Citation Nr: 1122287 Decision Date: 06/08/11 Archive Date: 06/20/11 DOCKET NO. 08-24 581 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an initial evaluation in excess of 10 percent for the service-connected posttraumatic stress disorder (PTSD), prior to November 19, 2008. 2. Entitlement to an initial evaluation in excess of 50 percent for the service-connected PTSD, since November 19, 2008. 3. Entitlement to a total disability rating based on individual unemployability by reason of service-connected disability (TDIU). ATTORNEY FOR THE BOARD A. Nigam, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1967 to September 1968. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a July 2007 rating decision and a December 2008 decision by the RO. In February 2010, the Board remanded the matter to the RO via the Appeals Management Center (AMC), in Washington, DC. As the claim for an increased rating for the service-connected PTSD involves a request for a higher rating following the grant of service connection, the Board has characterized this claim in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999). Of some importance, in a statement received in July 2010, the Veteran indicated that he elected not to pursue his claims for increased evaluations for service-connected malaria and bilateral hearing loss. Therefore, these issues are considered withdrawn, and the only issue currently before the Board is that reflected on the title page of this decision. The Veteran requested a hearing at the RO with Board. In November 2009, the RO sent the Veteran notice of his scheduled hearing at the RO and informed him that he could make a written request to change in his hearing date up to two weeks before his scheduled hearing if good cause could be shown. The record reflects that, in November 2009, the Veteran requested a videoconference hearing at the VA Medical Center (VAMC). Notably, he failed to submit his request in writing and did not provide cause for his request for a change in venue at the time of his call. Thus, the hearing request is deemed withdrawn. See 38 C.F.R. § 20.704 (2010). The the issue of service connection for hyperkinesia, claimed as secondary to the service-connected PTSD 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 and refers it to the AOJ for appropriate action. In recent statements, the Veteran has referred to having a "representative." The RO has advised the Veteran about representation in letters dated in April 2010 and May 2010. The Veteran's spouse has generally acted on his behalf and submitted various statements during the appeal. Thus, the RO should seek clarification on the matter of representation. Finally, as noted, the remaining issues concerning increased ratings for the service-connected PTSD to include the question of entitlement to a TDIU rating is being remanded to the RO via the AMC. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. Prior to November 19, 2008, the service-connected PTSD is shown to have been manifested by a level of impairment that more nearly approximated that of occupational and social impairment 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, and chronic sleep impairment. 2. Since November 19, 2008, the service-connected PTSD is shown to have been manifested by a level of disablement that more nearly approximated one manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood and an inability to establish and maintain effective relationships, due to symptoms such as suicidal ideation, near continuous depression and anxiety, difficulty in adapting to stressful circumstances, and impaired impulse control. CONCLUSIONS OF LAW 1. Prior to November 19, 2008, the criteria for the assignment of a rating of 30 percent for the service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 4.1, 4.7, 4.130 including Diagnostic Code (DC) 9411 (2010). 2. Beginning on November 19, 2008, the criteria for the assignment of a rating of 70 percent for the service-connected PTSD are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.130 including DC 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act (VCAA) VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. In this case, notice fulfilling the requirements of 38 C.F.R. § 3.159(b) was furnished to the Veteran in the July 2007, June 2008, and April 2010 letters. Specifically, in these letters the Veteran was notified of VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The claims were readjudicated in February 2011. As this course of action has corrected any initial notice errors, there is no prejudice to the Veteran. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). VA has also fulfilled its duty to assist in obtaining the identified and available evidence needed to substantiate the claims adjudicated in this decision. The RO has either obtained, or made sufficient efforts to obtain, records corresponding to all treatment described by the Veteran. Notably, the Veteran has been afforded VA examinations to address the nature and severity of his service-connected disability. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Hence, the Board is satisfied that all reasonable efforts to develop the record have been made with respect to the claims. As discussed, the Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process, identifying pertinent medical evidence and submitting evidence. Thus, the Veteran has been provided with a meaningful opportunity to participate in the claims process and has done so. Any defect in the sequence of events or content of the notice is not shown to have a prejudicial effect on the case or otherwise to cause injury to the Veteran. Therefore, any such defect is harmless and does not prohibit consideration of the matters addressed hereinbelow. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). To the extent that the action taken hereinbelow is favorable to the Veteran, further discussion is not required at this time. General Legal Criteria Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson, the Court noted an important distinction between an appeal involving a veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection to consider of the appropriateness of "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found), are both required. See Fenderson, 12 Vet. App. at 126; see also Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). The analysis in this decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The question of an extraschedular rating is a component of a claim for an increased rating. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." Id. Therefore, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). The governing norm in these exceptional cases is a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent period of hospitalizations as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2010). Specific Legal Criteria When evaluating mental health disorders, the factors listed in the rating criteria are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; analysis should not be limited solely to whether a Veteran exhibited the symptoms listed in the rating scheme. Rather, the determination should be based on all of a veteran's symptoms affecting his level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The service-connected PTSD currently is evaluated as 30 percent disabling under 38 C.F.R. § 4.130, DC 9411 (2010). This diagnostic code provides: 100% 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 or minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name; 70% 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; 50% Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; 30% 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 impairment, mild memory loss (such as forgetting names, directions, recent events); 10% Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. 38 C.F.R. § 4.130, DC 9411, 9440 (2010). Global Assessment of Functioning (GAF) scores are 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 the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 61 to 70 reflect 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, and has some meaningful interpersonal relationships. 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). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Standard of Review 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. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Analysis The Veteran asserts that increase compensation is warranted for the service-connected PTSD. A rating of 10 percent rating was assigned for the period of this appeal prior to November 19, 2008, and a 50 percent was rating, assigned beginning on November 19, 2008, due to symptoms of difficulty in establishing and maintaining effective work and social relationships, anxiety, depressed mood, panic attacks, chronic sleep impairment, short-term memory loss, difficulty concentrating, irritability, anger outbursts, hyperarousal, and social isolation. Prior to November 19, 2008 As will be discussed, the Board finds that, prior to November 19, 2008, a 30 percent disability rating, and no more is assignable in this case. In conjunction with the current appeal, the Veteran underwent a VA psychiatric examination in June 2007. Here, he reported having symptoms of ruminative anxiety, primarily related to stressors that included loss of his job in November 2006 when he was laid off from work and the death of his brothers. The Veteran denied having symptoms of panic attacks, anger outbursts, assaultiveness, or suicidal ideation or attempts. He reported experiencing depression with malaise and anhedonia occurring for the past two to three years, sleep disturbance, intrusive thoughts, nightmares, hypervigilance, irritability, and nervousness. During the interview, the Veteran reported being close to his siblings and having regular contact, but denied any post-military legal history. He had been married since 1970 to the same woman and described the relationship as positive and well connected without significant conflict or abuse and maintained positive, well connected family relationships as well as having many friends. He discussed how he enjoys recreational fishing, as well as attending Veterans of Foreign Wars (VFW) events in the past. He pursued a General Education Development (GED) certification after leaving active duty, but did not complete the necessary final steps to receive his GED. The examiner noted that the Veteran's general psychosocial functional status post-service appeared to have been marked by the maintenance of a well-connected social network, well-maintained family and marital relationships, and lengthy employment. The examiner opined that the Veteran's current psychosocial functional status appeared to be mildly impaired and that any judgment of his employment was unclear as he was laid off for reasons besides job performance. The examiner observed that the Veteran appeared currently to be able to maintain the routine responsibilities of self-care as well as family role functioning. On mental status examination, the Veteran denied and did not demonstrate impairment of thought processes or communication, delusions, or hallucinations. The examiner noted that the Veteran's eye contact, interaction, and behavior were all appropriate during the session, and that he denied and did not demonstrate current suicidal or homicidal thoughts, ideations, plans or intent, or auditory or visual hallucinations. The examiner indicated that the Veteran appeared to be able to maintain minimal personal hygiene and other basic activities of daily living; was oriented to person, place and time; and denied and did not demonstrate any memory loss or impairment. Further, the examiner noted that the Veteran denied and did not demonstrate obsessive or ritualistic behaviors. His rate and flow of his speech was logical, coherent and sequential. He did not report symptoms consistent with panic attacks, and denied and did not demonstrate impaired impulse control. He endorsed symptoms of depression, depressed mood and anxiety that had recently worsened, as well as sleep impairment. Significantly, the Veteran reported experiencing "premonitions," which included seeing possible future events, usually involving harm that people might experience from accidents or other activities, and possible auditory illusions that occurred on two occasions just after his mother died, where he heard a female voice say something innocuous. He reported no prior or subsequent incident of this symptom. The Veteran was diagnosed with adjustment disorder, with mixed emotional features, and PTSD, chronic, mild severity. The examiner opined that the Veteran's adjustment disorder appeared to be exacerbating his PTSD symptoms and noted that the adjustment disorder was the principal concern, as the Veteran had a long history of managing his PTSD with little impairment. The examiner assigned a GAF score of 70 and concluded that the PTSD caused an occasional decrease in his psychosocial functional status due to signs and symptoms of the disorder, but generally satisfactory functioning. The examiner added that this conclusion was supported by the Veteran's continued maintenance of social and interpersonal relationships and his ability to maintain routine responsibilities of self-care, social and interpersonal relationships, as well as his recreational and leisure pursuits. The VA treatment records, dated from August 2007 to May 2008, showed that an increase in the dosage of an antidepressant improved the Veteran's mood and lessened his anxiety. The Veteran was consistently observed to be awake, alert and oriented to person, place and time. He was described as being calm, pleasant, cooperative and verbal. He generally denying suicidal or homicidal ideation, although he did admit to having thoughts of being better off dead at times. He consistently was observed to be coherent, relevant and goal-directed, with fair memory, poor to fair concentration, and fair attention span, as well as fair judgment and insight. He was assigned a GAF score of 65 in August 2007. Notably, an October 2007 VA practitioner noted that the Veteran's feelings of anxiety and depression were exacerbated by several setbacks during the past year, including the loss of his job and the development of a medical disorder. The practitioner added that the Veteran had gradually healed and recovered from those setbacks and was currently employed in a part-time position that he enjoyed. Significantly, the Veteran did have some worries about experiencing fleeting suicidal ideations frequently whenever he was under stress. Additionally, he was repeatedly treated for poor sleep, chronically mild irritability, mild anxiety, mild depression, and nightmares for which he was prescribed various medications. In a June 2008 statement, the Veteran's wife of 38 years reported her observations of his inability to perform sex, inability to cry or show loving feelings, as well as experiencing war flashbacks, night sweats, difficulty sleeping, outbursts of anger, agitation, and concentration problems, due to his PTSD. She added that he had thoughts of suicide on many occasions and had struggled with his work for 27 years due to his PTSD. In light of the medical evidence prior to November 19, 2008, the Board finds that, the service-connected PTSD is shown to have been productive of a disability picture that more closely resembled the schedular criteria (DC 9411) warranting the assignment of a 30 percent rating. 38 C.F.R. § 4.130. In this regard, the Board notes that the medical evidence and lay evidence of record show reports of and treatment for depressed mood, anxiety and chronic sleep impairment. Additionally, GAF scores assigned during this time ranged between 65 to 70, which reflects some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. The Board acknowledges that during, the June 2007 VA examination, the Veteran reported experiencing premonitions and possible auditory illusions, suggestive of symptomatology that suggested manifestation of greater severity. Moreover, the examiner indicated that his adjustment disorder appeared to be exacerbating his PTSD symptoms. Accordingly, given the credible statements of the Veteran's spouse, the Board finds that the service-connected PTSD is shown to have been productive of a level of overall impairment that exceeded the established standards manifested by decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by continuous medication. Hence, for the initial portion of the appeal prior to November 19, 2008, an increased rating of 30 percent for the service-connected PTSD is warranted. Since November 19, 2008 As discussed, the Board finds that, prior to November 19, 2008, a 70 percent disability rating, and no more, under Diagnostic Code 9411 is assignable in this case. In November 2008, the Veteran underwent a second VA psychiatric examination and denied being hospitalized for a mental disorder, but endorsed treatment with counseling, and with anti-depressant and anti-anxiety medications, with fair results. The Veteran reported living alone with his wife of 38 years and having a close relationship with her. He had one son with whom he had not spoken for over six years. Most of his friends had died, so he primarily spent his time with his wife. The Veteran noted that he enjoys fishing and hunting with his older brother even though he did not like guns. He denied having a history of suicide attempts or of violence/assaultiveness. He struggled with maintaining his emotional balance and avoiding stress in his life. He functioned at an impaired level and depended almost entirely on his wife to the point she described as clinging. On psychological examination, the examiner observed that the Veteran was clean, casually dressed, cooperative, and soft spoken. He was found to have normal memory. He had restless psychomotor activity, constricted affect, anxiety and depressed mood, suicidal and homicidal ideation and rumination, and sleep impairment. The Veteran was observed to be oriented to person, time and place. He denied experiencing delusions, hallucinations, panic attacks or obsessive/ritualistic behavior. The examiner noted no episodes of violence and fair impulse control, and indicated that the Veteran maintained minimum personal hygiene. The VA examiner noted that the Veteran was not currently employed due to his retirement in 2006, due to being eligible by age or duration of work. He was diagnosed with PTSD, chronic, with anxiety, depression and social isolation, and was assigned a GAF score of 55. The examiner noted that the changes in the functional status and quality of life since the Veteran's last examination included routine responsibilities of self-care, physical health, social/interpersonal relationships due to sleep impairment, social isolation, depression, intrusive images/cognitions/dreams, nightmares, anger control and suicidal ideation. The examiner opined that there was not total occupational and social impairment due to the service-connected PTSD, although there were deficiencies in judgment, work, mood and school relations, thinking, family relations and mood. The examiner concluded that there was reduced reliability and productivity due to the PTSD symptoms. The VA treatment records, dated from December 2008, generally reflected treatment for anxiety; suicidal ideation; difficulty concentrating; intermittent morbid thinking without suicidal ideation, plan or intent; difficulty with speech; increased irritability; chronic depression; and auditory hallucinations. Specifically, in January 2009, the Veteran was placed on a psychiatric suicide watch after reporting trouble concentrating on things such as reading the newspaper or watching television, nearly every day; moving or speaking so slowly that other people had noticed; and being so fidgety or restless that other people had noticed, more than half the days; feeling bad about himself or that he was a failure or let down himself or his family, every several days; and thoughts that he would be better off dead or hurting himself in some way, nearly every day. The Veteran was deemed a danger to himself or others by the VA practitioner. He was discharged two days later after denying suicidal and homicidal ideation and being diagnosed with depressive disorder, not otherwise specified. A week after his discharge, the Veteran again reported having suicidal ideation, being depressed, more than half the days, having trouble concentrating, more than half the days, and moving or speaking slowly, or being so fidgety or restless that other people noticed, more than half the days. The Veteran was again classified as a suicide risk. A lay statement submitted by the Veteran's spouse in February 2009, related her contention that his mental disability warranted a 100 percent disability rating, due to his being hospitalized by VA in January 2009 for hypokenesia, which his physician related to his PTSD. A February 2009 VA psychiatric note showed reports of being in a depressed mood most days of the week for more than 2 weeks, abnormally and persistently elevated, expansive or irritable mood for a week or more, to include lashing out when people were giving him "orders," out of the blue anxiety; recurrent and persistent unwanted thoughts, impulses and flashbacks to Vietnam about once a week; auditory hallucinations, to include hearing sounds that were not there like laughter, easily startled, avoidance of social activities, angry feelings or dreams, easily startled, and interpersonal difficulties outside of the home. The Veteran reported being unable to again work in a cemetery because seeing military funerals really stressed and upset him, so he quit his job. He also indicated that he bought a horse in the hope that it would help calm him down. In April 2009 the Veteran began treatment in group psychotherapy at VA. A May 2009 VA psychiatric mental health treatment plan note revealed that a GAF score of 70 was assigned and the practitioner noted the Veteran exhibited poor coping skills, and had poor medical and physical status. An October 2009 VA psychology general note revealed ongoing symptom complaints of irritability and anger outburst with decreased frustration tolerance. A VA psychology note dated later that month reflected findings of anxious/dysphoric mood with restricted affect, and an increase in agitation during trauma history with responsiveness to interventions; however, the practitioner noted that his speech was logical, coherent and sequential, his insight and judgment appeared good, but he did demonstrate symptoms consistent with current suicidal ideation, homicidal ideation, or auditory or visual hallucination. An August 2010 VA treatment report reflected that a GAF score of 70 was assigned, although no formal mental examination was discussed and no explanation for the assigned GAF score was provided. In a subsequent August 2010 VA treatment report, the Veteran reported have been functioning generally well, and managing to participate in daily activities with good family relationships. Notably, a November 2010 VA treatment record showed that the Veteran reported having difficulty with anger for a long time and sometimes getting angry when things are not done fast enough for him. When things got bottled up, he could get loud and had slammed and thrown things. However, he denied making physical threats toward others or becoming physically aggressive with others. Most recently, in September 2010, the Veteran underwent a third VA psychiatric examination. Here, he reported having outpatient treatment for his mental disability from 2007 to the present, to include individual psychotherapy, group therapy, and medication, with good effect. The Veteran reported having marital and family relationships that included close relationships with his wife and several friends, but limited contact with his only son in recent years. He enjoyed leisure pursuits of spending time with friends and fishing. He denied a history of suicide attempts, and of violence/assaultiveness. On examination, the examiner observed the Veteran to be cleanly and casually dressed with fatigued, tense psychomotor activity; to have spontaneous, clear and coherent speech; to be cooperative and have attentive attitude, tearful affect, anxious, depressed, and dysphoric mood; and to have an attention disturbance, to include a short attention span. The examiner noted the Veteran had experienced significant problems with his attention and concentration. He was oriented to person, time, and place, having an unremarkable thought process. However, the examiner noted that thought content included ruminations, and he reported frequent worrying. The Veteran denied experiencing delusions, obsessive/ritualistic behavior, panic attacks, homicidal thoughts, suicidal thoughts, episodes of violence, impaired impulse control, and hallucinations, and had judgment described as understanding the outcome of his behavior and insight described as understanding that he had a problem. The examiner noted chronic sleep impairment, there were no problems with the activities of daily living or with the ability to maintain personal hygiene. The examiner noted that the Veteran acknowledged periods of suicidal ideation since his service, but denied having current suicidal or homicidal ideation, stating that he would not harm himself or others because he did not want to hurt his wife. The Veteran's recent memory and immediate memory were described as mildly impaired, but his remote memory was noted as normal. The Veteran reported frequent short-term memory problems. The examiner indicated that the degree of severity of the Veteran's PTSD symptoms based on psychometric data was found to be severe and that the Veteran's profile reflected significant anxiety, PTSD-related, depressed mood symptoms, anger/hostility, poor self-esteem, emotional alienation, and social avoidance. The examiner noted that the Veteran was not currently employed and had retired in 2006 after losing his job in a lay off. The Veteran was diagnosed with PTSD, chronic, and with depressive disorder, not otherwise specified, and was assigned a GAF score of 52. The examiner indicated that the Veteran presented with moderately severe intensity symptoms. The examiner noted changes in functional status and quality of life since the last examination included family role functioning, social/interpersonal relationships, and recreation/leisure pursuits. The Veteran reported experiencing significant problems with frequent, severe insomnia, with frequent, moderate combat-related reexperiences, anxiety/nervousness, worrying, impaired concentration and memory functioning, irritability, and having social isolation, frequent and moderate to severe depressed mood, and experiencing occasional suicidal thoughts since Vietnam. The Veteran also reported experiencing significant anxiety and mood symptoms since Vietnam. The examiner noted that the Veteran's depression had been very chronic, and had been severe at times during periods of suicidal ideation. However, the VA examiner did not find that there is total occupational and social impairment due to PTSD signs and symptoms, although PTSD signs and symptoms were noted as resulting in deficiencies in thinking. The examiner noted that the Veteran has also struggled with family relations, including alienation from his son and only child. Finally, the examiner opined that there was reduced reliability and productivity due to PTSD symptoms. In light of this recent medical evidence, the Board finds that the service-connected PTSD is shown to have been approaching the schedular criteria (DC 9411) for a 70 percent rating during the course of this appeal beginning on November 19, 2008. 38 C.F.R. § 4.130. The latest GAF score of 52, which is towards the low end of the moderate scale, is reflective of the Veteran's inability to maintain employment, his lack of friends, his poor relationship with his son, his desire to isolate and avoid, his severe depression, and his anger issues. See 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV, for rating purposes] (2010). Accordingly, beginning on November 19, 2008, the assignment of an increased rating of 70 percent for the service-connected PTSD is warranted. Additional Considerations As noted, the Board is not required to remand this matter to the RO for referral actions outlined in 38 C.F.R. § 3.321(b)(1), which concern the assignment of extra- schedular evaluations in "exceptional" cases. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 94-95 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Thun v. Peake, 22 Vet. App. 111, 115 (2008). The Board observes that the Veteran is not currently employed and that the question of a TDIU rating will be addressed in the remand portion of this decision. Consequently, the Board finds that the matter of entitlement to TDIU rating must be deferred at this time. ORDER Prior to November 19, 2008, an increased rating of 30 percent for the service-connected PTSD is granted, subject to the law and regulations governing the award of monetary benefits. Since November 19, 2008, an increased rating of 70 percent for the service-connected PTSD is granted, subject to the law and regulations governing the award of monetary benefits. REMAND The Board observes that a request for TDIU rating, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when the matter of TDIU rating is raised during the appeal of a rating for a disability, it is part of a claim for benefits of the underlying disability. Id at 454. A statement from the Veteran's spouse, received in July 2009, shows that the Veteran had to quit his job at a cemetery, which was the only job he could find after being permanently laid off and that he could not find another job due to his mental disability. The Board finds, therefore, that the record raises the issue of a TDIU claim in this matter. Moreover, in TDIU claims, the Court has held that the duty to assist requires that VA obtain an examination, which includes an opinion on what effect the Veteran's service-connected disabilities have on his ability to work. 38 U.S.C.A. § 5107(a) (West 2002 & Supp. 2010); Friscia v. Brown, 7 Vet. App. 294, 297 (1994); 38 C.F.R. §§ 3.103(a), 3.326, 3.327, 4.16(a) (2010). A review of the claims file does include such an opinion with respect to the TDIU matter. Accordingly, VA examination is warranted in order to obtain an opinion concerning the Veteran's employability. Additionally, the Veteran has not received notice of the evidence needed to substantiate a TDIU claim to date. Such action, and an adjudication of the claim, is needed in view of Rice. As noted hereinabove, the Veteran has indicated via a statement received in April 2011 that he wishes to have a videoconference hearing held from the VAMC. Videoconference hearings are scheduled by the RO. See 38 C.F.R. §§ 20.700, 20.704(a) (2010). Accordingly, the case is REMANDED to the RO for the following action: 1. The RO should take appropriate steps in order to schedule the Veteran for a personal hearing with a Veterans Law Judge at the VAMC in Wilkes-Barre, PA, in accordance with his request. 2. The RO also should furnish the Veteran with a notice letter addressing the type of evidence needed to establish his claim and the relative duties of VA and the claimant in obtaining such evidence. This letter should also set forth VA's practices in assigning disability ratings and effective dates for those ratings. 3. The RO should schedule the Veteran for a VA examination to address his entitlement to increased ratings for the period, to include whether he is whether he warrants a TDIU rating. The claims file must be reviewed by the examiner. All indicated tests should be performed and all findings should be reported in detail. Specifically, the examiner should provide an opinion as to whether, without regard to the Veteran's age or the impact of any nonservice-connected disabilities, it is at least as likely as not (50 percent probability or more) that his service-connected disabilities, either separately or in combination, would render him unable to secure or follow a substantially gainful occupation consistent with his education and occupational experience. The examiner should set forth the complete rationale for all opinions expressed and conclusions reached. If the Veteran fails, without good cause, to report to the scheduled examination, apply the provisions of 38 C.F.R. § 3.655(b), as appropriate. 4. Following completion of all indicated development, the RO should readjudicate the issues remaining on appeal based on all of the evidence of record. If any benefit sought on appeal remains denied, and the Veteran should be furnished with a fully responsive Supplemental Statement of the Case and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter 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). ____________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs