Citation Nr: 1319424 Decision Date: 06/14/13 Archive Date: 06/21/13 DOCKET NO. 99-05 234 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD), for purposes of accrued benefits. 2. Entitlement to a total disability rating based upon individual unemployability due to PTSD, for purposes of accrued benefits. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Mainelli, Counsel INTRODUCTION The Veteran served on active duty from January 1964 to March 1973. He died in April 2009. The appellant is his surviving spouse. This appeal to the Board of Veterans' Appeals (Board) arose from an October 1998 rating decision in which the RO denied a rating in excess of 50 percent for PTSD. The Veteran filed a notice of disagreement (NOD) in January 1999. A statement of the case (SOC) was issued in February 1999; and, the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in March 1999. In his substantive appeal, the Veteran requested a hearing before a Veterans Law Judge in Washington, D.C. Although notified that his hearing was scheduled for July 18, 2005, the Veteran failed to report for the scheduled hearing, and did not request rescheduling of the hearing. As such, his hearing request was been deemed withdrawn. See 38 C.F.R. § 20.702(d) (2012). In January 2001, June 2003 and November 2006, the Board remanded the claim on appeal to the RO, via the Appeals Management Center (AMC), in Washington, D.C., for additional development. After completing the requested action, the AMC continued to deny the claim (most recently, as reflected in a February 2008 supplemental SOC (SSOC)), and returned the matter to the Board for further appellate consideration. In June 2008, the Board denied a rating in excess of 50 percent for the PTSD. The Veteran, in turn, appealed the Board's June 2008 decision to the United States Court of Appeals for Veterans Claims (Court). In August 2009, the Court, having been notified that the Veteran had died in April 2009, granted a Motion to Dismiss due to the death of the Veteran. Subsequently, in September 2010, the Court granted a motion filed by the Veteran's surviving spouse to vacate the August 2009 dismissal and to substitute herself as an accrued benefits beneficiary for purposes of prosecuting the claim to completion. Thereafter, in January 2011, the Court granted the joint motion for remand (JMR) filed by representatives for both parties, vacating the Board's June 2008 decision, and remanding the claim to the Board for further proceedings consistent with the JMR. In June 2011 and December 2012, the Board remanded the claim to the RO, via the AMC, for additional development. After accomplishing further action, the AMC continued to deny the claim (as reflected, most recently, in a March 2013 SSOC), and returned the matter to the Board for further appellate consideration. A review of the Virtual VA electronic records storage system does not reveal any additional pertinent records not currently associated with the paper claims file. In written argument before the Board, the Veteran's representative has asserted that the Veteran was entitled to TDIU during his lifetime. As explained in more detail in the remand, below, the Board has now characterized the appeal as encompassing the matter of a TDIU as a component of the claim for higher rating for PTSD. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board has listed the TDIU issue due to PTSD as a separate claim for administrative purposes.. The Board's decision on the matter of a higher rating for PTSD is set forth below. The issue of entitlement to TDIU due to PTSD, for accrued benefits purposes is addressed in the remand following the order; this matter is being remanded to the RO, via the AMC VA will notify the appellant when action, on her part, is required. The Board notes that the issue of the appellant's entitlement to Dependency and Indemnity Compensation under the provisions of 38 U.S.C.A. § 1318 has been raised by the appellant's representative, but has not been adjudicated by the RO. As the Board does not have jurisdiction over this claim, and it is referred to the RO for appropriate action. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the matter herein decided has been accomplished. 2. For the entire period under consideration, the Veteran's PTSD more closely approximated occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking and mood, due to suicidal ideations with one apparent suicide attempt, impaired impulse control with unprovoked periods of verbal and physical abuse, neglect of personal appearance and hygiene, and partial inability to establish and maintain effective relationships. CONCLUSION OF LAW The criteria for a 70 percent rating for the Veteran's PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 -23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. In a claim for increase, the VCAA requires notice of 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. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting veteran-specific notice as to effect on daily life and as to the assigned or a cross-referenced DC under which the disability is rated). Here, the Veteran filed a claim for an increased rating prior to the passage of the VCAA in April 1998, which renders pre-adjudicatory VCAA compliance impossible. Due to the Veteran's death, the appellant has been substituted as the claimant to complete this appeal. In December 2012, the Board remanded this case to provide a compliant VCAA notice. A January 22, 2013 RO letter advised the appellant of the types of evidence needed to substantiate this claim which included evidence showing that the Veteran's service-connected PTSD had increased in severity before the time of his death, the respective duties upon herself and VA in obtaining evidence to substantiate the claim, and the criteria for establishing an effective date of award. Thus, VA has now provided content complying VCAA notice, and the timing deficiency was cured with readjudication of the claim in the March 2013 SSOC. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Board further observes that, during his lifetime, the Veteran was provided a VCAA letter on December 6, 2006 which advised him of the types of evidence needed to demonstrate that his PTSD had increased in severity, and the respective duties upon himself and VA in obtaining evidence to substantiate the claim. This included an advisement as to how VA determines disability ratings and effective dates of awards. On review of the record, the Board finds that no prejudicial error has occurred pertaining to the post-adjudicatory RO notice as the Veteran during his lifetime, and the appellant on appeal, have had a meaningful opportunity to participate effectively in the processing of this claim. Notably, the parties to the JMR did not allege any notice errors. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide this appeal as the timing error did not affect the essential fairness of the adjudication. VA has a duty to assist the claimant in the development of the claim. This duty includes assisting the claimant in the procurement of STRs and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. The RO has obtained the Veteran's STRs, relevant VA clinical records, and those private medical records which the Veteran and/or appellant has both identified and authorized VA to obtain on his/her behalf. The RO has also obtained medical and legal documents from the Social Security Administration (SSA). The Veteran has been afforded multiple VA examinations during the appeal period, and the reports of those examinations have been associated with the claims file. Important for this appeal, the record on appeal reflects that the Veteran's overall psychiatric pathology is the result of his service-connected PTSD as well as nonservice-connected schizophrenia, a 1979 head injury following a train derailment, residuals of meningioma excision, and a 2005 car accident. The Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). VA provided examinations in March 2001, April 2007 and November 2008 specifically for the purpose of delineating, to the extent possible, symptomatology attributable to service-connected PTSD. These examination reports reflect a thorough review of the complicated factual and medical history in this case. The November 2008 VA examination included a separate section which specifically focused on those symptoms which were attributable to service-connected PTSD. The Board finds that the November 2008 examination report provides a rationale for the conclusions reached to the extent that it is medically possible. The Board further finds that additional examination, which would be in the form of a claims file review only, is not necessary as any doubt as to symptomatology attributable to service-connected versus nonservice-connected origin will be resolved in the Veteran's favor. In the October 2012 Written Brief Presentation, the Veteran's representative argued that VA has adopted the standards of the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) which does not contain a protocol for assigning a percentum of disability to co-existing psychiatric disorders. It is argued that VA has no basis in law to separate the effects of a nonservice-connected psychiatric disorder from a service-connected disorder. It is also argued that VA's practice of attempting to differentiate the effects creates an institutional bias for VA examiners and places them in an unethical dilemma. The Board is bound by the law made applicable to it by statute, regulations, and the precedential decisions of the appellate courts. See 38 U.S.C.A. §§ 503, 7104 (West 2002). The Board notes that VA is only authorized to pay compensation for the effects of service-connected disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 3.4. See also 38 C.F.R. § 3.322 (when a preservice disability is aggravated, VA is only authorized to pay for the degree of disability over and above the degree existing at service entry). As such, the legal and ethical arguments presented by the Veteran's representative cannot supplant the Board's duty to implement the law as written. The Board is satisfied that the RO has substantially complied with the Board's prior remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). As directed by the Board in prior remands dated January 2001, June 2003, October 2005, November 2006, June 2011 and December 2012, the RO secured additional VA treatment records, afforded the Veteran and the appellant the opportunity to submit any additional evidence pertinent to the claims, arranged for the Veteran to undergo VA examination, and provided the appellant VCAA notice. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran during his lifetime, and the appellant as a substitute claimant, have been notified and made aware of the evidence needed to substantiate the claim, the avenues through which evidence might be obtained, and the allocation of responsibilities between the claimants and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the claimant or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Applicable law The appellant claims that the Veteran's PTSD should have been rated higher than 50 percent disabling from April 1997 to the time of his death. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. 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 the residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 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. This appeal stems from a claim for an increased rating for service-connected PTSD filed in April 1998. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may also be assigned for separate periods of time based on the facts found. 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. See generally 38 U.S.C.A. § 5110(b)(2). Consistent with Hart, the parties to the JMR state that the appeal period in question extends to April 1997. The 50 percent rating for the Veteran's PTSD has been assigned pursuant to DC 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. 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. 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. 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. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the 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 actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Under DSM-IV, GAF scores ranging from 61 to 70 are assigned when there are some mild symptoms (e.g., depressed mood and mild insomnia), or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging from 41 to 50 are assigned when there are serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging from 31 to 40 are assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b). The Board also observes that the words "slight," "moderate" and "severe" are not defined in the 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." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. The claimant bears the burden of presenting and supporting his/her claim for benefits. 38 U.S.C.A. § 5107(a). See Fagan v. Shinseki, 573 F.3d 1282 (Fed. Cir. 2009). In its evaluation, the Board shall consider all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board shall give the benefit of the doubt to the claimant. Id. Another way stated, VA has an equipoise standard akin to the rule in baseball that "the tie goes to the runner." Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The benefit of the doubt doctrine is not applicable based on pure speculation or remote possibility. See 38 C.F.R. § 3.102. A layperson is competent to provide testimony concerning factual matters of which he or she has firsthand knowledge (i.e., reporting something seen, sensed or experienced). Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Under certain circumstances, lay statements may serve to support a benefits claim by supporting the occurrence of lay-observable events or the presence of disability, or symptoms of disability, susceptible of lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In Barr, the Court emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of the presence or absence of the claimed symptomatology. However, there are clearly limitations regarding the competence of a lay claimant to speak to certain matters, such as those involving medical diagnosis and etiology. See Jandreau, 492 F.3d at 1377 (Fed. Cir. 2007) (noting that a layperson not competent to diagnose a form of cancer). VA has defined competent lay evidence as any evidence not requiring that the proponent have specialized education, training or experience. 38 C.F.R. § 3.159(a)(1). Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a layperson. Id. Further, competent medical evidence is defined as evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements or opinions. 38 C.F.R. § 3.159(a)(2). III. Analysis A. Mittleider Concerns At the outset, the Board notes that the contents of the Veteran's paper claims file are in chronological disarray - apparently as a result of the claims file being copied for Court review in the prior proceedings. Based upon review of prior RO rating actions and Board decisions, it appears that the record is nonetheless complete. As noted above, the Board has been presented with a record on appeal which indicates that the Veteran's overall psychiatric pathology is the result of his service-connected PTSD as well as non service-connected schizophrenia, a 1979 head injury following a train derailment, residuals of meningioma excision, and a 2005 car accident. The Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. See Mittleider, 11 Vet. App. at 182. The Board has conducted a longitudinal review of the record to delineate, to the extent possible, the service-connected and nonservice-connected symptomatology. Historically, the Veteran served on active duty from January 1964 to March 1973. In February 1979, he was involved in a train derailment resulting in a brief period of unconsciousness. He subsequent underwent surgical removal of a left frontal meningioma followed by symptoms of seizures, decreased memory and self-described "nervous spells." Thereafter, the Veteran had a history of psychiatric hospitalizations in August 1980, December 1980, August 1987, September 1988, May 1990, May 1991, July 1992, September 1992, November 1992, December 1993, August 1994, and October 1994. His various symptoms included suspiciousness, paranoia, disorientation, delusions with impaired ability for self-care, hostility, anger, vigilance, hyperalertness, overreaction, depression with suicidal ideations and forgetfulness, feelings of utter hopelessness and despair, anxiety, nightmares with sleep disturbance, hallucinations, crying spells, episodes of violence and verbal abusiveness, social withdrawal, assaultive agitation, marital discord, and substance abuse. The initial private evaluations provided diagnoses such as paranoid reaction secondary to organic brain syndrome secondary to brain injury, seizure disorder secondary to brain injury, paranoid type schizophrenia and dementia secondary to head trauma. In a November 1980 clinic report, a psychiatric described the Veteran as very depressed to the point of being suicidal, and being very forgetful. He demonstrated feelings of utter hopelessness and despair. It was felt that the Veteran was not employable due to the extremely poor memory, epilepsy, severe head pain, suicidal thoughts, and feelings of hopelessness. A December 1980 private neuropsychiatric evaluation described the Veteran as being barely able to direct and control his own activities with practically no general comprehension skills related to world around him. Following a neuropsychiatric evaluation, it was felt that 3 factors had contributed to the Veteran's level of dysfunction: 1) the high level of medication which dulled his responses and concentration; 2) the moderate brain damage suffered in the railroad accident which severely depressed functioning skills such as visual motor activities, memory skills, and coordination tasks; and 3) the severity of his acute depression. A May 1981 SSA decision found the Veteran as being unemployable effective June 1980. The primary diagnoses were mild mental deficiency, chronic brain syndrome associated with brain trauma, and psychoneurotic and depressive reaction. A March 1983 VA physician statement provided the following opinion: [The Veteran] has been treated in this clinic for Schizophrenia, Paranoid Type, Dementia Secondary to head trauma. He has been totally disabled since February 1979. He can work to a limited degree and pursue his education as a barber while the disability exists. A May 1986 VA Compensation and Pension (C&P) neuropsychiatric examination reflected the Veteran's history of hostility, nightmares with fear of going to sleep, nervousness, paranoia, fearfulness, delusions, hallucinations, daily intrusive thoughts of Vietnam, hyperalertness, startle response, survivor guilt, marked loss f libido, depression, intermittent homicidal thoughts, anxiety and crying spells. Psychiatric examination reflected an assessment that the Veteran was grossly impaired. The examiner felt that it was difficult to determine from the paucity of available records between service and 1980 as to whether the Veteran had been symptomatic with PTSD. The examiner indicated that the Veteran had an organic brain syndrome secondary to brain tumor and injury with psychotic process. The examiner felt that it was possible that the Veteran had a delayed PTSD which had been set off by the lack of frontal lobe cerebral control from the brain tumor and surgery. The examiner offered an assessment that, in addition to consideration of a paranoid schizophrenic illness, the Veteran appeared to have fairly severe symptomatology compatible with PTSD which was barely in minimal remission. The Veteran was hospitalized at VA from August 1987 to September 1987 due to symptoms of flashbacks and nightmares causing him to become violent, irritable and abusive at home. He also had been experiencing episodes of irritability, crying spells, withdrawal, insomnia and auditory hallucinations. The Veteran was given discharge diagnoses of chronic, paranoid schizophrenia and PTSD with depression. It was noted that the Veteran was deemed unable to work due to his mental illness. Thereafter, hospitalizations at Charter Westbrook Hospital in September 1988, November 1992, and October 1994, as well as at VA in May 1990, May 1991, September 1992, revealed concurrent diagnoses of PTSD and schizophrenia. On April 1991 hospitalization at St. Mary's Hospital, resulting from consuming approximately 50 barbituate tablets, the diagnosis was acute depression. The report of a December 1993 hospitalization at Charter Westbrook Hospital reflects a single diagnosis of an acute exacerbation of paranoid schizophrenia while an August 1994 hospitalization reflected diagnoses of paranoid schizophrenia and polysubstance abuse. Notably, a January 1993 letter from a physician at Charter Westbrook Hospital reported that the Veteran had been an inpatient from October 21, 1992 to November 11, 1992 due to ongoing psychiatric problems associated with PTSD. The Veteran underwent VA C&P examination in June 1996. The Veteran endorsed symptoms of paranoia, sleep difficulties with dreams reliving being blown up in a bunker, startleability, social isolation, flashbacks, hypervigilance, irritability, auditory hallucinations and a history of suicide attempts. On interview, the Veteran did not want to go into detail about his Vietnam experience but he became tearful with difficulty controlling his tears when he mentioned Caisson. The examiner found that the Veteran appeared to have continuing symptoms of a psychotic illness with some delusional constructs. Other than distress evoked when talking about Vietnam, the Veteran appeared to be without too much distress during the interview. The examiner diagnosed paranoid type schizophrenia and PTSD, which appeared to be co-existing. The Veteran was not regarded as employable. Based upon review of the claims file, a March 2001 VA C&P examiner delineated to the extent possible the symptoms attributable to service-connected PTSD and nonservice-connected psychiatric disorders. This examiner attributed symptoms such as intrusive thoughts, nightmares, flashbacks, emotional agitation, and anger dyscontrol to PTSD. It was opined that the Veteran's symptoms of auditory hallucinations, poor hygiene, poor motivation, inappropriate behavior and difficulty interpreting the motivation of others appeared more related to schizophrenia. However, the extent of examination was limited as the Veteran's "horrendous" hygiene precluded personality testing and cognitive screening. On April 2007 VA C&P examination, which included review of the claims file, the examiner found that the Veteran's nonservice-connected head injury affected his emotional control, which had the potential for decreasing his ability to manage his PTSD symptoms. It was also noted that the Veteran was demonstrating anxiety and depression related to his medical condition. On November 2008 VA C&P examination, which also included review of the claims file, the examiner delineated to the extent possible the symptoms attributable to service-connected PTSD and nonservice-connected psychiatric disorders. This examiner found that the prior diagnosis of schizophrenia was incorrect and may stem from problems mimicking schizophrenia related to executive functioning deficits associated with brain injury. It was further noted that it was not clear whether the Veteran's verbal and aggressive anger outbursts were related to PTSD, or other aspects of character shaped by an executive functioning decline associated with brain injury. It was stated that the Veteran's temper problems could not be clearly related to paranoia. The November 1998 VA examiner found that the Veteran demonstrated genuine distress and a meaningful level of anger related to his Vietnam experiences. Here, the report of the March 2001 VA examination contains clear opinion that the Veteran's auditory hallucinations were attributable to schizophrenia, which is congruent with a January 2008 VA record which also attributed auditory hallucinations to the Veteran's schizophrenia. With the exception of the Veteran's auditory hallucinations, the medical evidence does not successfully differentiate between symptomatology associated with the Veteran's PTSD and that resulting from his nonservice-connected psychiatric disabilities. The Board will therefore attribute the Veteran's auditory hallucinations to his schizophrenia, and all other psychiatric symptoms will be attributed to the Veteran's service-connected PTSD. B. Current appeal period Considering the pertinent evidence of record in light of the above, the Board finds that the criteria for a 70 percent rating have been met for the entire appeal period. In general, during the appeal period, the Veteran manifested PTSD symptoms such as recurrent nightmares, flashbacks and intrusive recollections of Vietnam, avoidance behavior, unprovoked irritability and anger outbursts, hypervigilance, exaggerated startle response, social isolation, impaired concentration, memory difficulty, suicidal ideations, panic attacks, depression, neglect of personal hygiene, impairment of affect and mood, anxiety, poor appetite, and forgetfulness. The record prior to the appeal period reflects the Veteran's history as early as 1980 of depression to the point of being suicidal. He was hospitalized in 1991 due to a drug overdose. He filed the increased rating claim on appeal in April 1998 which extends to April 1997 for compensation purposes. See Hart, supra. In June 1997, the Veteran was hospitalized due to an overdose of Tegretol. In a March 1999 statement, the Veteran's spouse reported that the Veteran "constantly talks of suicide." A February 2004 statement from the Veteran described suicidal ideations. The Veteran's spouse again reported the Veteran as being suicidal in December 2011. On the other hand, the Veteran denied having suicidal ideation, intent or plan on VA C&P examinations in 2001 and 2007. At the April 2007 VA examination, the Veteran stated that he had suicidal thoughts in the past but "that was years ago." Overall, the Board finds that the Veteran demonstrated some suicidal ideations, including one apparent attempted overdose, during the appeal period which, under the General Rating Formula, is listed as an example supporting a 70 percent rating. The record on appeal reflects that a strong feature of the Veteran's psychiatric impairment involved impaired impulse control with unprovoked periods of verbal and physical abuse. The Veteran was hospitalized, in part, for aggressive behavior in 1987, 1988, 1992 and 1993. In 1992, the Veteran had pulled a knife on his son. In March 1999, the appellant described the Veteran as demonstrating violence towards others. In February 2001, a private examiner described the Veteran as having occasional aggression and verbal abuse. In March 2001, the Veteran's spouse described emotionally disturbed behavior with minimally or unprovoked anger and aggressive behavior. VA nursing records in 2006 reference the Veteran's verbally abusive behavior. In October 2007, the Veteran was committed by the Richmond Behavioral Health Authority to VA due to decompensation. The Veteran had been described as having increased aggressiveness over the past two weeks which included verbal threats of harm, chasing his spouse with a motorized scooter, stabbing her with a screwdriver, and throwing around lit cigarettes. A November 2008 VA clinic record described the Veteran as being very loud, cursing, demanding and ramming into the walls with his wheelchair. On VA C&P examination in November 2008, the Veteran's spouse described him as being violent and aggressive. In December 2011, the appellant described instances where the Veteran threatened her with a pair of scissors and attempted to run her over with a wheelchair. Overall, the Board finds that the Veteran demonstrated impaired impulse control with unprovoked verbal abuse and physical violence which, under the General Rating Formula, is listed as an example supporting a 70 percent rating. The record next reflects that the Veteran displayed the trait of neglect of personal appearance and hygiene. In a March 1999 statement, the Veteran's spouse reported that the Veteran constantly needed to be reminded of his hygiene. A February 2001 physician statement noted that the Veteran appeared disheveled. On VA examination in March 2001, the VA examiner described the Veteran as being poorly groomed and smelling "horrendously." A February 2006 VA clinic record included the appellant's report that the Veteran refused to eat, drink or cooperate with his care. A February 2007 VA nursing note noted that the Veteran appeared disheveled, and commented that it was not unlike his baseline. Thus, the Board finds that the Veteran demonstrated neglect of personal hygiene during the appeal period which, under the General Rating Formula, is listed as an example supporting a 70 percent rating. The record also demonstrates that the Veteran demonstrated some inability to establish and maintain effective relationships. The Veteran was socially isolated with no outside friends or interests. He verbally and physically abused his family members. In February 2004, the Veteran described being estranged from his maternal family. A November 2008 VA examiner found that the Veteran was unable to manage the social interaction demands of almost any employment setting at his level of functioning. However, the Veteran had been married to his wife for over 40 years, and a December 2007 treatment record also indicated that the Veteran's daughter has remained in contact and assisted with his care. Thus, the Board finds that the Veteran demonstrated some aspects of an inability to establish and maintain effective relationships during the appeal period which, under the General Rating Formula, is listed as an example supporting a 70 percent rating. Collectively, the aforementioned lay and medical evidence reflects that, during the appeal period, the Veteran's PTSD more closely approximated occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking and mood, due to suicidal ideations with one apparent suicide attempt, impaired impulse control with unprovoked periods of verbal and physical abuse, neglect of personal appearance and hygiene, and partial inability to establish and maintain effective relationships. Thus, the Veteran's PTSD resulted in a level of occupational and social impairment which more closely approximated a 70 percent disability rating under the General Rating Formula. To this extent, the appeal is granted. However, the Board finds that the Veteran's PTSD did not meet, or more closely approximate, the criteria for a 100 percent rating under the General Rating Formula. The Board finds that the Veteran did not manifest gross impairment of thought processes or communication, which is listed as an example supporting a 100 percent schedular rating. A February 2001 private psychiatrist letter described the Veteran as demonstrating, inter alia, slow and flighty speech, fixed delusions, sporadic hallucinations, paranoia and suspiciousness. VA nursing records in November 2007 also described the Veteran as sometimes appearing confused with memory loss, forgetfulness and poor problem solving. On the other hand, VA C&P examination in August 1998 described the Veteran as being able to give all data consistent with a person of average intelligence. On VA C&P examination in March 2001, the Veteran's speech was described as clear, goal-directed and normally paced although the Veteran made little effort to provide information or interact spontaneously. A September 2002 VA neurology consultation described the Veteran has having a normal fund of knowledge with clear and fluent speech. VA nursing records in April and May 2006 described the Veteran as having complete dependence of verbal and non-verbal communication, and modified independence in comprehension and problem solving. A July 2008 VA clinic record described the Veteran as having an organized thought process. On VA examination in November 2008, the Veteran's speech was described as clear and goal-directed. Overall, the Board finds that the Veteran did not manifest gross impairment of thought processes or communication during the appeal period. Another example supporting a 100 percent rating under the General Rating Formula includes persistent delusions. There are reports of delusional thoughts in February 2001, possible hallucinations in January and April 2008 as well as September 2008. As held above, the Board has found that the Veteran's auditory hallucinations are not a feature of his service-connected PTSD. In any event, the Veteran's clinical records, lay statements and VA C&P examination reports in August 1998, March 2001, April 2007 and November 2008 found no delusional thoughts. Overall, the Board finds that the Veteran did not manifest "persistent" delusions during the appeal period. Another factor listed as an example supporting a 100 percent rating consists of grossly inappropriate behavior. The Veteran has, at times, been described being verbally aggressive to his family and VA nursing staff. He threatened physical harm to his spouse with scissors and attempting to run her over with a wheelchair. A March 2001 VA C&P examination report referred to inappropriate sexual behavior without any further details provided. Thus, the Board finds that the Veteran did demonstrate some aspects of grossly inappropriate behavior. Another factor listed as an example supporting a 100 percent rating consists of being a persistent danger of hurting self or others. As described above, the Veteran had one inpatient admission in July 1997 due to a drug overdose. He was committed for hospitalization in October 2007 due to behavior which included verbal threats of harm and physical threats of harm to his spouse by chasing her with a scooter, stabbing her with a screwdriver, and throwing around lit cigarettes. The appellant has described fear of the Veteran awakening from a dream and hitting her. During a VA examination in November 2008, the appellant described being afraid of the Veteran with her children begging her to leave the home. However, the extent of the Veteran's threat of harm to himself and others was not "persistent." The Veteran did not consistently report suicidal ideations, and had denied suicidal ideations during VA C&P examinations in March 2001, April 2007 and November 2008. In April 2007, the Veteran referred to his suicidal thoughts as being "years ago." The Veteran's nursing notes since 2005 reflect several notations that the Veteran had no episodes of agitation or disorientation wherein he was a threat to himself. Overall, the Board finds that the Veteran did not manifest a "persistent" threat to himself or others as contemplated by the criteria for a 100 percent rating under the General Formula of Rating. The record does demonstrate that the Veteran had an intermittent ability to perform activities of daily living, including the maintenance of minimal personal hygiene. The Veteran's tetraplegia clearly was a factor in his ability for self-care, but the records also reflected that the Veteran refused to cooperate in his care. At times, the Veteran refused to eat and, as discussed above, he did not always maintain minimal personal hygiene. With respect to orientation, a February 2001 private physician statement described the Veteran as partially oriented. However, the remainder of the records consistently described the Veteran as being oriented to time and place. See VA examination reports dated August 1998, March 2001, April 2007 and November 2008; VA clinic records dated May 2002, June 2002, September 2002, and July 2008. As such, the Board finds that the Veteran did not demonstrate disorientation to time or place which is an example supporting a 100 percent rating under the General Formula for Rating. Finally, at times, the Veteran was described as having memory problems. See January 1999 private psychiatrist letter. This was described as "mild" in degree by a February 2001 physician statement. A February 2007 VA nursing record described the Veteran as being forgetful while records in November 2007 described the Veteran as having short-term memory loss, forgetfulness and poor problem solving. On the other hand, a September 2002 VA neurology consultation described the Veteran as having normal recent and remote memories, concentration and fund of knowledge. Additionally, the Veteran's clinical records and VA examination reports in 1998, 2001, 2007 and 2008, as well as the lay descriptions, do not suggest that the Veteran ever demonstrated memory loss for names of close relatives, his occupational status or his own name. In April 2007, the Veteran was reported as being able to recall a number of mental health providers from 18 to 20 years previous. As such, the Board finds that the Veteran did not demonstrate memory loss for names of close relatives, his occupational status or his own name which is another example supporting a 100 percent rating under the General Formula for Rating. The Board also considers the GAF scores assigned during the time period, which include scores of 60 (VA C&P examination report dated August 1998), 40-45 with 50-55 for the prior year (January 1999 private psychiatrist letter), 45 (VA C&P examination report dated March 2001), 55 with 55-50 for the prior year (March 2003 private examination report), 55 (VA clinic record dated July 2006), 40 (VA discharge summary dated October 2007), 55 (VA examination dated April 2007), 45 (VA clinic record dated August 2008), and 50 (VA C&P examination report dated November 2008). There is one GAF score of 40-45 in 1999 and another of 40 in October 2007 after a period of commitment due to aggressive behavior. Otherwise, the Veteran's GAF scores have more generally ranged from 45-55 which represents symptoms intermediate between serious and moderate in degree. Overall, the GAF scores demonstrate some residual occupational and social capacity which is not consistent with a finding of "total" occupational and social impairment required for a 100 percent schedular rating under the General Formula for Rating. Otherwise, a private examiner in March 2003 described the Veteran as manifesting "moderate" paranoid schizophrenia, a February 2007 VA clinician described the Veteran as having significant cognitive impairment and multiple behavioral problems and an August 2008 VA examiner described "serious" symptoms of PTSD. The Board also observes that there have been several opinions regarding employability. As discussed above, a May 1981 SSA determination found the Veteran unemployable due to mild mental deficiency, chronic brain syndrome associated with brain trauma, and psychoneurotic reaction and depressive reaction. In March 1983, a VA physician found the Veteran totally disabled based upon diagnoses of paranoid schizophrenia and dementia secondary to head trauma. VA hospitalization records in 1987 found that the Veteran was unable to work due to paranoid schizophrenia and PTSD. In June 1996, a VA C&P examiner found that the Veteran was not employable due to co-existing diagnoses of paranoid-type schizophrenia and PTSD. In 1999, a private psychiatrist reported that the Veteran was disabled "due to his multiple and severe psychiat[ri]c problems." In November 2008, a VA C&P examiner stated that the Veteran was not medically able to manage the demands of almost any employment. As required by Maeurhan, the Board must look at all the factors and evidence identified above to determine whether the Veteran met or more closely approximated the criteria for a higher 100 percent rating for any time during the appeal period. When considering the overall evaluation of the examples which may support the 100 percent rating, the frequency, duration and severity of symptoms, the Veteran's capacity for adjustment, and the examiner assessments of the Veteran's overall psychological, social and occupational functioning (GAF scores), the Board is of the opinion that the Veteran's PTSD did not meet or more closely approximate the criteria for a 100 percent rating for any time during the appeal period. While the Veteran demonstrated some aspects of examples supporting a 100 percent schedular rating, the Board is of the opinion that the lay and medical evidence did not demonstrate "total" occupational and social impairment due to PTSD for any time during the appeal period. Here, the Veteran's GAF scores demonstrated some residual occupational and social capacity. His thought process, communication skills, orientation and memory remained largely intact. His lapses in engaging in inappropriate behavior, being a danger of hurting himself or others, and intermittent ability to perform activities of daily living were not so pervasive or persistent to render him totally disabled from a social or occupational standpoint. Notably, the Veteran and the appellant still maintained a relationship with his spouse and daughter until the time of his death. Additionally, the employability opinions considered the effects of service-connected and nonservice-connected psychiatric disability. Notably, a finding of unemployability does not necessarily demonstrate "total" occupational and social impairment as defined in the rating schedule. In so holding, the Board has generally found the statements and testimony of the Veteran and his spouse to be truthful and credible evidence in support of this claim, which has been relied upon in awarding further compensation. However, even when taking into account this testimony, the Board finds that the criteria for a rating greater than 70 percent for any time during the appeal period have not been met. To the extent that the descriptions of the Veteran and his spouse can be construed as supporting higher ratings still, the Board places greater probative weight to the clinical findings of the private and VA physicians who have greater expertise and training than the Veteran and his spouse in evaluating the extent and severity of a psychiatric disability-even while recognizing that the spouse appeared to have some type of nursing training. On these facts, the Board also finds no basis for a staged rating, pursuant to Hart. In this respect, the Board acknowledges the opinion from the November 2008 VA examiner that there appeared to be some evidence of an increase in the Veteran's PTSD since his prior VA examination. The Board has applied the approximating principles of 38 C.F.R. § 4.7 in awarding a 70 percent rating for the entire period pertinent to this appeal, which contemplates that the Veteran did not meet all the criteria for a 70 percent rating during the appeal period - e.g., impairment of speech, impaired abstract thinking, the capacity for adjustment during remissions, etc. Regardless of any increased severity of symptoms during the appeal period, the Board has found that the symptomatology as a whole has not met the criteria for a 100 percent schedular rating at any time during the period under consideration The above determinations are based upon consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point pertinent to the period under consideration did the Veteran's PTSD reflect so exceptional or so unusual a picture as render inadequate the schedular criteria for rating the disability and to warrant the assignment of the maximum, 100 percent rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b). To accord justice in an exceptional case where the scheduler standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extra-schedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1). The provisions of 38 C.F.R. § 3.321(b) state as follows: Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service- connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. In Thun v. Peake, 22 Vet. App. 111 (2008), the Court clarified the analytical steps necessary to determine whether referral for extra-schedular consideration is warranted. The Court stated that the RO or the Board must first determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extra-schedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extra-schedular rating. Id. VA's General Counsel has stated that consideration of an extra-schedular rating under 3.321(b)(1) is only warranted where there is evidence that the disability picture presented by the Veteran would, in that average case, produce impairment of earning capacity beyond that reflected in the rating schedule or where evidence shows that the Veteran's service-connected disability affects employability in ways not contemplated by the rating schedule. See VAOPGCPREC 6-96 (Aug. 16, 1996). In Thun, the Court further explained that the actual wages earned by a particular veteran are not considered relevant in the calculation of the average impairment of earning capacity for a disability, and contemplate that veterans receiving benefits may experience a greater or lesser impairment of earning capacity than average for their disability. The Thun Court indicated that extra-schedular consideration cannot be used to undo the approximate nature of the rating system created by Congress. The Board is precluded by regulation from assigning an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance. However, the Board is not precluded from raising this question, see Floyd v. Brown, 9 Vet. App. 88 (1996), and addressing referral where circumstances are presented which the Director of VA's Compensation and Pension Service might consider exceptional or unusual. Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The issue at hand involved the appropriate disability rating for service-connected PTSD. The disability ratings assigned are based on rating criteria which provide examples of the types of impairment expected of the particular disability level, but the rating analysis takes into account all factors which contribute to social and industrial impairment. Mauerhan, 16 Vet. App. 436 (2002). In adjudicating this case, the Board has considered all aspects of disability attributable to service-connected PTSD which also included use of the approximately principles of 38 C.F.R. § 4.7 to award further compensation. In the opinion of the Board, the currently assigned disability rating reasonably describes the Veteran's disability level and symptomatology for the entire appeal period. Notably, a higher schedular rating is available but the Board has determined that those criteria have not been met. Thus, there is no basis for extra-schedular referral at this time. For all for the foregoing reasons, the Board finds that, for criteria for a 70 percent, but no higher rating for the Veteran's PTSD, for accrued benefits purposes, are met. In reaching the conclusion to award a 70 percent rating, the Board has favorably applied the benefit-of-the-doubt doctrine, but finds that the preponderance of the evidence is against assignment of the maximum, 100 percent rating at any pertinent point. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A 70 percent rating for PTSD, for accrued benefits purposes, is granted, subject to the legal authority . REMAND The Board's review of the claims file reveals that further RO action in this appeal is warranted. During argument before the Board, the Veteran's representative argued that the Veteran's unemployability was due to service-connected PTSD. A claim for a TDIU may be a component of the claim for a higher rating for a service-connected disability. See Rice, 22 Vet. App. 447 (2009). See also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001) (holding that where a veteran submits evidence of a medical disability; makes a claim for the highest rating possible; and submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a TDIU). In the above decision, the Board awarded a 70 percent schedular rating for PTSD which renders the Veteran eligible for consideration of a schedular TDIU pursuant to 38 C.F.R. § 4.16(a). In light of the above, the RO should adjudicate the matter of the Veteran's entitlement to a TDIU due to PTSD in the first instance, to avoid prejudice to the appellant. See e.g. Bernard v. Brown, Vet. App. 384 (1993). Prior to adjudicating the TDIU claim remaining on appeal, to ensure that all due process requirements are met, the RO should also give the appellant opportunity to provide additional information and/or evidence pertinent to the claim on appeal. The RO's letter to the appellant should explain that she has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1) (West 2002); but see also 38 U.S.C.A. § 5103(b)(3) (West Supp. 2012) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). The RO's letter should also specifically explain how to establish entitlement to a TDIU due to service-connected PTSD. Thereafter, the RO should attempt to obtain any additional evidence for which the appellant provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159 (2012). After all additional evidence is obtained, if any, the Board finds that medical opinion is necessary to decide the TDIU claim due to PTSD. See 38 U.S.C.A. § 5103A(a). The record on appeal includes opinions that the Veteran's service-connected PTSD and nonservice-connected schizophrenia and residuals of brain trauma caused his unemployability. The Board requires medical opinion as to whether the Veteran's PTSD, when considered alone, rendered him unable to obtain and maintain substantially gainful employment at any point from April 1997 claim for increased rating up to the date of the Veteran's death. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). However, identification of specific actions requested on remand does not relieve the RO of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the RO should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claim for TDIU due PTSD, for accrued benefits purposes. Accordingly, this matter is hereby REMANDED for the following action: 1. Furnish to the appellant and her representative a letter requesting that she provide information and, if necessary, authorization, to enable it to obtain any additional evidence pertinent to the claim remaining on appeal that is not currently of record. Specifically explain how to establish entitlement to a TDIU due to service-connected PTSD. Clearly explain to the appellant that she has a full one-year period to respond (although VA may decide the claims within the one-year period). 2. If the appellant responds, obtain all identified outstanding pertinent records of evaluation and/or treatment not currently of record, following the procedures set forth in 38 C.F.R. § 3.159 (2012). All records and responses received should be associated with the claims file. If any records sought are not obtained, notify the appellant and her representative of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 3. After all records and/or responses received from each contacted entity have been associated with the claims file, the RO forward the Veteran's claims file for review by an appropriate physician, at a VA medical facility. A complete copy of the claims file, to include a complete copy of this REMAND must be made available to the physician designated to review this claims file, and the report of examination should include discussion of the Veteran's documented medical history and his and the appellant's assertions. The physician should be advised that the Veteran is service-connected for PTSD, and that his symptomatology of auditory hallucinations is deemed of nonservice-connected origin. Then with respect to the PTSD only, the physician should provide an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., there is a 50 percent or greater probability) that the Veteran's service-connected PTSD rendered him unable to obtain and maintain substantially gainful employment for any time since April 1997. In rendering the requested opinion, the physician should specifically consider and discuss all pertinent in- and post-service records (including the Veteran's SSA records), the effects of medications prescribed to treat PTSD on the Veteran's employability, and the lay assertions of record. The physician examiner should set forth complete rationale for the conclusions reached in a printed (typewritten) report. 4. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 5. After completing the requested action, and any additional notification and/or development deemed warranted, adjudicate the matter remaining on appeal in light of all pertinent evidence and legal authority. 6. If the benefit sought on appeal is denied, furnish to the appellant and her representative an appropriate supplemental statement of the case that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefit requested should be granted or denied. The appellant need take no action until otherwise notified, but she may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); Colon v. Brown, 9 Vet. App. 104, 108 (1996); Booth v. Brown, 8 Vet. App. 109 (1995); Quarles v. Derwinski, 3 Vet. App. 129, 141 (1992). This REMAND must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs