Citation Nr: 1310352 Decision Date: 03/27/13 Archive Date: 04/09/13 DOCKET NO. 07-09 999 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a skin disorder of the hands and feet, to include as secondary to service-connected posttraumatic stress disorder. 2. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder with major depressive disorder. 3. Entitlement to a disability rating in excess of 10 percent for hypertension. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD M. Moore, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1976 to March 1985. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois, which denied service connection for punctate keratoses of the hands and feet; a November 2006 rating decision of the VA RO in St. Petersburg, Florida, which continued a 10 percent evaluation for hypertension; and an October 2010 rating decision of the VA RO in Montgomery, Alabama, which granted service connection for PTSD with major depressive disorder (MDD), assigning a 10 percent evaluation effective October 20, 2004. His case is currently under the jurisdiction of the VA RO in Montgomery, Alabama. In June 2011, the Veteran presented sworn testimony during a video conference hearing in Montgomery, Alabama, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's claims file. In January 2012, the Appeals Management Center (AMC) increased the Veteran's disability rating for PTSD with MDD to 50 percent, effective October 20, 2004 (the date of his original claim). Because the AMC did not assign the maximum disability rating possible, the appeal for a higher evaluation remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed an NOD as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). In September 2011 and October 2012, the Board remanded the Veteran's increased rating claims and punctate keratoses claim to the AMC for further evidentiary development, including providing the Veteran with new VA examinations and obtaining outstanding VA and private treatment records and Social Security Administration (SSA) records. The Board is obligated by law to ensure that the AMC complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. See Stegall v. West, 11 Vet. App. 268 (1998). A review of the record reflects that the Veteran was afforded a VA skin examination in October 2011 and new VA psychiatric and hypertension examinations in October 2011 and November 2012. Additionally, updated VA treatment records from the Birmingham and Tuscaloosa VA Medical Centers (VAMCs) have been obtained and associated with the claims file. Finally, private treatment records from Hillcrest Hospital and the Veteran's SSA disability records have been obtained and associated with the claims file. Accordingly, all remand instructions issued by the Board have been complied with and these matters are once again before the Board. The record reflects that, in January and March 2013, the Veteran submitted additional medical evidence to the Board in conjunction with his claims accompanied by a waiver of initial review of this evidence by the agency of original jurisdiction (AOJ) in accord with 38 C.F.R. § 20.1304. In March 2013, the RO associated additional electronic VA treatment records with the Veteran's Virtual VA electronic file. Although the Veteran has not specifically waived AOJ consideration of these records, the Board finds that a remand is not necessary as the records are, in large part, duplicative of the records submitted with a waiver by the Veteran in January and March 2013. Additionally, the Veteran's representative's February 2013 brief stating that they waived AOJ consideration of "all evidence obtained/associated with the claims file (virtual and paper) since the most recent Statement of the Case." As the Veteran's representative appears to waive AOJ consideration of any and all new evidence and these treatment records are essentially duplicative of those previously submitted, the Board finds a remand for AOJ consideration of the newly uploaded VA treatment records is not necessary. As the Veteran is challenging the disability rating assigned for his service-connected PTSD with MDD, and the record raises assertions that he is unemployable because of this service-connected disability, the determination as to whether he is entitled to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is part and parcel of the determination of the increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). While the Board has jurisdiction over this matter, the claim for TDIU is remanded to the RO for further development, as discussed more fully below. The issues of entitlement to service connection for a skin disorder of the hands and feet and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC in Washington, DC. VA will notify the Veteran if further action on his part is required. Please note that 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). FINDINGS OF FACT 1. The Veteran's service-connected PTSD with MDD has resulted in no more than occupational and social impairment with reduced reliability and productivity. 2. The Veteran's service-connected hypertension is manifested by diastolic pressure predominantly less than 110, systolic pressure predominantly less than 200, and continuous medication for control. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for service-connected PTSD with MDD have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.59, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a disability rating in excess of 10 percent for service-connected hypertension have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.104, Diagnostic Code 7101 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board 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). I. Duties to Notify and Assist Before addressing the merits of the issues on appeal of entitlement to an increased initial rating for PTSD and an increased rating for hypertension, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the AOJ of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. With regard to the Veteran's hypertension claim, an April 2006 letter fulfilled all the above-described notice requirements. With regard to his PTSD claim, the Board notes that the November 2004 notice letter failed to provide information regarding a disability rating and an effective date for the award of benefits if service connection is granted. However, this claim stems from a rating decision that initially assigned the rating after granting service connection. Where service connection has been granted and an initial rating and effective date have been assigned, the claim of service connection has been more than substantiated, as it has been proven. As such, 38 U.S.C.A. § 5103(a) notice is no longer required since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, any defect as to 38 U.S.C.A. § 5103(a) notice is nonprejudicial. See Dingess; Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008) (where a claim has been substantiated after the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records, VA treatment records, and VA examination reports are in the file. Private treatment records identified by the Veteran have been obtained, to the extent possible. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to these claims. With respect to claims for increased ratings, 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). In addition, where the evidence of record does not reflect the current state of the veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran with VA examinations for his hypertension in May 2006, October 2011, and November 2012 and for his PTSD in August 2005, September 2010, October 2011, and November 2012. The examiners reviewed the claims file and provided thorough physical examinations, including obtaining blood pressure readings for the hypertension examinations. Thus, the Board finds that the examinations of record are adequate for determining the disability ratings for the Veteran's service-connected hypertension and PTSD. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (affirming that a medical opinion is adequate if it provides sufficient detail so that the Board can perform a fully informed evaluation of the claim). Additionally, there is no medical evidence indicating that there has been a material change in the severity of the Veteran's service-connected hypertension since he was last examined in November 2012. See 38 C.F.R. § 3.327(a) (2012). In fact, a December 2012 VA treatment record showed a lower blood pressure reading than the most recent VA examination. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. See VAOPGCPREC 11-95. Thus, the Board finds that a new VA examination is not necessary at this time for his hypertension. With regard to the Veteran's PTSD claim, he was last examined in November 2012. Since the time of the last examination, he had been admitted to inpatient psychiatric treatment at the Tuscaloosa VAMC. His Global Assessment of Functioning (GAF) score upon admission was 32. This is significantly lower than his GAF score of 54 at the November 2012 VA examination. Additionally, he submitted a statement in January 2013 indicating that his psychiatric symptoms had worsened. Although these pieces of evidence indicate a possible worsening of the Veteran's psychiatric symptomatology since his most recent VA examination, the Board notes that he submitted a PTSD Disability Benefits Questionnaire (DBQ) completed by his VA psychologist and dated in February 2013. As this DBQ fully addresses the Veteran's psychiatric symptoms and all recent VA psychiatric treatment records, the Board finds that it provides sufficient medical evidence as to the current state of the Veteran's PTSD with MDD. As such, the Board finds that a new VA examination is not necessary at this time for his PSTD with MDD either. Some discussion of the Veteran's personal hearing finally is necessary. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). See Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here. The issues on appeal were clearly identified. Information was also elicited from the Veteran concerning the nature and severity of his PTSD and hypertension, including whether the Veteran kept a log of his blood pressure readings for the Board's review. The Veteran indicated that he did not maintain such a written log. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of these claims, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Merits of the Claims Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that 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 will be resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2012). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31 (2012). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where the Veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in such cases, when the factual findings show distinct time periods during which a claimant exhibits symptoms of the disability at issue and such symptoms warrant different evaluations, staged evaluations may also be assigned. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. See 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). PTSD The Veteran has been assigned a 50 percent initial evaluation under Diagnostic Code 9411 for his service-connected PTSD with MDD. He seeks a higher initial rating. Under Diagnostic Code 9411, the General Rating Formula for Mental Disorders is used. The General Rating Formula provides that a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Finally, a 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Although PTSD is rated under the General Rating Formula, the use of the term "such as" in 38 C.F.R. § 4.130 indicates that the listed symptoms are not intended to constitute an exhaustive list. Rather, the symptoms listed under the General Rating Formula for Mental Disorders are to serve as examples of the type and severity of symptoms or their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The symptoms to be considered when rating a Veteran's PTSD are not limited to those listed in 38 C.F.R. § 4.130. Instead, VA shall consider all symptoms of a Veteran's PTSD that affect his level of occupational and social impairment, including, if applicable, those identified in the fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Within the DSM-IV, GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The same is true of any physician's statement as to the severity of a disability. It remains the Board's responsibility to evaluate the probative value of any doctor's opinion in light of all the evidence of record. A GAF score of 31 to 40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 is defined as 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). See Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). The Veteran most recently underwent a VA examination for his service-connected PTSD with MDD in November 2012. At that time, he complained of worsening PTSD symptoms after taking a job as a police dispatcher, which he subsequently quit. He reported that his living situation was tenuous as he was chronically behind in rent and that his relationship with his wife was sometimes okay and sometimes not. He also indicated that he had no contact with his son or daughter and did not have any friends that he regularly saw. He did, however, report regular contact with a sister, who he found to be encouraging, and that he was friendly with coworkers when he worked. The Veteran also reported recurrent dream and recollections of his military experiences with physiological reactions, avoidance of stimuli reminding him of his military stressor, disinterest in his usual activities, irritability, difficulty concentrating, hypervigilance, depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, and low energy. He denied any problems with personal hygiene and activities of daily living and indicated that his sleep and nightmares were improving. Although he reported serious thoughts about suicide a few weeks prior, he indicated that they had diminished. The examiner observed that the Veteran had normal attention, some difficulty recalling items after a long delay, fair to good abstract reasoning, and no homicidal or distorted thoughts. He diagnosed the Veteran with chronic PTSD and MDD and assigned him a GAF score of 54. He concluded that the Veteran's psychiatric symptoms resulted in occupational and social impairment with reduced reliability and productivity. The Veteran was previously examined in October 2011. At that time, he complained of occasional panic attacks, last occurring two weeks prior, suicidal ideation without plan or intent, three physical altercations in the past year, and chronic sleep impairment. He reported that his marriage was fine but that it suffered from his anger and rage. He also indicated that he had no contact with his daughter for the preceding year, no contact with his son for the preceding ten years, a very close relationship with his three sisters, good relationships with his coworkers, and regular church attendance. He was participating in inpatient PTSD treatment at that time, but anticipated being unable to return to his current police dispatch job after treatment because of its triggering effect on his PTSD symptoms. The examiner observed mildly impaired immediate and recent memory, anxious and depressed mood, constricted and occasionally tearful affect. She diagnosed the Veteran with chronic PTSD and MDD and assigned him a GAF score of 51. She concluded that his psychiatric symptoms resulted in occupational and social impairment with reduced reliability and productivity. Although his police dispatch job was triggering and he would be unable to effectively function at that job, the examiner did not believe that he was unemployable in another context. The Veteran had another VA examination in September 2010. At that time, he complained of depressive episodes, characterized by depressed mood, brief periods of crying, anhedonia, nightmares four to five times per month, poor appetite, low energy, and fatigue, lasting one month and last occurring one month prior. He treated his psychiatric symptoms with individual therapy and psychotropic medications with good outcomes and no side effects. He indicated that he was hospitalized twice for depression and substance abuse in 2006. He reported being married since 2006 and talking frequently with his daughter. Although he reported only having a few friends, he attributed this to his recent move to the area and anticipated making more friends soon. The examiner observed unremarkable psychomotor activity, speech, and thought process and content, periods of crying when describing the in-service stressor, anxious mood, no delusions or hallucinations, average intelligence, some insight and judgment, no inappropriate behavior, moderately impaired remote memory, mildly impaired recent memory, and normal immediate memory. The Veteran denied obsessive or ritualistic behavior, panic attacks, suicidal or homicidal thoughts, episodes of violence, inability to maintain minimum personal hygiene, or problems with activities of daily living. He also reported being employed fulltime with no time lost at work due to his psychiatric disability. The examiner diagnosed the Veteran with mild chronic PTSD and recurrent MDD and assigned him a GAF score of 59. She concluded that the Veteran's PTSD with MDD resulted in an occasional decrease in work efficiency with intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but generally satisfactory functioning. The Veteran was first examined for his PTSD with MDD in August 2005. At that time, he complained of improved depression with occasional down feelings, nightmares occurring two times per week. He denied suicidal or homicidal ideation and psychosis and indicated that his attention, concentration, and memory had improved with sobriety. He also reported that his impulsiveness had improved with psychotropic medication and that he had a girlfriend. He planned to continue his inpatient substance abuse and depression treatment with the long-term goal of returning to work. The examiner observed that the Veteran was dressed in clean clothing with a full range of affect and normal cognitive functioning, judgment, and insight, and full orientation in all three spheres. She diagnosed him with chronic polysubstance abuse and adjustment disorder with mixed emotional features and history of recurrent major depression and assigned a GAF score of 65. In addition to the VA examination reports, the record includes VA treatment records that are fairly consistent with the VA examination reports, reflecting similar complaints noted in the VA examination reports, including depressed mood, difficulty in his marriage, trouble sleeping, and loss of appetite, and assigning GAF scores between 30 and 65/70 for the periods on appeal. Notably, the record reflects multiple psychiatric hospitalizations for acute episodes and long-term inpatient substance abuse, PTSD, and depression treatment. Additionally, the VA treatment records indicate that when in a depressed state, the Veteran reported not leaving the house or bathing. Although some of the VA treatment records show more serious symptoms, such as the Veteran's complaints of unemployability or suicidal ideation, they also include concerns about malingering. See VA treatment records, January 2012. The Board notes that the sole self-report of hallucinations in February 2012 was in the context of attempting to avoid discharge and was possibly a sign of malingering, as noted by the treatment team. The February 2013 DBQ submitted by the Veteran and completed by his treating VA psychologist notes his complaints of depressed mood, anxiety, suspiciousness, panic attacks occurring weekly or less, chronic sleep impairment, mild memory loss, flattened affect, difficulty understanding complex commands, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, particularly in work settings, inability to establish and maintain effective relationships, and impaired impulse control. The VA psychologist diagnosed the Veteran with PTSD, depressive disorder NOS, and cocaine abuse and assigned a GAF score of 50. He concluded that the Veteran's psychiatric symptoms result in occupational and social impairment with reduced reliability and productivity. In light of the foregoing, the Board finds that the totality of the evidence of record does not establish that the Veteran's service-connected PTSD warranted more than a 50 percent disability rating for the period on appeal. The Veteran did not experience occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The Veteran has experienced suicidal ideation, alleged neglect of personal hygiene, impaired impulse control, which does convey clear impairment; however, there is no indication that this rises to the level of impairment resulting in deficiencies in most areas. He has maintained familial relationships, including with his siblings and a marriage, throughout the appeals period, as well as some friendships. He is also actively involved in his church. This goes against the February 2013 VA psychologist's determination that he was unable to establish and maintain effective relationships. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence). Further, although he had difficulty as a police dispatcher because it reminded him of his military service, the evidence does not suggest that he would be unable to adapt to stressful work circumstances in a different context. Rather, the evidence supports a finding that he was successful at his previous jobs until injuring his back. The Veteran has been hospitalized several times during the appeals period. However, after viewing the treatment records from these hospitalizations, the Board concludes that they do not warrant the assignment of a higher evaluation of 70 percent. Although the Veteran sought inpatient treatment for his symptoms and substance abuse, this was in the context of a lack of housing. The majority of the hospitalizations were not acute and none of the admission records indicate a serious incident, such as a suicide attempt or psychotic episode. The majority of Veteran's GAF scores during this time period are between 55 and 60, reflecting only moderate impairment. The GAF scores lower than 55, showing serious or more severe symptoms are few and far between. Finally, and while not outcome determinative, there is no indication that the Veteran experienced problems with obsessional rituals interfering with routine activities, intermittently illogical, obscure, or irrelevant speech, near-continuous panic or depression, or spatial disorientation, which are symptoms that are generally associated with the higher rating of 70 percent. There is also no evidence of even more severe symptoms, such as total occupational and social impairment due to gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, disorientation to time or place, or memory loss for names of close relative, own occupation, or own name to warrant an even higher rating of 100 percent. As demonstrated by his marriage and ability to work prior to the police dispatcher job, the Veteran does not experience total occupational and social impairment. The most recent DBQ, from his treating provider, conveys the exact opposite opinion - that the symptoms of his PTSD cause only a reduced reliability. Additionally, the Board notes that there is no indication in the evidence of record that the Veteran's symptomatology warranted other than the currently assigned staged ratings throughout the appeal period. As such, assignment of staged ratings is not warranted. See Fenderson, supra. In considering the appropriate disability rating, the Board has also considered the Veteran's statements that his PTSD is worse than the ratings he had been receiving. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is not, however, competent to identify a specific level of disability of his psychiatric disability according to the appropriate diagnostic code. On the other hand, such competent evidence concerning the nature and extent of the Veteran's PTSD has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports, February 2013 DBQ, and VA treatment records) directly address the criteria under which these disabilities are evaluated. Accordingly, the Board finds that the claim of entitlement to an initial disability rating for PTSD with MDD in excess of 50 percent must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an increased initial rating for PTSD with MDD, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed. Cir. 2001). Hypertension The Veteran has been assigned a 10 percent rating under Diagnostic Code 7101 for his service-connected hypertension. Diagnostic Code 7101 provides the rating criteria for hypertensive vascular disease (hypertension and isolated systolic hypertension). Under that diagnostic code, a 10 percent evaluation is assigned for diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires constant medication for control. A 20 percent evaluation is assigned for diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. A 40 percent evaluation is assigned for diastolic pressure predominantly 120 or more. Finally, a 60 percent evaluation is assigned for diastolic pressure predominantly 130 or more. See 38 C.F.R. § 4.104, Diagnostic Code 7101 (2012). Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. For purposes of this section, the term hypertension means the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1) (2012). Hypertension due to aortic insufficiency or hyperthyroidism, which is usually the isolated systolic type, is to be evaluated as part of the condition causing it, rather than by a separate evaluation. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (2) (2012). Hypertension is to be evaluated separately from hypertensive heart disease and other types of heart disease. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (3) (2012). As referenced above, the Veteran was afforded a VA examination most recently for his hypertension in November 2012. The Veteran reported taking metoprolol, hydrochlorothiazide, and losartan. He did not report and the examiner did not observe any functional impairments. The examiner specifically noted that the Veteran's hypertension did not affect his employability. The examiner diagnosed the Veteran with essential hypertension with normal renal function and recorded a blood pressure of 145/100. He also noted prior blood pressure readings from November 2012 and August 2012 of 135/94 and 146/90. He also indicated that there were no additional pertinent physical findings, complications, conditions, signs, or symptoms related to his hypertension. The Veteran was previously examined for his hypertension in October 2011. At that time, he reported using metoprolol and hydrochlorothiazide. The examiner recorded blood pressure readings of 149/93, 140/89, and 144/109, and indicated that the Veteran did not have a history of diastolic blood pressure elevation to predominantly 100 or more. Although the Veteran reported a history of heart disease and a light myocardial infarction, the examiner found that he had no additional pertinent physical findings, complications, conditions, signs, or symptoms, to include no history of renal failure. The examiner concluded that the Veteran's hypertension had no functional impact on his ability to work. The Veteran was first examined in conjunction with his present claim in May 2006. At that time, he reported using metoprolol and hydrochlorothiazide. The examiner diagnosed him with hypertension that was well controlled under his current medications and recorded blood pressure readings of 120/70, 116/72, and 120/93. The Veteran again reported a history of "light" myocardial infarctions, but the examiner did not find such diagnoses in the VA treatment records. The examiner did not note any other cardiac or renal abnormalities. The medical evidence also includes private and VA treatment records from the period on appeal. Notably, these treatment records show diastolic readings ranging from 54 (February 2012) to 115 (January 2012) and systolic readings ranging from 100 (December 2011) to 157 (January 2012). His diastolic readings tended to remain in the 80s and 90s and his systolic readings tended to remain in the 120s to 140s range. In addition to the medical evidence, the Veteran provided hearing testimony indicating that he took his blood pressure regularly and that it tended to be about 170-180/100. The medical evidence of record does not establish that the Veteran's service-connected hypertension warrants a disability rating in excess of 10 percent. The treatment records include dozens of blood pressure readings and only one of these readings showed a diastolic blood pressure of 110 or higher. Significantly, this reading was taken in conjunction with a January 2012 psychiatric decompensation and hospitalization. None of the systolic blood pressure readings of record rise to the level of 200 or higher. Indeed, the Veteran's own hearing testimony indicates that his average blood pressure readings do not meet the criteria for an increased rating of 20 percent. There is simply no evidence to show that the Veteran's diastolic blood pressure is predominantly 110 or higher or that his systolic blood pressure is predominantly 200 or higher. As such, a disability rating in excess of the current 10 percent for hypertension cannot be granted. Additionally, there is no indication that the Veteran's hypertension warrants an increased rating under any other diagnostic code. He is specifically service-connected for hypertension and there is no evidence of hypertensive heart disease or other heart disease. As such, an increased rating cannot be assigned for hypertension under any other diagnostic code relating to the cardiovascular system. See 38 C.F.R. § 4.104, Diagnostic Codes 7000-7020, 7110-7123 (2012). There is also no indication in the medical evidence of record that the Veteran's hypertension warranted other than the currently assigned 10 percent disability rating throughout the appeal period. As such, assignment of staged ratings is not warranted. See Hart, supra. In reaching the above-stated conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to an increased rating for hypertension, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012); see also Ortiz, supra. Extraschedular Considerations The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court set forth a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, a veteran's disability picture requires the assignment of an extraschedular rating. The evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the Veteran's disabilities outside the usual rating criteria. With regard to the Veteran's service-connected PTSD, the rating criteria for his currently assigned 50 percent disability rating contemplate his symptoms, including some occupational and social impairment, flattened affect, panic attacks, difficulty in understanding complex commands, impairment of memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Further, as the Board must consider any additional psychiatric symptoms that the Veteran exhibits, even if they are not specifically identified in the rating criteria, the Veteran's disability picture is adequately contemplated by the rating schedule. See Mauerhan, supra. With regard to the Veteran's service-connected hypertension, the rating criteria specifically contemplate his high blood pressure readings, as well as his use of medication to control his blood pressure. Therefore, this disability picture is also adequately contemplated by the rating schedule. As such, the threshold issue under Thun is not met for either disability on appeal and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, the evidence does not support the proposition that the Veteran's service-connected PTSD or hypertension presents such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2012). Thus, referral of either of these issues to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. ORDER Entitlement to an initial disability rating in excess of 50 percent for PTSD with MDD is denied. Entitlement to a disability rating in excess of 10 percent for hypertension is denied. REMAND After a thorough review of the Veteran's claims file, the Board has determined that additional evidentiary development is necessary prior to the readjudication of his claims of entitlement to service connection for a skin disorder of the hands and feet and TDIU. With regard to the Veteran's skin disorder, the Veteran was afforded a VA examination in October 2011. The examiner did not link the Veteran's current plantar warts to his military service, finding that the evidence did not show treatment in service for plantar warts. The examiner did, however, note that the Veteran's treatment began in the mid-1980s. He did not reconcile these seemingly contradictory statements (that the Veteran did not experience plantar warts in service between 1976 and 1985 and that he first received treatment for plantar warts in the mid-1980s). Additionally, in a February 2013 brief, the Veteran's representative argued that his plantar warts may also be caused or aggravated by his service-connected PTSD. The examiner did not provide an opinion on secondary service connection either. In light of these deficiencies, the Board finds that the October 2011 VA examination is inadequate to decide the claim. See Stegall, supra. With regard to the Veteran's claim of entitlement to TDIU, the Board notes the code sheet associated with a December 2012 rating decision indicated that TDIU had been denied. Earlier incomplete rating decisions dated in May and June 2012 make no reference to a determination on the TDIU issue. Such suggests that a decision may have been made on the TDIU issue sometime between June 2012 and December 2012. However, a detailed review of the complete claims file, to include the electronic record, failed to identify a narrative description of the alleged denial. The Board cannot determine what evidence was considered or what the rationale was for the TDIU denial and cannot proceed to a decision on the TDIU claim at this point. There is also insufficient evidence that the Veteran received proper notice of any denial of TDIU. As noted above, in Rice v. Shinseki, the Court held that a TDIU claim is part of an increased rating claim when such claim is raised by the record. See Rice, supra. SSA records indicate that the Veteran was found to be disabled due to his psychiatric disorder and back disorder as of December 2011. The Veteran's service connected hypertension was listed as a contributing cause. 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 nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012). While the Veteran has been afforded previous VA examinations to address his service-connected disabilities, a specific opinion as to his unemployability and the effect of all 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. As the Court explained in Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991), the Board may consider only independent medical evidence to support its medical findings. The Court went on to say that, if the medical evidence of record is insufficient, the Board is free to supplement the record by seeking an advisory opinion, ordering a medical examination or citing recognized medical treatises in its decisions that clearly support its ultimate conclusions. See Colvin at 175. For the reasons described above, the Veteran's claims of entitlement to service connection for a skin disorder of the hands and feet and TDIU must be remanded for new VA examinations and opinions. Finally, as the case is being remanded, the Board will take the opportunity to obtain any outstanding VA treatment records. (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.) Accordingly, the case is REMANDED for the following actions: 1. Copies of all outstanding VA treatment records from the Birmingham and Tuscaloosa VA Medical Centers, and any other VA facility identified by the Veteran should be obtained and added to the claims folder. 2. The Veteran should be afforded an examination with an appropriate examiner in order to determine the nature and etiology of his claimed skin disorder of the hands and feet. All indicated studies should be performed. The claims folder should be provided to the examiner for review of pertinent documents therein. The examination report should reflect that such a review was conducted. The examiner must identify all current skin disorders of the hands and feet and state whether each of diagnosed disorders was caused or aggravated (permanently increased in severity beyond the natural progression of the disorder) by his military service or by his service-connected PTSD with MDD. The examiner should specifically address the 1989 VA treatment records showing complaints of warts for 8 to 9 years prior. He or she should also address the Veteran's suggestion that there is a relationship/interaction between the symptoms of the Veteran's PTSD and the development/progression of his skin disorder It would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner should provide a complete rationale for any opinion provided. 3. Thereafter, schedule the Veteran for a VA examination to determine the effect of his service-connected disabilities on his employability. The examiner must review pertinent documents in the Veteran's claims file in conjunction with the examination. That such a review took place must be noted in the examination report. The examiner should opine as to whether the Veteran is unable to secure or maintain substantially gainful employment solely as a result of his service-connected disabilities. A complete rationale should be provided for any opinion offered. 4. After completing the above actions and any other development that may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims of entitlement to service connection for a skin disorder of the hands and feet and TDIU should be readjudicated. If either of the claims remains denied, a supplemental statement of the case should be provided to the Veteran and his representative. After they have had an adequate opportunity to respond, all issue(s) properly on appeal should be returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the rating of the claim on the evidence of record if it is an original claim or denial if it is a claim to reopen or for increase. See 38 C.F.R. § 3.655(b) (2012). 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). ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs