Citation Nr: 1317276 Decision Date: 05/28/13 Archive Date: 06/06/13 DOCKET NO. 09-41 845 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Sioux Falls, South Dakota THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) from April 30, 2008, to December 14, 2009. 2. Entitlement to an initial disability rating in excess of 50 percent for PTSD, for the portion of the appeal period extending from December 15, 2009, forward. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.R. Bryant, Counsel INTRODUCTION The Veteran had active military service from December 1967 to July 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating action of the above Regional Office (RO), which granted service connection for PTSD and assigned an initial disability rating of 50 percent as of April 30, 2008. By a rating action dated January 2010, the RO granted service connection for tinnitus and awarded a 10 percent disability rating, effective from April 30, 2008. A letter dated on January 7, 2010 informed the Veteran of that decision. At no time following receipt of notification of the January 2010 rating decision has the Veteran expressed disagreement with the rating or effective date assigned to this now service-connected disability. Accordingly, no issue pertaining to the Veteran's tinnitus is currently before the Board in appellate status. The issue of entitlement to an initial disability rating in excess of 50 percent for PTSD from December 15, 2009, forward, 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. FINDING OF FACT For the period April 30, 2008 to December 14, 2009, the Veteran's PTSD was primarily manifested primarily by symptoms of nightmares, sleep difficulty, intrusive thoughts, irritability, social isolation, flashbacks, exaggerated startle response, Global Assessment of Functioning (GAF) scores of 51 and 55, and difficulty in establishing and maintaining effective work and social relationships, rather than an inability to do so. These symptoms demonstrate no more than occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW During the period April 30, 2008 to December 14, 2009, the criteria for a disability rating in excess of 50 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code (DC) 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duty to Notify and Assist Before addressing the merits of the issues on appeal, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the AOJ of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. With regard to the claim for a higher disability rating for the service-connected PTSD, the Board notes that, where, as here, service connection has been granted and an initial rating has been assigned, the claim of entitlement to service connection has been more than substantiated. It has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). [In any event, neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board.] That being said, the Veteran was notified via letter dated in May 2008 of VA's duty to assist him in substantiating his claim under the VCAA, and the effect of this duty upon his claim. This letter also informed him of how disability ratings and effective dates are assigned. See Dingess, 19 Vet. App. at 484. A subsequent letter in July 2009 notified the Veteran of the types of evidence that may reflect a worsening of his service-connected PTSD, including the nature and symptoms of the condition; the severity and duration of the symptoms; and the impact of the condition and symptoms on employment and daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The timing defect of this correspondence was cured by the RO's subsequent readjudication of the claim and issuance of a Statement of the Case in October 2009 and Supplemental Statement of the Case in January 2010. The Board also finds VA has satisfied its duty to assist the Veteran in the development of the PTSD claim adjudicated herein. In-service and pertinent post-service treatment reports are of record. The Veteran has not indicated that any additional pertinent evidence exists, and there is no indication that any such evidence exists. VA examinations were obtained in December 2008 and December 2009. There is no objective evidence indicating that there has been a material change in the severity of his service-connected PTSD since he was last examined. 38 C.F.R. § 3.327(a) (2012). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations are more than adequate, as they reflect a full review of all medical evidence of record, are supported by sufficient detail, and refer to specific documents and medical history to support the conclusions reached. They also provide sufficient detail to rate the Veteran's service-connected PTSD, including a thorough discussion of the effect of his symptoms on his functioning. 38 C.F.R. § 4.2 (2012); Abernathy v. Principi, 3 Vet.App. 461, 464 (1992) (citing Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that if the examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate). Thus, there is no basis to find that the VA examinations are inadequate, or that a remand for a new examination is required. Accordingly, the Board finds that VA has satisfied its duty to assist the Veteran in apprising him of the evidence needed, and in obtaining evidence pertinent to his claims under the Veterans Claims Assistance Act of 2000. No useful purpose would be served in remanding this matter for yet more development. A remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit to the Veteran. 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); & Quartuccio v. Principi, supra. Law and Analysis In the current appeal, the Veteran contends that his service-connected PTSD is more disabling than is reflected in the current 50 percent disability rating. Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Although a review of the recorded history of a disability is necessary in order to make an accurate evaluation [38 C.F.R. §§ 4.2, 4.41], the regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). However, where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119 (1999). The United States Court of Appeals for Veterans Claims (Court) has also held that staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. As noted previously, service connection for PTSD was established by an April 2009 rating decision, which assigned a 50 percent disability rating under DC 9411, effective April 30, 2008, the date of the Veteran's informal claim. He appealed the initial evaluation assigned. Under the General Rating Formula for Mental Disorders, a 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411 (2012). A 70 percent evaluation requires 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 work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted if 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; memory loss for names of close relatives, own occupation or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. Evidence relevant to the severity of the Veteran's service-connected PTSD includes both VA clinical records, and VA examination reports. The current 50 percent evaluation is based in part on a July 2008 VA psychological note that shows the Veteran was evaluated for depression, sleep difficulties, and on-going emotional problems from his Vietnam-era experiences. He reported frequent feelings of sadness, loss of interest in activities, decreased sleep, and low energy/fatigue. He temporally related these symptoms to a recent period when he was side-lined from working following ear surgery. He stated that "with nothing to do, war memories started flooding in." When asked for specifics, the Veteran reported classic PTSD symptoms including nightmares, intrusive thoughts, flashbacks, exaggerated startle response, and avoidance of certain stimuli such as large crowds. He stated that he had been carrying all of this inside for decades and never sought formal help before. The examiner concluded that from a diagnostic viewpoint, both a depressive disorder and anxiety disorder appeared to be in operation in the Veteran. Based on the available evidence diagnoses of depressive disorder and PSTD appeared warranted. A GAF score of 55 was given. These records also show the Veteran is a self-employed truck mechanic who has his own repair shop. By December 2008, the Veteran reported feeling just a little less irritable and angry with his prescribed medication. He reported that he had been able to communicate with his son and people around him better. He also acknowledged some improvement in sleep with less dramatic nightmares. A GAF score of 55 was given. At a December 2008 VA examination to determine whether he was entitled to service connection for PTSD, the Veteran's mood was deeply depressed. During the interview, he also described feelings of guilt, extreme helplessness, poor quality sleep, nightmares, social isolation, intrusive thoughts, and occasional flashbacks. He had no history of psychiatric hospitalization. In terms of his relationships with others, the Veteran reported that he is the youngest of 8 children, but was not particular close to his siblings as they are all older than he is. He has been married since 1973 to the same woman and described the marriage as "ok with no problems," although there is other evidence in the claims file that suggests some marital conflict. The Veteran has three adult children, but described the relationships as "distant." Besides attending church he does not go out in public much and does not really have any friends. Since service discharge he has been self-employed running a repair shop. He also enjoys restoring old trucks. On examination the Veteran's grooming was normal with adequate hygiene. His mood was depressed and anxious. His affect was mood congruent and varied from flat to tearful. Attention was distractible and concentration was brief. Recent and remote memory appeared normal. Thought processes were obsessive with occasional suicidal ideation, but no definitive plan or intent. The Veteran's speech was halting at times as he described his experiences, but was otherwise linear, goal directed, and responsive to discussion. Interpersonally the Veteran was defensive and guarded initially, but became more open and cooperative as the session progressed. His eye contact was avoidant. Judgment, insight and impulse control appeared adequate. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) was administered, but the results were invalid and could not be interpreted as the Veteran indicated that he did not understand some of the questions or wording. The diagnosis was PTSD, chronic moderate and a GAF of 51 was assigned. Subsequent VA outpatient records show the Veteran was seen for medication review in November 2009. At that time he reported having more problems with sleep for the past month. On examination the Veteran was pleasant, engaged, and cooperative. He was nicely dressed and groomed. His speech was normal and spontaneous and eye contact good. The Veteran's mood was low and full with appropriate affect. His thoughts were linear and coherent with no suicidal or homicidal ideation. The clinical assessment was PTSD and depressive disorder. The GAF score was 55. At a December 2009 VA examination to assess the current state of his service-connected PTSD, the Veteran reported that he continued to experience intrusive thoughts and nightmares. He reported that in order to cope with his stressors he had been keeping himself busy with in his work restoring old trucks. He acknowledged a continued lack of desire to interact socially including having little contact with his wife. He also reported problems with irritability, temper, and concentration. He was finding it hard to cope with his symptoms because he is getting old. The Veteran also endorsed depression with feelings of hopeless and worthlessness. He complained about an inability to focus or concentrate, which caused him to make mistakes at work. He admitted to suicidal ideation at times, but stated that he would not act on it. He denied homicidal ideation, auditory or visual hallucinations, paranoia, obsessions or compulsions. The Veteran reported that there had been no significant changes in his social/occupational history since his last evaluation in December 2008. Clinical findings on psychiatric evaluation were also essentially unchanged. On examination the Veteran was appropriately dressed and fairly well groomed. He appeared irritated with the questioning and had difficulty answering or giving details at times. His mood was normal and affect mildly restricted and dysphoric. The Veteran was tearful when talking about his friend who was killed in the service, but was able to smile and give comments at the end of the interview. He had fair eye contact throughout the interview. His speech was hesitant at times, but normal in rate, rhythm and volume. Thought production was coherent and directed for the most part with no looseness of association or flight of ideas. Sensorium was clear and he was oriented time three. The Veteran's gross memory seemed intact for recent remote and immediate events. However he reported that he had to write notes in order to be able to recall things. Attention and concentration were both fair and insight and judgment seemed intact. The clinical impression was chronic moderate PTSD and depression. The GAF score was 51. The examiner concluded the Veteran did not reveal any significant change in comparison to his last examination in December 2008. Moreover, the Veteran himself indicated that his clinical symptomatology had been the same although he had been having difficulty coping with his symptoms due to aging. The Veteran also stated that there had been some impact on his job has he had been having difficulty concentrating and making mistakes. However it was worthwhile noting that the Veteran had also been having hearing loss and balance issues which affected his ability to work as well. There was no evidence of delusional beliefs, generalized impairment of cognitive function. or inability to care for his activities of daily living. By applying the Veteran's psychiatric symptomatology to the rating criteria noted above, it is apparent that his PTSD does not more nearly approximate the criteria for a 70 percent or higher rating from April 30, 2008 to December 14, 2009. The record during this time frame shows the Veteran's disability was found to be consistently manifested by the symptoms noted above, that are productive of no more than occupational and social impairment with reduced reliability and productivity. The evidence does not otherwise show significant disturbance of affect or mood, speech suggestive of disorders of thought or perception, difficulty understanding commands, or impairment of memory, judgment, or abstract thinking. Despite his suicidal ruminations, according to the Veteran he had no active suicidal plans and he has required no inpatient psychiatric treatment. The relevant clinical findings largely show periods when the Veteran was doing worse and at other times doing better, but in general show that his symptoms were under control. Moreover, even by the Veteran's own admission, his symptoms were less disabling through the use of prescription medication. While the Veteran's isolative behavior makes social interactions complicated, he does have the ability to establish and maintain effective relationships as shown by his long-term marriage to his wife, albeit with strain. There is no evidence that he has significant decreases in work efficiency. The Board finds it probative that despite his PTSD symptoms, the Veteran has been able to maintain his work relationships sufficiently to remain relatively stable in his employment and manage his own business since service discharge. The Veteran also reported meaningful leisure pursuits including restoring old trucks. Other symptoms of the type required for a higher 70 evaluation are neither complained of nor observed by medical health care providers, including obsessional rituals, illogical, obscure, or irrelevant speech, or impaired impulse control. The Veteran has not been shown to have symptoms equivalent in nature or severity to the criteria required for a higher rating. There is also no evidence of psychotic symptoms or cognitive deficits. In general, the Veteran was adequately groomed and able to take care of himself physically. The evidence also does not show spatial disorientation - the substantial weight of the evidence shows that he was alert and oriented in all spheres. Such findings are consistent with the rating criteria required for a 50 percent evaluation, and do not approximate the criteria required for assignment of a 70 percent or higher evaluation. While the clinical findings of record describe experiences, thoughts, and emotions due to PTSD that have had some impact on the Veteran's interpersonal relationships, particularly those within his immediate family, the evidence overall shows that he was able to function fairly well. In other words, the Veteran's tendency for isolative behavior suggests some difficulty in establishing and maintain effective work and social relationships with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, as is required for the next higher evaluation of 70 percent. Bowling v. Principi, 15 Vet. App. 1, 11 (2001); Vazquez-Claudio v. Shinseki, 2012-7114, (Fed. Cir. Apr. 8, 2013) (holding that a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation). The Board has also taken into account that the VA examiners who have examined the Veteran on both an inpatient and outpatient basis for treatment purposes or have evaluated him to assess the nature, extent and severity of his service-connected PTSD, have estimated GAF scores of 51 - 55 which, according to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV), denote moderate symptoms (e.g., flat effect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or co-workers). Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). These GAF scores are consistent with the symptomatology noted and do not provide a basis for a higher rating for the Veteran's PTSD in excess of 50 percent for the period prior to December 14, 2009. Accordingly, the Board finds that the Veteran's impairment due to PTSD for the period from April 30, 2008, to December 14, 2009 is more consistent with a 50 percent rating and that the level of disability contemplated in DC 9411 to support the assignment of a 70 percent or rating or higher is absent. It is also noted that the Veteran was found to have significant symptoms associated with depressive disorder in addition to symptoms of PTSD. This disorder is not service-connected, but, according to the evidence, causes some level of additional social and occupational impairment. However, in the absence of a medical opinion that clearly separates the symptoms of the Veteran's service-connected PTSD from the nonservice-connected depressive disorder, the Board has resolved all reasonable doubt in the Veteran's favor and has considered all of his psychiatric symptomatology in evaluating the severity of the service-connected PTSD. As a result the Board has considered all of his psychiatric symptomatology in evaluating the severity of the service-connected PTSD. See Mittleider v. Brown, 11 Vet. App. 181 (1998) (which stipulates that the Board is precluded from differentiating between symptomatology attributed to a service-connected disability and another service-connected disability in the absence of medical evidence which does so). Yet, for the reasons discussed herein, the evidence of record does not warrant ratings higher than the currently-assigned 50 percent evaluation at any time from April 30, 2008, to December 14, 2009, for the service-connected PTSD. The Board has carefully considered the Veteran's contentions in making this decision. However, inasmuch as the objective evidence does not otherwise substantiate the subjective complaints, his assertions do not suffice to assign a higher disability rating for his service-connected PTSD for the period from April 30, 2008 to December 14, 2009. The level of disability shown is encompassed by the rating assigned and, with due consideration to the provisions of 38 C.F.R. § 4.7, a higher evaluation is not warranted for this disability for any portion of the time period under consideration. See Fenderson, supra. The Board has also considered the provisions of 38 C.F.R. § 3.321(b)(1), which provide for consideration of an extraschedular rating is in order when there exists such an exceptional or unusual disability picture so as to render impractical the application of the regular schedular standards. Therefore, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the schedular evaluation in this case is not inadequate. The Veteran has not identified any factors which may be considered to be exceptional or unusual so as to render impractical the application of the regular schedular standards, and the Board has been similarly unsuccessful. As discussed above, there are higher ratings available for the Veteran's service-connected PTSD, but the required manifestations have not been shown in this case. Moreover, the evidence does not establish that the Veteran's PTSD necessitates frequent periods of hospitalization and VA examinations are void of any findings of exceptional symptomatology beyond that contemplated by the schedule of ratings. Although the Board has no reason to doubt that the Veteran's PTSD symptomatology adversely impacts his employability, this is specifically contemplated by the 50 percent schedular rating currently assigned. Accordingly, the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Lastly, the Court has recently held that a request for a total disability rating based on individual unemployability due to service-connected disability (TDIU), whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part of a claim for increased compensation. There must be cogent evidence of unemployability in the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009), citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). The holding of Rice is inapplicable here because the evidence of record does not demonstrate that the Veteran has been rendered unemployable due solely to his service-connected PTSD, nor has he so contended. Thus, at this point, there is no cogent evidence of unemployability due solely to this service-connected disability, and the issue of entitlement to a TDIU need not be addressed. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). ORDER A disability rating for PTSD in excess of 50 percent from April 30, 2008 to December 14, 2009 is denied. REMAND Unfortunately, a remand is required with respect to the Veteran's remaining PTSD claim. The Veteran asserts that the current 50 percent disability rating does not accurately portray the severity of his PTSD. He basically asserts that his psychiatric impairment has worsened since he was last examined by VA in December 2009. See Appellant's Brief dated April 2013, page 3. The Board notes that the Veteran is competent to provide evidence as to the severity of his symptoms. See 38 C.F.R. § 3.159(a)(2) (2012). Review of the claims folder reveals the Veteran has not been afforded a VA psychiatric examination since December 2009, more than 3 years ago. Moreover, since that VA examination there is little evidence in the claims file which adequately describes the current nature and extent of the Veteran's PTSD. As there may have been significant changes in the service-connected PTSD since the previous examination, and to ensure that the Veteran's own complaints are sufficiently considered by a VA examiner, the Board finds that a more contemporaneous examination is needed. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995); See Allday v. Brown, 7 Vet. App. 517, 526 (1995) (where the record does not adequately reveal current state of claimant's disability, fulfillment of statutory duty to assist requires a contemporaneous medical examination - particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the previous examination); Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (the Board should have ordered a contemporaneous examination of the veteran because a 23-month old examination was too remote in time to adequately support the decision in an appeal for an increased rating). The examination conducted pursuant to this Remand should include a review of the Veteran's claims file and past clinical history, with particular attention to the severity of present PTSD symptoms, as well as any significant pertinent interval medical history since his last VA examination in 2009. Also on remand, ongoing medical records should be obtained. 38 U.S.C.A. § 5103A(c) (West 2002). See also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if pertinent). In this regard, the Board notes that the most recent record of any outpatient treatment that the Veteran has undergone (and that is included in his claims folder or Virtual VA folder) is dated in November 2009. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to provide any medical records, not already in the claims file, pertaining to treatment or evaluation of his service-connected PTSD since November 2009, or to provide the identifying information and any necessary authorization to enable the AMC/RO to obtain such evidence on his behalf. Document the attempts to obtain such records. If the AMC/RO is unable to obtain any pertinent evidence identified by the Veteran, so inform him and request that he obtain and submit it. If any records are unavailable, do not exist, or further attempts to obtain them would be futile, document this fact in the claims file. All such available documents should be associated with the claims folder or Virtual VA folder (as appropriate). 2. Thereafter, the Veteran should be referred for a VA examination to determine the current severity of his service-connected PTSD. The claims folder must be made available to the examiner in conjunction with the examination. A notation to the effect that this record review took place should be included in the report of the examiner. The examiner should obtain a full history of the Veteran's relevant symptomatology and assess the current severity of his psychiatric disorder in accordance with 38 C.F.R. § 4.125 and the DSM-IV. All indicated tests and studies should be accomplished, and all signs and symptoms of PTSD should be reported in detail. The examiner is requested to use a multiaxial assessment, assign a GAF score, explain what the assigned score represents in terms of his psychological, social, and occupational functioning, and reconcile that score with earlier GAF scores. The examiner should also describe the impact of the Veteran's PTSD on his occupational and social functioning. 3. After completing the requested action, and any additional notification and/or development deemed warranted, readjudicate the issue of entitlement to an initial rating greater than 50 percent for the service-connected PTSD from December 15, 2009 forward. If the benefit sought on appeal remains denied, furnish the Veteran and his representative an appropriate supplemental statement of the case and give them an appropriate time period in which to respond. All evidence should be reviewed, to include evidence submitted since the January 2010 supplemental statement of the case. 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). ______________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs