Citation Nr: 1121069 Decision Date: 05/31/11 Archive Date: 06/06/11 DOCKET NO. 05-29 845 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for purpura, to include as secondary to service-connected Grover's disease. 2. Entitlement to an initial disability evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) and a disability evaluation in excess of 50 percent as of September 12, 2005. 3. Entitlement to a total disability evaluation based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD B. R. Mullins, Associate Counsel INTRODUCTION The Veteran had active service from January 1967 to September 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs Regional Office (RO) in Little Rock, Arkansas. These claims were previously remanded by the Board in March 2009 for additional evidentiary development. The Veteran was afforded a videoconference hearing before the undersigned Acting Veterans Law Judge in February 2008. A written transcript of this hearing has been prepared and incorporated into the evidence of record. In March 2011, the Veteran submitted a letter with voluminous private clinical records, in excess of 75 pages, dated from approximately 1972 to 1987. These private medical records appear to be duplicates of evidence already of record. The Veteran stated that these records were pertinent to a claim for service connection for hypertension. A claim for service connection for hypertension was denied by a Board decision issued in March 2009. That decision, which has not been appealed, is final. The Board does not have jurisdiction to review a claim for service connection for hypertension at this time. The Board notes that, if the Veteran seeks to reopen the claim for service connection for hypertension, following the March 2009 denial, he may bring this request to the agency of original jurisdiction. A May 2011 letter primarily raises arguments regarding the adequacy of medical examination of the severity of incontinence and arguments as to whether the Veteran currently had high blood pressure or low blood pressure. No claim regarding the severity of incontinence is before the Board for appellate review. The Veteran also noted that the service treatment records have been associated with the claims file. That statement is accurate. The Veteran also stated that he underwent VA examination as to the severity of PTSD in December 2010. That statement is accurate, and that examination is discussed below. As the March 2011 and May 2011 communications include no additional medical evidence pertinent to a claim before the Board for appellate review, and do not identify additional records pertinent to a claim on appeal, and do not present evidence or argument which has not been previously reviewed by the agency of original jurisdiction, appellate review may proceed. 38 C.F.R. § 20.1304(b)(2010). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to 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. The appellant will be notified if further action on his part is required. FINDINGS OF FACT 1. The Veteran's purpura did not manifest during, or as a result of, active military service, nor is it secondary to his service-connected Grover's disease. 2. The Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability, due to such symptoms as short-term memory impairment, disturbances of motivation and mood, and a difficulty in establishing and maintaining effective relationships, throughout the pendency of this appeal. 3. The Veteran's PTSD has not been manifested by total occupational and social impairment, occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, or, significant symptomatology such as near continuous panic or depression affecting the ability to function independently, impaired impulse control, spatial disorientation, or an inability to establish and maintain effective relationships. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for purpura, to include as secondary to service-connected Grover's disease, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103(a), 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2010). 2. The criteria for establishing entitlement to an initial disability evaluation of 50 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.130, Diagnostic Code 9411 (2010). 3. The criteria for establishing entitlement to a disability evaluation in excess of 50 percent for PTSD, at any time during the pendency of the claim, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify VA has a duty to notify and assist Veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). 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 in accordance with 38 C.F.R. § 3.159(b)(1). 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). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between a Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Regarding the Veteran's claim of entitlement to service connection, letters sent to the Veteran in April 2006, May 2006 and August 2006 addressed all notice elements listed under 3.159(b)(1) and were sent prior to the initial RO decision in this matter. The letters informed him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. Regarding the Veteran's claim of entitlement to an increased disability evaluation for PTSD, this claim arose from his disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), Goodwin v. Peake, 22 Vet. App. 128, 134 (2008), Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is required for this claim. Under these circumstances, the Board finds that the notification requirements have been satisfied as to both timing and content. Adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board that complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him 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 appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA obtained the Veteran's service medical records. Also, the Veteran received VA medical examinations in March 2006, January 2006, May 2007, August 2010 and January 2011, and VA has obtained these records as well as the records of the Veteran's private medical treatment. Significantly, neither the Veteran nor his representative has identified any additional existing evidence that is necessary for a fair adjudication of the claim that has not yet been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist him 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). Additionally, the Board finds there has been substantial compliance with its March 2009 remand directives. The Board notes that the Court has held that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand). An attempt was made to obtain additional private medical records and the Veteran was scheduled for the necessary VA examinations. Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remand. See Stegall, supra, (finding that a remand by the Board confers on the appellant the right to compliance with its remand orders). Entitlement to Service Connection for Purpura Relevant Laws and Regulations Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). To establish service connection, there must be: (1) a medical diagnosis of a current disability; (2) medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999) (citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996)). Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Also, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. See 38 C.F.R. § 3.310(b); Libertine v. Brown, 9 Vet. App. 521, 522 (1996); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). An appellant's own conclusion, stated in support of his claim, that his present disability is secondary to his service-connected disability is not competent evidence as to the issue of medical causation. See 38 C.F.R. § 3.159 (2010); see also Grivois v. Brown, 6 Vet. App. 136 (1994). A layperson is generally not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997); see also Bostain v. West, 11 Vet. App. 124, 127 (1998) (citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992) (a layperson without the appropriate medical training and expertise is not competent to provide a probative opinion on a medical matter, to include a diagnosis of a specific disability and a determination of the origins of a specific disorder)). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). Facts and Analysis The Veteran contends that he is entitled to service connection for purpura. Specifically, the Veteran has argued that his purpura arose as a result of his service-connected Grover's disease. However, as outlined below, the preponderance of the evidence of record demonstrates that this condition did not arise during, or as a result of, military service, nor is it secondary to his service-connected Grover's disease. As such, service connection is not warranted. The Board will first address the Veteran's contention that this condition is secondary to his service-connected Grover's disease. The Veteran was afforded a VA examination of the skin in April 2010. The examiner noted that a biopsy was performed in March 2005 that confirmed the diagnosis of Grover's disease. A May 2007 record notes a diagnosis of actinic purpura in May 2007 and the diagnosing physician indicated that this condition started in 2004. The examiner concluded that the Veteran suffered from Grover's disease and actinic purpura, which was unrelated to his Grover's disease. For purposes of information only, and without reliance thereon, the Board notes that Grover's disease, also known as acantholytic dermatosis, is manifested by pruritic (itchy) papular skin eruptions. Stedman's Medical Dictionary 482 (27th ed. 2000). Purpura, in contrast, is manifested by hemorrhage into the skin; the appearance of the hemorrhage varies with the type of purpura, with the color of the permanent lesion dependant on the type of unabsorbed pigment of the extravasated blood. Stedman's Medical Dictionary 1487 (27th ed. 2000). In this case, the medical evidence establishes that the Veteran's purpura is an actinic purpura, that is, a purpura related to the sun's rays. Stedman's Medical Dictionary 19 (27th ed. 2000). The examiner noted that upon review of the Veteran's claims file and the literature regarding Grover's disease and purpura, it was the examiner's opinion that it was not at least as likely as not that this condition was the result of Grover's disease, or, that it was aggravated by his service-connected Grover's disease. The examiner indicated that the Veteran's actinic purpura appeared to be a completely separate skin condition. According to the reviewed literature, Grover's disease did not cause purpura. This condition was noted to be a "solar" purpura that appeared to be related to sunlight exposure exclusively. In other words, the examiner noted that the Veteran was born with skin that was more sensitive to the sun's effects than the average person. Therefore, the preponderance of the evidence of record demonstrates that the Veteran's purpura is not secondary to his service-connected Grover's disease. The examiner concluded that the medical literature revealed no connection between Grover's disease and purpura. The record contains no other competent medical evidence suggesting any potential link between Grover's disease and a skin condition such as purpura. The Board recognizes that the Veteran believes these conditions are related. However, the record contains no evidence to suggest that the Veteran is competent to offer an etiological opinion as complex as relating these two medical conditions. See Routen, 10 Vet. App. at 186; see also Bostain, 11 Vet. App. at 127 (citing Espiritu v. Derwinski, 2 Vet. App. 492 (1992) (a layperson without the appropriate medical training and expertise is not competent to provide a probative opinion on a medical matter)). While the Veteran contends that this condition is secondary to his service-connected Grover's disease, the Board has also considered whether it may be directly related to military service as to afford the Veteran all possible avenues of recovery. However, as outlined below, the preponderance of the evidence demonstrates that this condition did not manifest as a result of active military service. The Veteran's service treatment records do not reveal that he suffered from purpura, or any chronic skin symptomatology, during active military service. According to a March 1967 treatment record, the Veteran developed a rash about 36 hours earlier after camping out at a relative's home. A subsequent March 1967 treatment record indicates that at this time, the rash had almost completely cleared up. The record contains no evidence of follow-up treatment for this rash. Also, according to the Veteran's September 1970 separation examination, an evaluation of his skin performed at this time was normal. The Veteran also indicated in his report of medical history associated with this examination that he did not then, nor had he ever, suffered from skin diseases. Therefore, the preponderance of the evidence of record demonstrates that the Veteran suffered from an acute rash in military service that resolved prior to separation from active duty. If there is no evidence of a chronic condition during service, or during an applicable presumptive period, then a showing of continuity of symptomatology after service is required to support the claim. See 38 C.F.R. § 3.303(b). However, post-service treatment records fail to demonstrate a continuity of symptomatology. The record contains a December 2003 private allergy evaluation. The Veteran was diagnosed with Pityrosporum folliculitis and contact dermatitis to several chemical agents, including methyldibromoglutaronitrile, Nizoral, carba mix, cocamidopropyl betaine and bronopol. The examiner discussed the Veteran's military history, but did not indicate that this was of any relevance to the Veteran's current allergic reactions. A March 2005 private treatment record from the Southwestern Medical Center notes that the Veteran was suffering from rashes and thinning of his skin with itching for the last two and a half years. There is no suggestion in the record that this condition had existed since the Veteran's military service. According to a June 2005 private treatment record, the Veteran was suffering from a chronic skin disease known as Grover's disease. This was noted to be associated with chloracne. However, the Veteran is already service-connected for Grover's disease and this record provides no evidence suggesting a relationship between the Veteran's purpura and his military service. A January 2006 private dermatologist note also indicates that the Veteran was suffering from Grover's disease that was very stable and pore acne behind his ears and on his chest that was all but resolved. Again, there was no suggestion that his purpura was somehow related to military service or that it was a long-standing condition. The Veteran was afforded an additional VA examination for his skin in May 2007. The examiner noted that the Veteran suffered from Grover's disease or transient acantholytic dermatosis. The Veteran reported that this condition first began in 2002 as a pruritic rash. Physical examination revealed a few scattered erythematous papules on the Veteran's chest and back. The Veteran also reported suffering from chloracne since 1969, but the examiner found no evidence of chloracne upon examination. Rather, the examiner concluded that the Veteran suffered from sebaceous hyperplasia. The Veteran has since been granted service connection for this condition. Finally, the examiner concluded that the Veteran suffered from actinic purpura, with physical examination revealing two small purpuric patches - one on each hand. The Veteran reported that the onset of this condition was in 2004. Finally, as already noted, the Veteran was afforded an additional VA examination of the skin in April 2010. The examiner agreed with prior examiners who had concluded that the Veteran suffered from actinic purpura. The examiner concluded that the etiology of the Veteran's condition appeared to be related to his exposure to sunlight exclusively. In other words, the examiner explained that the Veteran was born with skin that was more sensitive to the sun's effects than the average person's skin. The Veteran's skin was again examined in August 2010, and the examiner again concluded that the appropriate diagnosis for the Veteran's purpura was actinic purpura, and the examiner concluded that the Veteran's skin disorder were essentially unchanged in appearance since the April 2010 VA examination. The preponderance of the above evidence demonstrates that the Veteran is not entitled to service connection for purpura. There is no evidence of a chronic skin disorder manifested by extravasation of blood. There is no evidence of chronic symptomatology since separation. In fact, the clinical evidence of record establishes that the disorder was not present chronically and continuously since service, as the Veteran underwent numerous medical examinations to evaluate the skin disorder which was finally diagnosed as Grover's disease. There is no evidence that actinic purpura was present at the time of those examinations. Thus, the clinical evidence establishes that purpura has not been present chronically since the Veteran's service. The Veteran himself indicated that he did not notice the manifestations of purpura until 2004, which is more than three decades after his separation from active duty. When considering whether or not to grant a claim for service connection, the Board may take into consideration the passage of a lengthy period of time in which the Veteran did not complain of the disorder at issue. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In this case, the absence of any evidence of this condition for more than 30 years tends to demonstrate that the Veteran has not suffered from chronic symptomatology since service. Finally, the April 2010 VA examiner concluded that this condition arose as a result of the Veteran's sensitivity to sunlight - a sensitivity the examiner indicated the Veteran would have been born with. As such, the preponderance of the evidence of record demonstrates that the Veteran is not entitled to service connection for this condition. The Board recognizes that the Veteran believes this condition manifested during military service or as a result of service-connected Grover's disease. However, as already noted, the Board has received no evidence to demonstrate that the Veteran is competent to offer such a medical opinion. See Routen, 10 Vet. App. at 186. While the Veteran would certainly be competent to testify to chronic symptomatology, he indicated upon examination that this condition did not appear until around 2004. Therefore, the Veteran's testimony fails to demonstrate entitlement to service connection. Also, in his March 2011 and May 2010 communications, the Veteran again indicated that he had a rash in service which he believes is related to his current skin disorder, as he had testified at his 2008 videoconference hearing before the Board. The Veteran alleged that the service treatment records are not accurate. He again alleges, in the Mach 2011 and May 2011 communications, that a rash observed in service, was not an allergic reaction and that he did not go camping with relatives at this time (1967), but that the rash in service was related to scarlet fever for which the Veteran was treated in service. The Board notes that the Veteran testified, at his February 2008 videoconference hearing, that his current skin disorders were related to the diseases treated in service. The examiner has stated that the claims file was reviewed. The examiner did not specifically comment on the Veteran's allegations at his hearing regarding a rash in service. The examiner who conducted the April 2010 and August 2010 VA examinations of the Veteran's skin did note, however, that all skin disorders or skin manifestations of other disorders had resolved at the time of the Veteran's service discharge. The examiner also specifically found that the Veteran's current actinic purpura arose no earlier than 2004. As noted in the Introduction, above, the 2011 communications provide no evidence or contentions not previously raised and considered, and Remand for review of the communications is not required. The Board has considered the Veteran's lay statements, including those submitted in March 2011 and May 2011. After "due consideration" of these lay statements, the Board finds that the Veteran is not competent to determine the cause of his current purpura. Whether or not the Veteran in fact went camping in 1967 does not change the fact that the skin disorder treated in service, or the skin manifestations of a disorder treated in service, was acute and that it had resolved by the time of the Veteran's 1970 separation examination. The Veteran has not submitted any evidence which suggests that he continued to have a skin disorder after service chronically and continuously since his service separation many years ago. Since the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for actinic purpura must be denied. Entitlement to an Increased Disability Evaluation for PTSD Relevant Laws and Regulations Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). As is the case here, where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, in Fenderson v. West, the Court noted that where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" is required. 12 Vet. App. 119, 126 (1999). The General Rating Formula for Mental Disorders, including Diagnostic Code 9411, at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities. A 30 percent evaluation is provided for 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 conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is warranted if it is productive of 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; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating contemplates 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 Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV)). Scores ranging from 31 to 40 represent 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; child frequently beats up younger children, is defiant at home, and is failing at school). Scores ranging from 41 to 50 illustrate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Facts and Analysis The Veteran contends that he is entitled to an increased disability rating for his service-connected PTSD. Specifically, the Veteran contends that he is entitled to an initial disability evaluation in excess of 30 percent for his PTSD, and, a disability evaluation in excess of 50 percent as of September 12, 2005. Having reviewed the evidence of record, the Board finds that the Veteran is entitled to an initial disability evaluation of 50 percent for his PTSD. However, the preponderance of the evidence of record demonstrates that a disability evaluation in excess of 50 percent is not warranted at any time during the pendency of this claim. For historical purposes, the Veteran was originally granted service connection for PTSD in a March 2005 rating decision. A 30 percent disability evaluation was assigned under Diagnostic Code 9411, effective as of April 23, 2004. The Veteran submitted what has been interpreted to be a timely notice of disagreement in September 2005, and in a September 2006 rating decision, the Veteran's disability evaluation was increased to 50 percent, effective as of September 12, 2005. The Veteran appealed the assigned ratings to the Board in June 2007. When filing his claim, the Veteran submitted a number of private psychiatric treatment records prepared by a social worker with the initials K.A. According to a June 2003 record, the Veteran was dressed casually and cleanly. He was found to be fully oriented and cooperative with logical and sequential thoughts. There was no evidence of hallucinations, delusions or any other thought disorders. The Veteran's short-term memory was marked with forgetfulness but his long-term memory was deemed to be adequate. The Veteran reported recurrent depression with feelings of helplessness and hopelessness. He also described feeling of anxiety and decreased energy and motivation. Finally, he was noted to be suffering from isolation and emotional distancing. The examiner diagnosed the Veteran with chronic PTSD with secondary depression. It was noted that the Veteran had not had a GAF score over 40 in the past year. A March 2004 record from Mr. A again noted a GAF score of 40. It was also noted that the Veteran had no close friends, had no social outlets, and was finding that he was less able to tolerate close supervision at work. In a March 2004 evaluation, a private psychiatrist with the initials C.W.J. determined that the Veteran dressed appropriately and had articulate speech. His thoughts were noted to be orderly with no evidence of hallucinations, delusions or paranoia. His affect was blunted. The examiner concluded that the Veteran was alert and oriented in all spheres with well-preserved memory and intellect. A diagnosis of PTSD was made and a GAF score of 35 was assigned. Dr. J concluded that the Veteran's PTSD had progressed to the point of substantially impairing his ability to sustain personal relationships, participate in activities and sustain gainful employment. The Veteran was afforded a VA examination in March 2005. It was noted that the Veteran drove himself to the appointment and that he was alert, oriented and cooperative. The examiner indicated that the Veteran had good attendance and work ratings at his current job, despite losing his temper with his boss the previous November. The examiner also opined that the Veteran had moderate social impairment and family life impairment, having been married since 1984 with a 20 year old son that lived at home. The Veteran denied any close friends since moving to Louisiana. There was no evidence of suicidal or homicidal ideation and the Veteran denied hallucinations or delusions. The Veteran's behavior was appropriate during the examination. His personal hygiene was found to be good and his activities of daily living were described as good. Long-term memory was good and short-term memory was fair. Panic symptoms were also absent and the Veteran's impulse control was deemed to be good. The examiner diagnosed the Veteran with PTSD and concluded that his symptomatology was moderate. A GAF score of 60 was assigned at this time. The examiner noted that the Veteran had lost the ability to form close relationships, work well with others, interact appropriately with friends and find sustained enjoyment in other activities. The record contains an additional psychiatric assessment prepared by K.A. in June 2005. It was noted that the Veteran was treated regularly by this social worker and that the Veteran was unable to tolerate close supervision, he angered easily, and he had short-term memory and concentration impairment that interfered with his ability to follow and complete rather simple instructions and tasks. However, it was noted that the Veteran worked steadily for the Federal Government even though he was a loner who avoided people at work. He also denied having any close friends. K.A. further indicated that the Veteran reported frequent suicidal ideation with no plans. The Veteran was afforded an additional VA examination for his PTSD in January 2006. It was noted that the Veteran sought treatment from private providers, and as such, there was no evidence of medical treatment since his past VA examination. It was noted that the Veteran currently worked, but that he reported that he was using a lot of leave because he could not tolerate going to work sometimes. He also reported periodic angry outbursts at work. The Veteran also reported significant insomnia with nightmares. He described significant anxiety on a daily basis and problems with anger and resentment. He also indicated that he was depressed most of the time. His social activities were also noted to indicate detachment or estrangement from others. Examination revealed the Veteran to be appropriately groomed and dressed. It was noted that the Veteran was able to perform the basic activities of daily living independently and that he was fully oriented in all spheres. The Veteran's memory was deemed to be within normal limits with the exception of a mild to moderate deficit in short-term memory. His speech was deemed to be logical and intact with no evidence of impaired thought processes. The Veteran also denied any hallucinations, delusions, or obsessional or ritualistic behaviors. The Veteran also denied any suicidal or homicidal ideations or intent and symptoms of true panic attacks were not indicated. The Veteran was found to have high levels of anxiety and symptoms of depression. The examiner diagnosed the Veteran with PTSD and depression and assigned a GAF score of 50. The examiner indicated that despite his symptomatology, he had been able to maintain long-term steady employment. Therefore, the examiner opined that the Veteran was clearly not unemployable. The examiner further noted that the Veteran suffered from a serious impact on social functioning, while his occupational functioning was only mildly to moderately impacted. K.A. prepared a medical assessment update in May 2006. A diagnosis of chronic PTSD was noted and Mr. A indicated that the Veteran had not had a GAF score in excess of 35 in the past year. This conclusion is not supported by the January 2006 VA examination. The Veteran reported that he was unable to tolerate close supervision at work and that he was angering easily. It was also noted that his short-term memory loss and concentration impairment interfered with his ability to remember and complete rather simple tasks. The Veteran also reported that he would isolate himself from others and that he had no close friends. The record also contains a letter from the Office of Personnel Management (OPM) dated November 2006. According to the legal administrative specialist who prepared the letter, the Veteran was found to be disabled from his position as an Electronics Measurement Equipment Mechanic due solely to his PTSD. The Veteran was afforded an additional VA examination for his PTSD in May 2007. The Veteran reported depression and anxiety. He also reported nightmares occurring a couple of times per week. It was noted that the Veteran was married to his wife of 26 years. He reported that they got along well. He indicated that he had not worked since November 2006 and the Veteran felt this was due to his becoming angry and not liking the job, as well as other health issues. Examination revealed the Veteran to be casually groomed and fully cooperative with speech within normal limits. His mood was described as generally depressed and his affect was appropriate to content. Thought processes and associations were logical and tight and the Veteran did not report hallucinations or other delusional material. His memory was found to be grossly intact and he was oriented in all spheres. Insight and judgment were adequate. The Veteran denied any suicidal intent but he did report occasional ideation. The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 47. The examiner concluded that the Veteran's symptomatology was moderate. The examiner further noted that while there was not evidence of symptomatology that would preclude all employment, there was clearly evidence that his last employment at the army depot was affected by his PTSD. K.A. prepared another medical assessment update in July 2007. He noted that the Veteran was unable to work at any significant gainful employment of any kind. In support of this opinion, Mr. A noted that the Veteran demonstrated an increasing irritability to tolerate supervision, anger, short-term memory loss, and an ability to work cooperatively with others. It was also noted that the Veteran's age, experience and education were of no benefit to him due to the nature and severity of his PTSD and other health-related service-connected disabilities. Mr. A opined that the Veteran had not had a GAF in excess of 35 over the previous year. Mr. A prepared another medical assessment update in September 2007. It was determined that the Veteran was unable to do any significant gainful employment because of his PTSD. Mr. A again noted that the Veteran was unable to tolerate any close supervision. The Veteran also denied any close friends or social outlets and he reported recurrent depression and suicidal and homicidal ideation without intent or plan. It was noted that the Veteran's judgment and insight for normal events was fairly good, but K.A. indicated that the Veteran was occasionally disoriented to time. However, he reportedly became spatially disoriented on occasion as well. K.A. opined that the Veteran's symptomatology cut across his life in such a fashion as to make him dysfunctional throughout his life. The Veteran was most recently afforded a VA examination for his PTSD in December 2010. The Veteran was noted to have symptoms of depressed mood, insomnia, difficulty concentrating, apathy, anhedonia and psychomotor agitation. The Veteran reported that he was married to his wife and that his 25 year old son lived with him. He also indicated that he had a few friends in California and that he was currently in touch with one of them. Examination revealed the Veteran to be clean and appropriately dressed with clear and coherent speech. His psychomotor activity was described as tense. His mood was noted to be depressed and angry while his affect was constricted. He was found to be fully oriented in all spheres with unremarkable thought process. His thought content was noted to be preoccupied with one or two topics. There were no delusions or hallucinations. His judgment and insight were intact, and there was no inappropriate behavior, obsessive or ritualistic behavior, or panic attacks. The examiner also found no evidence of homicidal or suicidal thoughts and the Veteran's impulse control was deemed to be fair. The Veteran's memory was also intact. The examiner who conducted the December 2010 VA examination diagnosed the Veteran with PTSD and assigned a GAF score of 54. The examiner concluded that there was not total occupational and social impairment due to the Veteran's PTSD. It was also concluded that he did not suffer from deficiencies in areas such as judgment, thinking, family relations, work or mood. There was, however, evidence of reduced reliability and productivity due to PTSD symptomatology. The examiner further explained that the Veteran was not totally incapable of working due to PTSD and depression. The examiner noted that the Veteran worked for over 20 years at the same job, and although he did not like the job, he was able to perform essential functions. The examiner could not identify any significant worsening in PTSD or depressive symptoms that would suddenly or gradually render the Veteran wholly incapable of working at his job. There was nothing in the claims file to demonstrate that the Veteran had any significant disciplinary measures taken against him on the job due to symptoms of PTSD or depression, and that the current examination revealed the Veteran to possess solidly average intellectual ability and functional academic skills. The examiner also noted that the Veteran participated in rehab activities at a fitness center 5 days a week. Finally, the examiner noted that the Veteran reported that the main reason he could not work was his reported inability to get along with people. However, the examiner stressed that many Veterans with PTSD problems in social relationships are still fully capable of going to work every day. Analysis In light of the above evidence, the Board finds that the Veteran is entitled to an initial disability evaluation of 50 percent for his service-connected PTSD. As already noted, a 50 percent disability rating is warranted for psychiatric symptomatology that is productive of 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; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. According to the June 2003 private treatment record, the Veteran suffered from recurrent depression with feelings of helplessness and hopelessness. He was also noted to be suffering from decreased energy and motivation with social isolation and emotional distancing. He was also found to have a blunted affect upon evaluation in March 2004 and the examining psychologist concluded that the Veteran's PTSD substantially impaired his ability to sustain personal relationships, participate in activities and sustain gainful employment. The March 2005 VA examiner also concluded that the Veteran had lost the ability to form close relationships, work well with others, interact appropriately with friends, and find sustained enjoyment in other activities. Therefore, when affording the Veteran the full benefit of the doubt, the Board finds that he is entitled to an initial disability evaluation of 50 percent for his PTSD. However, the preponderance of the evidence of record demonstrates that the Veteran has not been entitled to a disability evaluation in excess of 50 percent for his PTSD at any time during the pendency of his claim. Again, a 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. The evidence of record does not demonstrate that the Veteran suffers from deficiencies in areas such as judgment, thinking or work. According to the June 2003 private report prepared by the social worker with the initials K.A., the Veteran was fully oriented with logical and sequential thoughts and no evidence of a thought disorder. His thoughts were again noted to be orderly upon evaluation in March 2004. However, the examiner also indicated that the Veteran had lost the ability to form close relationships. A June 2005 private treatment record indicates that the Veteran was still working full-time, and according to the January 2006 VA examination, there was no evidence of impaired thought processes. It was also noted that the Veteran only suffered from a mild to moderate impact on occupational functioning. The Veteran was again found to have logical and tight thought processes and associations upon examination in May 2007 and his insight and judgment were deemed to be intact. The examiner also concluded that the Veteran's overall symptomatology was moderate, and that while his PTSD clearly had an impact on his employment, it did not preclude him from all employment. Finally, upon VA examination in December 2010, the Veteran's thought processes were deemed to be unremarkable and his judgment and insight were intact. The VA examiner also opined that the Veteran did not suffer from deficiencies in areas such as judgment, thinking, family relations, work or mood, but rather, reduced reliability and productivity due to his PTSD symptomatology. The evidence also fails to demonstrate that the Veteran suffers from deficiencies in family relations, or, that he has an inability to establish and maintain effective relationships. The VA examiner who conducted March 2005 examination concluded that the Veteran's overall social and family life impairment was moderate. While the VA examiner who provided January 2006 evaluation did opine that the Veteran had a serious impact on social functioning, he has maintained a marriage throughout the claim, demonstrating that he does not have an inability to establish effective relationships. The Veteran himself indicated that he got along very well with his wife. Finally, during his 2010 VA examination, the Veteran reported having some friends in California with whom he was in contact, and, that his 25 year old son lived with him. This evidence demonstrates that the Veteran does not suffer from deficiencies in family life and that he does not have an inability to maintain effective relationships. The Board notes that during a private evaluation with K.A. in May 2006, the Veteran reported that he would isolate himself from others and that he had no close friends. K.A. also opined in September 2007 that the Veteran's PTSD had made him dysfunctional throughout his life. However, the January 2006 VA examiner concluded that the Veteran was capable of performing his basic activities of daily living independently. Also, upon examination in May 2007, the Veteran reported being married to his wife for 26 years and that they got along well. He also reported during his 2010 VA examination that he had some friends in California whom he was in contact with. Therefore, the opinions offered by K.A. as to the severity of the Veteran's PTSD are inconsistent with or contradicted by other objective medical evidence of record. The Board also recognizes that the Veteran has been noted to have some of the other symptoms outlined in the Diagnostic Code for a 70 percent rating. According to K.A. in June 2003, the Veteran had recurrent depression and decreased motivation. In June 2005, K.A. noted that the Veteran was unable to tolerate close supervision and that he would anger easily, suggesting that he had difficulty adapting to stressful situations. The Veteran has also reported suicidal thoughts, but he has routinely denied any actual intent or plan. In fact, it was noted in December 2010 that the Veteran participated in rehabilitation activities at a fitness center 5 days a week. This evidence discloses that the Veteran is thinking of the future, is able to engage in ongoing activities, and is able to maintain effective enough relationships to continue going to a fitness center. While the Board has considered such symptoms as suicidal thought and depression, the evidence of these symptoms, alone or in light of the totality of current symptoms, fail to demonstrate entitlement to a 70 percent disability evaluation currently or at any time during the pendency of the claim on appeal. The record fails to demonstrate that, even with this symptomatology, the Veteran suffers from deficiencies in areas of his life such as family, judgment or thinking. The Veteran has maintained a long-standing marriage, he has friends whom he is in current contact with, his judgment is intact, and his thought processes are logical. This evidence demonstrates that the Veteran's overall disability evaluation has been more appropriately characterized as 50 percent disabling, rather than as 70 percent disabling, throughout the pendency of this claim. The Board also notes that K.A. reported occasional spatial disorientation in a September 2007 medical assessment. However, the remaining evidence of record from throughout the pendency of the Veteran's claim has demonstrated that he did not suffer from spatial disorientation. In particular, the Board notes that the 2010 VA examination demonstrates that the Veteran participates in rehabilitation activities, which generally required spatial orientation or improve spatial orientation. As such, this single notation in the evidence of record fails to demonstrate that the Veteran is entitled to a 70 percent disability evaluation for his PTSD. The Board has also considered the repeated findings of K.A. suggesting that the Veteran is unable to perform any significant employment as a result of his PTSD. However, the evidence demonstrates that the Veteran worked until November 2006, clearly indicating that he was not unemployable as of this time. Also, K.A. based his opinion, in part, on the Veteran's inability to tolerate close supervision at work and that he angered easily. It is not clear from K.A.'s opinion, therefore, whether the Veteran could be employed in a position that required less supervision. The May 2007 VA examiner also concluded that the Veteran did not have symptomatology that would preclude him from all employment. The VA examiner who conducted December 2010 VA examination further concluded that the Veteran was not unemployable, noting that the Veteran worked for over 20 years at the same job. The examiner was unable to find evidence of a significant worsening in the Veteran's symptomatology to demonstrate why the Veteran would suddenly be totally unemployable. The Board also notes the work-like participation in rehabilitation activities 5 days a week. The Board also notes that there is no evidence that the Veteran requires assistance with activities of daily living. As such, the evidence of record fails to demonstrate that the Veteran suffers from total occupational impairment solely as a result of his service-connected PTSD. The Board also recognizes that the Office of Personnel Management indicated in November 2006 that the Veteran was disabled from his position as an Electronics Measurement Equipment Mechanic due solely to his PTSD. However, this opinion fails to suggest that the Veteran was disabled from all forms of gainful employment due to his PTSD. Nonetheless, as will be discussed in the remand portion below, this evidence is further support of the need for a medical opinion regarding the Veteran's all around employability. The Board is also cognizant of the fact that the Veteran has received GAF scores as low as 35 during the pendency of his claim. Scores ranging from 31 to 40 represent 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; child frequently beats up younger children, is defiant at home, and is failing at school). However, GAF scores alone do not demonstrate entitlement to a higher disability rating, as the Board must also consider the actual evidence of record. In the present case, the preponderance of the evidence of record fails to suggest the level of impairment outlined above. Also, the Veteran has received GAF scores as high as 60 in this case, which reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Therefore, due to the inconsistent nature of the assigned GAF scores in this case, and the lack of evidence to support major impairment in several areas, the Board does not find the assigned GAF scores to be determinative. In reaching the above decision, the Board has also considered the lay testimony offered by the Veteran in support of his claim. In an August 2005 statement, the Veteran indicated that he believed he was entitled to a higher disability rating due to his difficulties in holding a job, memory problems, and social isolation. However, such symptomatology is fully considered in a 50 percent disability evaluation. The Veteran has continued to assert that his PTSD results in occupational impairment. However, a significant degree of occupational impairment is inherent in a 50 percent disability evaluation. As such, the Veteran's testimony does not demonstrate entitlement to a disability evaluation in excess of 50 percent. The Board has also considered whether the Veteran's PTSD presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2010); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). 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. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). In the present case, the Veteran's PTSD is manifested by occupational and social impairment, depression and anxiety - all symptoms contemplated by the rating criteria. Therefore, the Veteran's PTSD does not present an exceptional disability picture. Also, the evidence demonstrates that the Veteran has not required frequent hospitalization or that he suffers from occupational impairment above and beyond that considered by a 50 percent disability evaluation. The rating criteria also provide for a greater evaluation for additional or more severe symptoms. As such, his disability picture is contemplated by the rating schedule and the assigned schedular evaluation is adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. Nonetheless, as outlined in the remand section below, the issue of employability is being remanded for further consideration. Affording the Veteran the full benefit of the doubt, the Board finds that he is entitled to an initial disability evaluation of 50 percent for his PTSD. However, as discussed in detail above, the preponderance of the evidence is against the claim of entitlement to a disability evaluation in excess of 50 percent at any time during the pendency of his claim, and as such, the provisions of 38 U.S.C. § 5107(b) regarding reasonable doubt are not applicable. That claim must be denied. ORDER Entitlement to service connection for purpura, to include as secondary to the Veteran's service-connected Grover's Disease, is denied. Entitlement to an initial disability evaluation of 50 percent for PTSD, prior to September 12, 2005, is granted; subject to law and regulations governing the effective date of an award of monetary compensation; the appeal is granted to this extent only. Entitlement to a disability evaluation in excess of 50 percent for PTSD is denied. REMAND TDIU The Veteran contends that he is entitled to TDIU based on his service-connected disabilities. Regrettably, further evidentiary development is necessary before appellate review may proceed on this matter. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Presently, the Veteran is service-connected for PTSD (rated as 50 percent disabling), the residuals of prostate cancer (rated as 40 percent disabling), sebaceous hyperplasia (rated as 30 percent disabling), and Grover's disease (rated as 30 percent disabling), for a combined disability evaluation of 90 percent. As such, the Veteran meets the percentage requirements laid out in 38 C.F.R. § 3.340. The record contains a great deal of evidence suggesting that the Veteran suffers from occupational impairment resulting from his PTSD, including numerous opinions from a private social worker with the initials K.A., as well as a finding of disability from the Office of Personnel Management dated November 2006. However, there is also evidence of record, such as the 2010 VA examination, indicating that the Veteran does not suffer from total occupational impairment as a result of his PTSD. Therefore, a medical opinion is necessary that discusses all of the opinions in favor and against the Veteran's claim. Furthermore, the record only contains opinions as to whether or not the Veteran has been rendered unemployable as a result of his service-connected disabilities individually. The record does not contain an opinion as to whether all of the Veteran's service-connected disabilities, when considered together, are at least as likely as not to result in total unemployability. Such an opinion is necessary before appellate review may proceed in this case. Accordingly, the case is REMANDED to the AMC for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). Expedited handling is requested.) 1. The Veteran should be scheduled for a VA examination before an appropriate specialist(s) regarding his claim of unemployability. The Veteran's claims file and a copy of this remand must be provided to the examiner upon examination. The examiner is asked to opine as to whether it is at least as likely as not that the Veteran's service-connected disabilities, either individually or as a whole, result in an inability to secure or follow a substantially gainful occupation. The examiner should be provided with a list of all disabilities for which service connection has been awarded. A complete rationale must be provided for any opinion offered, and if the Veteran is not found to be unemployable, the examiner should discuss the contrary evidence of record, including the November 2006 decision of the Office of Personnel Management and the conclusions of the private social worker with the initials K.A. 2. The AMC should then readjudicate the Veteran's claim. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case (SSOC), containing notice of all relevant actions taken on the claim, to include a summary of the evidence and applicable law and regulations. An appropriate period of time should be allowed for response. The Veteran 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. 2010). ____________________________________________ Tresa M. Schlecht Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2010). Department of Veterans Affairs