Citation Nr: 1318535 Decision Date: 06/06/13 Archive Date: 06/11/13 DOCKET NO. 08-22 084 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for hyperpituitarism (post pituitary tumor extraction), claimed as due to herbicide exposure. 2. Entitlement to increases in the ratings assigned for posttraumatic stress disorder (PTSD), currently assigned "staged" ratings of 30 percent prior to January 17, 2012, and 50 percent from that date. 3. Entitlement to a compensable rating for contact dermatitis and eczema. 4. Entitlement to total disability rating based on individual unemployability due to service connected disability (TDIU). REPRESENTATION Appellant represented by: Attorney Robert W. Gillikan, II WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from May 1968 to May 1970 and from June 1971 to July 1974. These matters are before the Board of Veterans' Appeals (Board) on appeal from January 2008 and May 2009 rating decisions by the Roanoke, Virginia RO, which in pertinent part denied service connection for pituitary tumor extraction (January 2008), and denied a rating in excess of 30 percent for PTSD and entitlement to a TDIU rating (May 2009). In May 2010, a Travel Board hearing was held before the undersigned on the matters of the rating for PTSD and entitlement to a TDIU rating; a transcript of the hearing is included in the claims file. In April 2011, the Board remanded the matters for additional development. An interim (February 2013) rating decision increased the rating for PTSD to 50 percent, effective January 17, 2012. The issue is recharacterized to reflect that staged ratings are assigned, and that both "stages" are on appeal. The issues of service connection for hyperpituitarism, and entitlement to a compensable rating for contact dermatitis and eczema and a TDIU rating are being REMANDED to the Department of Veterans Affairs Regional Office. VA will notify the appellant if further action on his part is required. FINDINGS OF FACT 1. Prior to August 23, 2006, the Veteran's PTSD was manifested by symptoms productive of impairment no greater than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; occupational and social impairment with reduced reliability and productivity due to PTSD symptoms was not shown. 2. From August 23, 2006 (but not earlier) it is reasonably shown that the Veteran's PTSD has been manifested by symptoms productive of occupational and social impairment with reduced reliability and productivity; at no time during the period under consideration is the PTSD shown to have been manifested by symptoms productive of occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The Veteran's PTSD warrants a 50 percent rating from (the earlier effective date of) August 23, 2006; a rating in excess of 30 percent prior to August 23, 2006 and a rating in excess of 50 percent for any period of time under consideration are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code (Code) 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The Veteran was advised of VA's duties to notify and assist in the development of the claim prior to the initial adjudication of his claim. An August 2008 letter explained the evidence necessary to substantiate his claim, the evidence VA was responsible for providing, and the evidence he was responsible for providing; it also informed him of effective date criteria. He has had ample opportunity to respond/supplement the record, and has not alleged that notice was less than adequate. At the May 2010 Travel Board hearing before the undersigned, the Veteran was advised of what he still needs to substantiate the claim; his testimony reflects that he is aware of what is still needed to substantiate the claim. The Veteran's pertinent treatment records and Social Security Administration (SSA) records are associated with his claims file. The RO arranged for VA examinations in September 2008 and January 2012 (with a May 2012 addendum opinion). The Board finds the examinations are adequate for rating purposes as the reports reflect the providers' familiarity with the Veteran's psychiatric history and note his complaints, and mental status evaluations with notation of all findings necessary for proper consideration of this matter. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). The Veteran has not identified any relevant evidence that remains outstanding. VA's duty to assist is also met. Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic database), with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claim. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. PTSD is rated under the General Rating Formula for Mental Disorders (General Formula). A 30 percent evaluation is warranted when the evidence demonstrates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when 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; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when 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. 38 C.F.R. § 4.130, Code 9411. The Veteran has been assigned various Global Assessment of Functioning (GAF) scores for his PTSD. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect 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). Lesser scores reflect increasingly severe levels of mental impairment. See 38 C.F.R. § 4.130 [incorporating by reference VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes]. 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 remissions. 38 C.F.R. § 4.126(a). 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. Id. However, 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 on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran's claim for an increased rating for PTSD was received in February 2007. The relevant appeal period is therefore from February 2006. On June 2006 VA treatment, the Veteran reported flashbacks with subsequent sleep disturbances. He denied having symptoms of avoidance and startle response. He denied having numbing of mood and avoiding factors that could trigger flashbacks. He reported having legal issues with his former workplace, after being fired in February 2006, although he was not agitated or extremely anxious; he was able to keep calm about the process. He denied symptoms suggestive of psychosis or delusions. He denied symptoms suggestive of depression or anxiety or of schizophrenia or bipolar disorder. He denied suicidal or homicidal ideation. He reported a good impulse control. On mental status examination, the Veteran showed no evidence of any psychomotor agitation or retardation. He showed no evidence of tangentiality or thought disorder; his thought process was linear, logical, and goal oriented. He described his mood as okay, and his affect was congruent to mood, euthymic, and normal range. His insight and judgment were fair. His cognitive functions were grossly intact. The diagnosis was polysubstance abuse in remission, and a GAF score of 70 was assigned. On August 23, 2006 psychiatric evaluation for SSA disability benefits, the Veteran reported flashbacks and nightmares, increasing in the previous six months. He also reported feelings of guilt, a sense of loss, not being able to sleep well, and problems with depression over the years and more acutely in the previous few months, especially since the Iraq war had begun. On mental status examination, he felt that he had an obligation to stand up for the citizens of the city and the country as an activist, and he felt that God called upon him to do these things. He was noted to have some paranoid tendencies and talked about a conspiracy that did not quite reach delusional proportions. He was alert and oriented to all spheres and showed some insight into his problems. The impressions included combat related PTSD and paranoid personality traits that were very well compensated for. A GAF score of 50 was assigned. On September 2006 VA treatment, the Veteran was noted to have a history of PTSD and polysubstance dependence in remission. He reported symptoms including nightmares, memories, reminders, avoidant behavior, hypervigilance, and hyperstartle response. He was treated with Paxil and trazodone, with some improvement with his PTSD symptoms. He was euthymic with no evidence of manic, depressive, or psychotic symptomatology. His social and leisure pursuits remained unchanged. He reported poor concentration, which it was noted likely played a role in his ongoing distress and had resulted in significant physiological distress and functional impairment. His outlook was positive and he denied any suicidal or homicidal thoughts or intentions. The assessments included PTSD and polysubstance dependence, in remission; a GAF score of 50 was assigned. On October 2006 VA psychiatric examination, the examiner noted that the treating psychiatrist's notes indicated a rather atypical presentation for PTSD: while the Veteran was having either nightmares or flashbacks, he was reported to remain very social and was denying a lot of other PTSD symptoms. The examiner noted that the records then suggested a worsening of symptoms. The Veteran reported seeking therapy for PTSD at the Veterans Center, and his medications included paroxetine and trazodone. He reported that these were not very effective, and that he also received treatment with other medication from a non-VA psychiatrist. He reported changes in his life over the previous year, including legal problems, breaking up with his fiancée, and being fired from his job in June 2006 and having significant financial stress since that time. He reported that his fiancée did not understand his disability and he feared he would lose his temper with her, as he was becoming increasingly irritable and had verbal anger outbursts, and he feared he would become physical. He reported getting along adequately with his 13 children as well as several of his siblings. He reported having a number of friends, although he was seeing less of them and kept more to himself, often due to fear of his own temper. He enjoyed attending church and live sporting events, and he was active in various city council meetings. On mental status examination, the Veteran was agitated and irritable. There was no impairment of thought processing or communication, and there were no delusions or hallucinations. He reported having periodic suicidal thoughts, as recently as one week earlier. He had no homicidal thoughts. He indicated no significant memory impairment or obsessive-compulsive behavior. His speech was within normal limits, and he reported no panic attacks. He reported feeling depressed most of the time, but he tried to "put on a good face" in front of others. He was more socially withdrawn, crying at times and often feeling sad. The examiner opined that recent life stress was likely the significant cause of the Veteran's depression, although he reported increased PTSD symptoms as well. He reported frequent feelings of anxiety and fear about his own temper; he had increased impulse control difficulties. He reported sleep problems, often being awakened by nightmares and intrusive memories, and checking the locks at night. The diagnosis was PTSD; no GAF score was assigned. The Veteran submitted a September 2007 treatment summary letter from John Whitlock, MSW, LCSW, at the Roanoke Vet Center, who indicated that he had been treating the Veteran for symptoms of chronic and severe PTSD since August 2006. Mr. Whitlock opined that he had observed the Veteran's symptoms progressively deteriorating despite regular group therapy sessions at the Vet Center; most notably that his depression, anxiety, and confusion had progressed to the point that he rarely left his residence except to attend VAMC appointments and Vet Center group sessions. Mr. Whitlock opined that the increasing isolation and social withdrawal as well as a notable decline in hygiene and grooming were indicators of the Veteran's marked decline. Mr. Whitlock also cited a June 2006 incident at a city council meeting which resulted in legal action and the Veteran's dismissal from employment with the city of Roanoke, which Mr. Whitlock opined are indicative of very poor judgment and extreme emotional lability characteristic of severe PTSD. Mr. Whitlock concluded that it was his opinion that the Veteran had been rendered unemployable by his PTSD symptoms and that the severity and chronicity of his condition indicated a very guarded prognosis for any future significant and sustained improvement. On September 2007 VA treatment, the Veteran reported that his PTSD symptoms had improved somewhat with paroxetine and trazodone, with which he was satisfied. The treating psychiatrist concurred with Mr. Whitlock's findings of traumatic re-experience in the form of intrusive memories, nightmares, flashbacks, and symptoms of avoidance, numbing, and hyperarousal affecting the Veteran's functioning at various levels. He reported no suicidal or homicidal ideation, and his outlook was positive. On mental status examination, the Veteran showed evidence of mild psychomotor retardation. He was very upset about his living situation and medical problems. His mood was "ok", and his affect was congruent to mood, stable, and restricted. There was no evidence of emotional incontinence or lability out of context. His speech was normal and his thought process was logical, linear, and goal-directed with no evidence of tangentiality or loosening of associations. His thought content was non-delusional and his perceptions showed no hallucinations or illusions. His insight and judgment were fair with impulse control preserved. The psychiatrist opined that the magnitude of the Veteran's PTSD symptoms, superimposed by his ongoing sudden onset of medical problems (adrenal insufficiency, pituitary macroadenoma, and panhypopituitarism) rendered him unemployable. The diagnoses included PTSD, polysubstance dependence in remission, and cluster B personality traits; a GAF score of 50 was assigned. On September 2008 VA mental health examination, the examiner noted that the Veteran had continued to have regular VA psychiatric treatment since the previous exam two years earlier (in October 2006). The examiner noted that the Veteran's medications were increased in May 2008 (at the most recent psychiatry appointment) due to worsening symptoms; specifically, both Paroxetine and Trazodone were increased. At the time of examination, the Veteran reported that the medications "really do not help much at all". The examiner noted that the Veteran remained out of work since June 2006 and there had been no further legal troubles since that time. The Veteran complained that [in addition to his PTSD] his arthritis and back problems would also interfere with any future employment. He reported that he had a new fiancée whom he saw daily, and he described his relationship as "wonderful", as they enjoyed each other's company and did many things together to stay busy and active, including picnics, fishing, walking around the mall, going to beaches, and going to high school sporting events at times. He reported that he had contact, and got along well, with his own 13 children, as well as his fiancée's daughter. He reported enjoying playing cards or dominoes with family members. He reported enjoying going to city council meetings and occasionally NAACP meetings. He reported attending church, where he was a deacon and taught a business course. He denied any recent problems with substance abuse, violent or assaultive behavior, or suicide attempts. On mental status examination, the Veteran's affect was broad and his mood appeared euthymic, animated, and friendly for the majority of the examination; however, as he drifted onto topics related to Vietnam toward the end of the examination, he became more dysphoric and anxious, slightly tearful, and in more distress. He began to tell stories about his Vietnam experiences in great detail. There were no impairment of thought processing or communication, and no delusions or hallucinations. The Veteran reported having spells when he "blanks out" from a few seconds to a few minutes, which was occurring more frequently in the prior two months. He described episodes of staring and being unresponsive until he "snaps back"; an Emergency Room note from that morning indicated a suspicion of a neurological problem. The Veteran reported some flashback experiences. He reported frequently having suicidal thoughts, but denied any intent to act on them, and he denied homicidal thinking. The examiner found the Veteran's attention to personal hygiene and basic activities of living to be adequate. Her was oriented and indicated no severe memory impairment or obsessive-compulsive behavior. Speech was within normal limits, and no panic attacks were described. The Veteran reported being sad and depressed most of the time, having periodic crying spells and loss of interest, though he reported that he enjoyed life and did not have low self-esteem. He reported sometimes wanting to withdraw and other times being more active, social, and engaging in many activities. He reported frequently feeling anxious, nervous, and on guard from potential danger related to his hypervigilance. He denied any significant problems with impulse control, saying he had not been having any significant anger outbursts. Sleep was poor, estimated at 3 to 4 hours of sleep per night in "extremely broken fashion". The Veteran reported nightmares of wartime experiences as frequently as 2 to 3 times per week. He reported pacing often at night and having a hyper-startle response to loud sudden noise or sudden movements. He reported hypervigilance, saying he is always on alert for danger, on guard, and sometimes re-checks the locks for security. Adequate concentration was reported. The September 2008 VA examiner opined that the Veteran meets the DSM-IV stressor criteria for PTSD related to Vietnam combat experience and continues to meet PTSD symptom criteria with no remissions since the last examination. The examiner noted the Veteran's reports of upsetting intrusive memories most days where he relives the war in excruciating detail and feels he cannot control the thoughts or memories, which "take over". The examiner also noted the Veteran's reports of frequent dissociative flashback episodes as often as five times per week, including a flashback the previous night in which he acted as if he were holding a friend who had died in the war. The examiner noted that anniversaries of wartime trauma, nighttime, the war in Iraq, TV violence, gunshot/explosion-type sounds, and helicopters trigger negative upsetting memories for the Veteran, who continued to have avoidance behavior regarding watching war-related news or movies, attending the Vietnam Memorial wall, and talking about wartime trauma. The examiner stated, "[the Veteran] seems to indicate that his problems with irritability and anger, while still having such feelings, have been somewhat improved and under better control." The diagnosis was PTSD; a GAF score of 53 was assigned. At the May 2010Travel Board hearing before the undersigned, the Veteran testified before the Travel Board that he receives VA-prescribed medications for PTSD, which had been increased since the Board hearing request was submitted [in November 2009]. He testified that he began receiving weekly individual therapy for PTSD, and that at the time of the hearing he was being treated approximately every 90 days, because he was "having the same problem over and over". He testified that he can also seek treatment as needed, which he did on two occasions in the previous year. He testified that he sought treatment at least twice since January 2010. He testified that in his daily life, he tried to get involved in community activities, but also tried his best to stay away from people. He testified that he lives by himself and has "plenty of friends", though he tries to avoid people as much as possible because he gets angry with himself and has outbursts. He testified that he stays in touch with his children as much as he can, though he is "not tolerant at all", and therefore it is best for him to stay by himself. On December 2011 VA treatment, the Veteran was noted to have had brain surgery in 2007, with subsequent occasional blackouts. He was noted to have been in jail multiple times for fighting and other issues; there was a history of medication noncompliance in the past. He had no psychiatric hospitalizations or past suicidal attempts. He reported feeling the same as on the previous treatment; he was doing very well on Paxil, reporting that he became depressed occasionally but felt "okay" most of the time. He denied any problems with appetite, concentration, or energy, and he was sleeping well with Trazodone. He denied feelings of hopelessness or helplessness. He had occasional flashbacks and nightmares; his PTSD symptoms were stable. He lived a full life, and his only stressor was his finances. He reported that medications helped him control his anger. He denied any current suicidal or homicidal thoughts or any visual or auditory hallucinations. He reported no paranoia or anxiety. On mental status examination, the Veteran made good eye contact and showed no psychomotor agitation or retardation. His speech was normal and his mood was "better", with a restricted affect. His thought process was linear and logical. His judgment and awareness were intact, and his insight was fair. His memory was grossly intact. The diagnoses were PTSD, rule-out depression not otherwise specified, and polysubstance dependence in full remission. A GAF score of 60 was assigned. On January 2012 VA psychiatric examination, the Veteran endorsed PTSD symptoms including recurrent and distressing recollections of the event; recurrent distressing dreams; a sense of reliving the experience; avoidance of thoughts/feelings/conversations associated with the trauma; efforts to avoid activities/places/people that aroused recollections of the trauma; difficulty falling or staying asleep; irritability or outbursts of anger; exaggerated startle response; anxiety; chronic sleep impairment; mild memory loss; suicidal ideation. The examiner noted that the Veteran failed to meet the full diagnostic criteria for PTSD, as only two of the three or more required symptoms in criterion C were reported. Nonetheless, he reported multiple symptoms of PTSD related to his combat experiences, and therefore anxiety disorder not otherwise specified (sub-threshold PTSD) was diagnosed. He appeared to meet all other diagnostic criteria for PTSD. The Veteran did not report the necessary symptoms for a diagnosis of major depressive disorder. A GAF score of 60 was assigned due to persistent moderate symptoms, but the Veteran was reportedly functioning with only mild transient impairment. The examiner opined that the Veteran's PTSD resulted in occupational and social impairment due to mild or transient symptoms which decreased his work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran reported on examination that he had ended his relationship with his fiancée one year earlier due to "going through too much" but they remained very close friends; he reported having "plenty of friends" and had no trouble making friends. He reported being close with his family and in frequent contact with his multiple children and grandchildren. He was active in his church as a deacon and received support from his church community. He was active in his community, both in organizations and as an "activist". He had not been employed since 2006; he reported that the incident that led to his termination as well as related charges made it difficult to find work. He considered himself retired, primarily due to his poor physical health. He stated that "flare ups" of his PTSD symptoms could potentially intermittently affect his ability to work, if he were employed. In a May 2012 addendum opinion, the January 2012 VA examiner noted that the Veteran reported that "flare ups" of his PTSD symptoms, such as flashbacks and exaggerated startle response) could potentially intermittently affect his ability to work, were he currently employed. However, he had also stated that he was able to function at work prior to ceasing work in 2006, primarily due to his physical health issues. He reported losing one job as a local government employee due to a verbal outburst at a town council meeting. Based a review of the records and the January 2012 examination, the examiner concluded that the Veteran's sub-threshold PTSD symptoms (anxiety disorder not otherwise specified) resulted only in "occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication". The Veteran reported good social functioning without any significant impairment due to his symptoms, and he denied any impairment in his ability to carry out activities of daily living due to his psychiatric symptoms. The examiner opined that the Veteran's sub-threshold PTSD symptoms would not preclude him from obtaining and maintaining gainful employment. Based on these results, a February 2013 rating decision increased the rating for PTSD to 50 percent effective January 17, 2012, the date of the VA examination. VA treatment records through June 2012 show largely similar symptomatology to that shown on the examinations and reports noted above. Taken as a whole, the medical evidence prior to August 23, 2006, shows that the impairment from the Veteran's PTSD more nearly approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, contemplated by a 30 percent rating, rather than the reduced reliability and productivity required for a 50 percent evaluation. On June 2006 VA treatment, the Veteran reported flashbacks with subsequent sleep disturbances but denied having any symptoms of avoidance, startle response, numbing of mood, agitation, psychosis, or any delusions. He denied any symptoms suggestive of depression, anxiety, schizophrenia or bipolar disorder. He denied any suicidal or homicidal ideations, and he reported a good impulse control. The diagnosis was polysubstance abuse in remission, and a GAF score of 70 was assigned, reflecting mild symptoms and impairment. In short, the Board finds that the evidence prior to August 23, 2006 is indicative of no greater impairment than that contemplated by the 30 percent rating assigned for PTSD at that time. However, the Board finds that ever since August 23, 2006 symptoms of the Veteran's PTSD are shown to have more nearly approximated the criteria for a 50 percent rating. On examination on that date, he reported increasing flashbacks and nightmares, as well as feelings of guilt, a sense of loss, not being able to sleep well, and problems with depression. On mental status examination, he was noted to have some paranoid tendencies. The impressions included combat related PTSD and paranoid personality traits that were very well compensated for, and a GAF score of 50 was assigned. The GAF scores of 50 to 60 assigned since that date continue to reflect moderate impairment due to his PTSD symptoms including flattened affect; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; and disturbances of motivation and mood. Accordingly, the Board finds that a substantial number of the criteria for a 50 percent rating have been met or approximated, and that the rating for the Veteran's PTSD warrants increase to 50 percent throughout from (the earlier effective date of) August 23, 2006. The evidence of record does not show that symptoms that meet (or approximate) the above-listed criteria for a 70 percent rating were manifest at any time during the evaluation period. At no time during the appeal period is it shown that the Veteran had occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships, or any other symptoms of similar gravity; no such symptoms have been shown. Consequently, the Board finds that the criteria for a 70 percent rating are not met or approximated for any period of time under consideration. The Board finds that the GAF scores assigned do not provide a separate basis for an award of a rating in excess of 50 percent. The symptoms and level of impairment represented by the GAF scores of 50 to 60 reflect moderate disability, but not severe disability so as to warrant a 70 percent rating. Furthermore, the Board finds that the evidentiary record presents no reason to refer the case to the Compensation and Pension Service for consideration of an extra-schedular evaluation under 38 C.F.R. § 3.321(b). There is no evidence of symptoms or impairment not encompassed by the schedular criteria, so as to render those criteria inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). Finally, the matter of a total rating based on unemployability is addressed below. ORDER A rating in excess of 30 percent for the Veteran's PTSD prior to August 23, 2006 is denied. A 50 percent rating is granted for the Veteran's PTSD, effective from (the earlier effective date of August 23, 2006, subject to the regulations governing payment of monetary awards; a rating in excess of 50 percent is denied. REMAND Regarding service connection for residuals of pituitary gland extraction, the Board noted on April 2011 remand that the Veteran requested a BVA hearing in Washington, D.C. in a July 2008 substantive appeal. As the May 2010 Travel Board hearing did not address that matter, he was asked to clarify whether he still desired a hearing in the matter. In a December 2010 response, the Veteran submitted a form with a checkmark by the statement, "I want to appear before a Veterans Law Judge of the Board via video conference at my local regional office." A February 2013 supplemental statement of the case stated that this issue is still being considered as part of the Veteran's appeal and that there would be a videoconference Board hearing for the issue pursuant to the April 2011 remand. However, no such hearing has been scheduled. He did not at any time withdraw his hearing request, he remains entitled to a hearing on appeal in this matter, and his request must be honored. 38 C.F.R. § 20.700. He should therefore be scheduled for a videoconference hearing at the RO on this issue only. Regarding the rating for contact dermatitis and eczema, a December 2012 rating decision granted the Veteran's claim of service connection and assigned a 0 percent rating. An April 2013 RO letter (as shown in Virtual VA) noted that the Veteran had filed a notice of disagreement with a December 2012 rating decision. The filing of a timely notice of disagreement initiates the appeal process. Godfrey v. Brown, 7 Vet. App. 398, 408-10 (1995). As a statement of the case (SOC) has not yet been issued in the matter, a remand for such action is required. Manlincon v. West, 12 Vet. App. 238 (1999). [The Board notes that the April 2013 RO letter to the Veteran also addressed a notice of disagreement with a February 2013 rating decision; however, the February 2013 rating decision granted an increased "staged" rating for PTSD, which matter was already on appeal and is addressed herein.] The matter of entitlement to a TDIU rating remains inextricably intertwined with the service connection and increased rating claims, and consideration of that matter must be deferred pending resolution of those claims. Accordingly, the case is REMANDED for the following action: 1. The RO should issue a SOC regarding the issue of an increased rating for contact dermatitis and eczema. The Veteran should be advised that this matter will only reach appellate status if he timely perfects an appeal by submitting a substantive appeal. If he does so, the matter should be returned to the Board for appellate consideration. 2. The RO should schedule the Veteran for a videoconference hearing before the Board on the matter of service connection for pituitary gland extraction [only]. This matter should then be processed in accordance with established appellate practices. 3. The RO should secure for the record copies of the complete updated clinical records (any not already associated with the claims file) of any VA treatment the Veteran has received since June 2012 for the disabilities on appeal. 4. After all further necessary development is completed, the RO should review the expanded record and readjudicate the Veteran's claims (TDIU in light of the determinations on the pending service connection and increased rating claims). If any remains denied, the RO should issue an appropriate supplemental SOC and afford the Veteran and his attorney the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the 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 for additional development or other appropriate action must be handled in an expeditious manner. ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs