Citation Nr: 1318589 Decision Date: 06/07/13 Archive Date: 06/11/13 DOCKET NO. 09-30 168 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial, compensable rating for peripheral neuropathy of the right upper extremity prior to July 18, 2011, and from 10 percent thereafter. 3. Entitlement to an initial, compensable rating for peripheral neuropathy of the left upper extremity prior to July 18, 2011, and from 10 percent thereafter. 4. Entitlement to service connection for gastroesophageal reflux disorder (GERD) secondary to service-connected diabetes mellitus, type II. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD B. Ogilvie, Counsel INTRODUCTION The Veteran served on active duty from October 1967 to May 1969. These matters come before the Board of Veterans' Appeals on appeal from August 2008 and March 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In an August 2008 rating decision, the RO granted entitlement to service connection for PTSD and assigned a 50 percent rating, effective January 8, 2007. In a March 2009 rating decision, the RO denied the Veteran's claim of entitlement to service connection for GERD, and granted claims of entitlement to service connection for peripheral neuropathy of the left and right upper extremities, and assigned a noncompensable evaluation for each, effective October 20, 2008. In an April 2012 rating decision, the RO increased the Veteran's rating for these disabilities to 10 percent, effective July 18, 2011. Because the Veteran has disagreed with the initial ratings assigned following the grants of service connection for PTSD, peripheral neuropathy of the left upper extremity, and peripheral neuropathy of the right upper extremity, the Board has characterized these claims in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). Moreover, although the RO has granted a higher rating during the pendency of the appeal of 10 percent for the Veteran's peripheral neuropathy of the left upper extremity and peripheral neuropathy of the right upper extremity, inasmuch as higher ratings for these disabilities are available, both before and after July 18, 2011, and the Veteran is presumed to seek the maximum available benefit for a disability, the Board has characterized the appeal as set forth on the title page. AB v. Brown, 6 Vet. App. 35, 38 (1993). In March 2013, the Veteran and his spouse testified before the undersigned at a Board hearing at the RO. A copy of the transcript is of record. At the hearing, the Veteran submitted additional medical evidence directly to the Board, with a waiver of initial RO consideration of the evidence. This evidence is accepted for inclusion in the record on appeal. See 38 C.F.R. §§ 20.800, 20.1304 (2012). The issue of entitlement to service connection for GERD, as secondary to service-connected diabetes mellitus, type II, is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ) via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. Since the grant of service connection, the Veteran's PTSD has been manifested by occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. Prior to July 18, 2011, the Veteran's peripheral neuropathy of the right upper extremity was manifested by mild incomplete paralysis of the median nerve. 3. From July 18, 2011, the Veteran's peripheral neuropathy of the right upper extremity has not been manifested by moderate incomplete paralysis of the median nerve. 4. Prior to July 18, 2011, the Veteran's peripheral neuropathy of the left upper extremity was manifested by mild incomplete paralysis of the median nerve. 5. From July 18, 2011, the Veteran's peripheral neuropathy of the left upper extremity has not been manifested by moderate incomplete paralysis of the median nerve. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent disability rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. Prior to July 18, 2011, the criteria for an initial 10 percent disability rating for peripheral neuropathy of the right upper extremity were met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.31, 4.124a, Diagnostic Code 7913-8515 (2012). 3. From July 18, 2011, the criteria for an initial disability rating in excess of 10 percent for peripheral neuropathy of the right upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.124a, Diagnostic Code 7913-8515 (2012). 4. Prior to July 18, 2011, the criteria for an initial 10 percent disability rating for peripheral neuropathy of the left upper extremity were met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.31, 4.124a, Diagnostic Code 7913-8515 (2012). 5. From July 18, 2011, the criteria for an initial disability rating in excess of 10 percent for peripheral neuropathy of the left upper extremity have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.124a, Diagnostic Code 7913-8515 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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 (West 2002 & Supp. 2012); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA applies to the instant matters. 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 VCAA notice 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. 38 C.F.R. § 3.159(b)(1) (2012). The VCAA notice requirements apply to all five elements of a 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. See Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA has satisfied its VCAA duty to notify obligations with respect to the Veteran's claims for increased initial ratings for PTSD and for peripheral neuropathy of the right and left upper extremities. The United States Court of Appeals for Veterans Claims (Court) has held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the instant appeal stems from the Veteran's disagreement with the initial disability rating and effective date assigned for PTSD and peripheral neuropathy of the right and left upper extremities, following the grant of service connection, VA's duty to notify has been satisfied with respect to these issues. Id.; see 38 C.F.R. § 3.159(b)(3) (2012); see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (noting that 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). VA's duty to assist, including gathering all relevant evidence necessary for an equitable resolution of the Veteran's increased initial rating issues, has also been satisfied. The evidence of record includes VA outpatient treatment records, reports of multiple VA examinations, statements from the Veteran and his wife, and the transcript of a March 2013 hearing before the undersigned. The Veteran and his representative have not identified any other outstanding relevant evidence. The Veteran was afforded VA examinations to assess the severity of his PTSD in April 2007, July 2008, February 2009, and July 2011. He was also provided with VA examinations to assess the severity of his peripheral neuropathy of the upper extremities in February 2009 and July 2011. The reports of these examinations are adequate for rating purposes as they reflect the examiners interviewed and examined the Veteran, reviewed the claims file, reported the clinical findings in detail, and provided complete rationales for the opinions or conclusions stated. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Veteran was provided an opportunity to set forth his contentions on the claims during the March 2013 hearing before the undersigned. The Court has held that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board and that a Veterans Law Judge has a duty to explain fully the issues and to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The record reflects that at the March 2013 hearing the undersigned explained the issues, focused on the elements necessary to substantiate the claims, and sought to identify any further development that was required to help substantiate the claims. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. Neither the Veteran 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 claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist under the VCAA. 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). All necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). II. Increased Ratings The Board has reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Disability evaluations are determined by the application of the Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual disorders in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). The veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is entitlement to a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. When all of 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). In addition to evaluating the evidence and rating criteria below, the Board has also considered whether referral for extraschedular consideration is appropriate for each disability on appeal. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Under the approach prescribed by VA, if the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (2012). Related factors include "marked interference with employment" and "frequent periods of hospitalization." Id. When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. A. Evaluation of PTSD The Veteran was initially granted service connection for PTSD in an August 2008 rating decision. A 50 percent disability rating was assigned, effective January 8, 2007. The Veteran maintains that a higher rating is warranted. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a) (2012). The rating for the Veteran's PTSD has been assigned pursuant to Diagnostic Code 9411. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (noting that the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in "most areas"). Under the formula, a 50 percent rating is assigned 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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 rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. Id. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). At the outset, the Board notes that, in addition to PTSD, the medical evidence reflects diagnoses of depressive disorder, generalized anxiety, and bipolar disorder. Where it is not possible to distinguish the effects of nonservice-connected conditions from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). After reviewing the medical and lay evidence of record, the Board finds that the Veteran's PTSD symptoms are most nearly approximated by the criteria for a 70 percent rating outlined above. In private evaluation dated in November 2006, the Veteran was oriented to time, place, and person, and his memory for recent and remote events was good. There was no evidence during the interview of illusions, delusions, or hallucinations. The Veteran described feeling depressed much of the time, but denied suicidal ideations. He described having a problem with controlling his anger. The Veteran was diagnosed with PTSD, major depression, and generalized anxiety, and assigned an overall GAF score of 40. The Veteran was afforded a VA examination in April 2007. The Veteran stated that he had been married to his present spouse for 31 years and described his marriage as great. He described having very few close friendships outside of his wife and children. On mental status examination, the Veteran had no impairment of thought process or communication, and he denied delusions and hallucinations. The Veteran maintained good eye contact and was responsive to questions. He described violent ideation toward people of Middle Eastern descent, without plan or intent to harm others. The Veteran had the ability to maintain minimal personal hygiene, and other basic activities of daily living were intact. He was oriented to person, place, and time. He reported an average memory compared to his peers. Panic attacks and depression were denied. The Veteran reported having non-specific nightmares with some sleep problems. The examiner diagnosed the Veteran with recurrent, moderate major depressive disorder, and assigned a GAF score of 52. The Veteran was afforded another VA examination in July 2008. The Veteran reported having anger management issues, some of which resulted in physical altercations. The Veteran described a history of unstable occupational functioning due to irritability and lack of tolerance for differences. He stated that he was unable to work with others. The examiner noted that the Veteran described a history of moderate to severe occupational impairment secondary to psychiatric symptoms. The Veteran had been married to his current wife for 32 years, but in the past had been physically and mentally abusive to his family. He reported, however, currently having a great relationship with his children and grandchildren. The Veteran reported having no friends and no real hobbies. Sometimes he would go out to eat, but could not sit with his back to the door. Due to symptoms of depression, such as lack of motivation, the Veteran did not attend to his personal grooming and hygiene as much as he used to. Otherwise, the Veteran reported that he was able to function in all activities of daily living. On mental status examination, the Veteran had good eye contact. Grooming was fair and hygiene was good. Speech and communication were normal in rate, rhythm, tone, and volume. Thought processes were clear, logical, goal directed, and coherent and thought content was relevant and appropriate. Behavior during the examination was appropriate. The Veteran denied delusions and hallucinations. He described his mood as moody with a quick temper. The Veteran denied any recent suicidal ideation. While the Veteran denied homicidal ideation, he did report episodes of physical violence that occurred in an impulsive fashion. The Veteran evidenced a fair remote memory and good short-term memory. Attention and concentration were excellent. The Veteran showed no deficits in abstract reasoning or social judgment. His level of insight was limited yet increasing. Overall, the Veteran reported using avoidance techniques, irritability, markedly diminished interest and participation in social activities, restricted range of affect and emotional distance, as well as severe problems with aggression, irritability, anger, and violent outbursts. He also reported severe hypervigilance, exaggerated startle response, and chronic sleep impairment. In summary, the examiner estimated that the Veteran was exhibiting moderate to severe symptoms of PTSD. The Veteran was diagnosed with moderate to severe chronic PTSD, and depressive disorder NOS (secondary to PTSD), and alcohol abuse (secondary to PSTD), and assigned a GAF score of 51. The examiner noted that the Veteran's PTSD resulted in deficiencies in work, family relations, judgment, thinking, and mood. The Veteran underwent another VA examination in February 2009. The examiner noted that the Veteran was vague and difficult to follow throughout the interview. The Veteran reported concentrating problems and having nightmares once every two months. He was able to engage in a normal range and variety of activities of daily living without interruption of his typical daily routine. He reported a great deal of violence towards his wife and others. At the interview, the Veteran's thought processes were logical, coherent, and relevant. He was overall articulate, verbal, well-dressed, and well-groomed. He was cooperative and exhibited good social skills. The Veteran was well-oriented to time, place, person, and situation. Affect was spontaneous and reasoning was good. Verbal comprehension and concentration were good. The Veteran complained about short-term memory problems. The Veteran endorsed anxiety, panic attacks, depression, insomnia, crying spells, anhedonia, and nightmares. He also complained of racing thoughts, head pain, procrastination, and unfinished long projects. He indicated anger control problems and rage reactions, including road rage. The Veteran denied having psychotic symptoms, and indicated a history of suicidal and homicidal ideation (although the suicidal ideation was not recent). The examiner opined that the Veteran's PTSD was "certainly no worse than has been measured to be in the past and certainly no worse than his current rating." The examiner found agreement with the April 2007 VA examination. The examiner noted that he believed the Veteran's main problem had to do with bipolar disorder. He noted that the Veteran's nightmares were very infrequent, and his persistent avoidance symptoms included anger and irritability. The examiner also noted that the Veteran claimed to have problems in concentration, and hypervigilance "can be assumed." He diagnosed the Veteran with bipolar disorder (as his primary diagnosis) and PTSD. He also diagnosed the Veteran with antisocial personality disorder, and assigned an overall GAF score of 55. He noted that the Veteran's PTSD accounted for a GAF score no lower than 60. The examiner found that the Veteran's condition was no worse than it had been measured to be in the past and certainly no worse than his current rating. As an example, he noted that the Veteran only had nightmares about once every two months. In July 2011, the Veteran underwent another VA examination. The Veteran reported a severe problem with his temper and controlling his anger. He also reported having panic attacks on occasion. He denied frequent distressing dreams about the war, but he reported difficulty falling and staying asleep as well as difficulty concentrating and extreme hypervigilance symptoms. The Veteran's wife reported that the Veteran had a lot of acquaintances, but he was "pretty reclusive." The Veteran admitted to having one friend, but generally, his family was his only source of social support. On mental status examination, the Veteran was dressed casually, with good eye contact, grooming, hygiene, and posture. Psychomotor activity was normal. The Veteran was described as "cooperative though intense." Speech and communication were normal in rate, rhythm, tone, and volume. Thought processes were clear, logical, linear, coherent, and goal directed. Thought content was notable for intrusive memories. Behavior was appropriate, and there were no delusions or hallucinations noted and none reported. The Veteran's mood was dysphoric and anxious. The Veteran admitted to both suicidal and homicidal ideation. He was oriented to all spheres. Concentration was fair, and remote memory was intact, while recent memory showed some deficits. The Veteran's wife noted that the Veteran had a great deal of trouble finishing tasks when he was upset, having a difficult time thinking straight and processing information during these times. Social judgment and insight were considered to be fair. The examiner found that the Veteran's noted speech, communication, and thought processes showed no evidence of abnormalities that would be expected to interfere with either social or occupational functioning. The Veteran was able to attend to all activities of daily living independently without assistance, except when he's depressed and had difficulty getting out of bed. The examiner diagnosed the Veteran with severe, chronic PTSD, and assigned a GAF score of 45. The examiner noted that the Veteran's PTSD did seem to have worsened since his original diagnosis at his VA examination years ago, to the point that the Veteran regularly contends with both suicidal and homicidal impulses and has very severe problems with impulse control and anger. During periods of stress, his thinking deteriorated, and he had a difficult time thinking clearly and making good decisions. His wife described days where the Veteran was so depressed that she could not motivate him up out of bed. The examiner noted that although the Veteran was diagnosed with bipolar disorder during a previous VA examination, he found no evidence that any of his treating providers had ever diagnosed him with bipolar disorder, and he personally saw no evidence of bipolar disorder during the current examination. Finally, he noted that the Veteran's PTSD symptoms resulted in deficiencies in work, family relations, judgment, thinking, behavior, reaction, and mood. The paper and electronic claims file also contains substantial VA and Vet Center treatment records documenting complaints of symptoms similar to those reported in his VA examinations. In summary, the Veteran specifically complained of hypervigilance, hyperstartle response, isolative tendencies, intolerance, anger problems, and impaired impulse control. In August 2007, the Veteran was assigned a GAF score of 40. In October 2008, the Veteran reported to a treating psychiatrist that he had intermittent suicidal ideation, and stated that he was last suicidal a few months ago. He had never attempted suicide, and he stated he would not because he loved his family. In February 2009, the Veteran admitted to having a recent thought about shooting his wife and committing suicide, but denied any plan or intent. In March 2009, the Veteran's treating nurse practitioner and psychologist noted that the February 2009 VA examiner's diagnosis of bipolar disorder was incorrect. They explained that the Veteran's PTSD symptoms mimicked bipolar disorder symptoms, but that his whole symptom picture was consistent with a diagnosis of severe, chronic PTSD. This was supported further by the fact that the Veteran suffered severe combat exposure and had no family history of bipolar illness. A GAF score of 40 was assigned. In May 2009, the Veteran was, again, assigned a GAF score of 40. In July 2009, the same nurse practitioner found that the Veteran's severe and chronic PTSD significantly impaired his life, including with his ability to obtain or maintain gainful employment. A GAF score of 43 was assigned. In considering this case, the Board has also considered lay statements provided by the Veteran and his wife, including the testimony from the March 2013 Board hearing. The statements provided by the Veteran and his wife are consistent with the symptoms reported in treatment and at VA examinations, and include complaints of hypervigilance, homicidal and suicidal ideation, impaired impulse control, anger problems, and panic attacks. Collectively, the aforementioned medical evidence reflects that the Veteran's PTSD has been manifested by avoidance, hyperarousal, inability to maintain and establish effective relationships, difficulty in adapting to stressful circumstances, impaired impulse control, intrusive thoughts, anger control problems, and periodic suicidal ideation. A 70 percent rating is specifically supported by the findings of the July 2011 VA examination, as the psychologist diagnosed the Veteran with severe, chronic PTSD. The examiner additionally found that the Veteran's PTSD symptoms resulted in deficiencies in work, family relations, judgment, thinking, behavior, reaction, and mood. A 70 percent rating is also supported by the July 2009 VA treatment record, where the Veteran's impact of his symptoms on his life, including his ability to obtain and maintain gainful employment, was described as "significant." The VA treating psychiatrists, nurse practitioner, and counselors have assigned GAF scores as low as 40, which is indicative of major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood, and the VA examining psychologist assigned a GAF score of 45 in July 2011 indicative of serious impairment or serious impairment in social, occupational or school functioning. Taken together, the examination findings, the other mental health evidence of record, and the Veteran and his wife's reports, reasonably establish that the Veteran's symptoms result in occupational and social impairment with deficiencies in most areas to include work, family relations, other social relations, mood and judgment. In this case, the extent and severity of the Veteran's actual PTSD symptoms reported and/or shown throughout the record are suggestive of occupational and social impairment with deficiencies in most areas, including work, family relations, other social relations, mood and judgment-the level of impairment contemplated in the higher, 70 percent, rating. The Board notes that the July 2008 VA examination contained a higher GAF score (of 51) and an assessment that the Veteran was exhibiting moderate to severe symptoms of PTSD, which would appear to indicate less severe impairment than that associated with a 70 percent rating. At this examination, the examiner, however, found that the Veteran's PTSD symptoms were creating "significant difficulty" in both occupational and social settings, which tends to indicate that the Veteran's PTSD symptoms more nearly approximate a 70 percent rating. The Board also notes the comments provided by the February 2009 examiner, who found that the Veteran had a primary diagnosis of bipolar disorder, as well as a personality disorder. He provided a GAF score for the Veteran's PTSD of 60. On review of the examiner's comments, however, the Veteran's treating nurse practitioner and psychologist found that the examiner's diagnosis of bipolar disorder was in error. Instead, they explained that while the Veteran's severe PTSD symptoms may mimic bipolar disorder in some ways, the whole symptom picture was more consistent with severe, chronic PTSD. Notably, the July 2011 VA examiner also found that the Veteran had no symptoms of bipolar disorder. Thus, the Board affords less probative weight to the findings of the February 2009 VA examiner, as they contain a less accurate impression of the Veteran's symptomatology. While the medical evidence does not reflect such symptomatology 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, neglect of personal appearance and hygiene, and spatial disorientation, the Board emphasizes that the symptoms noted in the rating schedule 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 disability rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, although not all of the listed symptoms compatible with a 70 percent rating have been demonstrated in this case, the Board concludes that the type and degree of symptomatology contemplated for a 70 percent rating appear to be demonstrated. Given this, and resolving all reasonable doubt in the Veteran's favor (see 38 U.S.C.A. § 5107(b) and 38 C.F.R. §§ 3.102, 4.3), the Board finds that the criteria for an initial 70 percent rating for PTSD are met for the entire rating period on appeal The evidence, however, preponderates against finding that the Veteran's PTSD warrants a 100 percent rating as the Veteran's PTSD has not resulted in total occupational and social impairment. The Veteran has not ever suffered from symptoms of, or similar in severity to, gross impairment in thought processes, persistent delusions or hallucinations, grossly inappropriate behavior, intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Suicidal and homicidal ideation has been reported, but there has been no plan or intent. At his VA examinations and during treatment, the Veteran was consistently appropriately groomed, cooperative, alert, and fully oriented to person, place, and time. His attention and concentration were often intact. The Veteran has been fully able to perform activities of daily living. He also maintains good relationships with his family, including his wife, children, and grandchildren, and has several acquaintances. In treatment in October 2010, the Veteran reported that he and his wife threw a party for other veterans his therapy group. In a March 2011 VA treatment record, the Veteran reported enjoying family and some friends. There is no indication in the record that the Veteran's symptoms do more than create deficiencies in most areas, including family relations, work, and mood. While the Board fully recognizes that the Veteran does not need to meet all, most, or even some of the criteria set forth in Diagnostic Code 9411, the overall picture of his symptomatology is most nearly approximated by a 70 percent rating because he is not totally occupationally and socially impaired due to PTSD and other related psychiatric symptoms. Mauerhan, 16 Vet. App. at 442. Accordingly, for initial rating period on appeal, the evidence supports a finding that his impairment is best approximated by the criteria for the 70 percent rating, but no more. 38 C.F.R. § 4.130, Diagnostic Code 9411. As discussed above, the Board has also considered whether any staged rating of the disability is warranted. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Here, the Board finds that the Veteran's psychiatric symptoms have been consistent with the rating that has been assigned for the entire initial rating period on appeal. The record indicates increase in the Veteran's symptoms of PTSD during the entire appellate period, and these changes are reflected in the rating currently assigned. While the Board acknowledges that the VA examiner in July 2011 reported that the Veteran's PTSD symptomatology had increased since he was originally diagnosed with PTSD, the Board finds that this increase remained within the approximated criteria of a 70-percent evaluation. Accordingly, staged ratings are not warranted and the rating the Board has assigned is appropriate for the initial rating period here on appeal. The Board has also considered whether referral for an extraschedular rating is appropriate. As noted above, the Veteran's psychiatric symptoms primarily involve avoidance, hyperarousal, inability to maintain and establish effective relationships, difficulty in adapting to stressful circumstances, impaired impulse control, intrusive thoughts, anger control problems, and periodic suicidal ideation. Such impairment is specifically contemplated by the rating criteria. Hence, the rating criteria reasonably describe the Veteran's disability. In short, there is no indication in the record that the average industrial impairment from the Veteran's PTSD would be in excess of that contemplated by the rating assigned for the initial rating period. Indeed, the Veteran's occupational and social impairment in most areas is specifically contemplated by the rating criteria discussed above. Therefore, the Board finds that the Veteran's disability picture is not shown to be exceptional or unusual. Therefore, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). B. Evaluation of Peripheral Neuropathy Procedurally, the Veteran was initially granted service connection for peripheral neuropathy of the left and right upper extremities in a March 2009 rating decision. A noncompensable rating was assigned, effective October 20, 2008. In an April 2012 rating decision, the Veteran's evaluations were increased to 10 percent, effective July 18, 2011. The Veteran's left lower extremity peripheral neuropathy is currently evaluated under 38 C.F.R. § 4.124a, Diagnostic Code 8515. For the period prior to July 18, 2011, the next highest rating of 10 percent is assigned for mild incomplete paralysis of the median nerve. For the period from July 18, 2011, the next highest ratings of 20 percent (for the left upper extremity) and 30 percent (for the dominant right upper extremity) are assigned for moderate incomplete paralysis of the median nerve. Words such as "mild" and "moderate" are not defined in VA's Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." See 38 C.F.R. § 4.6 (2012). In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31 (2012). i. Rating Period Prior to July 18, 2011 After reviewing the medical and lay evidence of record, the Board finds that, for the rating period prior to July 18, 2011, the Veteran's right and left upper extremity peripheral neuropathy has met the criteria for a 10 percent rating outlined above. On February 2009 VA examination, the Veteran described experiencing numbness in his arms, which occasionally interfered with his sleep. He also complained of decreased strength in both hands. Neurological findings were completely intact except for decreased monofilament testing and vibratory sensation in the upper extremities. The Veteran did not have muscle atrophy or spasm. Deep tendon reflexes of the upper extremities were normal. The Veteran was diagnosed with peripheral neuropathy in the upper extremities, described as mild in severity. As such, the criteria for a rating of 10 percent have been met for left and right upper extremity peripheral neuropathy. Notably, the Veteran's upper extremity peripheral neuropathy was assessed as mild, due to his descriptions of decreased strength and numbness, as well as an objective finding of decreased monofilament testing and vibratory sensation in the upper extremities. The Veteran did not have any atrophy of the upper extremities or any other objective findings indicating moderate, or higher, peripheral neuropathy. In light of this evidence, the Board finds that the peripheral neuropathy does not more nearly approximate a moderate median nerve disability. In sum, the Board finds that the Veteran's left and right upper extremity peripheral neuropathy symptomatology are more nearly approximated by the criteria for a rating of 10 percent, but no higher, evaluation. ii. Rating Period from July 18, 2011 After reviewing the medical and lay evidence of record, the Board finds that, for the rating period from to July 18, 2011, the Veteran's left and right upper extremity peripheral neuropathy has not more nearly approximated the criteria for a 20 percent and 30 percent rating, respectively, as outlined above. Notably, July 2011 VA examination revealed only decreased vibratory sensation. The examiner also noted that the Veteran's upper extremity peripheral neuropathy symptomatology was the same as it was in 2009. The Veteran did not have any atrophy of the upper extremities or any other objective findings indicating moderate, or higher, radiculopathy. The Veteran was taking medication to alleviate the symptoms, which helped some. The examiner noted that the symptoms in his upper extremities were about the same as they were in 2009. Neurological testing revealed "fairly good" monofilament testing and pinprick sensation in the upper extremities. Vibratory sensation was decreased. The Veteran did not have muscle atrophy or spasm. The Veteran was diagnosed with peripheral neuropathy in the upper extremities. At his Board hearing, the Veteran testified that his hands felt like they were "on fire," and that he often dropped items due to numbness. See Board Hearing Tr. at 8-9. In sum, the Board finds that the Veteran's left and right upper extremity peripheral neuropathy symptomatology has not more nearly approximated a rating in excess of 10 percent for the initial rating period from July 18, 2011. iii. Both Rating Periods As indicated, the RO has already granted staged ratings for the Veteran's upper extremity peripheral neuropathy disability under consideration. In addition to the Board's consideration of the propriety of the rating assigned at each stage, as discussed above, the Board has also considered whether any further staged rating of the disability is warranted. See Fenderson, 12 Vet. App. at 126. Here, the Board finds that the Veteran's left and right upper extremity peripheral neuropathy symptoms have been consistent with the rating that has been assigned for the entire rating period on appeal. The record indicates that the Veteran's upper extremity peripheral neuropathy has remained consistent in severity during the entire appellate period, and this is reflected in the rating currently assigned. See, e.g., July 2011 VA examination report. Accordingly, further staged ratings are not warranted and the 10 percent rating assigned is appropriate for the respective periods here on appeal. The Board has also considered whether referral for extraschedular ratings is appropriate. As noted above, the Veteran's symptoms primarily involve numbness. Such impairment is specifically contemplated by the rating criteria. Hence, the rating criteria reasonably describe the Veteran's peripheral neuropathy of the upper extremities disability. In short, there is no indication in the record that the average industrial impairment from the Veteran's left and right upper extremity peripheral neuropathy would be in excess of that contemplated by the 10 percent rating; the Veteran's disability picture is not shown to be exceptional or unusual. Therefore, referral for assignment of an extraschedular evaluation in this case is not in order. Floyd v. Brown, 9 Vet. App. 88, 95 (1996); Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER An initial rating of 70 percent for PTSD is granted, subject to controlling regulations applicable to the payment of monetary benefits. Prior to July 18, 2011, an initial rating of 10 percent, but no more, is granted for peripheral neuropathy of the right upper extremity, subject to controlling regulations applicable to the payment of monetary benefits. From July 18, 2011, entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the right upper extremity is denied. Prior to July 18, 2011, an initial rating of 10 percent, but no more, is granted for peripheral neuropathy of the left upper extremity, subject to controlling regulations applicable to the payment of monetary benefits. From July 18, 2011, entitlement to an initial rating in excess of 10 percent for peripheral neuropathy of the left upper extremity is denied. REMAND The Veteran is claim GERD secondary to his service-connected diabetes mellitus, type II. The Veteran stated at the March 2013 Board hearing that he was not claiming GERD directly related to his active service. See Transcript at 5. For secondary service connection to be granted, generally there must be (1) medical evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In February 2009, the Veteran was afforded a VA examination in response to his claim of entitlement to service connection for GERD. On examination, the Veteran was diagnosed with GERD, and the examiner opined that it was less likely than not related to the Veteran's diabetes mellitus, type II. The examiner, however, failed to provide a rationale for his opinion. Furthermore, the examiner did not consider whether the Veteran's diabetes mellitus, type II was aggravating his GERD. The Court has held that when aggravation of a veteran's nonservice-connected disability is proximately due to or the result of a service-connected disease or injury, it too shall be service connected for that degree of aggravation. See Allen v. Brown, 7 Vet. App. 439, 446 (1995); see also 38 C.F.R. § 3.310; 71 Fed. Reg. 52744 -47 (Sept. 7, 2006). For these reasons, the Board finds that the opinion on record is inadequate. In reviewing service-connection claims where a VA examination has been performed, the Board must make a determination as to whether the examination report is adequate to make a decision on the claim notwithstanding the fact that the Board may not have found the examination necessary in the first place. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Therefore, the Board has determined that the Veteran should be afforded another VA examination to determine the etiology of his GERD. While on remand, ongoing medical records should also be obtained. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (finding that VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following actions: 1. Obtain updated VA treatment records from the Dallas VA Medical Center. If the records sought cannot be obtained, notify the Veteran and his representative of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 2. After the development in #1 has been completed, forward the Veteran's complete claims file to the same examiner who administered the February 2009 VA examination to determine the etiology of his GERD. The claims file, as well as any records contained in Virtual VA, should be made available to and be reviewed by the examiner in conjunction with the evaluation. After a full review of the record, the examiner should provide opinions on the following questions: (a.) Is it at least as likely as not (50 percent or greater) that GERD is causally related to the Veteran's service-connected diabetes mellitus, type II? (b.) Is it at least as likely as not (50 percent or greater) that GERD is aggravated beyond the normal course of the condition by his service-connected diabetes mellitus, type II? If this examiner is not available, the claims folder should be forwarded to another qualified medical practitioner. If deemed necessary, the Appellant should be scheduled for another appropriate examination. A report of the evaluation should be prepared and associated with the Veteran's VA claims file. A complete rationale must be provided for all opinions rendered. If the examiner cannot provide any of the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 3. The Veteran is hereby notified that it is his responsibility to report for a VA examination if ordered, and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 4. Thereafter, review the claims folder and ensure that the foregoing development actions, as well as any other development that may be in order, have been conducted and completed in full. The requested opinions should be reviewed to ensure that they are in compliance with the directives of this remand. If either opinion is deficient in any manner, implement corrective procedures at once. 5. Thereafter, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, provide the Veteran and his representative with a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before returning the case to the Board for further appellate 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). ______________________________________________ Paul Sorisio Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs