Citation Nr: 1307907 Decision Date: 03/08/13 Archive Date: 03/11/13 DOCKET NO. 06-07 177 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to service connection for Meniere's disease. 2. Entitlement to a disability rating in excess of 10 percent for bilateral otitis externa. 3. Entitlement to an initial disability rating in excess of 10 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to a total disability rating due to individual unemployability as a result of service-connected disability (TDIU). REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J.A. Flynn, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from August 1951 to May 1953 and had subsequent service in the United States Army Reserve. He was awarded the Combat Infantryman's Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania, which, inter alia, awarded service connection for PTSD and assigned an initial 10 percent evaluation effective January 14, 2005. These matters were previously before the Board in May 2009, when the Board remanded the case. Specifically, the Board instructed the RO issue a statement of the case (SOC) as to the issues of entitlement to service connection for Meniere's disease and entitlement to a disability rating in excess of 10 percent for otitis externa. The Board also instructed the RO to provide the Veteran with a psychiatric examination. As will be discussed in further detail below, the RO issued an SOC as to these issues, and it then issued several supplemental SOCs as to these issues. The Veteran was provided with a psychiatric examination in August 2009. As an initial matter, the Board notes that when its remand orders are not complied with, it errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In the instant case, the Board finds that there has been effective compliance with the Board's remand instructions. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (noting that Stegall requires substantial compliance with remand orders, rather than absolute compliance). The Board's 2009 Remand also remanded the Veteran's claims for service connection for residuals of cold injuries to the feet. While on remand, a June 2011 rating decision of the VA RO granted service connection for residuals of cold injury to the bilateral extremities. The Board notes that when an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). In other words, a grant of service connection during the pendency of an appeal extinguishes the issue before the Board; therefore service connection for residuals of cold injuries to the feet is no longer in appellate status before the Board. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). See 38 U.S.C.A. § 7107(a)(2) (West 2002). The issues of entitlement to service connection for Meniere's disease, a disability rating in excess of 10 percent for otitis externa and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. VA will notify the Veteran if further action is required on his part. FINDING OF FACT The Veteran's PTSD is manifested by symptoms producing no more than occupational and social impairment with reduced reliability and productivity due to impaired memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. CONCLUSION OF LAW The criteria for an initial rating of 50 percent, but no greater, for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim decided herein. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). The Board must assess the credibility and weight of all evidence to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veterans Claims Assistance Act of 2000 (VCAA) The Board has given consideration to the VCAA, which includes an enhanced duty on the part of VA to notify a veteran as to the information and evidence necessary to substantiate claims for VA benefits. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). The VCAA also redefines the obligations of VA with respect to its duty to assist veterans in the development of their claims. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012). Upon receipt of a substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence that (1) is necessary to substantiate the claim; (2) VA will seek to provide; and (3) the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board observes, however, that the issue of a higher initial disability rating is a "downstream" issue. Once a decision awarding service connection, a disability rating, and an effective date has been made, section 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated. See Sutton v. Nicholson, 20 Vet. App. 419 (2006) (citing Dingess). Given that the issue on appeal relates to the assignment of a higher initial rating for service-connected PTSD, the Board concludes that VCAA notice requirements have been satisfied with respect to the issue on appeal. VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Service treatment records have been associated with the claims file. All identified and available treatment records have been secured, which includes VA treatment records, VA examinations, and private health records. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). More specifically, a VA examination must be conducted when the evidence of record does not reflect the current state of the Veteran's disability. See 38 C.F.R. § 3.327(a) (2012); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In the instant case, the Veteran was provided with VA examinations in July 2005 and August 2009. The examination reports indicate that the examiners reviewed the Veteran's claim file and past medical history, recorded his current complaints, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that the examination reports are adequate for the purpose of rendering a decision in the instant appeal. 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Neither the Veteran nor his representative have contended otherwise. The Board notes that the Veteran's last examination of his PTSD is now over three years old. The mere passage of time since that examination is not reason enough, alone, to require reexamination. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007); VAOPGCPREC 11-95 (April 7, 1995). There is no objective evidence indicating that there has been a material change in the severity of the Veteran's PTSD since the time of the August 2009 examination. The Veteran does not contend the contrary. In February 2010, the Veteran appeared at a hearing before a decision review officer, and a transcript of this hearing has been associated with the record. The Veteran appeared before the undersigned in an August 2012 hearing, and a transcript of this hearing has been associated with the record. The Board observes that all due process concerns have been satisfied. 38 C.F.R. § 3.103 (2012). Accordingly, the Board will proceed to a decision. Schedular Evaluation of PTSD Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate rating codes identify the various disabilities. See 38 C.F.R. Part 4 (2012). When there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2012). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. See Fenderson v. West, 12 Vet. App. 119 (1999). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Separate disabilities arising from a single disease entity are to be rated separately. See 38 C.F.R. § 4.25 (2012); see also Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Pyramiding-the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes-is to be avoided when rating a veteran's service-connected disabilities. See 38 C.F.R. § 4.14 (2012). The Veteran contends that he is entitled to a disability rating in excess of 10 percent for his PTSD. Under the general rating formula used to rate psychiatric disabilities other than eating disorders, the relevant criteria are as follows: 10 percent: Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress or symptoms controlled by continuous medication. 30 percent: Occupational and social impairment with occasional decreases 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, and mild memory loss (such as forgetting names, directions, recent events). 50 percent: 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 establishing effective work and social relationships. 70 percent: 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 that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. 100 percent: 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 and place; memory loss for names of close relatives, own occupation or name. 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). When evaluating a mental disorder, VA must 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 must assign an evaluation 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 must consider the extent of social impairment, but it cannot assign an evaluation solely on the basis of social impairment. See 38 C.F.R. § 4.126 (2012). The Board notes that the specified factors for each incremental rating are examples-rather than requirements-for a particular rating, and the Board will not limit its analysis solely to whether the Veteran exhibited the symptoms listed in the rating scheme. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Also relevant to the Board's analysis is the Global Assessment of Functioning (GAF) score assigned to the Veteran, which is a scale that reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). While the veteran's GAF score is not itself determinative of the most appropriate disability rating, the Board must consider it when evaluating the appropriate disability rating for the veteran. See VAOPGCPREC 10-95. A description of the relevant GAF ranges is as follows: 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). GAF scores ranging 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, has some meaningful interpersonal relationships. GAF scores ranging from 71 to 80 indicate the examinee has, if at all, symptoms that are transient or expectable reactions to psychosocial stressors but no more than slight impairment in social, occupational or school functioning. DSM-IV, pp. 46-47. See 38 C.F.R. § 4.130 (2012) (incorporating by reference the provisions of the DSM-IV for rating purposes.) The Board now turns to an evaluation of the relevant medical evidence in the Veteran's case. The Board observes that the Veteran generally received GAF scores of 60 between January 2005 and April 2005. A May 2005 clinician assigned the Veteran a GAF score of 65. The Veteran received a VA examination in July 2005. The Veteran indicated that he had married his current wife in 2001, and he typically spent his day with his daughter and her family, as well as with his wife's siblings and extended family. The Veteran enjoyed making wooden birdhouses and feeding birds and squirrels around his house. The Veteran independently completed his activities of daily life without difficulty. The Veteran described experiencing nightmares, recurrent intrusive thoughts, attempts to avoid reminders of combat, irritability, hypervigilance, difficulty concentrating, and significant sleep disruption. The Veteran indicated that his symptoms worsened over time, and he experienced periodic exacerbations with exposure to reminders of combat. The Veteran described his mood as "down" and reported experiencing tearfulness several times a week. The Veteran denied anhedonia and feelings of worthlessness, but he acknowledged experiencing guilt and regret about his active duty service. The Veteran was able to relax around his family, and he enjoyed their company. The Veteran felt financial strain, but he denied experiencing excessive and uncontrollable worry. The Veteran had no symptoms of panic, obsessive thoughts, compulsive behaviors, psychosis, suicidal or homicidal thoughts, or mania. The Veteran's energy level was somewhat low, and his appetite had declined recently. The Veteran reported having a poor memory for names of acquaintances and those whom he did not see frequently, but he had an adequate memory for routine events and familiar people. The Veteran's wife indicated that the Veteran had become increasingly argumentative and hostile over time. She indicated that the Veteran was restless in his sleep, easily brought to tears, moody, and somewhat suspicious of her social activities. The examiner observed that the Veteran was dressed in clean, casual clothing, and he was generally well groomed. The Veteran's mood and affect were "very anxious" throughout the evaluation. The Veteran easily became tearful. The Veteran's speech was rapid and mildly pressured. The Veteran's thoughts were often tangential. The Veteran was alert and oriented. The Veteran's remote memory was largely intact. The Veteran's judgment was intact, but his insight was limited. The examiner assigned the Veteran with a GAF score of 60. A January 2007 clinician noted that the Veteran visited Florida for four months each year and felt "no security" while visiting, and the clinician noted that the Veteran had difficulty adjusting to his environment in Florida. The clinician observed the Veteran's mood as mildly dysphoric. Another January 2007 clinician indicated that the Veteran reported having episodes of "extreme anger." Reviewing treatment records from January 2007 to February 2009, the Board observes that VA clinicians generally assigned the Veteran with GAF scores ranging from of 65 to 70. A May 2008 clinician assigned the Veteran with a GAF score of 80. A February 2009 clinician noted that the Veteran had been experiencing more of a dysthymic mood, but the Veteran denied pervasive or persistent symptoms of major depression. The Veteran's affect was relatively concerned but stable. The Veteran was provided with an additional VA examination in August 2009. The examiner noted that the Veteran had attended a weekly PTSD group at a VA medical center for many years. The Veteran indicated that he had been married to his second wife for nine years, and he continued to reside with her at their home. The Veteran had two children, three grandchildren, and one great-grandchild. The Veteran indicated that he enjoyed sitting outside and drinking coffee, watching television, and occasionally visiting his brother. The Veteran indicated that he enjoyed building birdhouses. The Veteran did not drive as a result of his physical problems, and he did not help with cooking or household chores. The Veteran indicated that he and his wife visited restaurants two to three times a week, and he visited grocery stores and shopping malls. The Veteran was independent with his activities of daily living, with the exception of his ambulation. The Veteran described his current relationship with his wife as "pretty good," although he noted that they occasionally argued due to his irritability. The Veteran saw his son a couple of times per week, and he saw his daughter almost daily. The Veteran described having good relationships with his children. The Veteran had frequent contact with his brother. The Veteran attended church on a weekly basis, and he visited the local American Legion once weekly to socialize. The Veteran took Celexa and clonazepam in treatment of his PTSD symptoms, and the Veteran indicated that these medications have been helpful in that they have improved his sleep and "settled [his] nerves down." The Veteran had no history of psychiatric hospitalizations. The Veteran reported that his symptoms had slightly increased in frequency and severity over the preceding year. The Veteran described experiencing a hyper-startle response following loud noises, and he indicated that he was irritable and short-tempered, and he frequently engaged in arguments with his wife and other veterans at the American Legion. The Veteran indicated that he had one physical altercation in the past year, at which time the Veteran "jumped over a table" at his brother-in-law. The Veteran experienced nightmares. He averaged ten hours of sleep per day, and he took daytime naps. The Veteran described his mood over the past year as depressed, due to his PTSD symptoms and multiple health problems. The Veteran endorsed symptoms of tearfulness, impaired attention and concentration, and feelings of helplessness, hopelessness, and worthlessness. The Veteran indicated that he occasionally experienced passive suicidal ideation, but he denied experiencing any active suicidal ideation or history of suicide attempts. The Veteran was alert, oriented, pleasant, and cooperative. The Veteran was casually and appropriately dressed, and his hygiene and grooming were good. The Veteran's speech was fluent, coherent, and normal in rate and volume. The Veteran's mood was slightly sad, and his affect was normal in range and appropriate to content. The Veteran reported experiencing a depressed mood over the past year, but no manic episodes were reported. The Veteran also indicated that he was anxious and tends to worry about finances. The Veteran estimated that he had experienced three or four panic attacks over the past year. The Veteran denied experiencing any obsessions or compulsive behaviors, though he acknowledged checking the doors and windows of his home before going to bed every night. The Veteran reported no inappropriate or reckless behaviors. The examiner observed no impairment in thought or communication. The Veteran's ideation was relevant and goal-directed, with no psychotic symptoms noted, and the Veteran denied any history of hallucinations or paranoia. The Veteran had some difficulty recalling his chronological history, and he experienced occasional word-finding problems. The Veteran's gross cognitive functioning was adequate. The Veteran's insight and judgment were fair to good. The examiner assigned the Veteran with a GAF score of 55. A June 2011 clinician assigned the Veteran with a GAF score of 60. In addition, the Board has reviewed the Veteran's psychiatric treatment records, including the Veteran's outpatient psychiatric treatment records and his weekly PTSD support group records. The PTSD support group records offer generally very similar descriptions of the Veteran's symptoms. They indicate that the Veteran was alert and oriented, and his grooming and dress were neat and appropriate. The Veteran's observed mood varied from good to euthymic to dysthymic, and his affect ranged from normal and responsive to constricted and irritated. The Veteran's speech was generally fluent, productive, and of normal rate and volume. The Veteran's thoughts were generally clear, organized, and goal-directed. The Veteran did not voice suicidal or homicidal ideation, and no delusions or hallucinations were present. The Veteran's judgment was grossly intact and his insight was fair. The Board has also considered the lay contentions of record concerning the Veteran's condition. In his August 2012 hearing before the undersigned, the Veteran indicated that he experienced nightmares and took medication to treat his anxiety. The Veteran indicated that he "exploded" at another participant in his PTSD support group approximately three times. The Veteran voiced having difficulty concentrating. The Veteran stated that he had a lot of close friends, and he visited with them once a week. The Veteran's spouse indicated that they engaged in social activities. She indicated that the Veteran had never hit her. She indicated that the Veteran was "short tempered and very aggressive." Turning now to an application of the relevant laws and regulations to the facts in the instant case, the Board first observes that a 100 percent evaluation is not warranted at any time during the period on appeal. The Veteran's symptoms do not create total occupational and social impairment. The Veteran has been in a long-term relationship with his current wife and enjoys his relationships with his children. The Veteran and his wife engage in social activities, and the Veteran has stated that he has a number of close friends. While mindful of the guidance from Mauerhan that the symptoms listed in the General Rating Formula for Mental Disorders are not meant to be used as an exhaustive list, the Board observes that the Veteran has not met or approximated any of the listed symptoms for a 100 percent rating. Furthermore, the Board observes that neither the Veteran nor his representative have argued that a 100 percent rating of the Veteran's PTSD is appropriate. For these reasons, the Board finds that a 100 percent rating of the Veteran's PTSD is not appropriate. The Veteran's representative has argued, however, that the Veteran's symptoms meet or approximate the criteria associated with a 70 percent rating. The Board disagrees, and instead finds that the Veteran's symptoms do not present occupational and social impairment with deficiencies in most areas. As noted above, the Veteran has reported enjoying close relationships with his wife, children, and friends. While it is again mindful of not using the General Rating Formula for Mental Disorders as a checklist, the Board notes that the Veteran's symptoms arguably meet or approximate only two of these symptoms. The Veteran has shown difficulty in adapting to stressful circumstances; for example in January 2007, he experienced anxiety when visiting Florida for an extended time. The Veteran has also indicated that he has experienced impaired impulse control in the form of unprovoked irritability. While the Board acknowledges the contentions of the Veteran and his wife that the Veteran experiences irritable moods and aggression, the Board finds no evidence suggesting that these episodes of irritability lead to behavior approximating periods of violence. The Veteran has shown none of the other symptoms associated with a 70 percent rating. Though the August 2009 examiner noted the Veteran's passive suicidal ideation, the examiner also noted that the Veteran had no active ideation or history of suicidality. The Board also notes that the records of the Veteran's PTSD group meetings and psychiatric treatment records consistently show the Veteran denying suicidal or homicidal ideation. Similarly, while the August 2009 examiner noted that the Veteran engaged in the ritualistic behavior of checking doors and windows before bed, the evidence does not suggest that this behavior rises to the level of an obsessional ritual that interferes with routine activities. Though the Board acknowledges that the Veteran showed tangential thought and pressured speech at his July 2005 evaluation, the Veteran's PTSD group meetings consistently indicate that the Veteran's speech was clear. The records do not indicate the Veteran's activities of daily living have been compromised by near-continuous panic or depression. For these reasons, the Board finds that a 70 percent rating of the Veteran's PTSD is not appropriate. Instead, after a thorough review of the evidence, the Board finds that the totality of the evidence indicates that the impact of the Veteran's PTSD on his social and industrial functioning is most congruent with a 50 percent initial evaluation. Although the Veteran does not have all the symptomatology consistent with the assignment of a 50 percent rating, the Board finds that the impact of the Veteran's PTSD on his social and occupational functioning sufficiently approximates the degree of impairment contemplated by a 50 percent rating. See 38 C.F.R. § 4.7 (2012). The Veteran has consistently complained of difficulty with his memory, and he has consistently shown disturbances of motivation and mood consistent with anxiety and depression. The Board finds that an initial 50 percent rating for the Veteran's PTSD is warranted throughout the period on appeal. In making this determination, the Veteran's GAF scores of record have been considered. During the appeal period, the Veteran has been assigned a number of GAF scores, ranging from a low of 55 in August 2009 to a high of 80 in May 2008. The majority of the Veteran's assigned GAF scores range from 61-70. The Board finds that the GAF evidence of record, which is consistent with moderate or mild symptoms, is consistent with the assignment of a 50 percent initial disability rating. In light of the foregoing, the Board concludes that while the Veteran demonstrates a few symptoms associated with a disability rating in excess of 50 percent, the evidence of record does not show that the overall level of severity more closely approximates the criteria for a 70 percent or 100 percent disability rating than a 50 percent rating. See 38 C.F.R. § 4.130 (2012). While acknowledging that the Veteran is certainly impaired by his PTSD in his social and occupational spheres, the facts nevertheless establish that for the time period at issue, the Veteran was not completely isolated and estranged from the community at large. Moreover, there are no other factors that would lead the Board to conclude that a 70 percent or 100 percent disability rating is warranted. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). A review of the medical evidence indicates that the Veteran's psychiatric symptomatology centers on his depression, anxiety, irritability, nightmares, and disturbances of mood and motivation. These symptoms are most congruent with a 50 percent disability rating. Consideration has also been give to the Veteran's personal assertions in support of his claim. The Veteran is competent, as a layperson, to report on that as to which he has personal knowledge, such as feelings of stress, anxiety, and depression. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a)(2) . However, as a layperson, without the appropriate medical training and expertise, he is not competent to provide a probative (persuasive) opinion on a medical matter, especially the severity of his psychiatric in terms of the applicable rating criteria and its effect on his ability to work. See King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). Rather, this necessarily requires appropriate medical findings regarding the extent and nature of his psychiatric disorder. The clinical evidence of record is consistent with the assignment of a 50 percent initial disability rating, but no greater. There is no basis for a staged rating of the Veteran's PTSD because the Veteran's disability picture is essentially uniform throughout the appeal period. See Fenderson. Extra-schedular Considerations In addition, the Board has considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors that render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). In Thun v. Peake, the Court set forth a three-step inquiry to determine a veteran's entitlement to an extra-schedular rating. See 22 Vet. App. 111 (2008). First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. In this case, it is not necessary to go any further than the first step of the Thun analysis. The rating criteria are not inadequate, and it does not appear that the Veteran has "exceptional or unusual" disabilities; he merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected PTSD that are unusual or different from those contemplated by the schedular criteria. The available schedular evaluations are adequate. Referral for extra-schedular consideration is not warranted. Further inquiry into extra-schedular consideration is moot. See Thun. ORDER An initial 50 percent disability rating, but no higher, is granted for PTSD, subject to the laws and regulations governing the award of monetary benefits. REMAND The Veteran's claims for service connection for both Meniere's disease and an increased rating for otitis externa must be remanded. Although the Board regrets the delay associated with this remand, further development of the record is required before the Board may render a decision. With respect to the Veteran's claim for service connection for Meniere's disease, once VA provides a Veteran with a medical examination, due process requires that VA notify the veteran prior to the adjudication of the claim of any inability to obtain evidence sought, including a VA examination with medical opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (noting that "[o]nce VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, VA must provide an adequate one or, at a minimum, notify the [veteran] why one will not or cannot be provided"); see also Daves v. Nicholson, 21 Vet. App. 46, 51 (2007), citing Green v. Derwinski, 1 Vet. App. 121, 123-124 (1991); Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence . . . is essential for a proper appellate decision"). Turning to the facts in the instant case, the Veteran has argued both that his Meniere's disease is directly related to service and secondarily related to his service-connected otitis externa. The Veteran received an examination of his Meniere's disease in October 2005. While the examiner opined regarding the relationship between the Veteran's Meniere's disease and his active duty service, the examiner did not offer an opinion whether the Veteran's service-connected otitis externa caused or aggravated his Meniere's disease. On remand, an additional opinion should be solicited regarding the relationship, if any, between the Veteran's Meniere's disease and his active duty service or his service-connected otitis externa. With respect to the Veteran's claim for an increased rating for his otitis externa, the present level of disability is of primary concern when entitlement to compensation has already been established and an increase in the disability rating is at issue. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). While a new VA examination is not warranted based solely upon the passage of time, VA's duty to assist includes providing a new medical examination when a veteran asserts or provides evidence that a disability has worsened and the available evidence is too old for an adequate evaluation of the current disability. See Palczewski v. Nicholson, 21 Vet. App. 174 (2007); Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that the Board should have ordered a contemporaneous examination of the veteran because a 23-month old exam was too remote in time to adequately support the decision in an appeal for an increased rating). Turning to the facts in the instant case, the Veteran last received a VA examination of his otitis externa in October 2005. The Board acknowledges that the Veteran's otitis externa is currently rated at the maximum 10 percent disability rating available under Diagnostic Code 6210, applicable to chronic otitis externa. The Board further observes that this 10 percent rating has been in effect since December 3, 1963 and is thus protected pursuant to 38 C.F.R. § 3.951. See Murray v. Shinseki, 24 Vet. App. 420 (2011). The Veteran has argued, for example at his August 2012 hearing before the undersigned, that the scaling associated with his otitis externa has worsened, and it now interferes with his hearing and occasionally prevents him from wearing a hearing aid. Treatment records also suggest that the Veteran now experiences drainage from his ears. Accordingly, an additional examination should be obtained on remand that fully addresses the current manifestations of the Veteran's otitis externa, and based on the results of this examination, the RO should consider whether any diagnostic codes in addition to the currently-assigned Diagnostic Code 6210 would better describe the severity of the symptomatology presented by the Veteran's otitis externa. With regard to the Veteran's claim for TDIU, in Rice v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of an increased rating claim when such claim is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). In July 2012, the Veteran claimed entitlement to a TDIU. Therefore, the issue of TDIU is raised by the record and it is properly before the Board. A review of the record shows that further development is needed to properly adjudicate the TDIU claim. The law provides that TDIU may be granted upon a showing that a veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disability or disabilities. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). Consideration may be given to a veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2011). While the Veteran has been afforded with VA examinations to address the severity of his service-connected conditions, an opinion as to the effect of his service-connected disabilities on his employability has not been rendered. The Board finds that the Veteran should be afforded an appropriate VA examination to determine whether he is unable to secure or maintain substantially gainful employment as a result of his service-connected disabilities. Accordingly, the case is REMANDED for the following actions: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Ensure that all records of which VA has notice have been obtained and either associated with the Veteran's claims file or his Virtual VA e-folder. 2. Then, schedule the Veteran for a VA examination with an examiner of appropriate expertise to determine the nature, extent, and etiology of the Veteran's Meniere's disease and service-connected otitis externa. All indicated tests and studies must be performed. The claims folder must be reviewed by the examiner in conjunction with the examination. Following a review of the service and post service medical records, as well as the Veteran's statements, the examiner must describe the nature of the Veteran's Meniere's disease and otitis externa in detail, and offer the following opinions: a) Describe the nature, current severity, and all symptoms associated with the Veteran's service-connected otitis externa. b) Describe the nature, current severity, and all symptoms associated with the Veteran's Meniere's disease. c) Is it at least as likely as not (that is, a 50 percent probability or greater) the Veteran's Meniere's disease had its onset in service or is otherwise related to service? d) Is it at least as likely as not that the Veteran's Meniere's disease was caused by the Veteran's service-connected otitis externa? e) Is it at least as likely as not that the Veteran's Meniere's disease was aggravated (that is, permanently worsened beyond the natural progression) by the Veteran's service-connected otitis externa? A complete rationale must be provided for all opinions. 3. Then, the Veteran should be afforded an examination to ascertain the impact of all of his service-connected disabilities on his employability. The claims folder should be reviewed and that review should be indicated in the examination report. The examiner must evaluate and discuss the effect of all of the Veteran's service-connected disabilities on his employability. The examiner should opine as to whether the Veteran's service-connected disabilities, without consideration of his non-service-connected disabilities, render him unable to secure or follow a substantially gainful occupation. The rationale for any opinion must be provided. 4. Then, after ensuring any other necessary development has been completed, readjudicate the Veteran's claims, to include consideration of whether a rating of the Veteran's otitis externa under any additional Diagnostic Codes is warranted. If action remains adverse to the Veteran, provide the Veteran and his representative with a supplemental statement of the case and allow them an appropriate opportunity to respond. Thereafter, the case should be returned to the Board. The Veteran has the right to submit additional evidence and argument on the matters that the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs