoms overall during the period from December 7, 1995 to September 10, 2003 reflect no more than occupational and social impairment with occasional decrease in work efficiency. These facts strongly suggest that the veteran had experienced no more than occasional decrease in social and work efficiency during this period. Consequently, the Board finds that an initial evaluation in excess of 30 percent is not warranted for the service-connected PTSD during the period from December 7, 1995 to September 10, 2003. The GAF score of 75 assigned by VA in March 1996 supports this conclusion. That score reflects only transient symptoms if present at all, and expectable reactions to psychosocial stressors; or no more than slight impairment in social or occupational functioning, which does not correspond to a higher degree of social and industrial impairment as required for the assignment of a 50 percent or higher disability evaluation. Consequently, the Board finds that a rating in excess of 30 percent rating is not warranted for PTSD for the period from December 7, 1995 to September 10, 2003. B. Rating from September 11, 2003 to August 2, 2005 Based on the evidence discussed above, the Board finds that the veteran is not entitled to an initial evaluation greater than 50 percent for his PTSD for the period from September 11, 2003 to August 2, 2005. The clinical evidence of record clearly demonstrates that during that period, the veteran had symptoms of sleep impairment; nightmares; avoidance of stimuli reminding him of Vietnam; diminished activities; constricted affect; anxious and depressed mood; mildly impaired short-term memory and concentration; anger control problems; thoughts of death but no intent or plan for suicide; and judgment sometimes compromised by stress. The VA medical evidence of record, as reflected in the August 2004 VA examination report, does not reflect that the veteran demonstrates the vast majority of the symptomatology needed to meet the criteria for a 70 percent rating under Diagnostic Code 9411. The medical evidence does not reflect that the impairment in most areas of occupational or social functioning. There is no evidence showing specific suicidal ideation; or symptoms of obsessional rituals interfering with routine activities. There is no evidence that his speech is illogical, obscure or irrelevant. There is no evidence of near-continuous panic or depression affecting his ability to function independently, appropriately, or effectively. He is not shown to have impaired impulse control such as unprovoked irritability; or spatial disorientation. He has not been found to neglect personal appearance or hygiene. Moreover, the August 2004 VA examiner made a specific finding indicating that overall, the veteran's disability picture was productive of no more than much "difficulty maintaining good work relationships," which is the essential wording of a key part of the rating criteria for a 50 percent rating. The comparable diagnostic criteria warranting a 70 percent rating would be that the disability picture was productive of an "inability to establish and maintain effective relationships." The latter has not been shown during the period from September 11, 2003 to August 2, 2005. While the veteran's reported work and family history may indicate some degree of disturbances of mood, or difficulty in maintaining effective work relationships, the veteran's difficulties associated with work and at home more appropriately approximate the criteria for the 50 percent disability rating. The veteran had not worked since about one year before the August 2004 examination, however, this was associated with a different, physical disability. The symptoms overall during the period from September 11, 2003 to August 2, 2005 reflect no more than occupational and social impairment with reduced reliability and productivity due to his PTSD symptoms. Consequently, the Board finds that an initial evaluation in excess of 30 percent is not warranted for the service-connected PTSD during that period. The GAF score of 55 assigned by VA in August 2004 supports this conclusion. That score reflects only moderate symptoms or moderate difficulty in social or occupational functioning. This does not correspond to a higher degree of social and industrial impairment as required for the assignment of a 70 percent or higher disability evaluation. Consequently, the Board finds that a rating in excess of 50 percent is not warranted for PTSD for the period from September 11, 2003 to August 2, 2005. C. Conclusions In summary, based on the evidence of record, the Board finds that the preponderance of evidence is against an initial evaluation for PTSD in excess of that currently in effect for the two periods on appeal. The Board concludes that there was no period between December 7, 1995 and September 10, 2003 for which a rating greater than 30 percent was warranted; and no period between September 11, 2003 and August 2, 2005 for which a rating greater than 50 percent was warranted. Fenderson, supra. The above determination is based on application of pertinent provisions of the VA's Schedule for Rating Disabilities. There is no showing that the veteran's psychiatric disability reflects so exceptional or unusual a disability picture as to warrant the assignment of an initial evaluation higher than that assigned during the two periods on an extraschedular basis. See 38 C.F.R. § 3.321(b)(1). There is no indication that the disability results in marked interference with employment (i.e., beyond that contemplated in the assigned evaluation) for any period since the grant of service connection. Moreover, the condition is not shown to warrant frequent periods of hospitalization, or to otherwise render impractical the application of the regular schedular standards. In the absence of evidence of such factors, the Board is not required to remand the claim to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER Entitlement to an initial disability rating in excess of 30 percent for PTSD for the period from December 7, 1995 to September 10, 2003 is denied. Entitlement to an initial disability rating in excess of 50 percent for PTSD for the period from September 11, 2003 to August 2, 2005 is denied. REMAND The veteran asserts that he is entitled to an increased disability rating for his residuals of a herniated disc and for his residuals of infectious hepatitis. The Board has reviewed the claims file and determined that further development is necessary prior to adjudicating these claims. During an October 2007 Video-Conference hearing before the undersigned, the veteran testified that the symptoms resulting from his service-connected residuals of a herniated disc have increased in severity since the last VA examination, which was in July 2005. In this regard, the transcript of the hearing indicates that the veteran now has increased pain with pain radiating down his extremities. Also, the veteran's representative noted that the July 2005 examiner did not address the veteran's pain associated with the herniated disc disability; this is confirmed on review of the examination report. Review of the record since the last VA examination substantiates the veteran's contention that his low back disability has worsened. The July 2005 VA examination contains a diagnosis of "retrolisthesis L5 on L4 and some canal stenosis." Review of the record since then includes a private MRI examination report in July 2005, which contains an impression of "a severe stenosis at L4-5 secondary to retrolisthesis, facet hypertrophy. Other medical record evidence also indicates that the veteran's low back disability has worsened since the last VA examination. Further, the veteran is competent to attest that he now has pain radiating to the lower extremities, a condition not addressed in the July 2005 VA examination. During the October 2007 Video-Conference hearing, the veteran also testified that the symptoms resulting from his service- connected residuals of infectious hepatitis have increased in severity since the last VA examination. The veteran was last examined by VA for compensation purposes in July 2005. He testified that since that examination, the symptoms had worsened and he now had a spot on the liver, which was getting bigger. Review of the record since the July 2005 VA examination shows that additional symptoms have developed that were not present at the time of the VA examination. In particular, since that examination, VA and private treatment records show new findings assessed as cirrhosis, and suspicious for hepatocellular carcinoma. This evidence substantiates the veteran's contention that the residuals of his infectious hepatitis have worsened. See 38 C.F.R. § 4.114, 7345 (2007) and Note 1 following that code. The United States Court of Appeals for Veterans Claims has held that when a veteran-claimant alleges that his service- connected disability has worsened since the last examination, a new examination may be required to evaluate the current degree of impairment, particularly if there is no additional medical evidence which addresses the level of impairment of the disability since the previous examination. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that the veteran was entitled to a new examination after a two year period between the last VA examination and the veteran's contention that the pertinent disability had increased in severity). As there is evidence that the condition of the two disabilities have worsened since the last examination, the veteran is entitled to a new VA examination of the veteran's service-connected residuals of a herniated disc and residuals of infectious hepatitis. Id.; Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The RO should schedule the veteran for new examinations of these service-connected disabilities by appropriate specialists. The fulfillment of the VA's statutory duty to assist the appellant includes providing additional VA examination by a specialist when indicated, and conducting a thorough and contemporaneous medical examination, and providing a medical opinion, which takes into account the records of prior medical treatment, so that the disability evaluation will be a fully informed one. See Hyder v. Derwinski, 1 Vet. App. 221 (1991); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Prior to any VA examination, the RO should obtain any relevant treatment records not on file. Accordingly, the case is REMANDED for the following action: 1. By appropriate means, request copies of any relevant and outstanding private and/or VA medical records of treatment of the veteran's residuals of a herniated disc (orthopedic and neurologic) and his residuals of infectious hepatitis; to specifically include any such records dated since the July 2005 VA examinations. 2. Thereafter, schedule the veteran for separate VA examinations by appropriate specialists (spine /orthopedic and neurologic; and liver/hepatology) to determine the severity of the veteran's residuals of a herniated disc, including any claimed orthopedic and/or neurologic manifestations; and his residuals of infectious hepatitis. Each examiner is to provide a detailed review of the veteran's current complaints; as well as findings as to the nature, extent, and severity of symptoms caused by the respective service-connected residuals. The examiner should perform all studies deemed appropriate, and set forth all findings in detail in the examination report. The RO should make the claims file available to each of the examiners, who should review the entire claims folder in conjunction with their examinations. The examiners should indicate this fact in the examination reports. The examiner should provide a complete rationale for any opinion offered in the respective examination reports as to the nature and extent of severity of the disability examined. If an examiner determines that it is not feasible to respond to any of the inquiries below, the examiner should explain why it is not feasible to respond. Residuals of a Herniated Disc The nerve examination should report all findings and note all associated symptoms, including those compatible with sciatic neuropathy, such as characteristic pain and demonstrable muscle spasm, absent ankle jerks, or other neurological findings appropriate to the site of the diseased disc or discs concerning the lumbosacral spine. The neurological examiner should specifically comment as to whether the veteran has incapacitating episodes associated with his service-connected low back disorder, and if so, the frequency of such incapacitating episodes. This must include a specific statement as to the total duration of any incapacitating episodes during the past 12 months for the spine disability. For purposes of evaluation, an incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome requiring bed rest prescribed by a physician, and treatment by a physician. The examiner should discuss the effect the veteran's lumbosacral spine disorder has upon his daily activities. The spine (orthopedic) examination should report all findings and note all associated symptoms of the service- connected low back disability. The orthopedic examiner should provide the range of motion of the spine in degrees. The examiner should note all symptoms such as pain, stiffness, or aching in the area of the spine affected by injury, as well as muscle spasm, guarding, or abnormal gait. The examiner should note the presence of objective evidence of pain, excess fatigability, incoordination, and weakness, and any additional disability due to these factors. The examiner should discuss, separately, the effects on the veteran's daily activities by his service- connected residuals of a herniated disc. Residuals of Infectious Hepatitis After reviewing the available medical records and examining the appellant, the examiner should render comments specifically addressing the following questions regarding the disability examined. The examiner should provide an opinion as to the existence of any of the following conditions due to the residuals of infectious hepatitis: fatigue, malaise, anorexia, weight loss (or other indication of malnutrition), hepatomegaly, nausea, vomiting, arthralgia, and/or right upper quadrant pain. If weight loss is found, the examiner should comment on whether the weight loss is minor or substantial. The examiner should comment on whether there are incapacitating episodes with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain; and if so, the total duration of the episodes during the past 12-months. If possible, the examiner should comment on whether or not the veteran's Hepatitis more closely approximates any one of the following three sets of criteria: i. Daily fatigue, malaise and anorexia with minor weight loss and hepatomegaly; or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least four weeks, but less than six weeks, during the past twelve-month period; or ii. Daily fatigue, malaise and anorexia with substantial weight loss (or other indication of malnutrition) and hepatomegaly; or incapacitating episodes (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain) having a total duration of at least six weeks, during the past twelve-month period, but not occurring constantly; or iii. Near constant debilitating symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper quadrant pain. The examiner should comment on the presence of any associated sequelae, such as cirrhosis or malignancy of the liver, and if so describe symptomatology of each. The examiner should comment on the impact of the service-connected residuals of infectious hepatitis on the veteran's ability to work; distinguishing effects of the residuals from effects of other conditions, but noting any residuals of debilitating effects of the hepatitis on other disabilities. 3. After the examination, the RO must readjudicate the claims under review. If any benefit sought is not granted, please issue the veteran and his representative a supplemental statement of the case (SSOC). Allow an appropriate period of time for the veteran/representative to respond. Thereafter, return the case to the Board for further appellate consideration. The appellant 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 Supp. 2007). ______________________________________________ TARA L. REYNOLDS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs