Citation Nr: 1304673 Decision Date: 02/08/13 Archive Date: 02/19/13 DOCKET NO. 10-42 674 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE 1. Entitlement to a higher initial rating, in excess of 50 percent, for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from October 1966 to September 1968. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which granted service connection for PTSD and assigned a 50 percent evaluation effective September 8, 2009. The issue of entitlement to a TDIU has been raised by the record. In that regard, the Board notes that in Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009), the United States Court of Appeals for Veterans Claims held that a request for a TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Accordingly, the Board has jurisdiction of the issue of entitlement to a TDIU and that issue has been added to the present appeal. See also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001) (a separate, formal claim is not required in cases where an informal claim for TDIU has been reasonably raised); VAOPGCPREC 12-2001 (July 6, 2001) (further expansion on the concept of when an informal claim for TDIU has been submitted). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's PTSD is manifested by deficiencies in most areas, including work and mood, due to symptoms such as depression, sleep impairment, intrusive thoughts, concentration problems, irritability and anger, impaired memory, and difficulty in establishing and maintaining relationships. CONCLUSION OF LAW The criteria for an evaluation of 70 percent, but no more, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004). VA has met its duty to notify and assist the Veteran in this case. In a September 2009 letter, VA informed the Veteran of the evidence necessary to substantiate his claim for service connection, evidence VA would reasonably seek to obtain, and information and evidence for which the Veteran was responsible. The September 2009 also letter provided the Veteran with notice of the type of evidence necessary to establish a disability rating and effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment and personnel records, private medical examinations, lay statements, and a VA examination have been associated with the claims file. The Board notes specifically that the Veteran was afforded a VA examination in November 2009 to address his claimed PTSD. 38 C.F.R. § 3.159(c)(4) (2012). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As set forth in greater detail below, the Board finds that the VA examination obtained in this case is adequate as it is predicated on a review of the claims folder and medical records contained therein; contains a description of the history of the disability at issue; document and consider the Veteran's complaints and symptoms; fully addresses the relevant rating criteria; and contains a discussion of the effects of the Veteran's PTSD on his occupational and daily activities. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board notes that additional evidence was received subsequent to the November 2009 VA examination, including psychological evaluations from Dr. W.A., dated February 1, 2010, February 23, 2010, and July 2012, which reflect an increase in the severity of the Veteran's symptoms. The Board finds that a new VA examination is not warranted because there is sufficient competent medical evidence of record to decide the claim. See 38 C.F.R. § 3.159(c)(4). Specifically, the most recent psychological assessment from Dr. W.A., dated July 2012, contains medical findings that are stated in terms conforming to the applicable rating criteria. The evaluation from Dr. W.A. contained a detailed description of the history of the Veteran; documented and considered the Veteran's complaints and symptoms (including the increase in severity of his PTSD); provided a diagnosis in accordance with the DSM-IV criteria; and assigned a Global Assessment of Functioning (GAF) score. As such, the Board finds that a new VA examination is not needed to adjudicate the Veteran's PTSD claim. See 38 C.F.R. § 3.159(c)(4). In a statement dated October 2010, the Veteran stated that he is receiving Social Security Disability benefits for PTSD. The duty to assist requires that VA obtain relevant records in the possession of a Federal agency, unless it is reasonably certain and documented that such records do not exist or that further efforts to obtain these records would be futile. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2011); 38 C.F.R. § 3.159 (2012). The RO requested records from SSA and received the documents in May 2010. The Veteran also submitted SSA records to the RO in August 2010 which were duplicative of the ones previously received. The Board finds that SSA medical records only reference a low back disorder, not PTSD. All SSA records have been received and the Board finds that additional requests for records to SSA are not warranted. Importantly, the Veteran and his representative have not made the Board aware of any additional evidence that needs to be obtained prior to appellate review. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2012). Therefore, the Board finds that there is no reason to believe that any possible outstanding records would contain information relating to the Veteran's PTSD claim. Law and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The United States Court of Appeals for Veterans Claims (Court or CAVC) has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. As the Board will discuss in more detail below, the Board has considered the symptoms related to PTSD and has determined that a 70 percent rating, but no more, is warranted for the entire appeal period. Accordingly, the Board finds that a staged rating is not warranted in this case. The Veteran is in receipt of a 50 percent disability rating for PTSD under Diagnostic Code 9411. A 50 percent rating is assigned 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 70 percent disability rating is 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 that is 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); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned 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; and memory loss for names of close relatives, or for the veteran's own occupation or name. Id. In applying the above criteria, the Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102 (2011); Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so). In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed. 1994) (hereinafter DSM- IV). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. Id. Within the DSM-IV, Global Assessment Functioning (GAF) scale scores ranging from 1 to 100, reflect "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). GAF scores from 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, with some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect 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 obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which 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., a depressed patient who avoids friends, neglects family, and is unable to do work). DSM-IV at 46-47. In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). The Veteran submitted psychological evaluations from a private licensed psychologist, Dr. W.A. dated August 2009, February 1, 2010, February 23, 2010, and July 2012. In the August 2009 evaluation, Dr. W.A. noted that the Veteran reported recurrent and intrusive thoughts, flashbacks, recurrent nightmares, cognitive and physiological responses to trauma cues, avoidance of thoughts, feelings conversations, and people. The Veteran reported feelings of detachment or estrangement from others and a restricted range of affect. During the mental status examination, Dr. W.A. found that the Veteran had cognitive difficulties, including the diminished ability to think and indecisiveness were reported. Homicidal ideation in conjunction with road rage were also acknowledged. Attention capacities, concentration abilities, and short-term memory fell below normal limits. Judgment and insight also fell below normal limits. Dr. W.A. diagnosed the Veteran with PTSD and assigned a GAF score of 54. Dr. W.A. reported that the Veteran's difficulties with impulse control, as evidenced by his road rage and its associated homicidality, were quite evident and likely to substantially negatively impact employment. Dr. W.A. stated that the Veteran is unable to maintain a normal standard of living. On February 1, 2010, Dr. W.A. conducted a second psychological evaluation of the Veteran. During this examination, the Veteran reported that he was deemed unemployable as a result of his difficulties with memory functioning. The Veteran reported being unable to recall his reasons for going even short distances. The Veteran reported increased problems with road rage. The Veteran also reported that recurrent intrusive thoughts related to his military service had intensified. During the mental status examination, Dr. W.A. found that the Veteran's memory fell within normal limits. As in the previous examination, the Veteran's attention capacities and concentration abilities fell below normal limits. Judgment and insight also fell below normal limits. Dr. W.A. assigned a GAF score of 49. He further stated that the Veteran evidenced severe symptoms of PTSD, as demonstrated by the symptom intensification he had experienced since his initial assessment in August 2009. Further, Dr. W.A. stated that the Veteran evidenced severe problems with cognitive functioning, which were likely to markedly impact his employability. During the February 23, 2010 session, the Veteran reported ongoing concerns related to his desire for romantic involvement, and the conflict inherent between that need and his additional need for isolation. The Veteran also expressed concerns regarding his desire to be involved in his children's lives. The Veteran's GAF score remained at 49 and Dr. W.A. reiterated his assessment that the Veteran evidenced severe symptoms of PTSD. In the most recent July 2012 session with Dr. W.A., the Veteran again reported experiencing memory problems. The Veteran described having difficulties recognizing other individuals with whom he had contact, noting that sometimes he was unable to recall his dog's name. A substantial pattern of social disengagement was described, including having difficulty following conversations and in "locking in" to the context of what was going on around him. The Veteran reported that his anger had escalated (road rage) "from a four or five last time" to approximately a "six or seven now." The Veteran's GAF score was again assessed at 49. Dr. W.A. again stated that the Veteran evidenced severe problems with cognitive functioning, which were likely to impact his employability. The Veteran also had a VA examination in November 2009. The examination included a review of the claims file and a discussion of the Veteran's medical history. The Veteran reported symptoms that included insomnia, nightmares, intrusive thoughts and memories, irritability, outbursts of anger (road rage), detachment or estrangement from other, restricted range of affect (e.g. unable to have loving feelings), intense fear, feelings of guilt and hopelessness and horror, difficulty concentrating, and exaggerated startle response. A mental status examination shows that the Veteran was appropriately groomed. Affect was appropriate. Speech was spontaneous, clear, and coherent. The Veteran's mood was "rather mellow" most of the time, but the Veteran reported becoming irritable with road rage when driving. He denied episodes of panic attacks, reported no obsessions or compulsions, and denied suicidal thoughts. The Veteran was noted as having attention disturbances as he was found to be easily distracted. The Veteran's memory impairment was noted as mild to moderate as evidenced by the Veteran's difficulties in tracking tasks and word-finishing problems. The examiner noted that the Veteran has a sleep impairment as evidenced by frequent awaking and nightmares. The Veteran reported that he retired in 2007 due to physical problems (pain and balance issues). The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 55. The examiner noted that the Veteran's PTSD symptoms result in deficiencies in work and mood, as evidenced by his intrusive thoughts, concentration difficulties, irritability and anger. On review of all the evidence above, the Board finds that the Veteran's PTSD results in deficiencies in most areas, including work and mood, indicative of a higher 70 percent evaluation for PTSD due to symptoms such as intrusive thoughts, concentration and memory difficulties, sleep disturbance, irritability, and an inability to establish and maintain effective relationships. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). The Veteran has been examined on five separate occasions, the majority of which indicate a GAF score of 49. This score reflects serious symptoms or serious impairment in social, occupational or school functioning. See DSM-IV at 46-47. Although the November 2009 VA examination reflects a higher GAF score of 55; the VA examiner nonetheless assessed the Veteran with deficiencies in work and mood. The Board notes that while the November 2009 VA examiner found that the Veteran did not have deficiencies in areas such as judgment and family relations due to PTSD; the VA examiner found that the Veteran had mild to moderate deficiencies in memory, irritability and anger, concentration difficulties, and intrusive thoughts. The Veteran was assessed by Dr. W.A. on four other occasions as having severe PTSD symptoms, with serious impairment in social and occupational functioning. Thus, resolving the benefit of the doubt in favor of the Veteran, the Board finds that the Veteran's overall symptomatology supports a higher 70 percent evaluation for PTSD. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 4.3, 4.7 (2012). The Board further finds that the record does not indicate total occupational and social impairment as described for a 100 percent evaluation for PTSD. The Veteran retired in 2007 due to medical issues (pain and balance problems). The November 2009 VA examiner found that the Veteran did not have total occupational and social impairment due to PTSD signs and symptoms. In that regard, the Veteran's current state of unemployment appears to be related, at least in part, to his age and back problems, as noted during the November 2009 VA examination. The Board finds that the weight of the lay and medical evidence does not demonstrate that the Veteran's PTSD symptoms more nearly approximate the severity indicated for an assignment of total occupational and social impairment, including symptoms such 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; and memory loss for names of close relatives, or for the veteran's own occupation or name. Although the Veteran reported some homicidal ideation in conjunction with his road rage in the August 2009 evaluation from Dr. W.A., in a later February 2010 assessment, Dr. W.A noted that the Veteran denied homicidal ideation. Likewise, in the November 2009 VA examination, the examiner noted that the Veteran did not have homicidal thoughts. The Veteran has also never reported having suicidal ideation and no recent episodes of violence have been noted. See November 2009 VA examination (Veteran reported some fighting during first few years following discharge from service). As such, the weight of the lay and medical evidence does not demonstrate a persistent danger of hurting self or others. The Veteran has reported experiencing memory problems (e.g. unable to recall his dog's name and difficulty recognizing individuals he had contact with). See evaluation by Dr. W.A. dated July 2012. However, in the February 1, 2010 evaluation, Dr. W.A. noted that the Veteran's immediate memory, memory for recent events, memory for recent past events, and remote memory, all fell within normal limits. The examiner in the November 2009 VA examination noted only mild impairment in recent and immediate memory and mild to moderate impairment in remote memory. The VA examiner noted that the Veteran reported increased difficulty in tracking tasks, but continued to manage family accounts and tasks with minimal or mild lapses of time. Aside from his reported anger associated with road rage, the Veteran does not exhibit grossly inappropriate behavior. According to the Veteran's statement in the November 2009 VA examination, he described himself as "rather mellow most of time; but get pretty irritable with road rage when driving." Similarly, in the August 2009 evaluation conducted by Dr. W.A., the Veteran again reported his mood as "pretty mellow." While the Veteran was found to have some difficulty forming effective relationships within and outside of his family, he did report having acquaintances and hobbies such as woodworking, motorcycles, sports cars, and working out at his local gym. See November 2009 VA examination. The Veteran also reported having a "good" relationship with his daughters. See August 2009 evaluation from Dr. W.A. There is no indication of an intermittent inability to perform activities of daily living. For these reasons, the Board finds that the severity of the Veteran's PTSD and related symptomatology more closely approximates a 70 percent rating in this case. In reaching the above conclusions, the Board has not overlooked the Veteran's statements with regard to the severity of his PTSD. In this regard, the Veteran is competent to report on factual matters of which he had firsthand knowledge; and the Board finds that the Veteran's reports have been credible. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran has provided lay evidence with respect to his current symptomatology in lay statements, during his VA authorized examinations, and during the private examinations. He is competent to provide such testimony, and the Board finds that the Veteran's statements are credible. The Board has considered lay evidence in evaluating the Veteran's assigned ratings. The Veteran's reported symptomatology has already been discussed above. The Board notes that the objective medical findings such as GAF scores and opinions provided by private examiners and VA examination reports, where relevant, have been accorded probative weight in this case. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) ("[t]he probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . the credibility and weight to be attached to these opinions [are] within the province of the adjudicator.") Based on all of the evidence of record discussed above, the Board continues to find that the Veteran's PTSD symptomatology and the severity of such symptomatology more closely approximates the criteria for a 70 percent evaluation for PTSD. Extraschedular Consideration The Board has considered whether an extraschedular evaluation would have been warranted for PTSD. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD is manifested by depression, social avoidance, intrusive memories, nightmares, episodic homicidal ideation relating to road rage, impaired memory, and trouble sleeping. These symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with an acquired psychiatric disorder, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Resolving the benefit of the doubt in favor of the Veteran, the Board concludes that the evidence supports a 70 percent rating for PTSD. ORDER A 70 percent rating, but no more, is granted for PTSD subject to the law and regulations governing the payment of monetary benefits. REMAND Pursuant to VA's duty to assist, VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4)(I). The United States Court of Appeals for Veterans Claims has held that a TDIU claim may not be denied without producing evidence, as distinguished from mere conjecture, that a veteran's disability does not prevent him from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994). In Friscia, the Court specifically stated that VA has a duty to supplement the record by obtaining an examination which includes an opinion on what effect the appellant's service-connected disability has on the ability to work. Friscia, at 297, citing 38 U.S.C.A. § 5107(a) (West 2002); 38 C.F.R. §§ 3.103(a), 3.326, 3.327, 4.16(a) (2011); Beaty v. Brown, 6 Vet. App. 532, 537 (1994) and Obert v. Brown, 5 Vet. App. 30, 33 (1993). The record indicates that the Veteran is service-connected for PTSD, tinnitus, and bilateral hearing loss. See December 2009 and March 2010 rating decisions. Additionally, the Veteran received a medical retirement in January 2007 due to physical problems (pain and balance problems due to medical condition). See November 2009 VA examination. In the August 2009 examination, Dr. W.A. reported that the Veteran's difficulties with impulse control, as evidenced by his road rage and its associated homicidality, were quite evident and likely to substantially negatively impact his employment. Dr. W.A. stated that the Veteran is unable to maintain a normal standard of living. A November 2009 VA examiner found that the Veteran's PTSD did not result in total occupational and social impairment. However, the VA examiner also noted performance impairments from concentration problems prior to leaving the workforce and similar impairments continuing with subsequent avocational involvements. The Board notes that in determining whether an individual is unemployable by reason of service-connected disabilities, consideration must be given to the type of employment for which the Veteran would be qualified. Such consideration would include education and occupational experience. However, age may not be considered a factor. 38 C.F.R. § 3.341. Unemployability associated with advancing age or intercurrent disability may not be used as a basis for assignment of a total disability rating. 38 C.F.R. § 4.19 (2012). Because factors such as the Veteran's age and period of unemployment may not be considered in determining whether his is unemployable by reason of service-connected disabilities; the Board finds that a remand for a supplemental VA opinion is necessary to clarify whether the Veteran is unable to secure or maintain substantially gainful employment due to his service-connected PTSD alone. The RO/AMC should associate any updated VA psychiatric treatment records with the Virtual VA e-Folder on remand. See 38 U.S.C.A. § 5103A(b); 38 C.F.R. § 3.159(c)(2); Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should send the Veteran VCAA- compliant notice addressing his claim for a TDIU. 2. The RO/AMC should afford the Veteran the appropriate VA examination to include a medical opinion to determine the current effect of the Veteran's service-connected disabilities (PTSD, tinnitus, and bilateral hearing loss) on his employability. The claims folder, to include a copy of this remand, must be made available to the examiner for review. The examiner should set forth an opinion as to whether the Veteran is unable to secure or maintain substantially gainful employment as a result of his service-connected PTSD, tinnitus, and bilateral hearing loss. The VA examiner must provide an explanation for all opinions and conclusions reached. 3. After all development has been completed, the RO/AMC should review the case again based on the additional evidence. If the benefits sought are not granted, the RO/AMC should furnish the Veteran and his representative with a Supplemental Statement of the Case, and should give the Veteran a reasonable opportunity to respond before returning the record to the Board for further review. 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. 2011). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals