Citation Nr: 1134572 Decision Date: 09/15/11 Archive Date: 09/23/11 DOCKET NO. 06-26 807 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an effective date earlier than August 8, 2005, for an initial 70 percent rating for posttraumatic stress disorder (PTSD). 2. Entitlement to an effective date earlier than August 8, 2005, for the grant of a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and Appellant's Spouse ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran served on active duty from January 1965 to April 1968. This appeal to the Board of Veterans' Appeals (Board) is initially from a February 2004 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, that granted service connection for PTSD and assigned an initial 30 percent rating, effective August 29, 2002. In a September 2005 rating decision, the RO increased his initial rating for PTSD to 70 percent, effective August 8, 2005, and granted TDIU, also effective August 8, 2005. Jurisdiction over his claims was subsequently transferred to the RO in Waco, Texas. In March 2009, the Veteran testified at a hearing at the RO in March 2009, before the undersigned Veterans Law Judge (VLJ). At the hearing the Veteran submitted additional evidence and waived his right to initial RO consideration. In July 2009 the Board remanded this case for further development. The issue of entitlement to an effective date prior to August 8, 2005, for the grant of a TDIU is addressed in the REMAND portion of the decision below and REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. In a September 2005 rating decision the RO increased the evaluation of the Veteran's PTSD to 70 percent disabling, effective August 8, 2005. 2. The medical evidence of record reveals that the Veteran's PTSD manifested symptoms more nearly approximate to an evaluation of 70 percent disabling beginning April 7, 2004. CONCLUSION OF LAW An effective date of April 4, 2004, for the award of an evaluation of 70 percent disabling for PTSD, is warranted. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. §§ 3.400, 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Because the application of the law to the undisputed facts is dispositive of this appeal, no discussion of VA's duties to notify and assist is necessary. See Mason v. Principi, 16 Vet. App. 129 (2002). In addition, as the Veteran indicated in his notice of disagreement, dated in November 2005, that he believed that his effective date should be April 18, 2004, the Board finds that a grant of entitlement to an effective date of April 7, 2004, represents a complete grant of the benefit sought on appeal. The general rule with respect to effective date of an award of increased compensation is that the effective date of award "shall not be earlier than the date of receipt of the application thereof." 38 U.S.C.A. § 5110(a). This statutory provision is implemented by regulation that provides that the effective date for an award of increased compensation will be the date of receipt of claim or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). The Board notes that this includes informal claims which are "[a]ny communication or action, indicating intent to apply for one or more benefits under the laws administered by the Department of Veterans Affairs, from a claimant, [or] his or her duly authorized representative." 38 C.F.R. § 3.155(a) (2010). An exception to that rule regarding increased ratings applies, however, under circumstances where the evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. If an increase in disability occurred within one-year prior to the claim, the increase is effective as of the date the increase was "factually ascertainable." If the increase occurred more than one year prior to the claim, the increase is effective the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. 38 U.S.C.A. 5110(b)(2); Dalton v. Nicholson, 21 Vet. App. at 31-32; Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. 3.400 (o)(1)(2); VAOPGCPREC 12-98 (1998). 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 (West 2002); 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2010). Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2 (2010); resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (2010); where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (2010); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10 (2010). See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal arises from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2010); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran seeks entitlement to an effective date earlier than August 8, 2005, for the award of an evaluation of 70 percent disabling for PTSD. The Veteran's PTSD is currently evaluated as 70 percent disabling, for the period beginning August 8, 2005, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Under Diagnostic Code 9411 a 30 percent disability rating 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 disability 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 disability 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; obessional 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 disability 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 ability 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 psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Words such as "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. 4.6 (2010). Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Board further notes that a Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). The Board notes that an examiner's classification of the level of psychiatric impairment, by a GAF score, is to be considered but is not determinative of the percentage rating to be assigned. VAOPGCPREC 10-95. 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). Scores ranging from 31 to 40 reflect 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 other children, is defiant at home, and is failing at school). See 38 C.F.R. § 4.130. Vet Center treatment notes dated from November 2002 indicate that the Veteran reported increasing sleep, anger, energy, and marital difficulties. He reported three failed marriages. He stated that he became obsessive and has had an increase in flashbacks. On mental status examination there was no evidence of delusions, disorganized thinking, or hallucinations. He had an excessive appetite, recent weight gain, sleep disturbance, low energy level, no recent losses, and his sex drive had changed. He denied suicidal and homicidal thoughts. He was noted to have extremely loud speech and to be disconnected from emotional content. The Veteran reported that since service he has had extreme difficulty with social and interpersonal relationships. He has been in three unsuccessful relationships and has had difficulty in all places he has been employed. He reported that he worked as a mechanic after discharge from the military. His longest employment was for a number of years as a mechanic. He lived in multiple residences largely due to his history of failed relationships and anger problems. He possessed weapons. He reported that immediately after discharge he drank but gave it up shortly and had nothing to drink since having a religious experience protestant 15 years prior to the examination. The Veteran stated that he received no compensation or pension and was looking for insight into anger and problems related to PTSD as well as relationship help. The assessment of the Vet Center counselor was that the Veteran experienced extreme anger problems and extreme family issues. He experienced an increase of flashbacks, nightmares, and hypervigilence. The Veteran pushed relationships away and avoids emotions. He was oriented times three during evaluation, speech was pressured and goal directed. There was no evidence of hallucinations or delusional content though the Veteran was noted to have a tendency at times to become obsessive and slightly paranoid. His motivation for treatment was good and he had support from his current spouse and extended family but the relationships were severely strained. Private counseling records dated January 2003 to December 2003 reveal that the Veteran had symptoms of ongoing nightmares, periodic reliving of experiences, mood problems, periodic experience of pseudo dissociative states, poor concentration, flattened affect, intense anger outbursts, difficulties in relationships, depression, feeling on edge, detachment, feelings of hopelessness, avoidance of friendships, and flashbacks. The Veteran was afforded an examination in September 2003. He indicated that he had private counseling in 1995 and then that he had been in private counseling for the prior two or three years on a twice a month basis. He also reported that he was in counseling in 1992. The examiner noted that the Veteran had a psychiatric admission while still in service. The Veteran denied having suicidal ideation. The Veteran's work history was examined and the examiner indicated that the Veteran had been at his most recent job since March 2003. He reported that his longest period of employment was for three years until 1997 when he could no longer work due to the pain from his fibromyalgia. He returned to work at the same place later and was fired in 2001. The Veteran reported nightmares and getting up between 2 a.m. and 5 a.m. The Veteran reported stressors at work. The examiner reports that the Veteran lost his job as a mechanic due to difficulties with his manager. The Veteran reported that he does some volunteer work and that he was a youth football coach in the past. The Veteran stated that he generally got along "good" with people, but that he did not have any close friends. His self-esteem was "OK". His appetite was reported as variable and his weight fluctuated. He reported that his concentration and memory were bad but that he did not know why. He indicated that he helped his wife with the activities of daily living. He had been married three times. At the time of the examination the Veteran had been married to his third wife for 16 years. The first and second marriages lasted one year each. He stated that he got along well with his oldest child but the youngest son would not talk to him. The Veteran reported that he still spoke with his father. He reported going to church. The Veteran had nightmares approximately every other night if he has reminders and averaged approximately one nightmare a week. He had waking recollections about once a month but that depended upon what he is exposed to that might remind him of his service. With reminders he tries to distract himself and avoid thoughts, feeling, conversations, activities, places, or people that remind him of Vietnam. The Veteran stated that he did not participate in activities like hunting due to his experience in Vietnam. He felt more detached from people as a result of his Vietnam experience. He had difficulty with sleep and anger and difficulty with concentration. He described hypervigilence and exaggerated startle response. The examiner noted that the Veteran's medical history shows he has had difficulty performing routine activities and could get so overwhelmed he could not function. The Veteran was punctual for his appointment, neatly attired, and mildly overweight. He was psychomotor appropriate, smiled and laughed frequently, had a mood that was neutral with congruent pleasant affect though there were times when he was frustrated by having to give history. There was no thought disorder. He was not psychotic or suicidal and was not hallucinating, disorganized, paranoid, or delusional. At times there were incongruent responses in that he would chuckle or laugh when talking about getting angry. The examiner diagnosed the Veteran with PTSD and alcohol abuse in remission. The Veteran was assigned a GAF score of 64 for PTSD. The examiner stated that the Veteran had some difficulty establishing and maintaining effective work and social relationships and that he had mild symptomology in that regard. He did not have difficulty understanding complex commands and he was not a danger to himself or others. From April 2004 to May 2004 the Veteran was treated as an inpatient by VA for his PTSD. Upon admission mental status examination revealed the Veteran to be alert and oriented times three and in no apparent distress. His speech was of normal rate and cadence. There was no psychomotor agitation or retardation, mood and affect appeared depressed, and his affect was flat. The Veteran denied suicidal ideation, homicidal ideation, and hallucinations. He had no psychosis and his memory was fair. The Veteran was motivated to seek assistance. The Veteran was diagnosed with posttraumatic stress disorder, depression not otherwise specified, and nicotine dependence in full remission. The Veteran was assigned a GAF score of 40. Later in April 2004 the Veteran was noted to have intrusive thoughts of his military experiences, nightmares, night sweats and tearing up the bed, flashbacks, and psychological and physical reactivity to reminders. He endorsed six of seven avoidance/numbing symptoms including avoiding thinking or talking about the trauma as well as reminders of it. He was much less interested in doing things that used to be important, felt detached from others, restricted range of affect, and a sense of foreshortened future. The Veteran endorsed all five symptoms of increased arousal including difficulties in both getting to and staying asleep, irritability with outbursts of anger, trouble concentrating, hypervigilence, and exaggerated startle response. The Veteran endorsed symptoms of depression. He denied active suicidal ideation or history of such. The Veteran acknowledged periods of homicidal ideation. He indicated that when angry he generally storms around and throws things. The Veteran was diagnosed with PTSD and depression and assigned a GAF score of 43. In May 2004 the Veteran was noted to have avoidance of reminders, chronic anxiety with panic attacks, depression, emotional numbing, exaggerated startle response, feelings of detachment, flashbacks of traumatic events, hypervigilence, insomnia, intrusive memories or trauma, nightmares, poor concentration, sense of foreshortened future, and survival guilt in regard to his PTSD. The symptoms were noted to manifest significant impairment in social functioning, purposeful activity, community involvement, and/or ability to work. The Veteran was assigned a GAF score of 45. Upon discharge from the inpatient program at VA in May 2004 the Veteran was diagnosed with PTSD and depression and assigned a GAF score of 49. The Veteran was afforded a VA Compensation and Pension (C&P) PTSD examination in November 2004. The examiner noted that the Veteran had been married three times and that his first marriage lasted one year, his second lasted 18 years, and his third lasted 16 years. The Veteran was in the PTSD program in Tacoma, Washington, from April 2004 to May 2004 and was noted to have been in the hospital the week prior to the examination for a heart condition, cluster headaches, and a spot on his lungs along with joint pain. The Veteran received weekly care for his PTSD at the VA. The Veteran reported loss of memory, anxiety, losing his temper easily, and nightmares. He reported that the group helped with his PTSD. The symptoms occurred at least once a week. The severity of the symptoms had stayed the same except for the nightmares. The duration of the symptoms were reported to last the whole day or days and sometimes less. The Veteran reported that he was not working and that he last worked in 2000 as a mechanic. He stated that he stopped working due to his pain. He reported having a good relationship with his first son and his second son was beginning to talk with him. He reported that his relationship with his current wife was borderline because of his behavior. He stated that he went to church and that he and his wife had no friends. He reported that he enjoyed fishing. He had a history of verbal violence and breaking things. He had thoughts of suicide and no attempts. Mental status examination revealed no impairment of thought process or the ability to communicate. He reported sometimes seeing things that are not there and hearing his name being called. The Veteran had good eye contact and interacted with appropriate behavior. He had suicidal thoughts but no attempts and some homicidal thoughts when angry but no attempts. He was able to maintain good personal hygiene and to handle basic activities of daily living. He was oriented to person, place, and time. He did not have any memory impairment. He reported no obsessive or ritualistic behavior. The rate and flow of speech were good. He reported panic attacks caused by people in close quarters. The attacks were noted to make him anxious and he cannot stand still. The attacks last as long as he is in the presence of crowds of people. On a scale of 1 to 10, with 10 being most depressed, he rated himself a 6. He was friendly and cooperative. He did not cry and exhibited adequate energy. He reported trouble with impulse control and is easily angered. He did not have trouble going to sleep but if he awakes at night he did have trouble going back to sleep. The Veteran was diagnosed with PTSD and assigned a GAF score of 65. A November 2004 VA treatment note states that the Veteran was not doing quite as well on a dosage reduction and that he felt a little more antsy and irritable. The Veteran's affect was calm and euthymic, and his thought process was linear. He had no homicidal ideation, suicidal ideation, audio hallucinations, visual hallucinations, or delusions. Nightmares and recollections were under control. The Veteran was diagnosed with PTSD. A January 2005 VA treatment note states that the Veteran reported a bad episode recently. The Veteran argued with his wife and reported some minimized nightmares. His affect was calm and euthymic. Mood was edgy from the marital issue. The thought process was linear. There was no suicidal or homicidal ideation or hallucinations. The Veteran was diagnosed with PTSD. A March 2005 VA treatment note reveals that the Veteran had a poor sleep pattern. He reported 2 to 3 hours of sleep at most and that his sleep was restless. He wakes up at night and paces the floor. He was noted to have anxiety. He reported that he felt anxious all the time but no descriptors of panic attacks. He stated that he felt down all the time and rated his depression as 8 out of 10 with 10 being most severe. The Veteran's wife reported that the Veteran was extremely irritable and had mood swings on a daily basis. The Veteran stated that sometimes he just wanted to escape as quickly as he could. He reported that in the past when he became depressed he would leave home for several weeks and use his unemployment to buy liquor without taking care of his family. He stated that he had episodic suicidal thoughts but had no plans and no past history of suicidal attempts. He reported that he felt "on-guard" at times but not as bad as he used to. He stated that he continued to be easily aroused by loud noises such as a car backfiring, helicopters, etc. He had avoidance and preferred being alone when possible. He had an ambivalent sense of future. He reported that he felt paranoid most of the time and his wife corroborated the paranoia. He stated that the holiday season had always been terrible for him and that his family does not celebrate the holidays for that reason. Mental status examination revealed the Veteran to be appropriately dressed and groomed. His behavior was anxious and guarded but he responded to most questions. He exhibited no signs or symptoms of disorganized thinking, mania, delusional beliefs or other paranoia. He was alert and oriented times three. There were no gross deficits of cognition. Judgment had been poor for many years and many instances of impulsivity have occurred that were very negative for the Veteran and his family at the time of the behavior. He was aware of his problems and was seeking active treatment. He was negative for suicidal and homicidal ideation. He was diagnosed with PTSD, chronic with delayed onset with significant symptoms of depression overlaying his PTSD. A March 2005 VA treatment note states that the Veteran had restricted expression, occasional sociability, minimal problem solving difficulties, mild verbalized decision making difficulties, and mild frustration symptoms. The Veteran was clean and neat in appearance. He was passively friendly and cooperative. He was able to work productively on a complex task following the recommended procedure with good quality workmanship. He needed minimal assistance for problem solving and he socialized occasionally with staff and select peers. His affect was restricted. An April 2005 VA treatment note states that the Veteran worked productively on a project, socialized and participated in the planned group activity. In an April 2005 statement, Dr. P.P. reports that the Veteran reexperienced events from service through images, thoughts, and perceptions. He had dreams of the events that occurred and sleeplessness. He experienced physiological and psychological cues that reminded him of experiences in Vietnam. He made significant efforts to avoid thoughts, feelings, and conversations regarding Vietnam. His interactions with other Veterans had improved. The Veteran avoided activities, places, and people that would remind him of the traumas. He reported that there were certain events that he knew occurred but that he had trouble recalling specifics. He did not participate in activities outside of when he was working and when he has work to do around his house. He often procrastinated and did not get things done that he need to do such as taking care of the bills, or helping around the house, despite his spouse's frustration. He reported not feeling close to anyone and that he could not tell others how he felt despite wanting to let them know. He showed symptoms of increased arousal, sleep difficulties, irritability, outbursts of anger, difficulty concentrating, and hypervigilence. The Veteran was diagnosed with PTSD, chronic and severe, with delayed onset and assigned a GAF of 50. A review of the record reveals that the Veteran's PTSD manifested symptoms more nearly approximate to the criteria for an evaluation of 70 percent disabling beginning April 7, 2004. Prior to April 7, 2004, the Veteran's PTSD manifested extreme anger, extreme family issues, flashbacks, nightmares, hypervigilence, pushed relationships away and avoided emotions. The Veteran was oriented times three, speech was pressured and goal directed. There was no evidence of hallucinations or delusional content though the Veteran was noted to have a tendency at times to become obsessive and slightly paranoid. His motivation for treatment was good and he had support from his current spouse and extended family but the relationships were severely strained. He had indicated that he had never been suicidal but that he loses his temper. He was noted to do some volunteer work and to generally get along well with people but to have no close friends. He attended church. He reported that his concentration and memory were bad but that he did not know why. He indicated that he helped his wife with the activities of daily living. He got along well with his oldest child but his youngest son would not speak with him. The Veteran had nightmares approximately every other night if he has reminders and averaged approximately one nightmare a week. He had waking recollections about once a month but that depended upon what he is exposed to that might remind him of his service and tried to distract himself and avoid thoughts, feeling, conversations, activities, places, or people that remind him of Vietnam. He stated that he did not participate in activities like hunting due to his experience in Vietnam and felt more detached from people as a result of his Vietnam experience. He had difficulty with sleep and anger and difficulty with concentration. He described hypervigilence and exaggerated startle response. He was noted to have difficulty performing routine activities and could get so overwhelmed that he could not function. He was neatly attired, mildly overweight, and psychomotor appropriate. He was psychomotor appropriate, smiled and laughed frequently, had a mood that was neutral with congruent pleasant affect though there were times when he was frustrated by having to give history. There was no thought disorder. He was not psychotic or suicidal and was no hallucinating, disorganized, paranoid, or delusional. At times there were incongruent responses in that he would chuckle or laugh when talking about getting angry. Prior to April 2004 the Veteran was assigned a GAF score of 64 for PTSD representing mild symptoms or some difficulty in social, occupational, or school functioning. The Veteran was noted to have some difficulty establishing and maintaining effective work and social relationships and that he had mild symptomology in that regard. He did not have difficulty understanding complex commands and he was not a danger to himself or others. As the Veteran's PTSD did not manifest 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; obessional 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; spatial disorientation; neglect of personal appearance and hygiene; and/or inability to establish and maintain effective relationships, the Board finds no entitlement to an evaluation of 70 percent disabling prior to April 2004. Beginning in April 2004, the Veteran's PTSD manifested nightmares, night sweats and tearing up the bed, flashbacks, psychological and physical reactivity to reminders, detachment, restricted range of affect, foreshortened sense of future, difficulties in both getting to and staying asleep, anxiety, loss of memory, irritability with outbursts of anger, troubles concentrating, hypervigilence, exaggerated startle response, and poor concentration. He admitted periods of homicidal ideation and anger. The Veteran was noted to have significant impairment in social functioning, purposeful activity, community involvement, and/or ability to work. The Veteran reported verbal violence and that he would break things. He reported thoughts of suicide but no attempts. He reported panic attacks caused by people in close quarters. The attacks were noted to make him anxious and he cannot stand still. The attacks last as long as he is in the presence of crowds of people. On a scale of 1 to 10, with 10 being most depressed, he rated himself a 6. He was noted to be friendly and cooperative. He exhibited no crying and exhibited adequate energy. He reported trouble with impulse control and gets angry easily. He did not have trouble going to sleep but if he awakes at night he did have trouble going back to sleep. He reported poor sleep patterns. The Veteran's wife reported that the Veteran was extremely irritable and had mood swings on a daily basis. He reported that he felt paranoid most of the time and his wife corroborated the paranoia. He did not participate in activities outside of when he was working and when he has to do around his house. Examinations revealed no impairment of thought process or ability to communicate. He reported sometimes seeing things that are not there and hearing his name being called. The Veteran had good eye contact and interacted with appropriate behavior. He had suicidal thoughts but no attempts and some homicidal thoughts when angry but no attempts. He was able to maintain good personal hygiene and to handle basic activities of daily living. He was oriented to person, place, and time. He did not have any memory impairment. He reported no obsessive or ritualistic behavior. The rate and flow of speech were good. Since April 7, 2004 the Veteran has been assigned GAF scores of 40, 43, 45, 49, 65, and 50, representing predominantly severe symptoms or any serious impairment in social, occupational or school functioning. As the manifestations of the Veteran's PTSD most nearly approximate the criteria for an evaluation of 70 percent disabling beginning April 7, 2004, entitlement to an effective date of April 7, 2004, for the award of the evaluation of 70 percent disabling for PTSD is granted. ORDER Subject to the law and regulations governing payment of monetary benefits, an effective date of April 7, 2004, for the award of an evaluation of 70 percent for PTSD is granted. REMAND The claims file reveals that the Veteran receives regular VA treatment for his PTSD, including group therapy sessions twice a month. He reports being treated at the Temple and Waco VA Medical Centers in Texas; however, the most recent VA treatment records associated with the claims file are dated in April 2005. At the Veteran's March 2009 hearing, his representative reported that the Veteran "requested assistance with Vocational training" in May 2005 and that he was found to be infeasible because of the symptoms of his PTSD. Subsequently, the Veteran's representative stated that the Veteran applied for "vocational training" in May 2003 and that the Veteran was found infeasible for any kind of vocational training. Review of the claims file does not reveal any records regarding a claim for "vocational training" or Vocational Rehabilitation services. VA is required to make reasonable efforts to help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody. See 38 U.S.C.A. § 5103A(b)(1); 38 C.F.R. § 3.159(c)(1). In Bell v. Derwinski, 2 Vet. App. 611 (1992), the Court held that VA has constructive notice of VA generated documents that could reasonably be expected to be part of the record, and that such documents are thus constructively part of the record before the Secretary and the Board, even where they are not actually before the adjudicating body. Thus, VA must attempt to obtain VA clinical records dated since April 2005, records regarding any application for Vocational Rehabilitation, and, after receipt of appropriate authorization, private treatment records dated since April 2006. The record shows that the Veteran indicated in May 2004 that he intended to file for benefits from the Social Security Administration (SSA). To date, VA has not obtained any SSA determination or the medical records on which any decision was made. Because any SSA's decision regarding the Veteran and the records upon which the agency based its determination are potentially relevant to VA's adjudication of this case, VA must attempt to obtain and consider those records in adjudicating this appeal. 38 U.S.C.A. § 5103A(c)(3) (West 2002); 38 C.F.R. § 3.159(c)(2) (2010); see also Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010); Diorio v. Nicholson, 20 Vet. App. 193, 199-200 (2006). For this reason as well, this case must be remanded. The Veteran has been awarded TDIU, effective August 8, 2005, based upon the date of a VA examination wherein the Veteran was noted to be unemployable primarily due to his PTSD. The Board notes that based upon the above decision to grant an effective date of April 7, 2004, for an evaluation of 70 percent disabling for PTSD, the Veteran meets the schedular criteria for a TDIU beginning April 7, 2004. However, to date, there is no opinion of record addressing whether the Veteran's PTSD rendered him unemployable since April 2004. Retrospective medical opinions are permitted in determining disability ratings. See Chotta v. Peake, 22 Vet. App. 80 (2008); see also Vigil v. Peake, 22 Vet. App. 63 (2008). As such, the Board finds it necessary for the Veteran's claims file to be reviewed and for an opinion to be rendered regarding whether he was unemployable due to his PTSD prior to August 2005. Accordingly, the case is REMANDED for the following action: 1. Attempt to obtain records regarding any application of the Veteran for VA Vocational Rehabilitation and VA medical records pertaining to the Veteran that are dated since April 2005, including those at the Temple and Waco VA Medical Centers. Any additional pertinent records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran, and associated with the claims file. 2. Attempt to obtain from the SSA the records pertinent to the Veteran's claim for SSA disability benefits and any medical records concerning that claim. All efforts to obtain the records should be fully documented, a negative response should be requested if no records are available. 3. Thereafter, schedule the Veteran for a retrospective examination to ascertain the impact of his service-connected disabilities on his unemployability for the period prior to August 8, 2005. The examiner must evaluate and discuss the effect of all of the Veteran's service-connected disabilities, both singly and jointly, on the Veteran's employability. The examiner should opine as to whether it is at least as likely as not that the Veteran's service-connected disabilities, without consideration of his non-service- connected disabilities, rendered him unable to secure or follow a substantially gainful occupation prior to August 8, 2005. The examiner should review the claims folder and the examination report should indicate that review. 4. Then readjudicate the appeal. If the benefits sought on appeal are not granted, issue the Veteran and his representative a supplemental statement of the case and provide them an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs