Citation Nr: 1312810 Decision Date: 04/17/13 Archive Date: 05/02/13 DOCKET NO. 07-02 554 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a cervical spine disorder, to include as secondary to service-connected headaches, residuals of head trauma. 2. Entitlement to increased initial evaluations for posttraumatic stress disorder (PTSD) with mood disorder associated with headaches, residual of head trauma (psychiatric disability), evaluated as 10 percent disabling prior to October 16, 2010 and 70 percent disabling on and after October 16, 2010. 3. Entitlement to increased initial evaluations for status-post cerebrovascular accident (CVA) with weakness of left lower extremity associated with headaches, residual of head trauma (left lower extremity disability), evaluated as 20 percent disabling from February 24, 2003 to June 15, 2007, 40 percent disabling from June 15, 2007 to November 29, 2011, and 60 percent disabling on and after November 29, 2011. 4. Entitlement to an effective date prior to June 15, 2007 for the grant of a 40 percent evaluation for the service-connected left lower extremity disability. 5. Entitlement to an effective date prior to May 23, 2006 for the grant of entitlement to a total disability rating based on individual unemployability (TDIU). 6. Entitlement to an effective date prior to May 23, 2006 for the grant of entitlement to Dependents Education Assistance (DEA) benefits. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Millikan, Counsel INTRODUCTION The Veteran served on active military duty from September 1972 to September 1976. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Roanoke, Virginia, Regional Office (RO) of the Department of Veterans Affairs (VA) and a March 2010 Board remand. The March 2010 Board remand directed development and readjudication of the issue of entitlement to special monthly compensation (SMC) for aid and attendance and/or housebound status. In a June 2012 rating decision, the RO granted entitlement to SMC. The Veteran did not appeal that rating decision as it relates to SMC. Accordingly, the Board finds that that issue is no longer on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997) (holding that a separate notice of disagreement must be filed to initiate appellate review of downstream elements such as the disability rating or effective date assigned). Certain records from the claims file have been stored electronically as part of the Virtual VA paperless claims processing system. This system uses, instead of paper, a highly secured electronic repository to store and review documents involved in the claims process. Although the majority of records from this claims file are associated with the physical, or paper, claims file, because some of the documents were added to the electronic version of this file as part of the virtual claims file, any consideration of this appeal must consider both the paper and virtual claims files. The Board has reviewed all electronic and paper records associated with this file. The issues of entitlement to service connection for a cervical spine disability and earlier effective date prior to May 23, 2006 for TDIU and DEA are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Effective February 24, 2003, the Veteran's service-connected left lower extremity disability was manifested by moderate severe incomplete paralysis of the sciatic nerve due to such symptoms as foot drop, loss of ankle dorsiflexion, and decreased sensation, but almost full knee flexion and no muscle atrophy. 2. On and after April 26, 2009, the Veteran's service-connected left lower extremity disability is manifested by complete paralysis of the sciatic nerve, due to such symptoms as foot drop, muscle atrophy, no active movement of the muscles below the knee, and weakened knee flexion. 3. Prior to October 16, 2010, the Veteran's service-connected psychiatric disability is manifested by deficiencies in most areas due to such symptoms as a depressed mood, deficiencies in family relations, self-isolation, anger, and withdrawal, but is not manifested by total occupational and social impairment. 4. On and after October 16, 2010, the Veteran's service-connected psychiatric disability is manifested by total social and occupational impairment due to such symptoms as depressed mood, inability to socialize, and an inability to form social relationships. CONCLUSIONS OF LAW 1. Effective February 24, 2003, the criteria for an initial evaluation of 40 percent, but no more, for the service-connected left lower extremity have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. § 4.124a, Diagnostic Code 8008-8520 (2012). 2. On and after April 26, 2009, the criteria for an evaluation of 80 percent, but no more, for the service-connected left lower extremity have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. § 4.124a, Diagnostic Code 8008-8520 (2012). 3. Prior to October 16, 2010, the criteria for an initial evaluation of 70 percent for the service-connected psychiatric disability, but no more, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (General Rating Formula), Diagnostic Code 9499-9435 (2012). 4. On and after October 16, 2010, the criteria for an evaluation of 100 percent for the service-connected psychiatric disability have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. § 4.130, General Rating Formula, Diagnostic Code 9435-9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to notify and assist Under the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and 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. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VCAA notice requirements 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. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. 396 (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, VA's duty to notify has been satisfied. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b). Regarding the increased initial evaluation and earlier effective date claims, "where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated-it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled." Dingess/Hartman, 19 Vet. App. at 490; Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007) (noting that once an initial VA decision awarding service connection and assigning a disability evaluation and effective date has been made, section 5103(a) notice is no longer required). Additionally, where service connection has been granted, the claimant bears the burden of demonstrating prejudice from defective notice with respect to downstream elements such as effective dates or disability ratings. Goodwin v. Peake, 22 Vet. App. 128, 137 (2008). The Veteran has made no such assertions here. Accordingly, VA's duty to notify has been satisfied. VA's duty to assist the Veteran has also been satisfied. 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records (STRs), VA medical records, and identified private medical records have been obtained. VA provided the Veteran with adequate medical examinations with respect to his claim. Regarding the psychiatric disability, VA provided the Veteran with examinations and/or addendums in 2006, 2007, 2009, 2010, 2011, and 2012. They are adequate as each examination contained a history elicited from the Veteran and addressed all relevant symptomatology and etiology. Additionally, although the 2011 VA examiner found that the psychiatric disability was less severe than the 2010 VA examiner found and did not address the 2010 opinion, there is no prejudice to the Veteran because a 100 percent evaluation is assigned as of the date of the 2010 examination. Regarding the left lower extremity disability, VA provided the Veteran with examinations in 2006, 2007, 2009, 2010, and 2011. Although not all are technically adequate, the 2011 examination cured the deficiencies of the examinations: the examiner reviewed the record and determined that muscle atrophy began in 2009, which is part of the bases of the increased evaluation as of that date. The examinations are otherwise adequate because each contains a history obtained from the Veteran and addresses the symptoms relevant to the diagnostic criteria. There is no indication in the record that additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. at 121-22. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 542-43 (2006), aff'd, Mayfield v. Nicholson, 499 F.3d 1317 (2007); see also Dingess/Hartman, 19 Vet. App. at 486. Increased evaluation claims Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2012). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). When it is not possible to separate the effects of service-connected and non-service-connected disabilities, such effects should be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Board notes, however, that this rule does not apply here, because the current appeal is based on the assignment of an initial rating for a disability following an initial award of service connection for this disability. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Instead, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson, 12 Vet. App. at 126. If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126. The relevant time period for consideration in a claim for an increased initial disability rating is the period beginning on the date that the claim for service connection was filed. Moore v. Nicholson, 21 Vet. App. 211, 216-17 (2007). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2012). However, separate evaluations for separate and distinct symptomatology may be assigned where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Furthermore, if two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding a degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). Left lower extremity By an April 2006 rating decision, the RO granted service connection for the left lower extremity disability, and assigned a 20 percent evaluation under 38 C.F.R. § 4.124a, Diagnostic Code 8008-8520, effective February 24, 2003. Although the Veteran did not file a notice of disagreement, new and material evidence was submitted via a VA examination dated in May 2006 and VA medical records received in April 2007 that addressed the disability. In an August 2007 rating decision, the RO assigned a 40 percent evaluation, effective June 15, 2007. The Veteran appealed that evaluation. Thus, the appeal period begins on February 24, 2003. In a December 2002 VA record, it was noted that the Veteran had been given an ankle foot orthosis (AFO) for left foot drop. On examination, there was 4-5/5 hip strength, 2/5 knee strength, and no active movements around the ankle. Deep tendon reflexes were exaggerated on the left side and there was hemisensory deficit to pinprick. The Veteran was able to come to a standing position and to ambulate approximately 100 feet with a slight foot slap and broad-based gait on the left side. Standing balance was good. In a January 2003 VA record, it was noted that the Veteran ambulated with an AFO on the left foot. In a January 2003 private record, it was noted that the Veteran ambulated with a single point cane. In an October 2004 VA medical record, the Veteran reported he was confined to a scooter, but was able to go five steps with a cane to do things around the house. There was full passive left knee extension but active left knee extension was lacking 25 degrees due to contraction and spasticity of his hamstrings. There was full active and passive knee flexion and passive dorsiflexion of the left ankle to 10 degrees, but no active dorsiflexion of the ankle. There was full passive and active range of motion of the left hip. On review of x-rays, there were no abnormalities of the hip, knee, or ankle. In a November 2004 VA record, there was hip strength of 3/5, knee strength of 5/5, and no active movements around the ankle. The Veteran was able to come to a standing position and he claimed he could walk a short distance with the assistance of a quad cane. It was noted that the Veteran was not expected to have any return of function to the left extremities. In February 2005 VA medical records, there was hip strength of 3/5, knee strength of 5/5, and no active movement around the ankles. He was able to stand, and claimed he could walk a short distance with a quad cane. There was 1/5 plantar flexion and no dorsiflexion. There was 4/5 knee flexion and extension strength and grossly 50 percent of sensation lost. Reflexes were 3+. In March 2005 VA records, the impression was stroke, with left hemiparesis, arm weaker than leg. Reflexes were 3+ on the left. The Veteran could rise out of the scooter without assistance, but had poor balance. Strength was 3/5 of the left lower extremity with no foot drop. There was decreased range of motion in the left ankle, with 40 degrees of dorsiflexion and plantar flexion. Pulses were 2+. The Veteran was not a candidate for additional physical therapy as additional recovery was not likely. In a June 2005 VA record, the Veteran reported that he was initially ambulatory after the CVA, but now was not. Upon examination, there was dorsiflexion of 0/5 and plantar flexion of 1/5. Sensation was 50 percent lost and there were 3+ reflexes. He could rise out of the scooter without assistance but had poor balance. In a July 2005 VA record, there was decreased range of motion of the left knee. There was left lower extremity 4/5 hip strength, 3+/5 knee strength, and 4-/5 ankle dorsiflexor strength. There was weakness of the adductors and abductors, decreased sensation of the left foot, and 2+/4 reflexes of the left lower extremity. In an August 2005 VA record, the Veteran's chief complaint was not being able to walk. He was walking some with a quad cane, but had multiple falls. There was full active range of motion in the left lower extremity except for ankle dorsiflexion. Sensation was decreased on the left side, with increased tone of the left lower extremity. The Veteran was functional for transfers and limited mobility with supervision but was not safe to ambulate without supervision. In a January 2006 VA examination, the Veteran reported an inability to fully extend the left leg. Upon examination, the Veteran was wheelchair bound because of left lower extremity weakness. On the left side, there was abnormal motor function, but sensory function was within normal limits. Reflex examination revealed knee jerk of 2+ and ankle jerk of 2+. In a February 2006 VA record, the Veteran reported for an evaluation of his gait. He stated that since the CVA, his ambulation had worsened and he was now confined to a scooter. Upon examination, there was dorsiflexion of 0/5 and plantar flexion of 1/5. There was sharp dull discrimination but grossly 50 percent of sensation was lost. There were 3+ reflexes, and the Veteran could rise out of the scooter without assistance with poor balance. In another February 2006 VA record, there was left knee weakness, but x-rays indicated no diagnostic abnormality. In a May 2006 VA examination, there was left lower extremity abnormal motor function. There were left lower extremity reflexes of knee jerk 2+ and ankle jerk 2+. In another May 2006 VA record, there was 3/5 strength of the left lower extremity. DTRs were 1+ and the Veteran was wheelchair bound. Muscular coordination was impaired. In a June 2006 VA record, the Veteran complained of an inability to walk. He was independent at home with his activities of daily living (ADL), but could not make his bed. There was left lower extremity full range of motion, with decreased sensation. He was able to weight bear but on standing shifts and leans significantly right. At home he walked some with a quad cane. In an August 2006 VA record, the Veteran was independent in transfers and sit to stand. He did not ambulate, used a chair for mobility, and was independent in his ADLs. In a June 2007 VA examination, there was weakness of the left lower extremity, especially with hip and knee flexion. The Romberg test could not be performed because the Veteran was unable to stand. There was no evidence of peripheral sensory neuropathy. Deep tendon reflexes of the patellar and calcaneal tendons were absent on the left lower extremity. In a July 2007 VA examination, there was +2/5 left lower extremity strength. The Veteran could stand, but could not ambulate. There was full passive range of motion of the lower extremity joints. In a March 2009 VA record, there was 5/5 motor strength, intact sensation, and 2+ knee and ankle jerks. In an April 6, 2009 VA examination, the Veteran was wheelchair bound. He reported left lower extremity numbness and weakness. He could stand but not ambulate. Palpation of the muscle did not reveal loss of muscle substance and impairment of muscle tone. There was 2/5 muscle strength and left lower extremity weakness. There was left hip flexion to 125 degrees, extension to 30 degrees, adduction to 25 degrees, abduction to 45 degrees, external rotation to 60 degrees, and internal rotation to 40 degrees. There was left knee flexion to 140 degrees and extension to zero degrees. Left knee stability testing was within normal limits. There was left ankle dorsiflexion to 20 degrees and plantar flexion to 45 degrees. Sensory function was within normal limits. There was knee jerk of 2+ and ankle jerk of 2+. In a June 2009 VA record, the Veteran was not able to walk. There was decreased sensation, 3+/5 hip strength, 3+/5 knee strength, and 0/5 great toe and ankle strength. There was limited range of motion in hip, knee, and ankle. In a July 2009 VA record, there was 5/5 strength and 2+ knee and ankle jerks. October 2010 VA aid and attendance, peripheral nerves, and brain and spinal cord examinations were conducted upon review of the claims file. Upon examination, there was left leg weakness. At the present, the Veteran could not stand and pivot, he was formerly able to walk 150 feet with a cane post his CVA in 2002. He used a scooter and required a brace for stability. Upon examination, there was 0/5 knee jerk and 1+ ankle jerk with an abnormal Babinski test. There was decreased vibration sense, decreased pain /pinprick sensation, decreased light touch sensation, and dysesthesias. There was a history of paresthesia, to include intermittent numbness of the left leg and foot. There was no history of rigidity, seizures, or impaired bladder function. There was left lower extremity limitation of motion, muscle weakness, and lack of coordination. He was unable to walk. The diagnosis was no use of left lower extremity due to CVA. In a February 2011 VA record, it was noted that the Veteran could not walk and used a wheelchair. He could stand up from the wheelchair without assistance. November 2011 VA aid and attendance and brain and spinal cord examinations were conducted. The Veteran could not walk without the assistance of another person and required the use of a wheelchair. The Veteran was able to support his body weight in stand and pivot only. There were severe symptoms including severe intermittent pain, moderate paresthesia and/or dysesthesias, and severe numbness. There was 5/5 left lower extremity strength in knee extension, ankle plantar flexion, and ankle dorsiflexion. There was muscle atrophy as noted the 2010 VA examination. There was 0/5 reflexes of the left knee and ankle. There was absent sensation of the left foot and toes and decreased sensation of the lower left leg and ankle. The examiner found complete paralysis of the left sciatic nerve and the external popliteal nerve, musculocutaneous nerve, anterior tibial nerve, internal popliteal nerve, posterior tibial nerve, the anterior crural or femoral nerve, the internal saphenous nerve, and the obturator nerve, the external cutaneous nerve, and the ilio-inguinal nerve. The examiner found that functioning was diminished and that amputation with prosthesis would equally serve the Veteran. In a March 2012 addendum, the examiner stated that the severity of the left lower extremity weakness had progressed since 2002, when the Veteran was able to ambulate 150 feet with a cane and standby assistance. There was a downhill progression per records in 2003, 2005, 2006, and 2009. Physical therapy notes essentially indicated no active movement of the LLE, which is not uncommon in post CVA patients who fail to maintain home exercise programs post injury. The Veteran's post CVA course was complicated by a number of factors. The examiner determined that muscle atrophy appears to have begun around 2009, during a period of depression with a decrease in the Veteran's normal activities. Most recent VA evaluation notes dated in November 2011 noted increasing spasticity and loss of muscle action. The examiner noted the Veteran was unable to walk and remained in a scooter, but was independent in transfers. He had home aides for assistance in ADLs approximately four times per week. There was 2+ dorsiflexion of the left ankle, atrophy of the quadriceps muscle, and that without his AFO (brace), there was left foot drop. There was no left knee flexion. He had lost 90% of the function of the leg, but due to his ability to lock his knee and bear weight, it was not equal to a complete loss such as an amputation. The paralysis of the sciatic nerve is severe, but incomplete, because he retains those two abilities. From February 24, 2003 to June 15, 2007, the Veteran's left lower extremity disorder is currently assigned a 20 percent evaluation, which contemplates moderate incomplete paralysis of the sciatic nerve. A 40 percent evaluation is assigned for moderately severe incomplete paralysis, a 60 percent evaluation is assigned for severe incomplete paralysis, with marked muscular atrophy, and a maximum 80 percent evaluation is assigned for complete paralysis of the sciatic nerve, the foot dangles and drops, no active movement possible of muscles below the knee, and flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, Diagnostic Code 8520. Incomplete paralysis indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The ratings for the peripheral nerves are for unilateral involvement; when there is bilateral involvement, the VA adjudicator is to combine the ratings for the peripheral nerves, with application of the bilateral factor. 38 C.F.R. § 4.124a. The Board finds that a 40 percent initial evaluation is for assignment as of February 24, 2003. Prior to April 6, 2009, the evidence of record demonstrates the use of an AFO for foot drop and no active ankle movement or dorsiflexion as noted in December 2002, November 2004, June 2005, and February 2006. The medical evidence of record indicated decreased dorsiflexion in October 2004 and August 2005. Deep tendon reflexes were 3+ in June 2005, normal in January 2006, 3+ in February 2006, 1+ in May 2006, and absent in June 2007. Additionally, there is evidence of decreased muscle strength, but not muscle atrophy although in May 2006, there was impaired muscle coordination. In addition, from 2002 through 2007, the Veteran could come to a standing position. In 2002 and 2004, he could ambulate a few steps with a cane, although he did have falls. He remained functional for transfers. By January 2006, the Veteran was wheelchair bound. His left lower extremity sensation was approximately 50 percent lost. A 2011 VA examiner opined, upon review of the record, that muscle atrophy began in 2009. The Board finds that the evidence thus shows moderately severe incomplete paralysis, including left lower extremity weakness, foot drop, loss of ankle movement, and loss of 50 percent sensation. This does not more closely approximate severe incomplete paralysis as the evidence shows full or almost full knee flexion and 50 percent sensation retained. Additionally, the evidence prior to 2009 does not demonstrate marked muscle atrophy. Thus, a 40 percent evaluation, but not a 60 percent evaluation, is for assignment. As of April 6, 2009, however, a maximum 80 percent evaluation is warranted. As of that date, the evidence more closely approximates complete paralysis of the sciatic nerve because there is foot drop, with no active movement of the left ankle, and weakened or absent knee flexion. The Board notes that the 2009 VA examination did not indicate foot drop, loss of muscle movement below the knee, or weakened knee flexion. However, the 2011 VA examiner placed the date of the onset of muscle atrophy as of the date of that VA examination and opined that there was complete paralysis of the sciatic nerve; thus indicating that the worsening began at that point. Additionally, in a July 2009 VA record, there was decreased knee strength and 0/5 toe and ankle strength. In the 2010 VA examinations, there was essentially a loss of deep tendon reflexes of the knee and ankle, with decreased sensation. There was 0/5 knee jerk, 1+ ankle jerk, decreased sensation, and the Veteran was unable to walk. The examiner found there was no use of the left lower extremity. The 2011 VA examiner found severe symptoms, including muscle atrophy and absent sensation of the left foot and toes. The examiner determined that functioning was so diminished that amputation with prosthesis would equally serve the Veteran. In a March 2012 addendum, the examiner revised that opinion and found that due to the Veteran's ability to lock his knee and bear weight, there was a 90 percent loss of function, but not a complete loss and concluded that the paralysis was severe, but incomplete. The examiner also noted, however, that there was no active movement of the left lower extremity, recent increasing spasticity, loss of muscle action, atrophy of the quadriceps, and no left knee flexion. Thus, when assessing the symptoms as a whole, despite the 2012 addendum indicating that there was not total loss of use, the 2011 VA examination indicated muscle atrophy, foot drop, no active movement at the ankle, and weakened knee flexion. This most closely approximates an 80 percent evaluation for complete paralysis of the sciatic nerve. 38 C.F.R. § § 4.3, 4.7. As this is the maximum evaluation provided for in this diagnostic code, no higher evaluation is warranted. The Board has considered the application of other diagnostic codes. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Only the 2011 VA examiner noted any involvement of other nerves; the other evidence of record demonstrates that the Veteran's sciatic nerve was the only one involved. However, the 2011 VA examiner noted complete paralysis of the external popliteal nerve, musculocutaneous nerve, anterior tibial nerve, internal popliteal nerve, posterior tibial nerve, the anterior crural or femoral nerve, the internal saphenous nerve, and the obturator nerve, the external cutaneous nerve, and the ilio-inguinal nerve. But the diagnostic codes for those nerves do not provide for evaluations in excess of 80 percent and do not provide for evaluations higher than 40 percent for moderately severe incomplete paralysis. See 38 C.F.R. § 4.124a, Diagnostic Codes 8521-8540 (2012). Furthermore, the diagnostic codes for amputation do not provide for higher evaluations than currently assigned. 38 C.F.R. § 4.71a, Diagnostic Codes 5160-5173 (2012). Accordingly, increased evaluations under alternative diagnostic codes are not for assignment. Additionally, the Board finds that a separate award of special monthly compensation is not warranted. Loss of use of a hand or a foot, for the purpose of special monthly compensation, will be held to exist when no effective function remains other than that which would be equally well served by an amputation stump at the site of election below elbow or knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function of the hand or foot, whether the acts of balance and propulsion, etc., in the case of the foot, could be accomplished equally well by an amputation stump with prosthesis. Complete paralysis of the external popliteal nerve (common peroneal) and consequent, foot drop, accompanied by characteristic organic changes including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve, will be taken as loss of use of the foot. 38 C.F.R. § 4.63 (2012). Here, the 2011 VA examiner expressly indicated that although the Veteran lost 90% of the function of the leg, he retained the ability to lock his knee and bear weight, and thus his lower extremity was not equal to a complete loss such as an amputation. The 2011 VA examiner, however, also found complete paralysis of the left external popliteal nerve. But there were no findings of characteristic organic changes including trophic and circulatory disturbances. Accordingly, an additional SMC award is not warranted. Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2012); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this regard, the schedular evaluations in this case are not inadequate. Ratings in excess of 40 percent are provided for certain manifestations of the service-connected left lower extremity disability but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's two assigned evaluations, as the criteria assess incomplete and complete paralysis, to include weakness, reflexes, muscle atrophy, and range of motion. The Board has attributed all potentially service-connected symptoms to the left lower extremity disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Accordingly, this issue need not be referred for consideration of an extraschedular rating. Psychiatric disability By a February 2006 rating decision, the RO granted service connection for a mood disorder and assigned a 10 percent evaluation under 38 C.F.R. § 4.130, Diagnostic Code 9499-9435, effective March 29, 2005. The Veteran appealed the evaluation. In a June 2012 supplemental statement of the case (SSOC), the RO assigned a 70 percent evaluation, effective October 16, 2010, under Diagnostic Code 9435-9411. Despite denying service connection for PTSD in 2009, in the June 2012 SSOC, the RO noted that the Veteran's PTSD was service-connected and evaluated along with the mood disorder. In an August 2004 VA medical record, the Veteran reported depression. He lived alone and had no family. He denied manic symptoms and suicidal and homicidal ideations or plans. There was no problem with sleep or appetite. Upon examination, he was casually dressed, pleasant, cooperative, alert, and oriented, with good eye contact and well organized thoughts. There were no delusions or hallucinations, somewhat slurred speech, and an appropriate affect. Insight and judgment were not impaired. Memory and cognition intact. The Global Assessment of Functioning (GAF) score was 50, which contemplates serious symptoms, for example suicidal ideation, severe obsessional rituals, and frequent shoplifting; or any serious impairment in social, occupational, or school functioning, for example no friends, unable to keep a job. DSM-IV at 46-47. In a February 2005 VA record, the Veteran reported depression and denied suicidal and homicidal ideations. He was alert, oriented, and cooperative, with coherent and relevant speech with normal rate and tone. There was good eye contact, well-organized thoughts, no delusion or hallucinations, and a dysphoric mood with full range of affect. There was fair insight and judgment. Memory and cognition were intact. The GAF score was 50, which contemplates serious symptoms or any serious impairment in social, occupational, or school functioning. DSM-IV at 46-47. In an August 2005 VA medical record, the Veteran reported depression, psychotic symptoms, manic symptoms, and suicidal and homicidal ideations. There was no problem with sleep or appetite. Examination indicated the Veteran was casually dressed, pleasant, cooperative, alert, and oriented, with coherent and relevant speech. There was good eye contact, well organized thoughts, and no delusions or hallucinations. There was a euthymic mood with full range of affect. Insight and judgment were not impaired. Memory and cognition were intact. The GAF score was 50, which contemplates serious symptoms or any serious impairment in social, occupational, or school functioning. DSM-IV at 46-47. In a January 2006 VA examination, the Veteran reported depression, irritability, and sleep difficulty. He was in counseling and took medication. He reported recurrent suicidal thoughts over the years, but had never directly attempted to harm himself. Upon examination, the Veteran was polite, cooperative, and maintained eye contact. There were no psychomotor abnormalities, and his speech and thought processes were goal directed. The Veteran was oriented in all spheres with good memory function. The mood was euthymic, and he was not acutely suicidal, homicidal, psychotic, manic, hypomanic, obsessive, or compulsive. There was good fund of knowledge, abstracting ability, and insight and judgment. A GAF score of 55 was assigned, which indicates moderate symptoms, for example, a flat affect and circumstantial speech, or occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, such as having few friends, and conflicts with peers or co-workers. DSM-IV at 46-47. In a February 2006 VA medical record, the Veteran denied major depression, psychotic symptoms, manic symptoms, and suicidal and homicidal ideations. The Veteran was casually dressed, pleasant, cooperative, alert, and oriented. Speech was coherent and relevant with normal rate and tone. There was good eye contact, well organized thoughts, and no delusions or hallucinations. The mood was neutral with congruent and appropriate affect. Insight and judgment were not impaired. Memory and cognition were intact. The GAF score was 50, which contemplates serious symptoms, for example suicidal ideation, severe obsessional rituals, and frequent shoplifting; or any serious impairment in social, occupational, or school functioning, for example no friends, unable to keep a job. DSM-IV at 46-47. In May 2006 VA medical records, the Veteran was alert and oriented and denied suicidal and homicidal ideations, audio and visual hallucinations, mood swings, and racing thoughts. He had an appropriate affect and mood. He reported good sleep and poor sleep. There were goal directed and organized thoughts and clear speech. The Veteran reported no energy, isolation, and increased thoughts of giving up, but denied any active plan or intent. Examination indicated the mood was sedate, the affect and mood were congruent, and insight and judgment were impaired. The GAF score was 35, which signifies some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood, for example where a depressed man avoids friends, neglects family, and is not able to work. DSM-IV at 46-47. A June 2007 VA examination was conducted. The Veteran reported anger and sleep impairment. He stated he is angry whenever he is around people, and that he last worked in 1993. He stated that he relapsed with drinking in 2006 and was hospitalized at that time. He reported recurrent suicidal ideations without attempts. Upon examination, there was good eye contact, and the Veteran was friendly and cooperative. There were goal-directed thought processes and speech, no psychomotor abnormalities, and the Veteran was fully oriented. There was good memory function, and euthymic mood and affect. The Veteran was not anxious, angry, depressed, acutely suicidal, homicidal, psychotic, manic, hypomanic, obsessive, or compulsive. There was a good fund of knowledge and fair insight and judgment. In the examiner's opinion, the Veteran could perform work in a structured and well supervised setting because he was cognitively capable of doing so. The GAF score was 55, which indicates moderate symptoms, for example, a flat affect and circumstantial speech, or occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, such as having few friends, and conflicts with peers or co-workers. DSM-IV at 46-47. In a February 2008 VA record, the Veteran reported increased depression. He stated he had not been sleeping and was isolating more. He denied suicidal and homicidal ideations and hallucinations. The Veteran was alert and oriented, pleasant, cooperative, and had good eye contact. The mood and affect were appropriate, and there was coherent and relevant speech, and organized and goal-directed thoughts. Insight and judgment were good. In an April 2008 VA record, the Veteran reported his mood was all right, but he had poor sleep. He attended church and denied hopelessness, suicidal and homicidal ideations, anxiety symptoms, and manic symptoms, but reported irritability, auditory hallucinations, and nightmares. Examination indicated the Veteran was pleasant, cooperative, alert, oriented, and dressed adequately, with good eye contact. He had a euthymic affect, congruent mood, and a logical, goal-directed, and a non-delusional thought process. Speech was relevant, immediate memory was 3/3, and recent memory was 2/3. There was fair insight and judgment. The GAF score was 45, which signifies serious symptoms, for example suicidal ideation, severe obsessional rituals, and frequent shoplifting; or any serious impairment in social, occupational, or school functioning, for example no friends, unable to keep a job. DSM-IV at 46-47. In a May 2008 VA record, the Veteran reported feeling sad, irritable, agitated, and paranoid. He stated he had poor interest except for the computer. He reported poor sleep and hopeless feelings for the future. He denied manic symptoms and suicidal or homicidal ideations. Upon examination, the Veteran was alert and oriented, dressed adequately, and was able to maintain good eye contact. He was pleasant and cooperative. The affect was euthymic and mood was congruent. The thought process was logical and goal directed, with nondelusional thought content. Speech was slurred due to the CVA, but relevant. Memory was intact and insight and judgment were fair. The GAF score was 45, which signifies serious symptoms, for example suicidal ideation, severe obsessional rituals, and frequent shoplifting; or any serious impairment in social, occupational, or school functioning, for example no friends, unable to keep a job. DSM-IV at 46-47. In a December 2008 VA record, the Veteran reported he needed to get back on his medication. He reported being moody and irritable, with poor interest other than his computer, agitation, paranoia, irritability, and poor sleep. He also reported hopeless feelings, but denied manic symptoms and suicidal and homicidal ideations. Upon examination, the Veteran was alert and oriented, dressed adequately, and able to maintain good eye contact. He was pleasant and cooperative. The affect was euthymic and his mood was congruent. The thought process was logical, and goal directed, and nondelusional. There was relevant but slurred speech. The GAF score was 45, which signifies serious symptoms, or any serious impairment in social, occupational, or school functioning. DSM-IV at 46-47. An April 2009 VA examination was conducted. The Veteran reported anger and depression. The Veteran stated he was last seen for his psychiatric disorders in 2008. He reported that he had discontinued drinking in 2000. He reported current symptoms of depressed mood, anxiety, irritability, intermittent social isolation, and intermittent difficulty falling asleep and remaining asleep. He spends most of his days by himself, although he goes try to go out whenever he can. Upon examination, the Veteran was friendly and cooperative. He indicated he frequently becomes irritable, but was open and friendly throughout the interview. The examiner found the Veteran evasive regarding his substance abuse. The Veteran was fully oriented, with good memory function, and a euthymic mood and affect, without acutely suicidal or homicidal thoughts. He was not psychotic, manic, hypomanic, obsessive, or compulsive. Insight and judgment were good. The examiner opined that the Veteran was capable of performing work under circumscribed circumstances, noting that he had obvious physical limitations and would not be able to work in a stressful environment in proximity to other people. The examiner also stated that if he were provided with repetitive work and positive reinforcement, he would be able to work on a part time basis, at least with respect to a mental health disorder. The GAF score was 55, which reflects moderate symptoms, for example, a flat affect and circumstantial speech, or occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, such as having few friends, and conflicts with peers or co-workers. DSM-IV at 46-47. In September 2009 VA medical record, the Veteran was alert and oriented to time, person, place and situation, with clear and coherent speech. The Veteran denied any homicidal or suicidal ideations. He stated he had not heard voices in a long time but endorsed thoughts that the VA was using him as a guinea pig and was trying to kill him. He reported paranoia. There was normal speech with a good mood and congruent affect. Thoughts were logical and direct. Veteran had fair to good insight and judgment. He denied long term memory problems but reported some problems with his short term memory. In a November 2009 VA record, the Veteran stated he ran out of his medicine and fell through the cracks. He acknowledged hearing voices, nightmares, social isolation, and withdrawal. The Veteran denied psychotic symptoms, depression, manic symptoms, and suicidal or homicidal ideations or plans. He endorsed occasional insomnia and nightmares. Upon examination, the Veteran was casually dressed, calm, cooperative, alert, and oriented, with good eye contact. There were no delusions, but auditory hallucinations. There was euthymic mood with full range of affect and unimpaired insight and judgment. The GAF score was 35, which indicates some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood, for example where a depressed man avoids friends, neglects family, and is not able to work. DSM-IV at 46-47. In a May 2010 VA record, the Veteran was alert and oriented with good eye contact, and appropriate mood and affect. He denied suicidal ideations and hallucinations and had coherent and relevant speech, organized and goal directed thoughts, and good insight and judgment. An October 2010 VA examination was conducted upon review of the claims file. The Veteran took medication and stated that his individual psychotherapy was very helpful. The Veteran reported depressive symptoms, anger, little patience, and trouble focusing; these symptoms were variable, mostly daily, but sometimes only occurred weekly. The Veteran was clean, neatly groomed, appropriately dressed. There was unremarkable psychomotor activity, and he was cooperative, friendly, and relaxed. There was a constricted and depressed affect, a depressed mood, and an unremarkable thought process. There was intact attention and the Veteran was fully oriented. The Veteran had unremarkable thought content, he understood the outcome of his behavior, and he had average intelligence and insight. There was sleep impairment, but no delusions, hallucinations, inappropriate behavior, obsessively ritualistic behaviors, episodes of violence, panic attacks, or homicidal or suicidal thoughts. There was fair impulse control and the Veteran maintained minimum personal hygiene. His remote memory was normal, but he had moderately impaired recent and immediate memory. The examiner assigned a GAF score of 50, which signifies serious symptoms, for example suicidal ideation, severe obsessional rituals, and frequent shoplifting; or any serious impairment in social, occupational, or school functioning, for example no friends, unable to keep a job. DSM-IV at 46-47. The examiner found the Veteran seriously impaired due to his mood disorder and PTSD. Finally, the examiner concluded that there was total occupational and social impairment because the Veteran was unable to function in his daily life, unable to have relationships, socialize, or gain employment. A December 2011 VA examination was conducted upon review of the claims file. The examiner diagnosed PTSD, a mood disorder, and alcohol and cocaine dependence, in sustained full remission. The examiner opined that it impossible to differentiate what symptoms, including cognitive symptoms, were attributable to each of the psychiatric diagnoses and to the in-service head trauma without undue speculation, noting that there was significant overlap between the symptoms. The examiner did note, however, that because the Veteran was in full remission of the alcohol and cocaine dependence, he was not exhibiting any symptoms in relation to those disorders. The Veteran reported that his relationship with his family had been poor since 2005; he had had limited contact with his family members due to his irritability and short temper. He lived alone during this period, and most people did not like socializing with him due to his anger management problems. He used to participate as a musician in his church band, but that had significantly decreased since 2005. His depressed mood caused him to withdraw from church and other social activities; he had an extreme sense of loss and hopelessness and he preferred to stay at home rather than go to social events. The Veteran reported that he often became angry and depressed when he has intrusive thoughts. Since 2005 he had been unemployed and reported that his irritability, anger management problems, problems concentrating, and discomfort interacting with most people led to him having severe problems attaining employment. He also stated that his significant problems with concentration would make it difficult for him to focus for long periods of time on repetitive tasks at work. The examiner noted that during the examination, the Veteran was easily agitated and that this interpersonal style would make it very difficult for him to attain and sustain employment in occupations where regular interactions with others are necessary. The Veteran also indicated that the depressed mood leads him to lack the confidence that he can complete work in college or specialized training and that his inability to concentrate means he would not be able to complete his coursework in a timely manner. The examiner stated that the Veteran's medical records beginning in 2006 indicate that the Veteran had consistently presented with a mood disorder, to include an irritable and depressed mood, suicidal ideation, and social withdrawing. The examiner concluded that the effects were occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The examiner noted that the Veteran's disorders caused the following symptoms: depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbance of motivation and mood, difficulty in adapting to stressful circumstances, including work or a worklike setting, and an inability to establish and maintain effective relationships. Collectively, the examiner determined that the Veteran's psychiatric symptoms since 2005 were associated with high levels of impairment in both social and occupational functioning, but that the psychiatric symptoms alone did not cause unemployability because the Veteran's left upper extremity was completely paralyzed. The GAF score was 35, which indicates some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood, for example where a depressed man avoids friends, neglects family, and is not able to work. DSM-IV at 46-47. Prior to October 16, 2010, the Veteran is assigned a 10 percent evaluation, which contemplates 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. 38 C.F.R. § 4.130, General Rating Formula. A 70 percent evaluation reflects occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, General Rating Formula. The Board finds that a 70 percent initial evaluation, but no more, is for assignment prior to October 16, 2010. The level of occupational and social impairment due to a psychiatric disorder is the primary consideration in determining the severity of a psychiatric disorder for VA purposes and not all the symptoms listed in the rating criteria must be present in order for a rating to be warranted. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding that the psychiatric symptoms listed in the rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings). In addition, as noted by the 2011 VA examiner, the symptoms of several service-connected and non-service-connected disorders overlap and are indistinguishable; all effects are thus considered within the psychiatric disability evaluation. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (holding that when a claimant has both service-connected and nonservice-connected disabilities, the Board must attempt to discern the effects of each disability and, where such distinction is not possible, attribute such effects to the service-connected disability); see also 38 C.F.R. § 38 C.F.R. § 4.14 (2012) (the evaluation of the same disability or the same manifestations of a disability under various diagnoses constitutes pyramiding and is prohibited). First, the Veteran's GAF scores prior to October 16, 2010 must be assessed. The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health - illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quotation omitted). A GAF score is highly probative, as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Here, the Veteran's GAF scores prior to October 16, 2010 were primarily in the range that indicates serious symptoms, or any serious impairment in social, occupational, or school functioning. DSM-IV at 46-47. There were intermittent findings of 55, which indicate moderate symptoms, or moderate difficulty in social, occupational, or school functioning, and 35, which indicate some impairment in reality testing or communication, or major impairment in several areas. DSM-IV at 46-47. These scores demonstrate a severity worse than a 10 percent evaluation, and suggest, but do not mandate, the assignment of a 70 percent evaluation, which requires deficiencies in most areas. Second, however, all the pertinent evidence of record must be considered and the decision must be based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. VA treatment records and examination reports consistently demonstrate deficiencies in most areas, to include a depressed mood, deficiencies in family relations, and deficiencies in the ability to handle personal interactions and work stressors. At a June 2007 VA examination, he stated he was angry whenever he is around people. At an April 2009 VA examination, the Veteran stated he spends most of his days by himself. The examiner opined that the Veteran was capable of performing work under circumscribed circumstances, but would not be able to work in a stressful environment in proximity to other people. The 2011 VA examiner noted the Veteran's relationship with his family had been poor since 2005, he had limited contact with his family, and that most people did not like socializing with him due to his anger management problems. The examiner found that the Veteran was easily agitated and that this interpersonal style would make it very difficult for him to attain and sustain employment in occupations where regular interactions with others are necessary. Despite a lack of symptoms such as obsessional rituals, illogical or irrelevant speech, impaired impulse control, spatial disorientation, and neglect of appearance or hygiene, the overall effect of the Veteran's psychiatric disability is deficiencies in most areas with an inability to maintain effective relationships. A 100 percent evaluation, however, is not for assignment. The Veteran was not totally socially and occupationally impaired. There was limited contact with his family. Additionally, the 2007 and 2009 VA examiners found the Veteran could work under specific guidelines. Thus, total occupational impairment was not shown. As of October 16, 2010, however, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the effects of his psychiatric disability more closely approximate a 100 percent evaluation. 38 C.F.R. §§ 4.3, 4.7. The October 2010 VA examiner expressly found that the Veteran's psychiatric disability manifested in total occupational and social impairment as he was unable to function in his daily life, and unable to have relationships, socialize, or gain employment. The 2011 VA examiner opined that there was not total social and occupational impairment; rather, the examiner found that there was occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. But the 2011 examiner did not address the 2010 opinion or explain the differing conclusions so close in time. Without a supporting explanation, the Board must resolve the issue in favor of the Veteran. Accordingly, a 100 percent evaluation is for assignment as of October 16, 2010. Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1); Barringer, 22 Vet. App. at 243-44. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the veteran's service-connected disability. Thun, 22 Vet. App. at 115. If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this regard, the schedular evaluations in this case are not inadequate. The Board has attributed all potentially service-connected symptoms, including cognitive symptoms, to the psychiatric disability. See Mittleider, 11 Vet. App. at 182. A rating in excess of 70 percent is provided for certain manifestations of the service-connected psychiatric disability but the evidence reflect that those manifestations are not present in this case prior to October 16, 2010. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's psychiatric disability, as the criteria assess both social and occupational functioning, which are the effects of the Veteran's psychiatric disability. In the absence of any additional factors, this issue need not be referred for consideration. Earlier effective date claim The Veteran alleges entitlement to an effective date prior to June 15, 2007 for the 40 percent evaluation assigned for his service-connected left lower extremity disability. Generally, the effective date of an evaluation and award of compensation for an increased rating claim is the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(o)(1). A claim is "a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." 38 C.F.R. § 3.1(p) (2012). An informal claim is "[a]ny communication or action indicating intent to apply for one or more benefits." 38 C.F.R. § 3.155(a) (2012). VA must look to all communications from a claimant that may be interpreted as applications or claims - formal and informal - for benefits and is required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). In some cases, a report of examination or hospitalization may be accepted as an informal claim for benefits. 38 C.F.R. § 3.157(b) (2012). The date of outpatient or hospital examination or date of admission to a VA hospital will be accepted as the date of receipt of a claim when such reports relate to examination or treatment of a disability for which service-connection has previously been established or when a claim specifying the benefit sought is received within one year from the date of such examination, treatment or hospital admission. 38 C.F.R. § 3.157(b). A report of examination implies that the medical record describes the results of a specific, particular examination. Massie v. Shinseki, 25 Vet. App. 123, 132-34 (2011) (noting that a letter from a VA physician generated for a pending Social Security claim was not a report of examination). An exception to the general rule applies where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of the claim for increased compensation. 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). Under these circumstances, the effective date of the award is the earliest date at which it was ascertainable that an increase occurred. 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(0)(2); Harper v. Brown, 10 Vet. App. 125, 126 (1997). In April 2006, the RO granted service connection for the left lower extremity disability and assigned a 20 percent evaluation, effective February 24, 2003. The Veteran submitted new and material evidence regarding the severity of the disability; the rating decision was thus not yet final. See 38 C.F.R. § 3.156(b) (2012). The Veteran did not submit any statements that can be construed as disagreement with the effective date assigned for the grant of service connection. In an August 2007 rating decision, the RO assigned a 40 percent evaluation, effective June 15, 2007. The Veteran appealed the effective date of the 40 percent evaluation. In this decision, however, the Board has granted a 40 percent evaluation effective as of the date of the grant of service connection, February 24, 2003. Thus, the Veteran's claim is moot because it has essentially been granted in full. ORDER Prior to October 16, 2010, an increased initial evaluation of 70 percent, but no more, for the service-connected psychiatric disability is granted, subject to the laws and regulations governing the payment of monetary benefits. On and after October 16, 2010, an increased evaluation of 100 percent for the service-connected psychiatric disability is granted, subject to the laws and regulations governing the payment of monetary benefits. Prior to April 26, 2009, an increased initial evaluation of 40 percent, but no more, for the service-connected left lower extremity disability is granted, subject to the laws and regulations governing the payment of monetary benefits. On and after April 26, 2009, the criteria for an increased evaluation of 80 percent, but no more, for the service-connected extremity disability is granted, subject to the laws and regulations governing the payment of monetary benefits. An effective date of February 24, 2003 for connection for the left lower extremity disability is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND Although the Board regrets the additional delay, remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claims. Remand is required to obtain an adequate opinion regarding the Veteran's service connection claim and to adjudicate intertwined issues. First, remand is required for an addendum opinion regarding the claim for entitlement to service connection for a cervical spine disorder. A Board remand confers upon the appellant the right to compliance with that order. Stegall v. West, 11 Vet. App. 268, 271 (1998). Substantial compliance is required. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Where an examiner makes the ultimate determination required by the Board's remand, such determination more than substantially complies with the Board's remand order. Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Here, in a March 2010 remand, the Board found a January 2006 VA examination and etiology opinion inadequate because it provided a negative nexus opinion based on the diagnosis of degenerative disc disease in 1996, over 20 years from service discharge, and because headaches were the only post-accident residuals noted, thus ignoring the cervical spine abnormalities noted in the STRs including post-traumatic syndrome of the head and cervical spine, suggestions of a neck injury with cervical plexus involvement, and a possible cervical sprain. In the remand directives, the Board requested a new examination and etiological opinions and directed the examiner to note whether each diagnosed cervical spine disorder was related to active service including the in-service head trauma and post-accident cervical spine abnormalities. Accordingly, a 2011 VA examination was conducted. The examiner diagnosed cervical spine degenerative disc disease and found that the disability was not related to service. The examiner noted only the following: that the Veteran did not develop degenerative disc disease until 22 years post trauma; that research had proven that post traumatic arthritis is generally found in imaging within two to three years post trauma; and thus, that because the Veteran had a negative spine x-ray in 1996 it was not present at that time and is less likely than not related. Thus, the examiner did not address the cervical spine abnormalities as evidenced in the STRs, instead basing the decision on almost the exact rationale that the 2006 examiner based the decision on. In fact, the examiner did not mention the in-service abnormalities in any part of the examination; the Board thus cannot find that there has been substantial compliance with its prior remand. D'Aries, 22 Vet. App. at 105; Dyment, 13 Vet. App. at 146-47. Remand is thus required for an addendum opinion. Second, remand is required as the TDIU and DEA issues are inextricably intertwined with the Veteran's service connection claim. Issues are inextricably intertwined when the adjudication of one issue could have significant impact on the other issue. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Here, the issues of entitlement to TDIU and DEA benefits will be impacted by the resolution of the service connection claim. A grant of service connection will potentially affect the date of the Veteran's entitlement to schedular TDIU, as it is based on a combined evaluation, and entitlement to DEA benefits, which may be based on the presence of a total disability that is permanent in nature. 38 U.S.C.A. § 3501(West 2002); 38 C.F.R. § 4.16 (2012); 38 C.F.R. § 21.3021 (2012). Additionally, as the Board has assigned higher evaluations within this decision, the RO should readjudicate these claims based on the Veteran's new combined evaluations. Accordingly, remand is required. Accordingly, the case is REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the paper or virtual claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Notice must be provided to the Veteran and his or her representative. 2. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of all cervical spine disorders from a VA examiner. The entire claims file (i.e., both the paper claims file and any electronic medical records) should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. If the examiner does not have access to electronic medical records, any such relevant treatment records must be printed and associated with the paper claims file so they can be available to the examiner for review. The rationale for all opinions expressed must be provided. If an opinion cannot be provided without resort to speculation, it must be noted in the opinion report, and a rationale provided for that conclusion. The examiner must provide a diagnosis for each cervical spine disability. The examiner must provide an opinion, in light of prior examination findings and the service and post-service evidence of record whether it is at least as likely as not (50 percent or greater probability) that each of the Veteran's diagnosed cervical spine disorders was caused or aggravated by military service. The examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the Veteran's service-connected headaches disorder caused or aggravated each cervical spine disorder. The examiner must also specifically address the cervical spine abnormalities immediately post-accident contained in the Veteran's STRs. The examiner must address all prior etiological opinions of record. 3. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 4. Review the opinion or examination report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AMC must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 5. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims for service connection for cervical spine disability and effective date prior to May 23, 2006 for TDIU and DEA must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ CHERYL MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs