Citation Nr: 1128530 Decision Date: 08/01/11 Archive Date: 08/10/11 DOCKET NO. 07-27 717 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a disability evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD), on appeal from an initial grant of service connection. 2. Entitlement to service connection for a cardiovascular disorder, inclusive of hypertension, to include as being secondary to the service-connected psychiatric disorder. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney WITNESSES AT HEARING ON APPEAL Appellant, his spouse, and his son ATTORNEY FOR THE BOARD Patrick J. Costello, Counsel INTRODUCTION This matter comes before the Board of Veterans' Appeals (Board or BVA) on appeal from an October 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida that denied the benefits sought on appeal. The Veteran, who had active service from August 1966 to November 1969, appealed that decision to the BVA and the case was referred to the Board for appellate review. The issues subsequently perfected to the Board included the following: 1. Entitlement to service connection for hypertension. 2. Entitlement to an increased initial evaluation for post traumatic stress disorder (PTSD), currently evaluated at 50 percent disabling. 3. Entitlement to an effective date prior to May 12, 2006 for service connection for PTSD. The Board acknowledges that the Veteran filed a claim for service connection for hypertension in November 1972. The claim was apparently disallowed in February 1973 because the Veteran failed to appear for a VA examination. However, the Board also notes that the Veteran was not informed of the disallowance. Hence, the Board must address the issue of entitlement to service connection for hypertension without regard to any prior disallowance. Upon reviewing the claim, the Board issued a Decision/Remand in May 2009. The Board found that the evidence did not support the assignment of a disability evaluation in excess of 50 percent for the service-connected psychiatric disorder. It further concluded that an effective date earlier than May 12, 2006, could not be assigned. Finally, the remaining issue, that involving a cardiovascular disorder, was remanded to the RO via the Appeals Management Center (AMC), in Washington, DC, for the purpose of obtaining additional evidence. The Veteran was then notified of the Board's action. After reviewing the May 2009 action, the Veteran appealed to the United States Court of Appeals for Veterans Claims, hereinafter the Court. The issue that that was reviewed was that involving an increased evaluation. Upon review, and after the Secretary and the Veteran's attorney submitted a Joint Motion for an Order Partially Vacating and Remanding the Board Decision, the Court concluded that the parties' motion had merit. Hence, the Board's action on the increased rating issue was vacated and subsequently returned to the Board for additional action. After the increased rating issue was returned to the Board, the Board remanded that issue in May 2010 so that additional medical information could be obtained and included in the claims folder. Both issues, those involving a cardiovascular disorder and PTSD, have since been returned to the Board for appellate review. Upon reviewing the development since February 2010, the Board finds there has been substantial compliance with its remand instructions with respect to the Veteran's PTSD claim. The Board notes that the Court has noted that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." 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 violation when the examiner made the ultimate determination required by the Board's remand, because such determination "more than substantially complied with the Board's remand order"). The RO was tasked by the Board to obtain additional medical evidence with respect to the Veteran's psychiatric disorder, and it has done so. Specifically, the RO was asked to obtain an examination of the Veteran along with an opinion concerning the Veteran's employability. The RO was also tasked to obtain and include in the claims folder medical treatment records. The results of that request and the treatment records have been included in the claims folder for review. The results were returned to the RO which, in turn, issued a Supplemental Statement of the Case in response to the information obtained. Based on the foregoing, the Board finds that the RO substantially complied with the mandates of the Board's most recent remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (finding that a remand by the Board confers on the Veteran the right to compliance with the remand orders). Thus, the Board will proceed to review and decide the claim based on the evidence that is of record. The issue of entitlement to service connection for a cardiovascular disorder, inclusive of hypertension, is addressed in the REMAND portion of the decision below. FINDING OF FACT The Veteran's PTSD is manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, but is not productive of total occupational and social impairment. CONCLUSION OF LAW The criteria for a disability evaluation of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1-4.14, 4.125-4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDING AND CONCLUSION The Board initially notes that it has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2010). 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 or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA 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) must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Here, the Veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, once service connection was granted there was no further duty to notify. Moreover, to the extent that there may be any deficiency of notice or assistance, there is no prejudice to the Veteran proceeding with this issue given the favorable nature of the Board's decision. The duty to assist has been met as the RO obtained VA medical records and a recent VA examination. The medical information of record is adequate as the examination was based on a consideration of the medical history, a mental status examination was performed, and the disability was described in sufficient detail such that the Board can render an informed decision. Disability evaluations are determined by evaluating the extent to which the Veteran's service-connected disabilities affect the ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. With respect to the issue before the Board, the appeal stems from a disagreement with an evaluation assigned in connection with the original grant of service connection, and as such, the potential for the assignment of separate, or "staged" ratings for separate periods of time, based on the facts found, are for consideration. Fenderson v. West, 12 Vet. App. 119 (1999). VA must determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim - a practice known as "staged ratings." See also Hart v. Mansfield, 21 Vet. App. 505 (2007). An evaluation of the level of disability present also includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. As reported above, the Veteran has been assigned a 50 percent disability rating pursuant to the criteria found at 38 C.F.R. Part 4, Diagnostic Code 9411. 38 C.F.R. § 4.130 establishes a general rating formula for mental disorders. The formula assesses disability according to the manifestation of particular symptoms, providing objective criteria for assigning a disability evaluation. Under the criteria, a 30 percent disability rating is warranted 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, or recent events). A 50 percent rating is warranted for 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. The next higher rating, a 70 percent rating, may be assigned for 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. The highest, or 100 percent schedular evaluation, 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. 38 C.F.R. Part 4, Diagnostic Code 9411 (2010). Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM- IV). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to DSM-IV. See 38 C.F.R. § 4,125(a). Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The 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). 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). In determining whether an increased evaluation is warranted, the VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case an increased rating must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107. The evidence for consideration includes VA treatment records, private psychiatric reports, VA examination reports, and the Veteran's statements in support of his claim. Also for consideration are the written statements provided by the Veteran's accredited representatives in support of the claim. The Veteran attended an initial psychological assessment in February 2006. He reported chronic insomnia and anhedonia. At that time, the examiner noted that Veteran's appearance was appropriate, but that he avoided eye contact. His mood was anxious and his affect was constricted. His thought processes were somewhat racing, tangential, and rambling at times. He denied suicidal/homicidal ideation and he was oriented, with his memory intact. The diagnoses recorded following the examination were R/O [rule out] PTSD, major depression and anxiety. The GAF score was 60. Another examination was afforded to the Veteran in August 2006. During the examination he appeared clean and casually dressed. His speech was overabundant. His mood was depressed and his affect appropriate. The Veteran was oriented regarding person, time, and place. His attention was intact and his attitude cooperative. The examiner stated that the Veteran's thought process was rambling with an overabundance of ideas and circumstantiality. He was verbose and had to be re-directed. He did report visual hallucinations that seemed to be illusions rather than psychotic symptoms. He reported no panic attacks and no homicidal/suicidal ideation. The examiner noted his impulse control as fair with episodes of violence. His remote and recent memory was mildly impaired, although his immediate memory was normal. The Veteran reported difficulty falling or staying asleep, irritability, outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. The diagnosis following the examination was chronic PTSD, and the GAF score assigned was 50. From March 2006 to July 2007, per the medical treatment records, the Veteran's mood remained dysthymic and anxious at most psychological appointments. He appeared oriented with his insight and judgment intact and no evidence of psychosis. He consistently reported nightmares and sleep disturbances. The Veteran also continuously complained of self-isolating behavior and general anhedonia. When his appearance was noted, the examiner consistently reported that the Veteran was neat, casually, or normally dressed and groomed. More specifically, in March 2006, the Veteran's speech was defensively evasive and circumstantial to tangential. His insight and judgment were limited to fair. The Veteran showed no homicidal/suicidal ideation in June 2006 and September 2006. In October 2006, the Veteran's mood was more euthymic. He showed no homicidal/suicidal ideation. In January 2007, the Veteran admitted to some suicidal and homicidal ideation, but denied any actual intent or plans. In February 2007, the Veteran had no suicidal ideation, but was concerned about his rage. His affect was restricted and somewhat intense. His speech was normal to increased in volume. In May 2007, the Veteran complained of increased anxiety, depression, and irritability. He remained self-isolated and hypervigilant. In June 2007, the Veteran reported less irritability, although the intrusive memories and olfactory flashbacks continue. He showed no suicidal/homicidal ideation. He was alert and oriented with a restricted affect. His speech was normal and his insight and judgment were fair. The examiner noted that the Veteran's depression was secondary to his PTSD. Two more VA psychiatric examinations were accomplished in September 2010 and February 2011 respectively. For the first examination, the examiner reviewed the Veteran's claim prior to the examination. It was first reported that the Veteran was not stringent in ensuring that he was taking his prescribed medications for his psychiatric disorder. The examiner found that the Veteran was talkative, his affect was appropriate, his mood was apathetic, and he was oriented to time, place, and person. The examiner further reported that the Veteran was not experiencing hallucinations, homicidal thoughts, or suicidal ideations. The Veteran was maintaining minimum personal hygiene and was reporting not having problems with the activities of daily living. Nevertheless, the Veteran's memory was questionable even though the examiner wondered whether the Veteran was over exaggerating his memory-loss symptoms. It was further found that the Veteran was experiencing recurrent and intrusive recollections and he was detached/estranged from others. The Veteran suffered from hypervigilance, sleeplessness, nightmares, irritability, and outbursts of anger. The examiner went on to opine that the Veteran was not totally occupationally and socially impaired. She further stated that it was her opinion that "the degree of social impairment due to PTSD would be estimated as moderate." It was noted that the Veteran's other nonservice-connected psychiatric disorders also had an effect on the Veteran's ability to cope with everyday living. The second VA examination took place in February 2011. The examiner reviewed the Veteran's claims folder before the examination. It was reported that the Veteran was taking prescription medications for the treatment of his psychiatric symptoms and manifestations. Also noted on the examination report was the fact that the Veteran was undergoing individual, verses group, therapy. The examiner indicated that the Veteran was living with his wife of twenty-one years and that he had contact with his sons and grandchildren. However, additional social contact with others was not reported. Instead, the report suggested that the Veteran avoided nonfamily members because of his tendency to get into arguments and physical altercations. It was further determined that the Veteran's mood was anxious and he was oriented to time, place, and person. Sleeplessness was complained of and the examiner did state that the Veteran was not delusional and that he understood the outcome of his behavior. Nevertheless, it was reported that the Veteran's impulse control was poor and that his memory was "normal". As in the past, the Veteran reported intrusive thoughts, nightmares, irritability, anger outbursts, hypervigilance, and difficulty in concentrating. A GAF score of 60 for PTSD was assigned, and a GAF score of 50 for adult antisocial behavior was assigned. The examiner completed the examination with the following observations: Mild social inhabitation to due to depression and anxiety symptoms related to PTSD. Important social activities are given up due to substance abuse or recovering of its effects during relapses. Veteran exhibits a strong pervasive pattern of disregard for and violation of the rights of others (Adult antisocial behavior, Antisocial personality traits). It would be with resort to mere speculation to delineate symptoms associated with each disorder and/or discuss their relationship because of overlapping symptoms. However, personality traits are more prominent than PTSD symptomatology. Also now of record are two private psychologist's reports that were accomplished in February and November of 2010. Of particular interest is the report of November 2010. In that report, the examiner emphasized the overlapping symptoms produced by the Veteran's disorders. In essence, the examiner suggested that the Veteran's PTSD symptoms brought about or highlighted other psychological deficits of the Veteran, which, in turn, drew attention to the Veteran's overall mental health. The examiner further opined that the Veteran's GAF score was much lower than calculated by the two VA examiners and that they needed to look at the totality of the symptoms exhibited by the Veteran when assigning a GAF score. It was also put forward by the psychologist that the Veteran suffered from a lack of impulse control, he could not work well with others, he was socially isolated, and that despite therapy and medications, he continued to suffer from depression, anxiety, and other symptoms indicative of PTSD. As noted, the Veteran's more recent VA medical treatment records have been obtained and included in the claims folder for review. These records stem from 2009 to 2010. These records generally show that the Veteran has sought repeated assistance by the VA in tackling or coping with his psychiatric symptoms. The medical evidence, private and VA, shows assignment of GAF scores ranging from 38 to 60, with a good number of the scores ranging from 50 to 60. In evaluating the Veteran's disability, the Board is mindful that when it is not possible to separate the effects of the service- connected condition from a nonservice-connected condition, 38 C.F.R. § 4.3, which requires that reasonable doubt be resolved in the Veteran's favor, dictates that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181 (1998). In Mittleider, the Veteran had been diagnosed with PTSD and various personality disorders and there was no medical evidence in the record separating the effects of the service-connected disability from the nonservice-connected disorders. Id. at 182. The Board finds this case is not distinguishable from Mittleider in that the medical evidence of record does not distinguish the symptoms that have been produced by the Veteran's PTSD and the other psychiatric manifestations that may be attributable to a nonservice-connected disorder. Accordingly, all psychiatric signs and symptoms will be considered herein. Upon reviewing the record, it is the conclusion of the Board that the evidence does support an evaluation of 70 percent, but no higher, for PTSD. The evidence shows that the Veteran has depression, great anger-management problems, sleep deprivation, hypervigilance, nightmares, and irritability. The Veteran has no social contact with others (except his immediate family). The record further indicates that the Veteran suffers at least some, if minimal, memory loss and his spatial awareness has diminished. He also has flashbacks, depression, insomnia, irritability, difficulty concentrating, hypervigilance, exaggerated startle response, intrusive thoughts, restricted/constricted affect, anxiety, and anger outbursts. In addition, a number of GAF scores have been in the 38 to 50 range indicating serious symptoms. Although the entire record is not without some measure of ambiguity, the Board concludes that the totality of the evidence in the file appears to be at least in approximate balance. It is the conclusion of the Board that the Veteran's overall disability picture indicates that a 70 percent evaluation, but no higher, should be assigned for PTSD from the date in which the Veteran submitted his claim. 38 C.F.R. § 4.7. Hence, the Veteran's claim is granted. However, it is also the conclusion that the evidence does not support an evaluation in excess of 70 percent. The Veteran's PTSD is not productive of total occupational and social impairment. The Veteran does not have gross impairment in thought processes or communication. While he was noted to occasionally have a circumstantial thought process, the remainder of the evidence shows that he does not have gross impairment in thought process. In addition, no deficits have been noted with respect to the Veteran's speech and communication skills. The Veteran does not suffer from persistent delusions. His behavior is not grossly inappropriate. The Veteran does not report nor is he assessed as being in persistent danger of seriously hurting himself or others. It was noted that he is verbally abusive to others but he did not appear to be at risk of self-harm. He is able to perform activities of daily living, including maintenance of minimal personal hygiene. The Veteran is oriented to time, person, and place. While the Veteran may have occasional memory impairment, he does not have memory loss for the names of close relatives, his previous activities, or his own name. None of the various VA or private health care providers who have provided treatment to the Veteran or who have examined him in conjunction with this claim has concluded that he has total occupational and social impairment due to PTSD. In fact, the most recent VA examiners have opined that he was not totally disabled. Moreover, while the Veteran does not socialize, he also reported that he has a good relationship with his wife, children, and grandchildren. Accordingly, total social impairment is not shown. While the medical evidence hints that the Veteran's PTSD may inhibit his ability to obtain and maintain gainful employment, those same records suggest that the Veteran could work for his children or work where he did not have contact with others. Additionally, as previously noted, none of the records show that the Veteran is totally socially impaired. Accordingly, the Board concludes that the criteria for a 100 percent rating are not met. Additionally, the Board has considered whether it is appropriate to assigned "staged ratings," in accordance with Fenderson, supra. However, the Board finds that the medical evidence demonstrates more consistently and throughout the appeal that the Veteran meets the criteria for a 70 percent rating from the date of his claim. However, at no point in time is it shown that there is total occupational and social impairment such that a total rating should be assigned for some distinct period of time. Therefore, the assignment of staged evaluations in this case is not necessary. The Board has also considered whether the Veteran is entitled to an extraschedular evaluation for his psychiatric disorder. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the psychiatric disorder is inadequate. A comparison between the level of severity and symptomatology of the Veteran's disability with the established criteria found in the rating schedule for mental disorders shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. The Board further observes that, even if the available schedular evaluation for the disability is inadequate (which it manifestly is not), the Veteran does not exhibit other related factors such as those provided by the regulation as "governing norms." The record does not show that the Veteran has required frequent hospitalizations for his mental disorder. Indeed, it does not appear from the record that he has been hospitalized for this condition during the period of time that is covered by this claim. Additionally, there is not shown to be evidence of marked interference with employment solely due to the Veteran's service-connected PTSD. The Veteran's manifestations and symptoms fit within the criteria for a 70 percent rating. There is nothing in the record which suggests that the service-connected disability, solely, has markedly impacted his ability to perform some type of a job. Moreover, there is no evidence in the medical records of an exceptional or unusual clinical picture. In short, there is nothing in the record to indicate that this service-connected PTSD on appeal causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) [noting that the disability rating itself is recognition that industrial capabilities are impaired]. The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER An evaluation of 70 percent, but no higher, for PTSD is granted, from the date of the Veteran's original claim for benefits, subject to the regulations governing the disbursement of monetary benefits. REMAND The other issue on appeal involves entitlement to service connection for a cardiovascular disorder, inclusive of hypertension, to include as being secondary to the Veteran's service-connected psychiatric disorder. The record shows that the Board remanded the claim via a Decision/Remand of May 2009. The purpose of the examination was to obtain additional medical information concerning the cardiac claim. The record shows that the Veteran underwent a VA cardiology examination in July 2009. Upon completion of the examination, the examiner provided the following: Veteran[']s HTN is less likely as not (less than 50/50 probability) caused by or a result of his SC PTSD. There is no objective for aggravation. Rationale: Medical literature review, medical record review, clinical experience. PTSD and its treatment to not cause HTN. Blood pressure may be elevated during an episode of distress related to PTSD or an acute exacerbation of this disorder; however, when the distress is relieved, the blood pressure returns to normal. . . . The examiner did not provide the names of the literature she reviewed nor did she address any literature that was contra to her opinion. See http://www.mayoclinic.com/health/stress-and-high-blood-pressure/HI00092, The Role of Anger and Hostility in Essential Hypertension and Coronary Heart Disease, Diamond, Eric L., Psychological Bulletin, Vol 92(2), Sep. 1982, 410-433; The Lancet, Volume 358, Issue 9295, Nov. 24, 2001, et. al. Also, a further reading of the opinion provided failed to address the Veteran's complaints in 1972 involving elevated blood pressure readings, and whether the condition complained thereof in 1972 was etiology related to service and the current disorder. The Board would also note that a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era, and has a disease listed in 38 C.F.R. § 3.309(e), shall be presumed to have been exposed during such service to an herbicide agent, such as Agent Orange, unless there is affirmative evidence to establish that he or she was not exposed to any such agent during that service. See 38 C.F.R. § 3.307(a)(6)(iii). If a veteran was exposed to Agent Orange during active military, naval, or air service, certain specified diseases shall be service connected, if the requirements of 38 C.F.R. § 3.307(a) (2010) are met, even if there is no record of such disease during service. 38 C.F.R. § 3.309(e) (2010). The list of diseases includes: chloracne or other acneform disease consistent with chloracne, type 2 diabetes, Hodgkin's disease, chronic lymphocytic leukemia, multiple myeloma, non-Hodgkin's lymphoma, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers, and soft-tissue sarcoma. See 38 C.F.R. § 3.309(e). The VA amended 38 C.F.R. § 3.309(e), see 75 Fed. Reg. 53202, effective August 31, 2010. In that amendment, ischemic heart disease was added to the list of diseases associated with exposure to certain herbicide agents. The intended effect of this amendment was to establish presumptive service connection for this disorder based on herbicide exposure. Ischemic heart disease includes, but is not limited to, acute, subacute, and old myocardial infarction, atherosclerotic cardiovascular disease (including coronary spasm), coronary bypass surgery, and stable, unstable, and Prinzmetal's angina. The service records of the Veteran clearly show that he served in the Republic of Vietnam and may have been exposed to chemical dioxins while stationed there. Because a medical expert has not provided an opinion as to whether the Veteran now suffers from a cardiac disability that may be the result of his service in Vietnam (and chemical dioxin exposure), and since the VA is now required to fully adjudicate all permutations of a claim, it is the Board's belief that further development of this issue must be done prior to the Board issuing a decision on this particular issue. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (per curiam) (finding that where a service member's claim "identifies PTSD without more, it cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any mental disability that may reasonably be encompassed" by the evidence of record); see also Mittleider v. West, 11 Vet. App. 181 (1998). Therefore, in order to give the Veteran every consideration with respect to the present appeal, it is the Board's opinion that further development of the case is necessary. This case is being returned to the RO via the Appeals Management Center (AMC) in Washington, D.C., and the Veteran will be notified when further action on his part is required. Accordingly, this case is REMANDED for the following action: 1. The RO/AMC should provide to the Veteran all notification action required by the Veterans Claims Assistance Act of 2000, Pub. L. No. 106- 475, 114 Stat. 2096 (2000). Any notice given, or action taken thereafter, must comply with current, controlling legal guidance. 2. The RO/AMC should afford the Veteran a VA examination, by an appropriate specialist, to determine whether the Veteran now suffers from a cardiac disability, to include hypertension or ischemic heart disease, and if so, what the specific symptoms and manifestations are. The examination should be accomplished by a doctor who has not previously treated or examined the Veteran, if possible. The claims folder is to be made available to the examiner before the examination, and the examiner is asked to indicate that he or she has reviewed the claims folder. All necessary tests and studies should be conducted in order to render the diagnosis of the claimed disability. Following an examination of the Veteran and a review of his medical records and history, the examiner is asked to express an opinion concerning whether the Veteran now suffers from any type of cardiac disability, and the etiology of said condition. The examiner should specifically address whether it may be determined whether any found disability of the heart may be etiologically linked to the Veteran's in-service exposure to chemical dioxins. Additionally, the examiner should further provide a detailed opinion as to whether there is an etiological relationship between the Veteran's service-connected psychiatric disorder and any found cardiac disorder. Included in this analysis should be a discussion of whether a service-connected disability has aggravated the found cardiac disorder in accordance with Allen v. Brown, 7 Vet. App. 439, 448 (1995). The examiner should also discuss the Veteran's complaints of high blood pressure made in 1972 - three years after he was honorably discharged from service. It would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should not invoke the phrase "without resort to mere speculation" without first explaining the basis for such an opinion. That is, if the examiner is unable to provide the requested opinion without resorting to speculation, the examiner must provide an explanation for the basis of that determination, for example, does the examiner lack the expertise to render such an opinion, or is some additional testing or information needed, and possibly available, that would permit an opinion. If so, a qualified examiner should provide an opinion and/or the additional testing should be accomplished. If the examiner cannot provide an opinion because it cannot be determined from current medical knowledge whether a specific in-service injury or disease can possibly cause the claimed condition, or the actual cause cannot be selected from multiple potential causes, this should be fully explained. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). The examiner must provide a comprehensive report including rationales for all opinions and conclusions, citing the objective medical findings leading to the examiner's conclusions. Also, if the examiner indicates that his/her opinion is based on medical literature and treatises, the examiner must provide the names of those articles. Additionally, it is requested that the examiner address the proposals and hypotheses addressed in the following - http://www.mayoclinic.com/health/stress-and-high-blood-pressure/HI00092, The Role of Anger and Hostility in Essential Hypertension and Coronary Heart Disease, Diamond, Eric L., Psychological Bulletin, Vol 92(2), Sep. 1982, 410-433; The Lancet, Volume 358, Issue 9295, Nov. 24, 2001, et. al. - and whether the assertions made in these publications apply to this claim. The results proffered by the examiner must reference the complete claims folders and any inconsistent past diagnoses given. 3. Following completion of the foregoing, the AMC/RO must review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. Specific attention is directed to the examination report. If the examination report does not include fully detailed descriptions of pathology and all test reports, special studies or adequate responses to the specific opinion requested, the report must be returned for corrective action. 38 C.F.R. § 4.2. See also Stegall v. West, 11 Vet. App. 268 (1998). When the development requested has been completed, the case should again be reviewed by the RO on the basis of the additional evidence. If the benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The purpose of this REMAND is to obtain additional development, and the Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. The Veteran is free to submit any additional evidence and/or argument he desires to have considered in connection with his current appeal. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until he is notified. ______________________________________________ RAYMOND F. FERNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs