Citation Nr: 1040176 Decision Date: 10/26/10 Archive Date: 11/01/10 DOCKET NO. 06-19 977 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an increased evaluation for posttraumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney at Law ATTORNEY FOR THE BOARD Elizabeth Jalley, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1970 to December 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from a July 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Togus, Maine. In a September 2009 decision, the Board, in pertinent part, denied the Veteran's claims of entitlement to a rating in excess of 50 percent for PTSD and entitlement to a TDIU. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In May 2010, while the case was pending at the Court, the VA Office of General Counsel and the appellant's attorney filed a joint motion for partial remand, requesting that the Court vacate the Board's September 2009 decision as to these issues and remand the claim. In July 2010, the Court granted the joint motion, vacating the Board's September 2009 decision as to these issues and remanding the claim to the Board for compliance with directives that were specified by the joint motion. In October 2008, the Veteran testified at a personal hearing before a Decision Review Officer (DRO) at the RO in Indianapolis, Indiana. A transcript of this hearing was prepared and associated with the claims file. The record reflects that the Veteran submitted additional evidence to the Board accompanied by a waiver of initial review by the agency of original jurisdiction. See 38 C.F.R. § 20.1304. The issue of entitlement to service connection for Parkinson's disease, claimed as secondary to herbicide exposure, has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The disability picture associated with the Veteran's PTSD is consistent with occupational and social impairment with reduced reliability and productivity. The overall evidence does not support a finding that the Veteran's PTSD is productive of occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for an evaluation greater than 50 percent for PTSD are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION I. Preliminary Matters The Veterans Claims Assistance Act of 2000 (VCAA), Public Law No. 106-475, 114 Stat. 2096 (2000), substantially amended the provisions of chapter 51 of title 38 of the United States Code, concerning the notice and assistance to be afforded to claimants in substantiating their claims. VCAA § 3(a), 114 Stat. 2096, 2096-97 (2000) (now codified as amended at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2009)). In addition, VA published regulations, which were created for the purpose of implementing many of the provisions of VCAA. See 66 Fed. Reg. 45,620 (Aug. 29, 2001) (now codified, in pertinent part, at 38 C.F.R. § 3.159 (2010)). The notice requirements of the VCAA require VA to notify the veteran of any evidence that is necessary to substantiate a claim, as well as the evidence VA will attempt to obtain and which evidence the veteran is responsible for providing. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Such notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). The VCAA notice requirements, however, may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Dingess, supra; Pelegrini, supra. The Board finds that the notification requirements of VCAA have been satisfied in this case. In this regard, the Board notes a December 2006 evidentiary development letter in which the RO advised the appellant of the evidence needed to substantiate his increased rating claim. The appellant was advised in this letter of his and VA's responsibilities under VCAA, to include what evidence should be provided by him and what evidence should be provided by VA. This notice further advised the Veteran as to the type of evidence needed to substantiate both the disability rating and effective date elements of his claim, pursuant to the Court's holding in Dingess, supra. A May 2008 letter provided further notice of how to establish a disability rating and notified the Veteran of the rating criteria that are applicable to his PTSD claim. The Board further finds that the duty to assist requirements of VCAA have also been satisfied in this case. 38 U.S.C.A. §§ 5103 and 5103A. Specifically, the Board finds that all obtainable evidence identified by the Veteran relative to the issue on appeal has been obtained and associated with the claims folder. In particular, the Board notes that the RO obtained the Veteran's VA medical records and his records from the Social Security Administration (SSA). Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), in initial service connection claims, the VA must provide a VA medical examination where there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service; and (4) insufficient competent medical evidence on file for VA to make a decision on the claim. In the case at hand, the Veteran underwent VA examinations in connection with this claim in April 2007 and November 2008. The Board finds that these examination reports are adequate for the purpose of determining the claim that is decided herein. During the examinations, the examiners elicited from the Veteran his history of complaints and symptoms, conducted thorough examinations, and provided clinical findings detailing the examination results. For these reasons, the Board concludes that the reports of the April 2007 and November 2008 VA examinations provide adequate bases for a decision. The evidence of record provides sufficient information to adequately evaluate the claim. Therefore, no further assistance to the Veteran with the development of evidence is required, nor is there notice delay or deficiency resulting in any prejudice to the Veteran. 38 U.S.C.A. § 5103A(a)(2); 38 C.F.R. § 3.159(d); see Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). II. Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2010). The basis of disability evaluations is the ability of the body as a whole to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two evaluations shall be applied, 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. Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7. Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. However, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). PTSD is evaluated pursuant to the General Rating Formula for Mental Disorders. A 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). A 70 percent 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 the inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted if 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 symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). With regard to the Global Assessment of Functioning (GAF) scores assigned, the GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. Carpenter v. Brown, 8 Vet. App. 240 (1995). According to the American Psychiatric Association's DSM- IV, GAF scores from 61 to 70 indicate 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 generally functioning pretty well, has some meaningful interpersonal relationships. GAF scores from 51 to 60 indicate moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social or occupational functioning (e.g., few friends, conflicts with peers and co- workers). GAF scores of 41 to 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job). GAF scores of 31 to 40 indicate 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). As noted above, this claim was previously denied by the Board in a September 2009 decision. The Board's decision as to this issue was vacated by a May 2010 Court Order, and the claim was remanded to the Board for further adjudication in compliance with the directives of the May 2010 joint motion for remand. The May 2010 joint motion states that "vacatur and remand are required because the Board failed to provide a sufficient statement of reasons or bases for its decision in as much as it appears to have failed to consider Mittleider v. West, 11 Vet.App. 181 (1998)." Mittleider provides that, when it is not possible to separate the effects of a service-connected disability from a non-service-connected disability, 38 C.F.R. § 3.102 requires that reasonable doubt be resolved in the claimant's favor, thus attributing such signs and symptoms to the service-connected disability. The joint motion notes that the Veteran suffers from service- connected PTSD, non-service-connected major depression, and non- service-connected alcohol dependence. It further notes an April 2007 VA examination report reflecting that the Veteran's PTSD symptoms overlap with those of his major depression and alcohol dependence, "and that all three conditions impact his social problems, his ability to tolerate work stress, and his ability to perform in the workforce." The joint motion asserts that "The examination report did not articulate the precise levels of impact attributable to Appellant's service-connected condition versus his non-service-connected conditions, and it is unclear from the Board's decision whether the Board distinguished between the conditions in its assessment of the severity of Appellant's service-connected PTSD." The Board has thus been directed to fully articulate whether or the extent to which the evidence of record distinguishes the effects of the Veteran's PTSD from those of his non-service- connected major depression and alcohol dependence. If no such distinction may be made based on the evidence of record, the Board is to resolve reasonable doubt in the Veteran's favor and attribute all of the Veteran's psychiatric symptomatology to his service-connected PTSD. As noted in the September 2009 decision, VA medical records show sporadic treatment for PTSD. A September 2005 mental health intake record indicates the Veteran was seen following a positive depression and trauma screen. He reported that he was divorced but was close to his children and to two of his grandchildren. He was cooperative, alert, and oriented times three. He was tearful when talking about Vietnam and he endorsed depression most of the time since service. He reported that he sometimes hears voices that are not there. He denied suicidal ideation but reported thoughts of harming himself in the past. He endorsed multiple PTSD symptoms, including nightmares and social isolation. Diagnoses were PTSD, major depression, and alcohol dependence. GAF was reported as 47. An October 2005 VA medical record indicates the Veteran had insomnia, irritability, flashbacks, startle response, avoidance of others, anger, emotional withdrawal, and intrusive thoughts. He indicated that everything seemed to be getting worse. It was noted that he had received no treatment for PTSD. The Veteran was described as cooperative, but rather irritable and cynical. His mood was depressed. There was no suicidal or homicidal ideation or psychotic material. He was alert and oriented with intact memory. Insight and judgment were fair. Impression was PTSD with depression. He was given a trial of citalopram and trazodone for sleep. A December 2005 VA medical record indicates that he was getting more sleep but could use more. His mood was a bit better but not as good as it could be. A March 2006 gastrointestinal clinic note reflects that the Veteran became very tearful during the conversation and described anhedonia and sadness. Due to his severe depression and suicidal thoughts, he was sent to the emergency room for a psychiatric evaluation. A mental health note indicated that the Veteran has suicidal thoughts a couple of times a week but he denied any current suicidal thoughts. He was future oriented and was working full-time although he was concerned about losing his job. He reported a remote history of a suicide attempt. He also acknowledged that he had a drinking problem but rejected referral for treatment programs. The Veteran was alert and fully oriented with logical and goal-directed thinking. Mood and affect were depressed. Diagnosis was depression, not otherwise specified, PTSD by history, and alcohol dependence. A primary care note dated in July 2006 indicates that the Veteran had lost his job and since then feels worthless. He has Celexa but was not 100 percent compliant with medications. He admitted to suicidal thoughts but no plans of recent. He denied any homicidal tendencies. Assessment included depressive symptoms. In connection with his SSA claim, the Veteran underwent a medical examination in August 2006. He reported that his depression was getting worse and he has trouble sleeping. It was noted that he is able to take care of himself and perform basic activities of daily living. He helps his sister with shopping. The Veteran's speech was fluent and he followed directions and commands without difficulty. Memory for recent and remote medical events was preserved and intellectual function was grossly normal. Impression included depression and PTSD. A VA mental health note dated in October 2006 indicates the Veteran was scraping by on his VA disability and some savings. Sleep was still poor although trazodone helped somewhat. Mood was fairly good. Diagnosis was PTSD. The Veteran underwent a VA PTSD examination in April 2007. He reported psychiatric treatment about 4 times a year and that he takes antidepressant medication and a sleep aid. He had been dating a girlfriend since September 2006. He does not have close friends and sees family members for a short time every two weeks. He does not have any hobbies. The Veteran's general appearance was clean and speech was unremarkable. Affect was constricted and mood was dysphoric. He was oriented to person, time, and place. Thought process and content were unremarkable and there were no delusions. The examiner noted that the Veteran understands the outcome of behavior and understands that he has a problem. He reported problems falling asleep and waking during the night. There was no inappropriate behavior, obsessive/ritualistic behavior, panic attacks, suicidal/homicidal thoughts, or episodes of violence. Impulse control was reported as good and there were no problems with the activities of daily living. Memory was normal. The Veteran reported daily PTSD symptoms of moderate severity. He attributed social withdrawal, irritability, difficulty getting close to others, and depressed mood to his stress exposure. Axis I diagnoses were PTSD, major depression, and alcohol dependence. The examiner noted that the Veteran's social withdrawal overlaps with his depression. GAF was 55. A VA primary care note dated in June 2007 indicates the Veteran is supposed to be on citalopram and by dates appears that he is. He still feels very anxious. At the October 2008 hearing, the Veteran reported that he sleeps approximately 5 to 6 hours a night. He testified that PTSD affects most everything that he does including his social life. When he worked he did not like being around the boss. He reported that they got along well and that he got along with the people he had to be around. He did not like to be around them but made the best of it. He is sure that he did have conflicts with people that he worked with. His wife testified that he startles easy, and is forgetful and irritable. The Veteran most recently underwent a VA PTSD examination in November 2008. The Veteran's previous psychiatric treatment was discussed. The Veteran reported that he had been married for a year and a half. The only socialization he does is with his wife and he reported getting along quite well with her. He attends church. He denied any violence but reported persistent irritability. He reported having been unemployed for the last 2.5 years. He worked as a forklift driver and in shipping. He reported that he was fired following a failed drug test due to narcotics that he had been prescribed following an on-the-job accident. On mental status examination, thought process was logical and sequential. He stated that he hears some distant voices about 4 days a week that he feels are related to Vietnam. He did not appear internally preoccupied and did not appear to be hallucinating during the session. He had fairly good eye contact and no suicidal or homicidal ideations. Activities of daily living were fairly adequate and he was casually groomed. He was alert and oriented in all spheres and memory was intact. He did exhibit some mild irritability and mild sarcasm. He did not appear significantly depressed or appear overly anxious. There was some mild psychomotor retardation. He experiences crying spells and sleeps about 5 hours per night. He reported daily nightmares. GAF was reported as 70. A January 2009 statement from the Veteran's spouse indicates that he is very moody and sullen and content to stay in a dark room. In short, the Board agrees that most of the relevant evidence of record does not distinguish between the effects of his service- connected PTSD and his non-service-connected major depression and alcohol dependence. However, as will be evident in the discussion below, the Board has not attempted to differentiate between the manifestations of service-connected versus non- service-connected disabilities in any of these records, as such distinctions were not made in the records themselves. The VA medical records discuss symptoms, most notably depression and social and occupational impairment, that are likely attributable, at least in part, to the Veteran's non-service-connected major depression and alcohol dependence. Nevertheless, because these records contained no clear evidence of non-service-connected manifestations of psychiatric disability, the September 2009 Board decision implicitly attributed all such symptomatology to the Veteran's service-connected PTSD. In this regard, the Board recognizes that the April 2007 VA examination report is the only evidence of record to distinguish between the effects of the Veteran's PTSD and those of his major depression and alcohol dependence. It attributes social impairment, including social withdrawal, social problems at work, social problems away from work, impaired ability to appropriately interact with others, and deficiencies in family relations, to his PTSD, depression, and alcohol dependence. These symptoms were noted to affect the Veteran's employment. Occupational impairment, including decreased tolerance of work stress, decreased attendance, reduced reliability, reduced persistence on jobs, and social problems at work, were attributed to his PTSD and alcohol dependence. The Veteran's impairment of mood, including deficiencies in mood, irritability, lack of interest in activities, and hypervigilance, were attributed to his PTSD and depression. The Veteran's impaired mood was also noted to affect his employment. Despite the attempts at clarification by the examiner, however, the Board is ultimately unable to conclusively separate the effects of the Veteran's service-connected PTSD as described in the April 2007 VA examination report from those of his non- service-connected major depression and alcohol dependence. These non-service-connected disabilities are broadly depicted as producing social and occupational impairment similar to that which is caused by the Veteran's PTSD, but the precise nature and degree of such impairment are not clearly established by the April 2007 examination report. The Board notes that the April 2007 examination report is itself ambiguous with respect to whether it describes the complete extent of the Veteran's psychiatric impairment or whether its own discussion is limited to his PTSD. In any event, the Board finds no prejudice to the Veteran in using the April 2007 examination report to decide his claim as the Board's decision herein will attribute all of the described symptomatology to the Veteran's PTSD, thus resolving any Mittleider uncertainty in the Veteran's favor. The Board will thus turn its attention to consideration of the propriety of the 50 percent rating itself. In determining whether an increased evaluation was warranted, the Board's September 2009 decision found the Veteran's level of impairment to more closely approximate the 50 percent rating criteria. This conclusion is supported by the competent evidence of record, most notably the April 2007 VA examination report. Specifically, the April 2007 VA examiner found no that there is no total occupational and social impairment due to PTSD signs and symptoms. He did endorse the 70 percent criteria that the Veteran's PTSD signs and symptoms result in deficiencies in judgment, thinking, family relations, work, and mood. The Board notes, however, that the examiner's discussion of these criteria expressly finds deficiencies in family relations, work, and mood, but not in judgment or thinking. As examples of such impairment, the examiner cited the Veteran's having brief contact with family members as evidence of deficiencies in family relations. He also described social withdrawal and irritability at work and depressed mood and irritability in social settings. The Board observes that these types of impairment are consistent with the 50 percent rating criteria, which were also endorsed by the examiner in his finding of reduced reliability and productivity due to PTSD symptoms of social withdrawal, depressed mood, and irritability affecting his persistence on jobs and ability to tolerate work stress. Furthermore, the November 2008 examiner found that the Veteran does have some degree of social functioning and he was not felt to be significantly disabled from a psychiatric standpoint. He also noted that based on previous VA records, it appears the Veteran has been doing reasonably well in regards to his PTSD and that overall, his condition has been stable. The examiner further stated that there have been no episodes psychiatrically that he could find that were incapacitating. The Board finds that the severity of the Veteran's psychiatric symptoms themselves are also more consistent with the 50 percent rating criteria. The overall evidence shows that due to his PTSD, the Veteran suffers from poor sleep with nightmares, depression, anxiety, and irritability. The Board notes that the evidence does not reflect the difficulties of speech, understanding complex commands, frequent panic attacks, and memory impairment that characterize the 50 percent rating. Overall, however, the findings remain most consistent with a 50 percent evaluation. The Board has also considered whether the criteria for a 70 percent evaluation are met or more nearly approximated by the evidence of record. However, the Board does not find the overall disability picture to be productive of occupational and social impairment with deficiencies in most areas, to include as due to symptoms contemplated by the rating criteria. The Board acknowledges that there is some evidence of suicidal ideation, which is listed among the criteria for a 70 percent rating. Furthermore, the November 2008 VA examination report reflects the Veteran admitted to hearing voices. However, the Board finds that this latter contention is not supported by the most probative evidence of record. The VA examination report expressly notes that the Veteran did not appear to be internally preoccupied and did not appear to be hallucinating during the session, while there are no objective indications of hallucinations elsewhere in the record. Acknowledging that the Veteran's suicidal ideation is consistent with a 70 percent disability rating, the Board finds that, overall, the severity of his symptoms most closely approximates the 50 percent rating criteria. There is no evidence of obsessional rituals, speech problems, or panic attacks. Although the Veteran experiences depression, there is no indication that he is unable to function independently. On the contrary, evidence of record indicates he is able to complete his activities of daily living. The Veteran exhibits irritability, but impaired impulse control or periods of violence are not shown. There is no evidence of spatial disorientation or neglect of personal appearance and hygiene. The Veteran's PTSD interferes with his social life and although he has difficulty establishing relationships, the evidence does not show that he is unable to establish and maintain any effective relationships. The Veteran reportedly has some contact with family members and a good relationship with his spouse. He also attends church. In short, the Board finds that most of the criteria for a 70 percent rating are not met. In view of the Board's findings that several of the 50 percent rating criteria and most of the 70 percent rating criteria are not satisfied, the Board must conclude that the Veteran's overall disability picture does not most closely approximate the criteria for a 70 percent disability rating. The Board notes that the Veteran's GAF scores have varied widely during the period on appeal. As noted above, GAF scores as low as 47 (indicating serious impairment) and as high as 70 (indicating some mild symptoms) have been assessed. As discussed above, however, the accompanying qualitative descriptions of the Veteran's psychiatric disability consistently depict a disability level that most closely approximates the 50 percent rating criteria. While the GAF scores are of some probative value, the Board ultimately places more probative weight on the specific clinical findings describing the nature and severity of his symptoms. Finally, the Board notes that the Veteran recently submitted a September 2010 employability evaluation. While the purpose of this evaluation was to determine whether the Veteran's service- connected disabilities as a whole render him unemployable, the Board does finds this evaluation to be relevant to the extent that it discusses his PTSD symptomatology. This evaluation includes a summary of the pertinent medical records, all of which are contained in the claims file. While most of this evidence was discussed in the September 2009 Board decision and in the decision herein, the Board notes that the September 2010 employability evaluation also mentions an April 2009 medical record reflecting that the Veteran was brought to the emergency room after reporting he was suicidal. He was angry after being told of this admission and the police had to be called. Also of note is the vocational rehabilitation consultant's characterization of the Veteran in the months prior to and following the November 2008 VA examination report as "a very troubled individual" with "continued and serious psychological problems." With respect to the first concern, the Board notes that the evidence as discussed above does include consideration of the Veteran's suicidal ideation. For example, the Board has expressly noted and discussed the March 2006 record reflecting the Veteran was sent to the emergency room following reports of suicidal ideation. With respect to the consultant's characterization of the severity of the Veteran's disability, the Board notes that her conclusions are based largely upon the evidence that was of record at the time of the November 2008 VA examination report and does not assert a worsening of the Veteran's symptomatology since the most recent VA examination. Most importantly, the Board notes that the consultant's qualitative description of the Veteran's pertinent symptomatology is largely consistent with that of the other evidence of record. That is, the consultant's evaluation provides no new evidence suggesting symptomatology that more closely approximates the 70 percent rating criteria as discussed above. The consultant also asserts that the Veteran lost his job following the escalation of his psychological problems and his associated drinking. However, the most probative evidence of record, including a December 2006 statement from the Veteran's former employer, reflects that he lost his job because he refused a drug screen. In short, the Board finds that the September 2010 evaluation does not represent a worsening of the Veteran's PTSD and does not change the above analysis. The Board has considered whether the Veteran is entitled to a staged rating. See Hart, supra. However, at no time during the pendency of this appeal has the Veteran's service-connected PTSD been more than 50 percent disabling. As such, a staged rating is not warranted. The Board has also considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, entitlement to a rating in excess of 50 percent for PTSD must be denied. ORDER Entitlement to an increased evaluation for PTSD, currently evaluated as 50 percent disabling, is denied. REMAND The Veteran has also claimed entitlement to a TDIU. Because this issue was found to be intertwined with the PTSD claim, it was remanded for readjudication by the May 2010 joint motion. Following the Court's May 2010 Order, the Veteran submitted the September 2010 employability evaluation that is discussed in part above. This evaluation concludes that "based on review of the ongoing and severe restrictions and limitations documented in the medical record related to the service-connected knee and PTSD conditions, it is at least as likely as not that [the Veteran] has been unable to secure or follow any type of substantial gainful occupation since last employed in April 2006." This evaluation includes a detailed report of the Veteran's pertinent medical and employment history and a detailed assessment of the limitations that are caused by the Veteran's service-connected disabilities. The Board notes that, at the time of the September 2009 Board decision, the most probative evidence on file was an August 2006 SSA examination report. This report reflects that the Veteran was seeking disability for left knee impairment, emphysema, PTSD, depression, degenerative disc disease, lung problem, arthritis, hypertension, and cardiovascular disease. He reported 8 years of formal education and that he has a GED. He reported that he was terminated from his last job because he had to take pain medication and could not pass the urine test. Impression was (1) history of left knee injury, bilateral knee pain; (2) COPD/emphysema; (3) depression and PTSD; (4) hypertension; (5) chronic low back pain; (6) alcohol abuse; and (7) liver disease probably secondary to alcohol drinking. The examiner provided the following assessment: In regard to the workplace, based on today's physical examination the claimant should be able to work 4 hours a day primarily in a seated position with occasional standing and walking. He has decreased sensations and mild weakness on the left upper extremity. The etiology is unknown. He should be able to lift, push, pull or carry 5 pounds frequently and 10 pounds occasionally. He should be able to use his upper bilateral extremities for reaching or fine manipulation. He is not able to bend over, kneel or squat. He is probably not able to climb. His left knee pain is worse than the right knee pain. The left lower extremity for operating foot controls is markedly limited. He should be able to use his right lower extremity for light duty operating foot controls in sitting position. There should be no restrictions with working in extremes of temperature or humidity changes. There should be no restrictions with working with exposure to dust, fumes or gas environment. There should be no restrictions for working around moving machinery... He should [be] able to drive automotive equipment.... As noted above, a December 2006 statement from the Veteran's previous employer indicated that he was terminated in April 2006 for refusing a drug screen. The Veteran's previous employer did not suggest that the Veteran's service-connected PTSD, hearing loss, tinnitus, or left knee disabilities were factors in his dismissal. Various diagnoses were noted on the April 2007 VA general medical examination. The examiner indicated that the Veteran's back disability, bilateral knee disability, and COPD would have significant effects on his usual occupation. On VA PTSD examination in November 2008, the Veteran reported that he had an accident on the job and had narcotics prescribed to him and his job was fully aware of this. He reported that he failed his drug test and he was fired. Based on the evidence that was of record at the time of the September 2009 Board decision, the Board found it clear from the record that the Veteran is significantly limited in his abilities due to both service-connected and nonservice-connected disabilities. The Board acknowledged that the Veteran's PTSD caused some problems at work and that the Veteran does not like being around people. By his own testimony, however, he was able to get along with others as needed. Evidence of record showed that despite his mental and physical disabilities, the Veteran was able to maintain full-time gainful employment until he was terminated for refusing to take a drug test. Therefore, considering the SSA evaluation, the GAF scores assigned on mental health evaluation, and the remaining clinical findings of record, the September 2009 Board decision concluded that it appears the Veteran remained capable of gainful employment. Furthermore, even if it were assumed that the Veteran was no longer unemployable, the Board concluded that the overall evidence suggested the bulk of his occupational impairment was attributable to non service- connected disabilities. Now, however, the Veteran has submitted a September 2010 employability evaluation that expressly finds the Veteran unemployable due to his PTSD and left knee disability. The Board notes that the September 2010 employability evaluation is the only evidence of record that directly addresses the question of whether the Veteran is unemployable due to his service-connected disabilities. This evidence is thus highly probative to determining entitlement to a TDIU. The Board finds that the evidence as it now stands is sufficient to warrant a remand to conduct a proper TDIU examination. Accordingly, the case is REMANDED for the following action: 1. The AMC should make arrangements for the Veteran to undergo a VA examination to determine whether or not the Veteran is prevented from securing and maintaining substantially gainful employment based solely on his service-connected disabilities. The claims folders must be thoroughly reviewed by the examiner in connection with the examination, and a complete history should be elicited directly from the Veteran. Any tests and studies deemed necessary by the examiner should be conducted. All findings should be reported in detail. In rendering this opinion, the examiner should discuss each of the Veteran's service- connected disabilities individually as well as in the context of the entire disability picture that is presented by all of these service-connected disabilities together. Consideration should be given to the Veteran's level of education, special training, and previous work experience, but not to his age or the impairment caused by nonservice-connected disabilities. The Veteran's service connected disabilities are as follows: 1.) PTSD; (2) tinnitus; (3) hearing loss, left ear; (4) posttraumatic arthritis of the left knee; and (5) ligamentous instability of the left knee. The examiner should offer a complete rationale for any opinions that are expressed and should cite the appropriate evidence to support his or her conclusions. 2. After the development requested above has been completed, again review the record. If any benefit sought on appeal remains denied, the appellant and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs