Citation Nr: 1243688 Decision Date: 12/26/12 Archive Date: 12/31/12 DOCKET NO. 09-06 910A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for post-traumatic stress disorder (PTSD). 2. Entitlement to service connection for bilateral hearing loss. 3. Entitlement to service connection for asbestosis, due to exposure to asbestos. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD F. Yankey, Counsel INTRODUCTION The Veteran served on active duty from October 1966 to October 1968. This case comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. The Board notes that the Veteran reported noise exposure in service and recurrent tinnitus during his May 2008 VA audiology examination. However, the examiner did not offer an opinion as to whether the Veteran's tinnitus was related to his active military service. The Veteran has not filed a claim for service connection for tinnitus. However, to the extent that the Veteran would like to pursue a claim for service connection for this disability, it is referred back to the RO for adjudication. In January 2010, the Veteran submitted additional medical evidence pertinent to his claim for service connection for asbestosis, which has not yet been considered by the RO. However, the Veteran waived initial RO consideration of that evidence. The issue of entitlement to service connection for asbestosis is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The evidence of record shows that the Veteran's PTSD is manifested throughout the appeal by deficiencies in most of the areas of work, school, family relations, judgment, thinking and mood, without total social and occupational impairment. 2. The evidence of record shows that current bilateral hearing loss is related to in-service noise exposure. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating, but not greater, for PTSD are met throughout the appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. Bilateral hearing loss was incurred in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2011) defined VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The appeal with regard to PTSD arises from disagreement with the initial rating following the grant of service connection. The courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required; and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The United States Court of Appeals for Veterans Claims (Court) has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as an effective date) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). Where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Id. There has been no allegation or evidence of prejudice. The VCAA is not applicable where further assistance would not aid the appellant in substantiating his claim. Wensch v. Principi, 15 Vet App 362 (2001); see 38 U.S.C.A. § 5103A(a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); see also VAOPGCPREC 5-2004; 69 Fed. Reg. 59989 (2004) (holding that the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance). In view of the Board's favorable decision, further assistance is unnecessary to aid the Veteran in substantiating his claim for service connection for bilateral hearing loss. The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103S; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.1599(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records, and VA and private treatment records. Additionally, the Veteran was provided proper VA examinations in October 2007 and May 2009 for his PTSD, and a proper VA audiology examination in May 2008. The Board finds that VA has complied with the VCAA's notification and assistance requirements and the appeal is ready to be considered on the merits. Increased Rating for PTSD Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2012). 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. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). A 30 percent rating is warranted for PTSD if there is 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, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted for PTSD 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted 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 worklike setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent evaluation is warranted for 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. § 4.130, Diagnostic Codes 9411. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is based on 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 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). 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)." Id. A score of 41 to 50 is indicated where there are "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)." Id. A score of 51-60 is appropriate where there are, "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)." Id. A score of 61-70 is indicated when there are, "Some mild symptoms (e.g., depressed mood and mild insomnia OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships." Id. In accordance with 38 C.F.R. §§ 4.1, 4.2 (2007) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to this disability. Evidence The Veteran filed his claim for service connection for PTSD in March 2006. The pertinent evidence of record at that time consisted of outpatient treatment records from the VA Outpatient Clinic in Baton Rouge, Louisiana dated from January 2007 to June 2007. These records show complaints of sleep impairment, occasional nightmares and frequent intrusive thoughts. The Veteran also complained of hypervigilance, jumpiness, nervousness, anxiety, easy startle response, and crowd avoidance. He also complained of depression, feeling numb, guilt, fleeting suicidal and homicidal thoughts, low energy, and decreased interest in things. The Veteran reported that he was married with three children and employed full-time with the railroad. However, he also reported social isolation, in that he considered himself a loner and did not want friends, and noted that he did not socialize with his co-workers, who thought that he was "crazy." The Veteran also complained of being irritable and short-tempered, and reported a past history of violent behavior, which resulted in jail time on more than one occasion. He also reported a history of private treatment for an anxiety disorder, for which he was taking psychotropic medication. He presented on evaluation at that time with an anxious and constricted affect. The examiner diagnosed with PTSD, MDD, and panic disorder with agoraphobia, and assigned a GAF score of 45, indicative of serious impairment. Based on the evidence noted above, in a July 2007 rating decision, the RO granted service connection for PTSD. An evaluation of 50 percent was assigned, effective March 14, 2006. The Veteran appealed the initial rating and as a result, was afforded a VA examination in October 2007. The examiner noted that the Veteran had a 35-year history of severe chronic depressive symptoms, for which he was taking psychotropic medication and receiving individual counseling. It was also noted that the Veteran had a history of physical violence in 1968, including a few workplace scuffles and a few bar fights, some of which resulted in his arrest. However, he reported that he had not gotten into any fights in over twenty years. The Veteran reported that he had been married for 39 years, and described his relationship with his wife as good. He also reported that he had three children and seven grandchildren, and claimed that his family was close, despite his absence due to work. However, he also noted that he was not as intimate with his wife and other family members at times as he would like. The Veteran also reported that he had casual social relationships, but no close friends, and that he socialized primarily with his family. He reported that he did not have many leisure pursuits due to his busy work schedule (6 days/week, 12 hours/day until he retired in September 2007), but he did enjoy spending time with his grandkids and sitting on the back porch watching the animals. On mental status examination, he was oriented in all spheres; his mood was dysphoric, and his affect was congruent to his mood; attention was intact; thought process and content were unremarkable; there was no impairment in judgment; he did not endorse delusions or hallucinations; he denied obsessive/ritualistic behavior, panic attacks, homicidal or suicidal thoughts; and he was noted to have fair impulse control, albeit with reported past episodes of violence. Remote, recent and immediate memory were noted to be grossly intact. It was also noted that he was able to maintain minimum personal hygiene, and that there were no problems with activities of daily living. Specifically regarding PTSD symptoms, the Veteran reported recurrent intrusive thoughts and memories, avoidance behavior, numbing of general responsiveness, isolation and detachment, which had gotten worse since he retired. It was also noted that the Veteran displayed symptoms of mild to moderate adhedonia, stemming from diminished interest in things, which caused less participation in activities. The Veteran also endorsed persistent symptoms of increased arousal, including sleep deprivation, irritability, outbursts of anger, and difficulty concentrating. The examiner diagnosed PTSD, and MDD, recurrent, and assigned a GAF score of 51, indicative of moderate impairment. The examiner also noted that while the Veteran's vocational life did not suffer per se, as a result of his PTSD, he chose to use his work (over 70 hours/week) as a means of escape, which was no longer there for him since he retired in September 2007. The examiner felt that the adjustment to life after employment had been difficult for the Veteran, and had caused an exacerbation in symptoms of his PTSD and MDD. The examiner also noted that the Veteran endorsed suicidal thinking, but adamantly denied any intent or plan. The examiner also concluded that the Veteran's inability to feel as emotionally attached to his wife and other family members as he would like was probably related to his PTSD. It was also noted that the Veteran's PTSD symptoms likely resulted in depressive symptoms significant enough to warrant a separate diagnosis of MDD, and his recurrent MDD, was likely the primary reason for his diminished ability to experience happiness or satisfaction (adhedonia) from various aspects of his life. The examiner also concluded that the Veteran's PTSD did not cause total occupational and social impairment. He also found that the Veteran's PTSD resulted in deficiencies in family relations, and resulted in reduced reliability and productivity. Outpatient treatment records from the VA Medical Center in New Orleans, Louisiana, New Orleans VAMC, including records from a PTSD support group, dated from September 2007 to February 2009 show that the Veteran reported some mild improvement in his PTSD symptoms in 2008. In this regard, in September 2007, he reported guilt feelings, and intrusive thoughts, and was noted to be taking an antidepressant. In February 2008, the Veteran presented with a teary affect. He reported increased depression, continued sleep deprivation, poor appetite, very low energy, an inability to find pleasure in activities he once enjoyed, irritability, and a history of suicidal ideation for years. In March 2008, he reported that he continued to experience bouts of depression, although not as severe as before he started treatment. He also reported continuing sleep deprivation, slight frustration, nightmares and intrusive thoughts, arousal behavior and avoidance behavior. He did report however, that he had fair concentration, fair energy and interest in things, and a good appetite. In August 2008, he reported that he was not depressed, had a good appetite, good concentration, fair energy, and that he had interest in things. He also denied suicidal or homicidal ideation, and reported that he no longer felt alone. However, he continued to report sleep problems, nightmares and intrusive thoughts and recollections. His diagnoses of PTSD and MDD were continued, and he was assigned a GAF score of 50, indicative of serious impairment. In October 2008, he reported improvement in his relationship with his wife of 40 years. However, he continued to be diagnosed during this time with severe PTSD and severe MDD, and to be assigned GAF scores of 50. In December 2008, the Veteran filed a claim for individual unemployability, contending that he was unable to work due to his PTSD and diabetes mellitus. Outpatient treatment records from the New Orleans VAMC dated from February to May 2009 note that the Veteran, who was continuing to take medication for his psychiatric disabilities, was relating well to others, was not expressing thoughts or plans to hurt himself or others, and he was not overtly psychotic. Subsequently, he was afforded another VA examination in May 2009. The Veteran complained of nightmares and sleep impairment, feelings of guilt, suicidal ideation, mild impairment of recent memory (increased forgetfulness), decreased energy and sexual interest; loss of appetite and weight loss; psychomotor slowing; and problems with his temper and aggressive behavior. He also reported social isolation and feeling estranged from people around him. More specifically, he noted that he spent most of his time alone and had difficulty getting along with others, even family members. He also reported that he was only able to relate to his wife, but he noted that he had problems in his marriage, due to his temper and irritability, and admitted to physical violence towards his wife years before. The examiner noted that the Veteran presented with a constricted affect and depressed mood. In fact, he found him to be severely depressed and to meet the criteria for major depressive disorder (MDD). The examiner also noted that the Veteran displayed symptoms of impaired thinking and judgment. In this regard, the Veteran endorsed symptoms of guilt, and the examiner noted that the Veteran had significant problems with thinking and concentration, accompanied by prominent distress and dysphoria, and that he was discouraged and plagued by thoughts of worthlessness and hopelessness. He also found that the Veteran's feelings of hopelessness, pessimism and impaired judgment placed him at risk for self-harm. As noted above, the Veteran reported suicidal ideation. The Veteran also endorsed feelings of sadness, loss of interest in normal activities, and a loss of sense of pleasure in things that he previously enjoyed. It was also noted that the Veteran displayed symptoms of psychomotor slowing; impaired thinking and thought processes (confusion, destractability, difficulty concentrating); poor judgment; impairment in reality testing; hallucinations; magical thinking and delusional beliefs. He also noted that the Veteran had symptoms of anxiety, which affected his ability to concentrate and focus, as well as agoraphobia. The Veteran also complained of mild impairment of recent memory. The Veteran was also noted to have significant social impairment, in that he was withdrawn and isolated, and as noted above, felt estranged from people around him. It was also noted that he was very uncomfortable in social situations; avoided most social interactions; took a passive, submissive stance when dealing with others; and had little interest or need for interacting with others. It was also noted that the Veteran had few interpersonal relationships that could be described as close and warm and limited social skills, and that his working relationships with others was very strained. The Veteran also reported symptoms of significant impulse control, including excessive irritability, with difficulty controlling outbursts of anger and the expression of feelings. The Veteran was also noted to have problems with his temper and aggressive behavior, and to be impulsive, suspicious, hostile and unforgiving towards others, as well as hypervigilant and mistrustful. He was also noted to be emotionally labile, which manifested in rapid and extreme mood swings and poorly controlled anger. The examiner diagnosed PTSD and MDD, which the examiner opined was linked to or part of the Veteran's PTSD, and assigned a GAF score of 40 for the past two years, indicative of impairment in reality testing and communication. The examiner also noted that the Veteran's condition had further deteriorated since his last examination, in large part, due to the loss of the distractability provided by his job. He noted further, that with regard to employment possibilities, given the severity of his PTSD symptoms at that time, he would be unable to deal with the public or with any type of close supervision, and due to his mental/emotional state, he would not be able to fully concentrate on work tasks on a consistent basis. Outpatient treatment records from the VAMC in New Orleans, Louisiana dated from May 2009 to August 2009 note again that the Veteran was continuing to take medication for his psychiatric disabilities, was relating well to others, was not expressing thoughts or plans to hurt himself or others, and was not overtly psychotic. However, in a January 2010 statement, the Veteran reported that he suffered from severe PTSD. The Veteran's Virtual VA e-folder reflects that the Veteran has continued to participate in PTSD group therapy at the New Orleans VAMC. In May 2011, the Veteran reported that he was doing better since joining the PTSD group and that he had been able to manage his symptoms with his medication regimen. The majority of the records show that as noted above, the Veteran was continuing to take medication for his psychiatric disabilities, was relating well to others, was not expressing thoughts or plans to hurt himself or others, and was not overtly psychotic. However, the records also show that the Veteran reported still experiencing feelings of anger and guilt, as well as intrusive memories of Vietnam. Furthermore, in April 2011, he complained of panic attacks, and was diagnosed with PTSD, depression and panic attacks, and assigned a GAF score of 45. He continued to report feelings of anger in 2012. Analysis The evidence of record shows that throughout the appeal period, the Veteran has exhibited deficiencies in work, school, family relations, judgment, thinking and mood. The deficiencies in judgment and thinking are exhibited in the Veteran's reported symptoms which include impaired impulse control, in the form of unprovoked irritability and anger; inability to control temper; physically violent, aggressive, and hostile behavior (at home and work);impulsive behavior; and rapid and extreme mood swings. They are also exhibited in his reported feelings of hypervigilance; anxiety; jumpiness; nervousness; mistrust of others; suspiciousness and hostility towards others; increased arousal, including sleep deprivation; nightmares; intrusive thoughts; difficulty concentrating; suicidal and homicidal thinking; thoughts of worthlessness, hopelessness, helplessness, and pessimism; loss of interest in normal activities, and loss of sense of pleasure in things he previously enjoyed; difficulty concentrating; and problems with forgetfulness. The Veteran has also been noted throughout the appeal period to suffer from severe depression, related to his PTSD, which has been diagnosed as MDD. During outpatient treatment from January 2007 to June 2007, the Veteran complained of depression, feelings of numbness, guilt, suicidal and homicidal ideation, low energy, and decreased interest in normal activities. During his VA examination in October 2007, the Veteran continued to complain of severe depression, for which he was taking psychotropic medication and receiving individual counseling. He also exhibited symptoms of adhedonia, stemming from diminished interest in things, which caused diminished participation in activities. During his most recent VA examination in May 2009, the examiner noted that the Veteran presented with a constricted affect and depressed mood, and noted that he continued to be severely depressed and to meet the criteria for MDD. The Veteran has reported difficulties with employment due to his PTSD symptoms. Although he was employed up until September 2007, he reported that while he was employed he was socially isolated, in that he considered himself a loner and did not want friends. He also noted that he did not socialize with his co-workers, who thought that he was "crazy." He also reported having a few fights at work. The October 2007 VA examiner found that the Veteran's PTSD symptoms resulted in reduced reliability and productivity. Furthermore, the May 2009 VA examiner opined that, with regard to employment, given the severity of the Veteran's PTSD symptoms, he would be unable to deal with the public or with any type of close supervision, and that due to his mental/emotional state, he would not be able to fully concentrate on work tasks on a consistent basis. The Veteran has not reported that he was enrolled in school during the appeal period, however, the Board finds that due to his reported memory loss and difficulty with concentration and attention, diminished interest or participation in significant activities, feelings of hopelessness, helplessness and pessimism; lack of motivation and energy; social isolation and detachment; impaired judgment and thinking, as well as his problems with anger management; anxiety; irritability; and volatile and violent behavior, the Veteran would also likely have deficiencies in the area of school if he attempted such a pursuit. The Veteran has reportedly maintained a relationship with his wife and children throughout the appeal. However, these relationships have been strained due to the Veteran's PTSD symptoms, including isolation and emotional detachment, mood swings, irritability, anger management issues, which resulted in physical violence towards his wife, as well as his diminished interest in activities, including spending time with his grandkids. The Veteran also reported that he does not have any close friends, and that he did not have any leisure pursuits. He reported that he considers himself a loner and did not want friends. Furthermore, the October 2007 VA examiner found that the Veteran's PTSD resulted in deficiencies in family relations. The May 2009 examiner noted that the Veteran's interpersonal style was best characterized as being very uncomfortable in social situations, and that he appeared to have little interest in or need for interacting with others. He noted further that it would be expected that the Veteran would avoid most social interactions, rather than run the risk of being forced to make an active commitment to a relationship. While there are entries in the record indicating some instances of improvement, for the vast majority of the appeal period, the Board finds it significant that the Veteran has received GAF scores of 50 and below, which is indicative of the more significant symptoms and serious impairment he was reporting and displaying. Indeed, such symptomatology is generally consistent with the schedular criteria of for a 70 percent disability rating. Although the Veteran has demonstrated some social functioning, the reported deficiencies in most of the areas needed for a 70 percent rating, the findings with regard to occupational functioning, and the GAF scores, place the evidence in relative equipoise. Resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's symptoms approximate the criteria for a 70 percent rating throughout the appeal period. The evidence does not show that the Veteran had total occupational and social impairment. In this regard, he has maintained his long-term marriage of over forty years during the entire appeal period, albeit with some problems; he has also maintained some sort of relationship with his children and grandchildren, although it has been strained more recently due to the Veteran's increased irritability with them. The record also reflects that the Veteran worked for the railroad over 30 years, before retiring in 2007, and there is no indication in the record that he was forced to retire due to his PTSD. Accordingly, the evidence is against a rating in excess of 70 percent. Extra-schedular consideration Pursuant to § 3.321(b)(1), 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." 38 C.F.R. § 3.321(b)(1) (2012). The question of an extraschedular rating is a component of a claim for an increased rating. See 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). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service- connected disability are inadequate. Therefore, initially, 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). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The Veteran's PTSD is manifested by impairment in social and occupational functioning. This impairment is contemplated by the schedular rating criteria, namely, social and occupational functioning. Hence, referral for consideration of an extraschedular rating is not warranted. Service Connection for Bilateral Hearing Loss Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In relevant part, 38 U.S.C.A. § 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, No. 2009-7075 (Fed. Cir. Sept. 14, 2009). "[L]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as opposed to merely isolated findings or a diagnosis including the word "chronic." When the fact of chronicity in service (or during any applicable presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). For the purpose of applying the laws administered by VA, impaired hearing will be considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2012). Analysis The Veteran contends that service connection is warranted for bilateral hearing loss disability because it is related to his exposure to noise from small arms fire and helicopters during combat in Vietnam. Service treatment records show that the Veteran's hearing was within normal limits during active duty and at the time of his separation examination in September 1968. However, the Veteran is competent to report noise exposure in service, and his service records, including his DD-214, show that he served in an infantryman regimen, and that he is in receipt of the Vietnam Service Medal w/3 Bronze Service Stars, and the Combat Infantryman Badge. Thus, the Board finds that the Veteran's reports of noise exposure are credible and consistent with the circumstances of his service, and the acoustic trauma is deemed to have occurred. See 38 U.S.C.A. § 1154 (a), (b) (West 2002); 38 C.F.R. § 3.304(d) (2012). The Board notes that the absence of service treatment records showing in-service evidence of hearing loss is not fatal to the claim for service connection. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Competent evidence of a current hearing loss disability (i.e., one meeting the requirements of 38 C.F.R. § 3.385, as noted above), and a medically sound basis for attributing such disability to service, may serve as a basis for a grant of service connection for hearing loss. See Hensley v. Brown, 5 Vet. App. 155, 159 (1993). During private audiological testing in March 2008, the Veteran was found to have a bilateral, moderate sensorineural hearing loss in the mid to high frequencies. The examiner, K.S., an audiology intern, opined that the hearing loss was as likely as not due to noise exposure. The Veteran was afforded a VA audiology examination in May 2008. The Veteran reported difficulty hearing in both ears, which he first noticed about 40 years prior to the examination, but had gotten significantly worse in the 12 years prior to the examination. He also reported excessive noise exposure from artillery, small arms fire and helicopter engines, while serving in the Army. He also reported excessive noise exposure while employed for the railroad for 38 years, but claimed to have worn hearing protection when mandated. The Veteran also reported bilateral, recurrent tinnitus, which he first noticed about 12 years before the examination. The examiner noted that service treatment records were negative for any complaints, treatment or diagnosis of hearing loss; service treatment records showed normal hearing at all frequencies in both ears with no change and no OSHA defined threshold shift at the time of the Veteran's induction in April 1966 and at the time of his separation in September 1968; and there was a lack of documentation of any hearing loss prior to 2008. As such, he opined that the Veteran's hearing loss was less likely as not (less than 50/50 probability) caused by or a result of the Veteran's military service. Hearing loss is manifested by symptoms that the Veteran is competent to report. The Veteran has consistently reported in statements and on VA examination that he was exposed to noise from artillery, small arms fire and helicopter engines, during active duty in the Army. Therefore, the Board finds his reports credible. He has also provided competent evidence of a continuity of symptomatology, and a private physician has also provided a medical opinion linking his current hearing loss to service. The Board also notes that while the Veteran's private audiologist did not specifically indicate that she was referring to in-service noise exposure when rendering her opinion, the Veteran has consistently reported that his hearing loss was due to noise exposure in service, and as noted above, the Board finds his reports credible. Furthermore, although he reported noise exposure during post-service employment with the railroad, he also reported that he wore hearing protection. There is evidence against the claim, inasmuch as the contemporaneous record does not document hearing loss for many years after active duty, and the May 2008 VA examiner provided an opinion against the claim. The evidence is, however, in at least equipoise. Resolving reasonable doubt in the appellant's favor, the claim is granted. 38 U.S.C.A. § 5107(b) (West 2002). ORDER Entitlement to an increased rating of 70 percent, but not greater, for PTSD is granted, effective March 14, 2006. Service connection for bilateral hearing loss is granted. REMAND In a November 2009 rating decision, the RO denied the Veteran's claim for entitlement to a TDIU. In January 2010, the Veteran filed a notice of disagreement with the November 2009 rating decision. The RO has not provided the Veteran with a statement of the case in response to his January 2010 notice of disagreement. Because the notice of disagreement placed the issue of entitlement to a TDIU in appellate status, the matter must be remanded for the issuance of a statement of the case. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). The Veteran contends that he has current asbestosis as a result of exposure to asbestos from brakes, while working as a truck vehicle mechanic during his active military service. The Veterans' service treatment records show that he reported employment in the construction industry as a roofer helper prior to military service. They also show that he had a MOS of truck vehicle mechanic during active duty service from August 1968 to October 1968. The record also reflects that the Veteran was employed as a locomotive helper for the Kansas City Southern Railroad for more than thirty years after military service. Outpatient treatment records from the VA Medical Center in Baton Rouge dated from January 2007 to February 2009 are negative for any evidence of asbestosis. Private treatment records from G.T., MD show that in October 1999, the Veteran reported that he had been given a chest x-ray for asbestosis and told that he had chronic obstructive pulmonary disease (COPD). He also reported that he quit smoking around 1982, but that he had experienced second hand smoke inhalation since he quit. He was diagnosed with emphysema. He was diagnosed again with emphysema in August 2001. A master problem list from Dr. G.T. shows a diagnosis of COPD (asbestosis) in October 1999. Most recently, private physician, R.E., MD noted in September 2009 treatment records that based upon a review of the work history, medical history, a B-reading of the Veteran's chest x-ray that shows bilateral intestinal fibrosis and his physical examination, his opinion, within a reasonable degree of medical certainty was that the Veteran does have asbestosis. However, this submission did not include a copy of the physical examination report or chest X-ray with the accompanying B-reading. There is no specific statutory or regulatory guidance with regard to claims for service connection for asbestos-related diseases. However, in 1988, VA issued a circular on asbestos-related diseases which provided guidelines for considering asbestos compensation claims. See Department of Veterans Benefits, Veterans Administration, DVB Circular 21- 88-8, Asbestos-Related Diseases (May 11, 1988). The information and instructions contained in the DVB Circular have since been included in VA Adjudication Procedure Manual, M21-1, part VI, para. 7.21 (October 3, 1997) (hereinafter "M21-1"). Also, an opinion by the VA General Counsel discussed the development of asbestos claims. VAOPGCPREC 4- 00 (April 13, 2000). The Board notes that the aforementioned provisions of M21-1 have been rescinded and reissued as amended in a manual rewrite (MR) in 2005. See M21-1MR, Part IV, Subpart ii, Chap. 1, Sec. H, Para. 29, entitled "Developing Claims for Service Connection for Asbestos- Related Diseases," and Part IV, Subpart ii, Chap. 2, Sec. C, Para. 9, entitled "Service Connection for Disabilities Resulting from Exposure to Asbestos." VA must analyze the Veteran's claim of entitlement to service connection for asbestosis under these administrative protocols using the following criteria. Ennis v. Brown, 4 Vet. App. 523, 527 (1993); McGinty v. Brown, 4 Vet. App. 428, 432 (1993). The latency period for asbestos-related diseases varies from 10 to 45 or more years between first exposure and development of disease. The exposure may have been direct or indirect, and the extent or duration of exposure is not a factor. See M21-1MR, Part IV, Subpart ii, Chap. 1, Sec. H, Para. 29a. The manual provisions acknowledge that inhalation of asbestos fibers and/or particles can result in fibrosis and tumors, and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and cancer of the lung, gastrointestinal tract, larynx, pharynx and urogenital system (except the prostate), with the most common resulting disease being interstitial pulmonary fibrosis (asbestosis). Also noted is the increased risk of bronchial cancer in individuals who smoke cigarettes and have had prior asbestos exposure. As to occupational exposure, exposure to asbestos has been shown in insulation and shipyard workers, and others. The clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. See M21-1MR, Part IV, Subpart ii, Chap. 2, Sec. C, Para. 9a-f. The manual further provides that VA must determine whether military records demonstrate evidence of asbestos exposure in service; whether there is pre-service and/or post-service evidence of occupational or other asbestos exposure; and then make a determination as to the relationship between asbestos exposure and the claimed diseases, keeping in mind the latency and exposure information pertinent to the Veteran. See M21-1MR, Part IV, Subpart ii, Chap. 2, Sec. C, Para. 9h. The applicable section of Manual M21-1 also notes that some of the major occupations involving exposure to asbestos include mining, milling, work in shipyards, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, manufacture and installation of roofing and flooring materials, asbestos cement and pipe products, military equipment, etc. Also of significance is that the exposure to asbestos may be brief (as little as a month or two) or indirect (bystander disease). See Department of Veterans Affairs, Veteran's Benefits Administration, Manual M21-1, Part 6, Chapter 7, Subchapter IV, § 7.21 b. In Dyment v. West, 13 Vet. App. 141, 145 (1999), the Court found that provisions in former paragraph 7.68 (predecessor to paragraph 7.21) of VBA Manual M21-1, Part VI, did not create a presumption of exposure to asbestos. Medical nexus evidence is required in claims for asbestos-related disease related to alleged asbestos exposure in service. VAOPGCPREC 4-00. In short, with respect to claims involving asbestos exposure, VA must determine whether or not military records demonstrate evidence of asbestos exposure during service, develop whether or not there was pre-service and/or post-service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. See M21-1, Part VI, 7.21; DVB Circular 21- 88-8, Asbestos-Related Diseases (May 11, 1988). Thus, VA must analyze the appellant's claim of entitlement to service connection for asbestosis under these administrative protocols. Ennis v. Brown, 4 Vet. App. 523, 527 (1993). As noted, the latency period for asbestos-related diseases varies from 10 to 45 or more years between first exposure and development of disease. M21-1, Part VI, 7.21(b)(2), p. 7-IV- 3 (January 31, 1997). An asbestos-related disease can develop from brief exposure to asbestos. Id. Thus, development and adjudication of this matter should be in accordance with the appropriate criteria, including that set forth in the above guidelines. The Veteran's reported history of asbestos exposure in service, his MOS having been shown to have been a mechanic in service, which strongly suggests likely in-service exposure through the servicing of brakes, See M21-1, Part 6, Chapter 7, Subchapter IV, § 7.21 b., the time period of his active duty (i.e., primarily before dangers of asbestos exposure became known, and protective measures were instituted), are sufficient to establish his in-service asbestos exposure. Furthermore, as noted above, the Veteran has a current diagnosis of asbestosis. However, the private physician did not offer an opinion as to the etiology of the diagnosed respiratory disability. Under the VCAA, VA is obliged to provide an examination in a claim for service connection when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C.A. § 5103A(d) (West 2002); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The types of evidence that 'indicate' that a current disability 'may be associated' with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon v. Nicholson, at 83. As such, the Board finds that under the circumstances of this case, a VA medical examination and/or opinion should be undertaken to ascertain whether the Veteran has current asbestosis or an asbestosis related pulmonary disorder, and if so, whether it is related to his asbestos exposure in service. In asbestos related claims, medical examination and any associated opinions should include review of the claims file by a physician who is a certified "B reader." As a matter of background information, B reader approval is granted to physicians with a valid U.S. state medical license who demonstrate proficiency (via examination) in the classification of chest radiographs for pneumoconioses using the International Labor Office Classification System. It is also used to classify chest radiographs of asbestos-exposed workers governed by the U.S. Department of Labor regulations, and for medical screening, surveillance, research, or compensation programs. See National Institute for Occupational Safety and Health (NIOSH) Website on Safety and Health Topic: Chest Radiography. As was noted earlier, private medical records indicate that there may already be medical evidence available to VA which diagnoses asbestosis or asbestosis-related lung disease in accordance with the B-reader provisions discussed above. VA should attempt to obtain any such records in adjudicating this claim. Accordingly, the case is REMANDED for the following action: 1. The Veteran and his representative should be provided a statement of the case on the issue of entitlement to a TDIU. They should also be informed of the requirements to perfect an appeal with respect to this issue. 2. If the Veteran does perfect an appeal, the RO or the AMC should ensure that all required development is completed before this matter is returned to the Board for further appellate action. 3. Take the necessary steps to obtain copies of the aforementioned examination report, B-reading of the Veteran's chest x-ray, etc. from private physician, R. E., MD in Zachary, Louisiana, in accordance with 38 C.F.R. § 3.159(e)(2). The Veteran is advised that to obtain these records, it may be necessary for him complete an authorization for their release. If the Veteran fails to provide necessary releases, advise him that he may obtain and submit the records himself. If, after all reasonable attempts, such evidence cannot be obtained and further efforts to do so would be futile, appropriate documentation thereof shall be placed in the record. 4. If the evidence identified above from Dr. R. E. is obtained and deemed adequate for use by VA under the applicable law, regulations, procedures, it should be reviewed by a pulmonary specialist in conjunction with review of the claims file and all relevant evidence, to determine the current nature and likely etiology of any current lung disease. The examiner should include consideration of the Veteran's history during service, such as his MOS as a truck vehicle mechanic changing brake shoes and his pre and post service pulmonary history (including working in the construction industry and 30+ years working for the railroad), as well as his smoking history. Specifically, if it is found that the Veteran does have asbestos-related pulmonary disability, the examiner should opine whether such disability is, at least as likely as not (a 50 percent probability or greater), related to asbestos exposure in service. The examiner should specifically comment upon the role of any pre or post-service factors affecting his lungs. If the Veteran is diagnosed with a lung disorder that is not related to asbestos exposure, the examiner should comment as to whether such disability is otherwise at least as likely as not (a 50 percent probability or greater), related to some aspect of the Veteran's period of service. If the examiner determines that additional examination, tests, etc. is necessary to fully address the nature and etiology of the claimed disability in the format requested above, a complete explanation therefor shall be provided and such development shall be undertaken. 5. If the B-reading from Dr. R. E. cannot be obtained, another appropriate VA examination should be conducted, including chest x-ray with a B-reading by the appropriate pulmonary specialist, to determine the current nature and likely etiology of his lung disease. The claims folder must be made available for review by the examiner in conjunction with the examination. Any other indicated studies should be conducted. The examination should also include obtaining a history from the Veteran of his history of asbestos exposure, to include during service via his MOS as a truck vehicle mechanic changing brake shoes and his pre and post service pulmonary history (including working in the construction industry and 30+ years working for the railroad), as well as his smoking history. Based on the examination, review of the record, and a detailed reading of scan and test results, the examiner should provide a medical opinion as to whether or not the Veteran has asbestosis, or any other lung disability due to asbestos exposure, and to provide a definitive diagnosis of the lung disability. The examiner should also identify any non-asbestos related lung disorder found. If it is found that the Veteran does have asbestos-related disability, the examiner should further opine whether such disability is, at least as likely as not (a 50 percent probability or greater), related to asbestos exposure in service. The examiner should specifically comment upon the role of any pre or post-service factors affecting his lungs. If the Veteran is diagnosed with a lung disorder that is not related to asbestos exposure, the examiner should comment as to whether such disability is otherwise at least as likely as not (a 50 percent probability or greater), related to some aspect of the Veteran's period of service. 6. The basis for all opinions expressed should be discussed for the record. It would be helpful if the examiner, in expressing his or her opinion, would use the language "likely," "unlikely" or "at least as likely as not." 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 causation as it is to find against causation. If any opinion cannot be provided without resort to mere speculation, the examiner shall provide a complete explanation for why this is so. In so doing, the examiner specifically shall indicate whether or not the inability to render the opinion is the result of a need for additional information or of the limits of current medical knowledge having been exhausted. 7. The AOJ should 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 reports of examinations. If the requested reports do not include fully detailed descriptions of pathology and all test reports, special studies or adequate responses to the specific opinions requested, the reports must be returned for corrective action. 38 C.F.R. § 4.2 (2012); see also Stegall v. West, 11 Vet. App. 268 (1998). 8. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claims based on the entirety of the evidence. If the benefits sought on appeal are not granted to the Veteran's satisfaction, he should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. The case should be returned to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs