Citation Nr: 1307571 Decision Date: 03/07/13 Archive Date: 03/11/13 DOCKET NO. 09-00 164A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for the service-connected posttraumatic stress disorder (PTSD) with depressive disorder prior to January 16, 2010. 2. Entitlement to a disability rating in excess of 70 percent for PTSD with depressive disorder since January 16, 2010. 3. Entitlement to an effective date prior to January 16, 2010 for the assignment of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 4. Entitlement to service connection for a back disability. 5. Entitlement to service connection for a gastrointestinal disorder, including but not limited to, Crohn's disease and/or irritable bowel syndrome (IBS), to include as secondary to the service-connected PTSD. 6. Entitlement to service connection for tinnitus, to include as secondary to the service-connected tension headaches. REPRESENTATION Appellant represented by: Linda Cox WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD L. B. Cryan, Counsel INTRODUCTION The Veteran served on active duty from June 1964 to June 1966. His DD Form 214 reveals that he had three years, two months and five days of prior service with the Naval Reserves. The dates of any active duty for training during this period, if any, have not been established. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2007 and a March 2010 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado. In the October 2007 rating decision, the RO granted service connection for PTSD, and assigned an initial 30 percent rating, effective from June 30, 2006. Also, in pertinent part, claims of service connection for a back disability, tinnitus, and a gastrointestinal disorder were denied. The Veteran disagreed with the initial 30 percent disability rating assigned for the service-connected PTSD, as well as the denials of service connection for a back disability, tinnitus and a gastrointestinal disorder, to include Crohn's disease and IBS. This appeal ensued. After the Veteran submitted his substantive appeal to the Board, but before the case was transferred to the Board on appeal, the RO increased the 30 percent disability rating to 70 percent for the service-connected PTSD, effective from March 16, 2010. This increase was established via a Supplemental Statement of the Case (SSOC) issued in March 2010. In a simultaneously issued March 2010 rating decision, the RO granted entitlement to a TDIU, effective from January 16, 2010. The Veteran disagreed with the effective date for the assignment of the TDIU. In December 2012, the Veteran testified at a video conference hearing at the RO in Denver, Colorado, before the undersigned Veterans Law Judge sitting at VA's Central Office in Washington, DC. A transcript of the testimony is of record. The Board notes that the Veteran has executed a VA Form 21-22a, Appointment of Individual as Claimant's Representative, in favor of the individual named above, pursuant to 38 C.F.R. § 14.630. This provision allows for representation by an unaccredited individual one-time only. The issues of entitlement to service connection for a back disability, tinnitus, and a gastrointestinal disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Throughout the appeal, and since the effective date of service connection, the Veteran's service-connected psychiatric disorder, as likely as not, has been manifested by symptoms of severe anxiety and depression affecting the ability to function appropriately and effectively; significant sleep disturbance; a difficulty in adapting to stressful circumstances due to constant worry, avoidance of all things military, significant isolation from most people other than family members, irritability, lack of patience, poor short term memory and lack of concentration; and isolated incidence of suicidal ideation; all of which results in an overall disability picture that more nearly approximates that of deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. 2. At no time during the appeal period has total occupational and social impairment been demonstrated due to the service-connected PTSD. Nor has the record demonstrated symptoms on par with those contemplated in the maximum, 100 percent criteria, such as gross impairment in thought processes or communication; persistent hallucinations or delusions; or persistent danger of hurting self or others. 3. The Veteran's informal claim for a TDIU was received in January 2008, at which time (consequent to this decision), service connection was in effect for PTSD rated at 70 percent. Subsequently, service connection was granted for associated tension headaches, rated noncompensably, effective in May 2009. 4. Near-constant headaches, which have been medically linked to the Veteran's PTSD, are shown by the record to have begun in or around January 2009; and these headaches, along with the Veteran's other PTSD symptoms result in total occupational impairment. CONCLUSIONS OF LAW 1. Resolving all doubt in the Veteran's favor, the criteria for the assignment of a 70 percent disability rating have been more nearly approximated since the effective date of service connection. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.16, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a rating in excess of 70 percent for PTSD are not met at any time during the appellate period. 38 U.S.C.A. §§ 1155, 5107, 7104 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.16, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for the assignment of a TDIU have been met since January 1, 2009. 38 U.S.C.A. §§ 5107 , 5110 (West 2002); 38 C.F.R. §§ 3.102 , 3.400 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). With regard to the claim of entitlement to a higher disability rating for the service-connected PTSD, initially rated as 30 percent disabling from June 30, 2006, and rated as 70 percent disabling from January 16, 2010, notice of the underlying service connection claim was provided to the Veteran in August 2006 and February 2007, prior to the initial adjudication of the claim of service connection for PTSD. Those letters provided notice of all five elements of a service connection claim, including notice of how VA assigns disability ratings and effective dates for all grants of service connection. With regard to the increased rating claim, here, the Veteran is challenging the initial rating assigned following the grant of service connection. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Thus, because the notice that was provided before service connection was granted was legally sufficient, VA's duty to notify in this case has been satisfied. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). With respect to the TDIU claim, proper notice was provided the Veteran in December 2008, prior to the adjudication of the claim. Moreover, additional notices provided to the Veteran over the course of the appeal provided all information necessary for a reasonable person to understand what evidence and/or information was necessary to substantiate his claims. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). The Veteran has not alleged any prejudice with regard to notices provided to him with respect to the claims on appeal. VA has obtained service treatment records, assisted the Veteran in obtaining evidence to the extent possible, including VA and private treatment records, and has afforded the Veteran physical examinations. First, an examination was provided to assess whether the Veteran had PTSD related to service, and then additional examinations were provided to assess the extent and severity of the PTSD throughout the appeal period, and to determine whether the Veteran's headaches were related to the PTSD for purposes of establishing entitlement to a TDIU. All necessary opinions were obtained in this regard, and the Veteran was afforded an opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file and the Veteran has not contended otherwise. In addition to the paper claims file, there is a Virtual VA (VVA) electronic claims file associated with the Veteran's claim. The documents in the VVA file have been reviewed, and all relevant records are either duplicative of the evidence in the paper claims file or are separately identified and summarized below. Furthermore, the most recent VA PTSD examination of January 2012 is adequate as the examiner reviewed the history of the condition, conducted a mental status examination, and provided sufficient information so the Board's determination is an informed one. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim with regard to the proper ratings assigned for the service-connected PTSD, as well as the proper effective date for the assignment of the TDIU. II. Increased Ratings - PTSD The Veteran seeks a higher rating for the service-connected PTSD, rated as 30 percent disabling since June 30, 2006, the effective date of service connection, and rated as 70 percent disabling since January 16, 2010. He asserts that his PTSD symptoms are productive of near-continuous anxiety, depression and agitation; significant sleep disturbance, constant worry, avoidance of all things military, significant isolation from most people other than family members, impaired impulse control due to a lack of patience, poor memory and lack of concentration. Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity resulting from a disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When there is a question as to which of two evaluations should 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. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. §§ 3.102, 4.3. The Veteran's service-connected PTSD was assigned an initial 30 percent rating, effective from June 30, 2006. An increased rating to 70 percent was assigned during the course of this appeal, effective from June 16, 2010. As the award is not a complete grant of benefits, the issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). The Veteran asserts that a higher rating is warranted. In cases such as this, where the Veteran appeals the initial rating assigned for a service-connected disability, consideration must be given to "staged" ratings, i.e., disability ratings for separate periods of time based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. See 38 C.F.R. § 4.126. Under 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders, diagnostic Code 9411 governs ratings for PTSD. Regardless of which diagnostic code is used to rate the psychiatric disability, the outcome is the same because all mental disorders are rated pursuant to the Schedule for Rating Formula for Mental Disorders at 38 C.F.R. § 4.130. Under Diagnostic Code 9411, a 30 percent evaluation is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted when the veteran exhibits occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The next higher, 70 percent, evaluation is warranted for a mental disorder where the veteran exhibits 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); and inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent rating is warranted where the veteran exhibits 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. The only criteria for a total disability rating for any disability rated in accordance with the VA General Rating Formula for Mental Disorders are total occupational and social impairment. Sellers v. Principi, 372 F.3d 1318, 1324 (Fed. Cir. 2004). The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Global Assessment of Functioning (GAF) scores, which reflect the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health, are also useful indicators of the severity of a mental disorder. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV). GAF scores ranging between 61 to 70 reflect 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 indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships. Scores between 51 to 60 are indicative of 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). GAF scores between 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores between 31 to 40 indicate 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). The was afforded VA psychiatric examinations in September 2007, March 2009, January 2010 and January 2012, and the results from those reports are consistent. At all of the VA examinations, the Veteran was well-groomed with good hygiene, and communicated well with the examiner. There was no gross impairment of thought process, and no psychosis identified. The Veteran's behavior was always appropriate during examinations, although he appeared anxious and depressed. The main PTSD symptoms noted at all examinations were anxiety, depression, significant isolation from the public, chronic sleep impairment, disturbances of mood, including the loss of patience at times. The examination reports also noted hyperarousal symptoms, avoidance behaviors, and re-experiencing traumatic events, as well as irritability, difficulty concentrating and poor memory. The Veteran's PTSD was described as chronic and moderate at the VA examination in September 2007. The Veteran's social functioning was noted to be impaired by his high level of anxiety and his depressive symptoms, and the examiner felt that the Veteran would do best in settings where he had little or no contact with the public and very loose supervision. The GAF was listed as 56. At the VA examination in March 2009, the Veteran appeared depressed and slightly fragile. On St. Louis University Mental Status Examination, the Veteran scored approximately 24/30, showing some difficulty with long-term memory, working memory and short-term memory; as well as difficulty with attention to focus. At the time of the March 2009 examination, the Veteran still helped out with the family business for a couple of hours a day, though was unpaid, and was free to come and go as needed. Although the examiner described the Veteran's PTSD as mild to moderate, the examiner provided a separate diagnosis of depressive disorder secondary to PTSD, with overlapping symptoms of sleep disturbance, guilt and social withdrawal. The examiner also noted that the Veteran had a cognitive disorder, not otherwise specified, but could not opine as to whether it was related to service, or to the PTSD. VA outpatient treatment records dating from November 2007 through June 2011 have been associated with the claims file. These records contain numerous mental health treatment records assessing the severity of the Veteran's PTSD and depression. These records, in addition to the VA examinations, show that the Veteran's psychiatric symptoms have remained fairly stable since the effective date of service connection, until the Veteran began complaining of severe headaches, which were subsequently linked to the Veteran's PTSD, and service connection was established. The first evidence of the onset of the headaches was January 2009. More specifically, the outpatient treatment records provide a timeline, and show consistency with regard to the Veteran's PTSD symptoms throughout the appeal period. For example, an April 2008 mental health individual psychotherapy note shows that the Veteran continued to have a great deal of anxiety and sleep disturbance. In September 2008, the Veteran reported feeling frequently anxious, worried and overwhelmed. A September 2008 neuropsychological consultation report notes that the Veteran's mind often wandered during conversations and while reading books, which left him feeling uncomfortable during casual conversations and not wanting to read. The Veteran's depression left him with a feeling of hopelessness, which the Veteran described as "intense, bleak, and always on my mind." The Veteran had passive suicidal thoughts, but no intent or plan. The Veteran had remained married to his wife for 40 years and their overall relationship was described as good, although he felt that there intimate relationship was "complicated." As with the Veteran's self-reported history at all VA examinations of record, the Veteran continued to describe the same symptoms on the September 2008 neuropsychiatric consultation. Those symptoms included feeling depressed, irritable, anxious, as well as fearful in social situations. He also endorsed having difficulty with attention, concentration, multi-tasking, word finding, and following conversations. On mental status examination, the Veteran was quiet, reserved, and slightly anxious. Affect was flat, and his mood seemed mildly dysphoric. The Veteran's cognitive functioning was tested in detail, as noted on the report. According to the examiner, the convergence of evidence suggested that emotional distress was negatively affecting the Veteran's ability to attend and concentrate, leading to moderately reduced global cognitive functioning. In other words, chronic rumination, excessive worry, and feelings of despondency likely functioned as internal sources of distraction and lessened the Veteran's ability to concentrate. According to a November 2008 VA mental health clinic Report of Telephone Contact, the Veteran started taking Citalopram and noted symptoms of a dull headache and head tightness. The Veteran also reported that it was harder to motivate himself and he felt jumpy at times. Finally, the Veteran reported that the medication gave him an emotional calm, but also a sense of emotional dullness that was uncomfortable for him. A November 2009 outpatient note shows that the Veteran was going to try a third medication for depression and anxiety as past trials of Citalopram and Sertraline had been unsuccessful. Additional VA treatment records from April 2009 through September 2009 show that the Veteran began developing severe headaches in approximately January of that year. Various VA physicians, social workers and psychologists have addressed the etiology of the Veteran's headaches, and the overwhelming consensus is that the headaches are tension-type headaches, secondary to anxiety and other PTSD symptoms. See April 2009 VA neurology consult signed by C.B., MD; June 2009 VA memorandum from M.B., MD; August 2009 VA memorandum to the Veteran from M.C., PhD; and January 2010 neurology compensation and pension examination. A June 2009 memorandum from the Veteran's VA psychiatrist, M.B., MD, notes that the Veteran was in treatment for PTSD, depression, panic attacks and generalized anxiety disorder, with ongoing daily symptoms that included nightmares, intrusive thoughts, hyperarousal, hypervigilance, survivor's guilt, depression, insomnia, poor concentration, low energy, poor appetite, occasional suicidal ideation, excessive worry, and panic attacks. Dr. M. B. noted that the Veteran's symptoms had been worsening since he began VA treatment in 2007, and had developed chronic severe daily headaches for the prior 6 months. Dr. M.B. further indicated that the Veteran's psychiatric condition caused a strained relationship with his wife and had limited his capacity to work. A June 2009 VA pain management consult notes that the Veteran's PTSD was a likely contributor to the cause of the headaches; and, unfortunately, the Veteran had not responded well to medication interventions for headaches or PTSD and has been sensitive to side effects. An August 2009 memorandum to the Veteran from M.C., PhD notes that the Veteran's headaches followed the pattern of a severe tension headache, as disabling as a migraine; and, they were best described as being secondary to his chronic PTSD. As having worked exclusively with PTSD for many years in the outpatient PTSD Clinical Team at a VA Medical Center and having been the director of the interdisciplinary pain team since 1997, M.C. opined that the Veteran presented with ongoing severe symptoms of PTSD, and concluded that the presence of the PTSD and headache did significantly impacted the Veteran's daily activities, social function, and relationships. The January 2010 VA neurology compensation and pension examination was provided to determine whether the Veteran's headaches were indeed secondary to the service-connected PTSD. In relying on the April 2009 neurology consultation findings, the January 2010 examiner opined that the Veteran's headaches were, as likely as not, secondary to the PTSD/anxiety. A January 2010 VA psychiatric examination notes that the Veteran retired from work two years prior in order to begin collecting his Social Security; but, he continued to help his wife with the family costume jewelry business, more in an administrative position. However, since the onset of his headaches, he had been unable to tolerate doing any work, and had increased anxiety in general. He reported the onset of headaches in January 2009. The Veteran noted his involvement with the church, and indicated that he and his wife try to engage in church activities and go to services regularly, but his ability to do so has been limited by the severe headaches. On examination, the Veteran appeared in pain and anxious; and, although he was able to maintain minimal personal hygiene and other basic activities of daily living, the examiner emphasized that it was only at a minimum level. The Veteran continued to have nightmares with sleep problems, and his anxiety and depressed mood appeared to be exacerbated by his health problems in more recent years. There was no impairment of impulse control, no evidence of delusions or hallucinations, and no obsessive or ritualistic behavior. The Veteran's PTSD symptoms which included heightened physiological arousal and avoidance and numbing symptoms indicated a slight worsening overall, and especially now that the Veteran appeared to have somatic issues that arose from his stress. The examiner opined that the Veteran had a decrease in overall functioning due to the headaches and an increase in anxiety. Global Assessment of Functioning (GAF) was 55. The examiner indicated that the Veteran had moderate symptoms which interfered with his social and occupational functioning; and, that the Veteran was more socially isolated and unable to work because concentration was too impaired by the pain from the headaches. The examiner concluded that with the increased symptomatology, there was now occupational and social impairment with deficiencies in most areas such as work, school, family relationships, judgment, thinking or mood due to symptoms of increased pain, increased psychological distress, and disturbances of motivation and mood, leading to difficulty in establishing and maintaining effective work and social relationships and precluding his ability to continue being of aid to his wife in their business of 40 years. VA mental health records dated through 2010 and 2011 show continued treatment for PTSD and depression. GAF scores ranged from 46 to 52 and symptoms were fairly consistent. These records also show that in late 2010, the Veteran and his wife had to foreclose on their home because their family business was not doing well. This added additional stress, but the Veteran reported that he felt a close and strong relationship with his wife, which he hoped would help him through the crisis. At the most recent VA examination in January 2012, the examiner summarized that the level of the Veteran's PTSD and depression produced occupational and social impairment with reduced reliability and productivity. The examination report confirmed that the Veteran decreased his involvement with the business in 2009 with the onset of severe headaches. The examiner confirmed the PTSD diagnosis by finding that the Veteran's symptoms of avoidance, feelings of detachment from others, restricted range of affect, sleep disturbance, irritability or outbursts of anger, and difficulty concentrating did cause clinically significant distress or impairment in social, occupational or other important areas of functioning. The examiner also found that the Veteran's depression caused a depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood and difficulty in adapting to stressful circumstances, including a work or a worklike setting. In the narrative portion of the examination report, the examiner described the Veteran's increased anxiety whenever he left the home. The Veteran reportedly became so anxious, particularly before trips to the VAMC that his wife had to drive him to all appointments because he became unable to drive. The Veteran reported avoiding social contact because of an increase in anxiety when he is around people. He described himself as isolating. The Veteran reported night sweats on average of once per month and nightmares several times per month. The Veteran continued to have difficulty with irritability and occasionally snapped at his wife, although medication helped with this. During the interview with the examiner, the Veteran appeared tense and distressed, and his affect was flat. Overall, however, the Veteran was able to remain attentive, cooperative and responsive throughout the interview. Additional outpatient VA treatment records dated through August 2012 have been associated with the Veteran's Virtual VA electronic record. A review of these records reveals that the Veteran still remained very isolated from the public and knew that he had to start forcing himself to get out more. Finally, the Veteran's December 2012 video hearing transcript has been made part of the Veteran's VA electronic record. A review of the transcript reflects that the Veteran continues to suffer from anxiety and depression. He takes prescription medication for his symptoms, which have always included sleep disturbance, severe anxiety and worry, depression, irritability, isolation, lack of concentration and memory loss. The Veteran still reported headaches. At a June 2012 VA mental health assessment, the Veteran's GAF was listed as 50, and the examiner indicated that the Veteran was not struggling with the same level of anxiety and depression that he had a few years prior. Nevertheless, the examiner noted that the Veteran remained highly sensitive to stress and continued to worry a great deal. The examiner felt it unlikely that the Veteran would ever be able to work again, but felt it would be beneficial to try volunteering somewhere a couple of days per week to get him out of the house. In summary, the evidence of record shows that all of the symptoms associated with the Veteran's service-connected PTSD, other than his headaches, have been fairly stable, and consistent, throughout the appeal period. These symptoms include severe depression and anxiety; excessive worry and significant isolation from the public; chronic sleep impairment; nightmares, irritability, anger, lack of concentration, and memory impairment. Importantly, the examination reports show varying degrees of overall severity of the Veteran's PTSD, but the severity of the reported symptoms has remained the same, until the Veteran developed debilitating headaches in January 2009. Although the VA examiners have suggested that the above symptoms (without consideration of the headaches) cause no more than moderate impairment and only reduced reliability and productivity due to social and occupational impairment, the more detailed mental health assessments, individual therapy notes, and memoranda provided by the Veteran's treating psychiatrists, psychologists and social workers tend to show a more severe overall disability picture. These records, which are provided by mental health care workers who treat the Veteran on a regular basis, provide greater insight and detail with respect to the Veteran's occupational and social functioning, including during the time period prior to the onset of his headaches. For example, according to the November 2008 VA neuropsychiatric examiner, the convergence of evidence suggested that emotional distress was negatively affecting the Veteran's ability to attend and concentrate, leading to moderately reduced global cognitive functioning. In other words, chronic rumination, excessive worry, and feelings of despondency likely functioned as internal sources of distraction and lessened the Veteran's ability to concentrate. This is in contrast to a VA compensation and pension examiner of March 2009 who noted some cognitive impairment, in addition to the Veteran's other PTSD and depressive disorder symptoms, but could not provide any other insight regarding this matter. Although GAF scores range in the low to mid 50's, which is generally indicative of moderate impairment, it is unclear as to whether these scores consider the social and occupational impairment, particularly in light of the fact that the January 2010 examiner listed a GAF of 50, while also opining that the Veteran was too occupationally and socially impaired to work. Generally, GAF scores between 51 to 60 are indicative of 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). In this case, however, the evidence clearly shows that the Veteran has more than moderate difficulty in social and occupational functioning during the entire time covered by this appeal. The Veteran's fear of crowds, fear of conversations with strangers, and inability to concentrate or remain focused, has created a consistent pattern of isolation. Although the Veteran and his wife attempted to attend church services and church activities as often as possible, there is no indication from the record that the Veteran interacts with anyone outside of his wife and children. The only reported activities are yard work and watching television. The Veteran is so anxious that he is unable to drive himself to his doctor's appointment at the VAMC. Finally, before the Veteran developed severe debilitating headaches in January 2009, the Veteran's ability to work was limited to working in an environment where he did not have to answer to a boss, could work at his own pace, in a loose environment, and without having contact with others, other than his wife. These symptoms alone, establish that the Veteran had social and occupational deficiencies in most areas, including work, thinking and mood. When there is a question as to which of two evaluations should 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. Given that the interpretation of the medical and lay evidence in this case provides doubt as to whether the assignment of a 50 percent rating is adequate for the service-connected PTSD with depressive disorder prior to the onset of the Veteran's headaches, the Board must resolve all doubt in the Veteran's favor and assign the higher rating. In light of the foregoing, the criteria for the assignment of a 70 percent rating, but no higher, have been more nearly approximated since the effective date of service connection. In essence, the evidence shows deficiencies in most areas, and more than just reduced reliability and productivity. Since the effective date of service connection, the Veteran had very little productivity. Thus, an increased evaluation, specifically from 30 percent to 70 percent, from June 2006 to January 2010 is warranted. Moreover, the assignment of staged ratings has been considered pursuant to Fenderson v. West, 12 Vet. App. 119 (1999); however, at no time since service has the service-connected disability been more disabling than as currently rated. Significantly, at no time since the effective date of service connection, has the Veteran exhibited total occupational and social impairment sufficient to warrant the maximum (100 percent) rating. As noted in more detail below, the record clearly demonstrates that the Veteran became unemployable when he began experiencing debilitating headaches, which were found to be related to the service-connected PTSD with depressive disorder. The record also clearly reveals that the Veteran began experiencing these headaches in January 2009. At that point, the Veteran became totally occupationally impaired. However, at no time during the course of this appeal has the Veteran been totally socially impaired. Certainly he has social impairment, as demonstrated by his isolative behavior, lack of friends, and anxiety or fear of being around people other than family members. However, the Veteran has remained married to his wife for over 40 years, has recently described the relationship as "good" and has always been able to attend doctor's appointments and mental health counseling sessions, despite his anxiety. In other words, the evidence shows that the Veteran has significant social impairment, but not total social impairment. Although the examinations beginning in January 2010 indicate that the Veteran's PTSD symptoms had recently worsened, there is no demonstrable difference in the level of anxiety, fear, depression, chronic sleep impairment or worry before or after that date. The only obvious difference in the level of severity is the headaches, which do negatively affect the Veteran's cognitive functioning, by further increasing the inability to concentrate and remember, etc., but that level of increase does not rise to a level that would warrant the assignment of a 100 percent rating. At no time during the appeal period has the Veteran ever experienced signs of psychosis, or disassociation from reality. There have never been hallucinations or delusions, and the Veteran has no problem with his long-term memory, as noted in the video hearing testimony of December 2012. At every examination, the Veteran has been fully oriented, and his behavior has been appropriate. As total social impairment is not demonstrated, the criteria are not met for the assignment of a 100 percent schedular rating at any time during the course of this appeal. The Board has also considered whether the record raises the matter of an extraschedular rating under 38 C.F.R. § 3.321(b)(1). 38 C.F.R. § 3.321(b)(1) applies when the rating schedule is inadequate to compensate for the average impairment of earning capacity for a particular disability. 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. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the Veteran's symptoms are significant social impairment with severe anxiety and depression. These are specifically contemplated by the schedule. Furthermore, the competent evidence does not show that the disability at issue causes marked interference with employment prior to the grant of a TDIU (as will be more fully discussed below). Nor does it show that the disability requires frequent hospitalizations, or otherwise produces impairment unrecognized by the schedule. Thus, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. III. Earlier Effective Date - TDIU In a March 2010 rating decision, entitlement to a TDIU was granted, with an effective date of January 16, 2010, the date of a VA compensation and pension examination. At that examination, the Veteran was found unemployable due to the service-connected PTSD symptoms which included debilitating headaches. The Veteran asserts that he is entitled to an effective date for the grant of a TDIU prior to January 16, 2010. As noted above, a series of VA outpatient treatment reports and VA examination reports reveal that the Veteran's debilitating headaches began in January 2009. See April 2009 VA neurology consult signed by C.B., MD; June 2009 VA memorandum from M.B., MD; August 2009 VA memorandum to the Veteran from M.C., PhD; and January 2010 neurology compensation and pension examination. In general, the effective date of an evaluation and award of compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110(a) (West 2002); 38 C.F.R. § 3.400 (2012). Where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation, the effective date of the award shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date. 38 U.S.C.A. § 5110(b)(2) (West 2002); 38 C.F.R. § 3.400(o)(2) (2012); Harper v. Brown, 10 Vet. App. 125 (1997). Furthermore, a TDIU claim is a claim for increased compensation, and the effective date rules for increased compensation therefore apply to a TDIU claim. Hurd v. West, 13 Vet. App. 449 (2000). The effective date of an award of increased compensation shall be the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if the application is received within one year from such date. Otherwise, the effective date will be the date of VA receipt of the claim for increase, or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a), (b)(2) (West 2002); 38 C.F.R. § 3.400(o) (2012); Hazan v. Gober, 10 Vet. App. 511 (1997); Harper v. Brown, 10 Vet. App. 125 (1997); VAOPGCPREC 12-98 (1998), 63 Fed. Reg. 56704 (1998). As an initial matter, contrary to the Veteran's testimony before the undersigned, the Veteran's initial allegation of unemployability came from a January 2008 Notice of Disagreement (NOD), as opposed to his initial claim for service connection in June 2006. In the NOD, the Veteran appealed the denials of service connection for a back disability, IBS/Crohn's disease and tinnitus, as well as the initial rating assigned following the grant of service connection for PTSD. The January 2008 NOD also served as a new claim of service connection for a skin disease (which was later denied in an unappealed July 2008 rating decision). The Veteran asserted that all of the claimed disabilities rendered him unemployable. Based on these statements, the RO undertook development of the Veteran's TDIU claim. The Veteran's TDIU claim was initially denied in a May 2009 RO rating decision. The denial was based on findings from the March 2009 examination report summarized above, which indicated that the Veteran retired from his job two years earlier because he was eligible for Social Security retirement benefits, but continued to work part time for the family company that was run by his wife. Moreover, the examiner opined that the service-connected PTSD symptoms did not render the Veteran totally occupationally impaired because the Veteran was capable of doing simple work tasks in a loosely supervised environment. The Veteran appealed that denial, and before the case reached the Board, the RO granted a TDIU, effective from January 16, 2010. The effective date for the grant of the TDIU was based on the date of a VA examination report which showed that the Veteran was unemployable due to his service-connected PTSD symptoms which now included debilitating headaches. The RO, in essence, found that the medical evidence did not show that the Veteran was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities until the January 16, 2010 examiner opined as such. Thus, the RO concluded that unemployability was not factually ascertainable until January 16, 2010. Based on these same findings the RO also found that the criteria were met for the assignment of a 70 percent rating for the service-connected PTSD as of the date of the January 16, 2010 examination report. A TDIU rating is warranted when the schedular rating is less than total, where it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340 , 4.16(a) (2012). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). Here, the Veteran's service-connected disabilities met the schedular criteria as of the grant of service connection for PTSD at the 70 percent level, that is, June 2006. The question, therefore, remains, at what point does the evidence demonstrate that the Veteran was no longer capable of employment. A January 2010 VA psychiatric examination notes that the Veteran retired from work two years prior in order to begin collecting his social security; but, he continued to help his wife with the family costume jewelry business, more in an administrative position. He then developed headaches in January 2009 and could no longer tolerate working in the family business. The examination report notes that the Veteran continued his involvement with his church activities, but was limited in this regard because of the headaches. The January 2010 examiner described the Veteran's PTSD symptoms over the years as being "mild" until they were exacerbated by stress and headaches. Other than headaches, the examiner noted symptoms of nightmares, heightened physiological arousal and avoidance and numbing symptoms so that his PTSD appears to be slightly worsened, particularly because of the headaches. The GAF was 55 and the overall level of severity was moderate. The examiner opined that the Veteran was unable to work due the pain from the debilitating headaches. Despite an inability to work, the examiner specifically noted that the Veteran was able to maintain activities of daily living, with no evidence of impaired thought processes or inappropriate behavior. With the increased symptomatology, the examiner opined that there was now occupational and social impairment with deficiencies in most areas such as work, school, family relationships, judgment, thinking and mood. It is undisputed that the Veteran's debilitating headaches resulted in total occupational impairment; however, in contrast to the RO's finding that the Veteran's unemployability was not factually ascertainable until a doctor opined as such on January 16, 2010, the totality of the evidence clearly establishes that the Veteran became unemployable with the onset of his debilitating headaches in January 2009. The Veteran, his wife, the January 2010 examiner and the Veteran's treating physicians all agree that the Veteran's debilitating headaches began in January 2009, and this was the cause of his unemployability. There is no evidence to the contrary. Just because the opinion regarding unemployability was not obtained until the January 2010 examination, does not mean that unemployability was not factually ascertainable prior to that date. In this case, all of the facts point to January 2009 as the first month of unemployability. Although the Veteran first alleged unemployability in January 2008, the evidence clearly demonstrates that he became unemployable in all capacities in January 2009. Certainly the Veteran's employment options were limited prior to this date, but total occupational impairment was not shown prior to January 2009. The Veteran was able to help his wife with administrative matters, even if only on a part time basis because it was the type of job that did not require contact with others outside the family, no more than loose supervision, and the flexibility necessary to accomplish at least some meaningful work. However, when the Veteran's debilitating headaches began in January 2009, it affected his cognitive ability to function in any working capacity, particularly with consideration of his other PTSD symptoms. For the foregoing reasons, and resolving all doubt in favor of the Veteran, it is factually ascertainable that the Veteran was unable to obtain or maintain gainful employment as of January 1, 2009. Because the Veteran's service-connected PTSD is 70 percent disabling effective from June 30, 2006, the effective date of service connection; and, because the date on which the Veteran became unemployable follows the date on which the claim of unemployability was first submitted (in January 2008), the correct effective date for the assignment of a TDIU is January 1, 2009, and no earlier. ORDER The assignment of an initial 70 percent rating, but no higher, for the service-connected PTSD with depressive disorder and tension headaches is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 70 percent for PTSD is denied. An effective date of January 1, 2009 for the assignment of a TDIU is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND With regard to the Veteran's claim of service connection for a back disability, the Veteran asserts that he suffered an injury in service when he was electrocuted in the boiler room of his Naval ship. He asserts that he was hit with 440 volts of electricity which threw him across the compartment into a wall and knocked him unconscious. He does not recall how long he was unconscious, but remembers being against a wall and feeling a lot of pain. He did not seek treatment for the condition because he did not feel there was anything that could be done for him aboard the ship. The Veteran further asserts that he later sustained another injury when he was unloading a truck of supplies for the ship. In that incident, he was receiving a 50 pound bag of supplies from a supplier, when the bag slipped and hit the Veteran's right shoulder, throwing him off balance and severely twisting his back. The Veteran's STRs show that he complained of a back ache prior to service. The Veteran specifically wrote on his June 1964 Report of Medical History that he had lower back pain, and that he had two letters from a doctor. He also indicated that he was unable to hold a job because of the inability to perform certain motions and the inability to assume certain tasks, presumably due to lower back pain, as the Veteran listed this condition under "other medical reasons" for being unable to hold a job. The examiner, however, noted that the Veteran had a backache NCD (not considered disabling). No doctor's letters regarding any pre-existing back pain could be located in the STRs. On the June 1964 Report of Medical Examination, the examiner noted that the Veteran had a backache NCD. X-rays were negative at that time, and the examiner was found qualified for active duty in the U.S. Navy and all duties of his rate at sea and on foreign shores. Despite being found fit for duty, the Veteran sought treatment for back pain in July 1964 and August 1964. There was no history of recent trauma identified at that time. X-rays of the lumbar spine taken in August 1964 demonstrated a minimal scoliosis with a convexity to the right with some exaggeration of the normal lordotic curve. An August 1964 narrative notes that the Veteran reported difficulty with severe low back pain for the prior 3 to 4 years, especially after heavy lifting. On examination, the Veteran stood with a 10 degree tilt to the right of the pelvis. A rough measurement of the lower extremities revealed that the right leg was a quarter inch shorter than the left. A week later, however, another examiner found the leg lengths equal, and determined that the Veteran had low back discomfort of a slightly disabling degree. On the doctor's Report of Medical Examination at discharge in May 1966, there was no mention of back pain or of any back disability. The Veteran testified at his December 2012 video hearing that he did not have a back disability prior to entering service. At first blush, this statement appears to contradict his own statements at the time he entered active duty in 1964; however, additional development is necessary to resolve the issue of whether a pre-existing back disability existed prior to service given the facts in this case. First, the examiner at the time of entry noted only that the Veteran had a non-disabling backache, and therefore it remains unclear as to whether the Veteran had an actual chronic pre-existing back disability prior to service. Moreover, the STRs appear to show that the x-rays in June 1964 at the time of entry were negative, but the x-rays in August 1964 were positive for some disabling condition. At that same time, the STRs note numerous complaints of severe back pain. Although these records refer to a history of pre-existing back pain, there remains a question as to whether the Veteran suffered an injury to his back in service, as he has asserted, regardless of any pre-existing disability. Finally, the Veteran's DD Form 214 and the STRs show that the Veteran had three years of service in the Naval Reserves prior to his active duty service. Medical examination reports from March 1961, December 1963 and June 1964 have been reviewed. Significantly, no back pain or back disability was noted on the March 1961 examination report. The first examination report noting complaints of back pain comes from the December 1963 examination. Although no disabling back disability was found on examination, the onset of the Veteran's back pain may have occurred during his Reserves service; thus, the possibility of a back injury during a period of active duty for training is left open. The Veteran has yet to provide the date of the alleged boiler room accident or the incident involving the food bag falling on his right shoulder causing the back twisting injury. Because the Veteran has provided evidence of a current back disability, and there is evidence of treatment for back pain in service, the VA's duty to assist requires that the Veteran be afforded a VA examination to determine the likely etiology of the current back disability, particularly because the issue of a pre-existing back injury has not yet been resolved. Under 38 U.S.C.A. § 5103A(d)(2) (West 2002), VA must provide a medical examination and/or obtain a medical opinion when there is: (1) competent evidence that the veteran has a current disability (or persistent or recurrent symptoms of a disability); (2) evidence establishing that he suffered an event, injury or disease in service or has a disease or symptoms of a disease within a specified presumptive period; (3) an indication the current disability or symptoms may be associated with service; and (4) there is not sufficient medical evidence to make a decision. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. The Veteran has not been afforded a VA examination with respect to the issue of entitlement to service connection for a low back disability. The Veteran should be accorded a VA examination to address the etiology of any current back disorder. With regard to the Veteran's claim of service connection for tinnitus, the Veteran maintains that he has suffered from tinnitus ever since the in-service boiler room accident as described above. The Veteran also noted that he developed tinnitus as a result of working in the boiler room 10 to 12 hours per day without ear protection. The STRs are negative for complaints or findings of tinnitus. The Veteran's claim of service connection for tinnitus was initially denied because a VA examiner opined that the Veteran's hearing loss was more likely than not unrelated to service, and therefore his tinnitus was also more likely than not unrelated to service. During the course of the appeal, the Veteran raised an alternate theory of entitlement to service connection for tinnitus. At an April 2009 VA neurology consultation, the Veteran reported tinnitus that was related to his tension headaches. At a January 2010 VA audiology consultation, the Veteran reported constant tinnitus, stronger than before the onset of his headaches. The tinnitus was bilateral and constant. The examiner opined that the Veteran's hearing loss was most consistent with presbycusis, but did not comment on a diagnosis or etiology of the tinnitus. An examination is necessary to determine whether the Veteran has tinnitus, and if so, whether it, as likely as not, had its onset during service or whether it is secondary to the service-connected PTSD with tension headaches. Regarding the claim of service connection for IBS and/or Crohn's, the STRs do not show complaints that would normally be associated with IBS or Crohn's such as excessive diarrhea and/or chronic abdominal pain. The Veteran did report a history of indigestion at the time of entry into service. In addition, the Veteran also reported on his various Reports of Medical History that he had excessive worry, depression, and nervous trouble. More recently, the Veteran has asserted that his IBS and/or Crohn's disease is secondary to his service-connected PTSD with depression and tension headaches. The Veteran has not been notified of the information and evidence needed to substantiate a claim for secondary service connection under 38 C.F.R. § 3.310. Secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310 (2012) and compensation is payable for the degree of aggravation of a nonservice-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Notice should be accomplished upon remand. Private treatment records from November 1995 through May 2003 show that the Veteran was treated for a gastrointestinal disorder manifested by excessive diarrhea and abdominal pain. At one point, doctors diagnosed the Veteran with Crohn's disease, although subsequent testing appears to have ruled out that diagnosis. Nevertheless, the Veteran continues to maintain that he has a gastrointestinal disorder, manifested by excessive diarrhea and abdominal pain. Although the exact cause of IBS is unknown, it is a well-established principle that stress and anxiety can trigger IBS symptoms. Because these symptoms of excessive worry, nervousness and depression were noted in service, and because the Veteran has current medical evidence of IBS and/or Crohn's, an examination is necessary to obtain a medical opinion as to the current nature and likely etiology of the IBS, and Crohn's disease if present. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file all outstanding medical and personnel records in connection with the Veteran's three year period of Naval Reserve service prior to entry into active duty in June 1964. Pertinent records include those that would show evidence of a back injury during any period of active duty for training or inactive duty for training. All attempts to fulfill this development should be documented in the claims file, including attempts to contact the Veteran in order to obtain specific dates of injury. If after continued efforts to obtain the records it is concluded that it is reasonably certain they do not exist or further efforts to obtain them would be futile, notify the Veteran and (a) identify the specific records that are unable to be obtained; (b) briefly explain the efforts made to obtain those records; (c) describe any further action to be taken with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 2. Notify the Veteran of the information and evidence needed to substantiate a claim for secondary service connection under 38 C.F.R. § 3.310. 3. After completion of #1 and #2 above, schedule the Veteran for an orthopedic examination to determine the current nature and likely etiology of the Veteran's current back disability. The claims folder and a copy of this remand must be made available to the examiner. The examiner should note in the examination report that the claims folder has been reviewed. Any appropriate evaluations, studies, and testing deemed necessary by the examiner should be conducted at this time, and included in the examination report. In particular, the examiner is asked to express an opinion as to when the Veteran's currently diagnosed low back disability was first manifested (i.e., prior to service, in service, or after service). In this regard, the examiner should opine as to whether the Veteran's in-service complaints of back pain and reports of a pre-existing backache clearly and unmistakably represent a pre-existing back disability. In this regard, the examiner should consider the Veteran's service treatment records showing normal x-rays at induction in June 1964, and abnormal x-rays in August 1964. The examiner should also consider the Veteran's statements during service, as well as his hearing testimony about the onset of his back disability. If the examiner determines that the Veteran's low back disability is a disease which clearly and unmistakably (i.e., undebatably) preexisted service, the examiner is asked to indicate whether the condition was aggravated (i.e., a permanently increase in severity) during service. If the examiner answers this question affirmatively, the examiner is then asked to express an opinion as to whether the increase in severity is due to the natural progress of the disease. If the examiner determines that the low back disability did not increase in severity during service, the examiner should indicate as such. The examiner must provide a complete rationale for any stated opinion. If the examiner determines that the low back disability was first manifested after service, the examiner should indicate whether the condition is at least as likely as not (i.e., 50 percent or greater possibility) related to the Veteran's period of active service, to include the reported boiler room injury and/or the episodes of in-service treatment for back pain in August 1964. The examiner must provide a complete rationale for any stated opinion. In responding to this question, the examiner should consider the Veteran's comments regarding continuity of symptoms since discharge from service. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 4. Schedule the Veteran for a VA audiological examination to assess the current nature and likely etiology of his bilateral tinnitus. The claims folder should be forwarded to the examiner for review and the examiner should indicate in the examination report that the claims folder was reviewed. All indicated tests and studies should be performed, and all findings should be set forth in detail. The examiner is asked to opine whether it is at least as likely as not (a probability of 50 percent or greater) that current tinnitus began in or is related to service, to include excessive noise exposure in therein to include long hours spent in the boiler room. A complete rationale for all opinions is requested. If the examiner finds that tinnitus did not have its onset during service, or is not otherwise related thereto, the examiner should opine as to whether it is at least as likely as not that the Veteran's current tinnitus is secondary to the service-connected tension headaches. In providing this opinion, the examiner is directed to the January 2010 VA audiology consultation addressed above which explains that the Veteran's debilitating headaches are secondary to the service-connected PTSD, and which also cause a ringing in the ears. The examiner must provide a complete rationale for any stated opinion. In responding to this question, the examiner should consider the Veteran's comments regarding continuity of symptoms since discharge from service. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 5. Schedule the Veteran for a gastrointestinal examination by a doctor who is qualified to determine whether the Veteran has a diagnosis of Crohn's disease and/or IBS. The claims must be reviewed by the examiner in conjunction with the examination and the examination report should indicate that the claims folder was reviewed. All indicated tests and studies should be performed, and all findings should be set forth in detail. The examiner is asked to opine whether it is at least as likely as not (a probability of 50 percent or greater) that any current gastrointestinal disorder, including but not limited to IBS and/or Crohn's disease began in service, is otherwise related to service, including whether it is at least as likely as not caused by or aggravated by the service-connected PTSD with depressive disorder and tension headaches. The examiner must provide a complete rationale for any stated opinion. In responding to this question, the examiner should consider the Veteran's comments regarding experiencing symptoms when nervous or anxious. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 6. Following the above, ensure that the examination reports are complete and responsive and, if not, return the report(s) as inadequate. Then readjudicate the Veteran's claims after undertaking any other development deemed warranted. If any benefit on appeal remains denied, a Supplemental Statement of the Case should be issued, and the Veteran and his representative should be afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate 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. 2012). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs