Citation Nr: 1316601 Decision Date: 05/21/13 Archive Date: 05/29/13 DOCKET NO. 07-22 337 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUES 1. Entitlement to service connection for ankylosing spondylitis. 2. Entitlement to service connection for a skin disorder. 3. Entitlement to an initial disability rating in excess of 50 percent for service connected posttraumatic stress disorder (PTSD). 4. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD E. D. Anderson, Counsel INTRODUCTION The Veteran served on active duty from January 1968 to December 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from September 2006 and September 2008 decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Milwaukee, Wisconsin. In December 2010, the Board remanded this matter to the RO via the Appeals Management Center (AMC) in Washington, D.C. to afford the Veteran VA medical examinations. The actions specified in the December 2010 Remand completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). The issue of entitlement to service connection for a skin disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's ankylosing spondylitis did not have onset in service; it was not diagnosed within one year of service separation; and there is no competent credible evidence establishing it is related to service. 2. The Veteran's PTSD was most appropriately characterized throughout the period on appeal by occupational and social impairment with reduced reliability and productivity due to such symptoms including, but not limited to: flattened affect; panic attacks more than once a week; disturbances of motivation and mood; and difficulty establishing and maintaining effective work and social relationships. 3. The Veteran was not unable to find or maintain substantially gainful employment during the period on appeal. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for ankylosing spondylitis have not been met. 38 U.S.C.A. § 1110, 1112, 1113 (West 2002); 38 C.F.R. § 3.303, 3.307. 3309 (2012). 2. The criteria for entitlement to an initial disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for entitlement to TDIU have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002) 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to these claims. 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 claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board must note that in reviewing this case the Board has not only reviewed the Veteran's physical claims file, but the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). In general, service connection requires competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson v. West, 12 Vet. App. 247, 253 (lay evidence of in-service incurrence is sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). However, in Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit held that the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic by 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1337-39 (Fed. Cir. 2013). For disabilities that are not listed as chronic under 38 C.F.R. § 3.303(b), the only avenue for service connection is by showing in-service incurrence or aggravation under 38 C.F.R. § 3.303(a), or by showing that a disease that was first diagnosed after service is related to service under 38 C.F.R. § 3.303(d). While ankylosing spondylitis is not listed as a chronic disease under 38 C.F.R. § 3.303(b), arthritis is, and ankylosing spondylitis is a form of chronic, inflammatory arthritis. Certain chronic diseases, including arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service. See 38 U.S.C.A. §§ 1101, 1112, (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.307, 3.309 (2012). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). VA regulations also provide that if a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service connected if the requirements of 38 C.F.R. § 3.307(a) are met, even if there is no record of such disease during service: AL amyloidosis, chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as Type II diabetes mellitus); Hodgkin's disease; chronic lymphocytic leukemia (CLL); multiple myeloma; Non-Hodgkin's lymphoma; acute and subacute peripheral neuropathy; porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx or trachea); soft tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma), chronic B-cell leukemias, Parkinson's disease, and ischemic heart disease. 38 C.F.R. § 3.309(e) (2012). A veteran, who during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during service. 39 U.S.C.A. § 1116(f) (West 2002); 38 C.F.R. § 3.307(a)(6)(iii) (2012). VA has determined that there is no positive association between exposure to herbicides and any other condition for which it has not specifically determined a presumption of service connection is warranted. 61 Fed. Reg. 41,446 (1996); 59 Fed. Reg. 341 -46 (1994). However, an appellant is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039, 1041-42 (Fed. Cir. 1994). Here, the Veteran served in the Republic of Vietnam; however, ankylosing spondylitis is not one of the disabilities for which service connection can be granted on a presumptive basis due to exposure to Agent Orange. As noted above, the Veteran is seeking entitlement to service connection for ankylosing spondylitis, a type of chronic, inflammatory arthritis. In his May 2006 claim, the Veteran initially noted the onset of his ankylosing spondylitis to be in 2004, more than thirty years after his separation from service. However, in later statements to VA and his treatment providers, he began claiming that he noticed symptoms of his disability in service. He has also suggested that his disability was caused by exposure to Agent Orange. The Veteran's service treatment records are negative for a diagnosis of ankylosing spondylitis, arthritis, or other similar disability. Additionally, there are no complaints of or treatment for muscle or joint pain or stiffness. The Veteran's November 1969 separation examination is negative for any abnormalities of the spine or musculoskeletal system. In December 1969, the Veteran signed a form indicating that there had been no change in his medical condition since his November 1969 VA examination. Post-service, the earliest evidence of ankylosing spondylitis is a February 1999 treatment record by Dr. S.H.. It notes that the Veteran was seen with complaints of severe pain in both feet and the right shoulder, as well as an elevated sedimentation rate with positive ANA. In February 2006, the Veteran reported that he was diagnosed with ankylosing spondylitis in October 2005. He described an approximately five year history of increasing pain and stiffness in his cervical spine and bilateral shoulder. See VA Rheumatology Nursing Outpatient Note (February 2, 2006). In June 2007, the Veteran again described onset of his ankylosing spondylosis approximately five years earlier, with progressively worsening pain in his neck and shoulders. See VA Rehuematology Nursing Note (June 5, 2006). At a November 2007 hearing before the RO, the Veteran denied that he had any problems with his back in service or that he ever sought treatment for a back problem during service. He estimated that he first received treatment approximately fifteen years ago, but reported that none of his providers was able to determine the cause of his symptomatology. A friend of the Veteran, S.M., testified that the Veteran first mentioned problems with his back three to five years after he separated from service. However, in February 2009, the Veteran reported a more than forty year history of back pain and stiffness. He claimed that he had symptoms of ankylosing spondylitis in service, including pain and stiffness in the neck and shoulders, as well as episodes of dysentery, iritis, keratodermia blenorhagium, and a bladder infection. He claimed that he received eye drops in service on multiple occasions to treat his eye irritation. He also claimed that he was treated during the 1980s by a private physician, Dr. S.H., for ankylosing spondylitis, although he was diagnosed at the time with reactive arthritis. See Rheumatology Attending Note (February 11, 2009). Based solely on this history as reported by the Veteran, the nurse treating the Veteran, S.A., as well as his treating rheumatologist, Dr. M.M., concluded that his ankylosing spondylitis more likely than not began during his service in Vietnam. Id. In January 2011, the Veteran was afforded a VA examination. At that time, the Veteran reported first experiencing symptoms consistent with ankylosing spondylitis eight years after separation from service. He stated that he was first treated by Dr. S.H. in the 1980s, then by VA. The examiner concluded that it is less likely than not that the Veteran's ankylosing spondylitis was caused by a disease or injury in service, to include combat service in Vietnam. The examiner explained that ankylosing spondylitis is a disease that develops in those with genetic susceptibility. She further noted that there is no evidence of symptoms suggestive of ankylosing spondylitis in the Veteran's service treatment records and multiple post-service medical records place onset of the disability around 2000. While the examiner considered the Veteran's testimony that his symptoms began in the early 1970s, she noted that the Veteran has also reported a much later onset of his disability which is more consistent with the available medical evidence and concluded that there is no evidence of ankylosing spondylitis in service or within one year of service. Based on all the above evidence, entitlement to service connection for ankylosing spondylitis must be denied. There is no evidence in the Veteran's service treatment records of symptoms consistent with ankylosing spondylitis, including joint pain and stiffness, dysentery, iritis, and keratodermia blenorhagium. The earliest evidence of his current disability is approximately thirty years after service. Private medical records from Dr. S.H., as well as early treatment records from VA describe a relatively recent onset of his symptoms. At his November 2007 RO hearing, the Veteran denied symptoms of ankylosing spondylitis in service. Additionally, in January 2011, a VA examiner concluded that it was less likely than not that ankylosing spondylitis had onset during the Veteran's service or was caused by the Veteran's active military service, including the Veteran's service in Vietnam. The examiner relied not only on the absence of the Veteran's disability in service or for decades after service, but also noted that ankylosing spondylitis develops in those with a genetic susceptibility, implying that the development of this condition is unrelated to the Veteran's service. While the Veteran has at times claimed that he first experienced symptoms of his ankylosing spondylitis in service, at other times, he has described a much more recent onset of his disabilities. The Veteran's various accounts regarding the initial onset of his disability are inconsistent, not only with each other, but also with the hearing testimony of the Veteran's friend, S.M., and with the contemporaneous medical evidence, including service treatment records. Accordingly, the Board finds that the Veteran is not a credible historian and that his lay testimony is entitled to little weight. See Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (Credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). Additionally, the Board gives little weight to the February 2009 conclusion of Dr. M.M. and S.A. that the Veteran's ankylosing spondylitis more likely than not had onset in service, since their conclusion was based on the Veteran's reported medical history, a history that the Board has determined is not credible due to the Veteran's highly inconsistent statements through the years. In evaluating the evidence of record the Board has both the duty and authority to consider the credibility of and probative weight to be assigned to evidence. The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) has recognized the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Federal Circuit has also provided that " the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc." Buchanan v. Nicholson, 451 F3.d 1331, 1336-37 (Fed. Cir. 2006). Similarly, the Veterans Court has stated that "the credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character." Caluza v. Brown, 7 Vet. App. 498, 511 (1995). Additionally, in cases such as this, where there are conflicting statements or opinions from medical professionals, it is within the Board's province to weigh the probative value of those opinions. In Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993), the U.S. Court of Appeals for Veterans Claims (Court) stated: The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . . As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the adjudicators; . . . So long as the Board provides an adequate reason or basis for doing so, the Board does not err by favoring one competent medical opinion over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). Greater weight may be placed on one examiner's opinion over another depending on factors such as reasoning employed by the examiners and whether or not, and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). Additionally, the thoroughness and detail of a medical opinion are among the factors for assessing the probative value of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Here, the Board has determined after careful review of all the evidence of record, that the lay testimony placing onset of the Veteran's claimed disability in service is not credible, as are any medical opinions which are based solely on the Veteran's reported medical history. Instead, the Board gives greater weight to the contemporaneous medical evidence placing onset of the Veteran's disability decades after service, as well as the opinion of the VA examiner, whose conclusions are based on a review of all the lay and medical evidence of record and her medical knowledge and training regarding the etiology of ankylosing spondylitis. For all the above reasons, entitlement to service connection for ankylosing spondylitis is denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2010); 38 C.F.R., Part 4 (2012). Separate diagnostic codes identify the various disabilities. 38 C.F.R. § 4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.2 requires that medical reports be interpreted in light of the whole recorded history, and that each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding the veteran's increased evaluation claim, the Board has considered the determinations in Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 22 Vet. App. 505 (2007), and whether the veteran is entitled to an increased evaluation for separate periods based on the facts found during the appeal period. In Fenderson, the U.S. Court of Appeals for Veterans Claims (Court) held that evidence to be considered in the appeal of an initial assignment of a rating disability was not limited to that reflecting the then current severity of the disorder. In that decision, the Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Id. at 126. Hart appears to extend Fenderson to all increased rating claims. The Veteran's PTSD is rated under the General Rating Formula for Mental Disorders, found at 38 C.F.R. § 4.130 (2012). A 50 percent evaluation 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 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; difficult establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is 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. Id. It is further noted that the nomenclature employed in the portion of VA's Schedule for Rating Disabilities ("the Schedule") that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130 (2012). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. Higher scores correspond to better functioning of the individual. GAF scores ranging between 61 and 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th. ed., 1994). GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. GAF scores ranging between 41 and 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. GAF scores ranging between 31 and 40 are assigned when there is 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). Id. GAF Scores between 21 and 30 are assigned when behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). Id. Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a) (2012). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). The Veteran was granted entitlement to PTSD in a September 2006 RO decision and assigned an initial 10 percent disability rating, effective May 2006, the date of the Veteran's claim. The Veteran appealed his initial disability evaluation and in May 2007, the Veteran's disability evaluation was increased to 30 percent disabling. In April 2009, his disability evaluation was again increased to 50 percent. In both cases, the effective date of the increased rating was May 2006. Because this increase does not represent a grant of the maximum benefits allowable for this disorder, the Veteran's claim remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In January 2006, the Veteran was referred to a VA social worker to explore treatment options related to PTSD. At that time, he reported poor sleep, intrusive thoughts of his combat experience, and alcohol abuse. See VA Social Work Initial Evaluation Note (January 30, 2006). In May 2006, a VA psychiatrist noted persistent nightmares, as well as apprehensiveness and irritability without anger dyscontrol. He reported that with the use of Ambien, his sleep pattern was adequate and restorative. He denied suicidal ideation. He was assigned a GAF score of 50. See VA Mental Health Outpatient Note (May 26, 2006). Similar complaints were noted in July 2006 and the Veteran was assigned a GAF score of 52. See VA Mental Health Outpatient Note (July 11, 2006). The Veteran was first afforded a VA examination of his PTSD in August 2006. He described a history of early childhood abuse at the hands of his biological father and reported that he began drinking alcohol at age 18 on the weekends, but characterized his use as moderate. He was drafted at age twenty and served overseas for almost a year in Vietnam, where he reported frequent combat, as well as a shrapnel injury. Post-service, he described a stable employment history as a machinist. He got along well with his supervisors overall and didn't report any significant conflict with any co-workers, although he indicated that some were "clannish" and discriminating towards outsiders such as himself. He eventually developed carpal tunnel syndrome and was forced to retire due to this disability, for which he receives disability payments from his former employer. The Veteran was never married but reported a series of long term relationships. He has a son and step son, with whom he has a close relationship. He described himself as "socially involved", but indicated that there was no one person he was particularly close to. He reported that his closest relationship was with a friend who is also a veteran, who he sees three or four times a week when that individual is in town. The Veteran also reported hobbies that include gardening, working on cars, and going to car shows. His only legal trouble was a DUI in 2001 which resulted in the loss of his driver's license. His primary psychiatric complaints were repetitive thoughts and nightmares of his combat experiences in Vietnam. He also endorsed sleep difficulties and hypervigilance. However, the examiner noted that the Veteran otherwise reported surprisingly little distress, describing his mood as "fine" and denied fatigue, loss of appetite, or anhedonia. He denied suicidal ideations, mania, or psychosis, as well as generalized anxiety or panic attacks. The Veteran was characterized as cooperative with the interview, with good eye contact and clear, goal directed thought processes. He denied suicidal or homicidal ideations, delusions or other perceptual disturbance, or traumatic intrusions. He gave no evidence of responding to internal stimuli. He was cheerful during the interview and his affect was euthymic, stable, and consistent with interview content in that he showed some slight distress when discussing his deployment. He showed no evidence of hyper-alertness or an exaggerated startle response. When there was a loud noise outside of the examining room, the Veteran did not startle. Motor activity was within normal limits. The rate, rhythm, and tone of his speech was normal. His judgment appeared intact and he had moderate insight into his disability. The Veteran produced an invalid profile on the MMPI-2, which indicated exaggeration of both difficulties and virtues. The examiner felt that the Veteran was suffering from symptoms of PTSD, but did not meet the full diagnostic criteria at the time of the examination. He was diagnosed with anxiety disorder not otherwise specified and assigned a GAF score of 65. In October 2006, the Veteran was admitted to the St. Cloud VA Medical Center for the detoxification program after a possible suicide attempt in which he became intoxicated and took a dozen Lortab tablets. However, he later denied any suicidal intent or attempt. He was diagnosed with alcohol dependence (principal diagnosis) and PTSD. He was assigned a GAF score of 40 at admission and 47 at discharge, with a GAF score of 29 assigned during his inpatient treatment. See VA Mental Health Outpatient Note (October 6, 2006); VA Mental Health Note (October 10, 2006), VA Discharge Summary (October 11, 2006). In an October 2006 letter, the Veteran claimed that that he suffered severe sleep disturbances, near nightly panic attacks, hypervigilance, and auditory and visual hallucinations. A September 2007 VA Mental Health Outpatient Note documents continuing complaints of nightmares, sleep difficulties, exaggerated startle response, irritability, hypervigilance, and intrusive thoughts. However, the VA psychiatrist noted that the Veteran admitted that he was not taking his prescribed medication and continued to use alcohol. The Veteran was diagnosed with PTSD, depressive disorder NOS, alcohol abuse, and tobacco use disorder. He was assigned a GAF score of 41-50. See VA Mental Health Note (September 4, 2007). At a November 2007 hearing before the RO, the Veteran described poor sleep, hypervigilance, and a desire to isolate himself from other people. A friend of the Veteran, S.M., reported that the Veteran has difficulty relating to anyone other than fellow Vietnam veterans and that he was familiar with the Veteran's sleep difficulties and intrusive recollections of his military experience. In May 2008, the Veteran reported that his flashbacks and nightmares had worsened following frequent flights of a helicopter over his house, as this reminded him of Vietnam. However, he did report that his sleep had improved with the use of Remeron. While he described occasional sadness, he denied helplessness or hopelessness, suicidal or homicidal ideations, and manic or psychotic episodes. The Veteran was reported to be friendly and cooperative, with a euthymic mood. Affect was somewhat constricted. Memory and concentration were good and there was no evidence of thought disorder. He denied hallucinations or delusions. Insight and judgment were fair. The Veteran was assigned GAF score of 50. In July 2008, the Veteran was afforded another VA examination. The Veteran reported symptoms that included recurrent intrusive thoughts of trauma, nightmares, avoidance, sleep difficulties, hypervigilance, exaggerated startle response, sadness, sleep difficulties, and panic attacks seven or eight times a month. However, his energy, motivation, and concentration generally remained good, and he denied helplessness or hopelessness. He denied suicidal or homicidal ideations or impulsive or violent behavior. He was able to maintain minimal personal hygiene. He was able to perform most activities of daily living without difficulty, but did report some problems performing household chores, shopping, and engaging in sports or exercise. Although the Veteran retired due to physical health problems, he claimed that his PTSD has worsened and would affect his ability to work. The Veteran reported that he has a girlfriend, who he has been seeing for four years, as well as a son with whom he has a good relationship. He has three good friends that he talks to about once a month. He gardens and helps others with yard work and gardening. He also spends time at a friend's cabin when the friend is not using it. The Veteran was cooperative with the interview and well oriented, but his mood was dysphoric and his affect flat. There was no evidence of thought disorder. Judgment and insight were adequate. Memory was intact. He was diagnosed with PTSD with panic symptoms and assigned a GAF score of 50. In December 2008, the Veteran continued to report symptoms of PTSD, including nightmares, hypervigilance, and an exaggerated startle response. He endorsed some anxiety regarding the upcoming holidays, but also reported that he had enjoyed a recent hunting trip with friends. His mood was stable and euthymic and his affect was constricted but appropriate. He denied hopelessness, helplessness, suicidal and homicidal ideations, hallucinations, delusions, and manic or psychotic episodes. There was no evidence of thought disorder. Memory and concentration were good. Judgment and insight were fair. The Veteran was assigned a GAF score of 55. See VA Mental Health Note (December 2, 2008). In February 2009, the Veteran reported a stable mood and noted that although he continued to experience PTSD symptoms, overall they were not too bad. His primary concern at the time was his physical health. The Veteran was friendly and cooperative. He was well oriented and grooming and personal hygiene were adequate. Mood was euthymic and affect constricted, but appropriate. There was no evidence of thought disorder. Memory and concentration were good. He denied suicidal and homicidal ideations and hallucinations. Insight and judgment were fair. He was assigned a GAF score of 55. In a May 2009 letter, the Veteran claimed that he frequently has thoughts of suicide and asserted that he was entitled to at least a 70 percent disability rating. In May 2010, the Veteran's treating psychiatrist noted the Veteran appeared to be in a good mood. His mood continued to be stable and he denied hopelessness or helplessness. He continued to have nightmares, hypervigilance, exaggerated startle response, and avoidance. However, he denied suicidal or homicidal thoughts, manic or psychotic episodes, and hallucinations. He reported that his sleep is good and alcohol use is minimal. Memory, concentration, and thought processes were intact. Judgment and insight were fair. A GAF score of 65 was assigned. In November 2010, the Veteran continued to report a stable mood and overall felt that his medications were working, although he continued to experience symptoms of PTSD. He reported that his friends had visited him lately and he had enjoyed their time together. He described his sleep as good and his alcohol use as minimal. He denied suicidal and homicidal ideations, manic or psychotic episodes, and delusions or hallucinations. Memory and concentration were good. Judgment and insight were fair. Mood was euthymic and affect constricted but appropriate. He was able to maintain personal hygiene. He was assigned a GAF score of 65. See VA Mental Health Note (November 16, 2010). In January 2011, the Veteran was afforded another VA examination. At that time, the Veteran continued to report recurrent intrusive thoughts on a daily basis, nightmares two or three times a week, avoidance, sleep difficulties, difficulty concentrating, hypervigilance, and an exaggerated startle response. He reported that although he still has bouts of depressive symptoms, he is doing fairly well. He has low moods that occur every few weeks, usually in response to a trigger. These bouts of depression last for several days, during which he avoids contact with other and lacks motivation. However, overall he described his mood as relatively good and indicated that he tends to be hopeful. He was usually able to enjoy pleasurable activities and denied the tendency to worry too much. He reported that he gets along well with his son, with whom he currently resides, and has a number of friends, including some from his time in the service. He belongs to the VFW and Purple Heart Society. He also reported that he enjoys fishing and gardening, although his physical disabilities somewhat limit his participation in those activities. During the interview, the Veteran's speech was clear, coherent, and spontaneous. He was cooperative and friendly with the examiner and his affect was appropriate. His mood was described as good, dysphoric. Although the Veteran reported subjective problems with his concentration, he was able to perform serial 7s and spell world backwards. Recent and immediate memory were mildly impaired. The Veteran was oriented to time, place, and person. There was no evidence of thought disorder. Judgment and insight were intact. Impulse control was good. He denied hallucinations, inappropriate behavior, episodes of violence or obsessive/ritualistic behavior. He also denied suicidal or homicidal ideations. He reported having fewer panic attacks than he used to, stating he could have them three times a week or none for several weeks. He was diagnosed with PTSD and assigned a GAF score of 64. The examiner stated that the Veteran's PTSD would result in occasionally decreased work efficiency and intermittent inability to perform occupational tasks, but the Veteran would generally function satisfactory. He concluded that it is less likely than not that the Veteran's mental health condition precludes him from securing or maintaining substantially gainful employment. He observed that the Veteran's PTSD would cause mild intermittent impairment in reliability, productivity, concentration, and mood; however, his symptoms would have no significant impact on the Veteran's ability to follow directions, ability to interact with coworkers, ability to interact with supervisors, judgment, abstract thinking, or self care. Based on all the above evidence, the Board finds that an initial disability rating in excess of 50 percent for the Veteran's service connected PTSD is not warranted. The Veteran has consistently reported symptoms such as intrusive thoughts and dreams of combat experiences, avoidance, an exaggerated startle response, hypervigilance, sleep disturbances, panic attacks, and depressed mood. However, the effect of these symptoms on the Veteran's occupational and social functioning appears to be mild to moderate at best. Despite his mental health problems, the Veteran has reported having a relationship of many years with his current girlfriend, a close relationship with his son, and a number of good friends with whom he meets regularly. The Veteran has also reported involvement in several veterans organizations, as well as engagement in a number of hobbies such as gardening, fishing, and working on cars. Thus, it appears that the Veteran is socially engaged and has a number of close personal relationships that provide him with support. Additionally, although he has not worked during the pendency of this appeal, the Veteran has described a stable work history prior to his retirement with no significant conflict with supervisors or coworkers. The record reflects that the Veteran left his previous employment because of physical disabilities for which he receives a disability pension from his prior employer. The January 2011 VA examiner concluded that the Veteran's PTSD would not prevent him from finding or maintaining substantially gainful employment, and would at worst cause mild, intermittent impairment of the Veteran's reliability and productivity. All the VA examiners, as well as the Veteran's mental health treatment providers, have found the Veteran's insight and judgment to be intact, with no evidence of any thought disorder or impaired impulse control. The Veteran has consistently been described as well oriented, with stable mood and appropriate affect. He has been able to communicate coherently and logically with medical professionals, as well as VA employees. There is no evidence of mania or psychosis. The Board notes that the symptoms and level of impairment described by the General Formula for Rating Mental Disorders for a disability that is 70 percent disabling, such as "obsessional rituals that interfere with routine activities"; "speech intermittently illogical, obscure, or irrelevant"; "near-continuous panic or depression affecting the ability to function independently, appropriately and effectively"; "impaired impulse control (such as unprovoked irritability with periods of violence)"; "spatial disorientation"; and "neglect of personal appearance and hygiene" indicate an individual that is severely debilitated by his psychiatric disability, incapable of self care and out of touch with reality. The preponderance of the evidence is against a finding that the Veteran's PTSD is so disabling. GAF score throughout the period on appeal have ranged from a low of 29 to a high of 65; however, they have predominantly been in the 50s and 60s, indicating a generally mild to moderate disability. The Veteran's lowest GAF scores of 29, 40, and 47 were all assigned over a week long period in October 2006 when the Veteran was receiving detoxification treatment. The Board has considered whether a staged rating is warranted for any period on appeal, but notes that the Veteran's impaired functioning during this period was of an extremely limited duration related to non-serviced connected alcohol abuse and is not consistent with the overall severity of the Veteran's disability as described by both VA examiners and the VA mental health professionals who have treated the Veteran over the pendency of this appeal. The Board has also considered the Veteran's assertions that his disability is not appropriately rated, as well as his statements to VA in which he describes frequent suicidal ideations, near daily panic attacks, and even auditory and visual hallucinations. However, these accounts are inconsistent with the descriptions of his symptoms he gives to VA treatment providers and VA examiners. The Board gives greater weight to the accounts of the Veteran's symptoms documented in VA examination reports and in the Veteran's VA outpatient treatment records, with particular weight given to the assessments made by trained mental health professionals regarding the severity of the Veteran's disability. For the reasons detailed above, the Board finds that entitlement to an initial disability rating in excess of 50 percent cannot be awarded on a schedular basis. The Board has also considered whether the Veteran's disability warrants referral for extraschedular consideration. To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2012). The criterion for such an award is a finding that the case presents an exceptional or unusual disability picture with related factors as marked interference with employment or frequent periods of hospitalization as to render impractical application of regular schedular standards. The Court has held that the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance; however, the Board is not precluded from raising this question, and in fact is obligated to liberally read all documents and oral testimony of record and identify all potential theories of entitlement to a benefit under the law and regulations. Floyd v. Brown, 9 Vet. App. 88 (1996). The Court further held that the Board must address referral under 38 C.F.R. §3.321(b)(1) only where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). In a recent case, the Court clarified the analytical steps necessary to determine whether referral for extraschedular consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. In this case, it does not appear that the Veteran has an "exceptional or unusual" disability; he merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is not required. See Thun, supra. For all the above reasons, entitlement to an initial disability rating in excess of 50 percent for service connected PTSD is denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). TDIU The schedular rating criteria are designed to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155 (West 2002). "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (2012). A total disability evaluation may be assigned where the schedular evaluation is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2012). Here, the Veteran does not meet this criteria. However, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reasons of service-connected disabilities shall be rated totally disabled. Therefore, rating boards should submit to the Director, Compensation and Pension Service, for extra-schedular consideration of all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). The rating board will include a full statement as to the veteran's service-connected disabilities, employment history, educations and vocational attainment and all other factors having a bearing on the issue. 38 C.F.R. § 4.16(b). The term "unemployability," as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. See VAOPGCPREC 75-91 (Dec. 17, 1991). The issue is whether the Veteran's service-connected disability or disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a "living wage"). See Moore v. Derwinski, 1 Vet. App. 356 (1991). In a claim for TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that the Veteran's service-connected disability or disabilities do not prevent him from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994). In determining whether the Veteran is entitled to a TDIU, neither his non-service connected disabilities nor his age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The United States Court of Appeals for Veterans Claims ("Court") has held that the central inquiry in determining whether a Veteran is entitled to a total rating based on individual unemployability is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). The test of individual unemployability is whether the Veteran, as a result of his service-connected disabilities alone, is unable to secure or follow any form of substantially gainful occupation which is consistent with his education and occupational experience. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. The Veteran has the following service connected disabilities: PTSD, currently assigned a 50 percent disability rating, and tinnitus, currently assigned a 10 percent disability rating. The Veteran's combined disability rating is 60 percent. The Veteran also has a number of serious non-service connected disabilities, including ankylosing spondylitis and carpal tunnel syndrome. While the Veteran has complained frequently that he suffers from severe non-service connected hearing loss which he believes affects his ability to work, the Veteran has not suggested that his service connected tinnitus significantly affects his ability to work. The Veteran's PTSD has been discussed extensively above, but the Board again notes that the January 2011 VA examiner stated that the Veteran's PTSD would result in occasionally decreased work efficiency and intermittent inability to perform occupational tasks, but the Veteran would generally function satisfactory. He concluded that it is less likely than not that the Veteran's mental health condition precludes him from securing or maintaining substantially gainful employment. He observed that the Veteran's PTSD would cause mild intermittent impairment in reliability, productivity, concentration, and mood; however, his symptoms would have no significant impact on the Veteran's ability to follow directions, ability to interact with coworkers, ability to interact with supervisors, judgment, abstract thinking, or self care. Additionally, the Board notes that while the Veteran has not been employed during any period on appeal, there is no evidence that his PTSD in any way caused his current unemployment. Rather, records from the Railroad Retirement Board reflect that the Veteran was forced to retire due to a non-service connected physical disability, specifically carpal tunnel syndrome. The Veteran has reported a stable employment history prior to his retirement with no evidence of any significant problems interacting with co-workers or supervisors. Given the Veteran's age and non-service connected physical disabilities, it seems unlikely that the Veteran would be able to return to his previous job as a machinist or perform any other physically demanding labor and he may even be unable to manage even sedentary employment. However, there is no evidence that the Veteran's service connected disabilities alone, without considering the Veteran's non-service connected health problems or age, would preclude him from finding and maintaining substantially gainful employment. The Board gives considerable weight to the findings of the January 2011 VA examiner, who discussed in detail the impact of the Veteran's PTSD on various aspects of employment. Accordingly, entitlement to TDIU is denied. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of- the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and 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. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the VCAA duty to notify was satisfied by letters sent to the Veteran in June 2006 and March 2008. These letters informed the Veteran of what evidence was required to substantiate his claims, as well as of VA and the Veteran's respective duties for obtaining evidence. The Veteran was also informed of how VA assigns disability ratings and effective dates. VA also has a duty to assist the veteran in the development of the claim. This duty includes assisting the veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records, as well as VA treatment records and records from the Social Security Administration. The Veteran submitted private medical records and was provided an opportunity to set forth his contentions during a November 2007 hearing before a Decision Review Officer (DRO). The appellant was afforded a VA medical examination in August 2006, July 2008, and January 2011. These examinations are based upon review of the claims folder, and thoroughly discuss the nature and severity of the Veteran's disabilities, as well as the functional impairments resulting therefrom. Additionally, the examinations are adequate and probative for VA purposes because the examiner relied on sufficient facts and data, provided a rationale for the opinion rendered, and there is no reason to believe that the examiners did not reliably apply reliable scientific principles to the facts and data. See 38 C.F.R. § 4.2; Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, neither the appellant nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Entitlement to service connection for ankylosing spondylitis is denied. Entitlement to an initial disability rating in excess of 50 percent for service connected PTSD is denied. Entitlement to TDIU is denied. REMAND The Veteran is also seeking entitlement to service connection for a skin disorder. The Veteran has described a chronic skin condition affecting his hands, feet, and groin area which he has characterized as "jungle rot" and attributed to his military service. According to the Veteran, this disability only manifests on an intermittent basis, but has persisted since his military service in Vietnam. VA treatment records reflect that the Veteran suffers from a 'rash" of some kind, but a specific diagnosis has not been provided by any of the Veteran's treatment providers. In December 2010, the Board remanded the Veteran's claim to afford the Veteran a VA examination. The purpose of this examination was twofold: to diagnose the Veteran's current skin disorder and to determine whether it is at least as likely as not that this disability had onset in service or was caused by or otherwise related to the Veteran's active military service. However, at the January 2011 VA examination, the examiner was not able to find any evidence of a current disability and noted that absent a current diagnosis, she was unable to offer an opinion concerning the etiology of the Veteran's skin disorder without resorting to speculation. The Board observes that in Ardison v. Brown, 6 Vet. App. 405, 407 (1994), the Court held that where fluctuating conditions escape detection on examination, VA must conduct an examination during the active stage of the disease. Accordingly, the case must be remanded to afford the Veteran a new VA examination during the active stage of his disease. The Board notes that this will require the cooperation of both the RO and the Veteran. The RO is asked to accommodate the intermittent nature of the Veteran's disability by promptly scheduling the Veteran for a VA dermatological examination as soon as they are notified by the Veteran that his disability has entered an active phase. The Veteran, for his part, has a responsibility to promptly notify the RO when his disability has entered an active phase so that an examination of his condition can be scheduled. The examiner is asked to provide a diagnosis of the Veteran's current skin disorder and then opine whether it is at least as likely as not that the Veteran's condition either had onset in service or was caused or permanently aggravated by the Veteran's active military service, to include his service in the Republic of Vietnam. In reaching his or her decision, the examiner is requested to consider not only the available medical records, but also the Veteran's lay testimony regarding the onset of his disability. Accordingly, the case is REMANDED for the following action: 1. When the Veteran's skin disorder enters an active phase, the Veteran should notify the RO. Once this is done, the RO should schedule the Veteran for a VA examination by a dermatologist. The examiner should provide a diagnosis of the Veteran's current skin disorder and note any functional impairment caused by the Veteran's disability, including a full description of the effects of his disability upon his ordinary activities, if any. The VA examiner is asked to render an opinion as to whether it is at least as likely as not (fifty percent or greater) that the Veteran's skin disorder had onset in service or was caused or permanently aggravated by the Veteran's active military service. A rationale for this opinion should be provided. The Veteran's claim folder and a copy of this REMAND should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file. The examiner should also consider the Veteran's lay testimony concerning the onset of his current disability. All findings should be described in detail and all necessary diagnostic testing performed. 2. When the development requested has been completed, and the RO has ensured compliance with the requested action, this case should again be reviewed by the RO on the basis of the additional evidence. If the benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs