Citation Nr: 1319616 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 08-13 568 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cheyenne, Wyoming THE ISSUES 1. Entitlement to a higher initial rating for service-connected posttraumatic stress disorder (PTSD) in excess of 10 percent prior to November 4, 2010, and in excess of 50 percent from November 4, 2010. 2. Entitlement to a higher initial rating in excess of 20 percent for service-connected diabetes mellitus. 3. Entitlement to a higher initial rating in excess of 10 percent for service-connected residuals of a left leg fracture. 4. Entitlement to a total disability evaluation based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD T. M. Gillett, Counsel INTRODUCTION The Veteran had active service from August 1965 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office in Cheyenne, Wyoming (RO), which, in pertinent part, granted the Veteran's claim for service connection for diabetes mellitus and assigned an initial disability rating of 20 percent for the disability. This matter also comes before the Board on appeal from a December 2007 rating decision by the RO, which, in pertinent part, granted the Veteran's claim for service connection for PTSD and assigned an initial disability rating of 10 percent for the disability. This matter also comes before the Board, in part, on appeal from a January 2010 rating decision by the RO, which, in pertinent part, denied an application to reopen service connection for residuals of a left leg fracture, and entitlement to a TDIU. In July 2010, the Veteran testified at the RO at a hearing before a Veterans Law Judge, seated in Washington, DC, via videoconferencing (Board Videoconference hearing). A transcript is of record. In an October 2010 Decision and Remand, the Board granted an application to reopen service connection for residuals of a left leg fracture and granted the reopened claim for service connection. As the Board's October 2010 Decision fully granted the Veteran's claim on appeal, the issue of service connection for residuals of a left leg fracture is no longer in appellate status and is not before the Board. In a November 2011 rating decision, the RO assigned a 10 percent initial rating for service connection for residuals of a left leg fracture. In April 2012, the Veteran submitted a statement indicating that he experienced constant pain and a lack of flexion related to his service-connected residuals of a left leg fracture. The Veteran's April 2012 statement is a timely Notice of Disagreement (NOD), disagreeing with the initial 10 percent rating assigned for the service-connected residuals of a left leg fracture. The RO did not subsequently issue a Statement of the Case (SOC) regarding this issue. In an April 2013 brief, the Veteran stated that the RO's November 2011 assignment of a 10 percent initial rating for the Veteran's residuals of a service-connected left leg fracture was "clearly and unmistakably erroneous." However, as the Veteran filed an NOD, the November 2011 rating decision, assigning an initial rating of 10 percent for residuals of a left leg fracture, is not final. See 38 U.S.C.A. § 7105 (West 2002 & Supp. 2012). Therefore, any claim seeking the reversal or amendment of the November 2011 decision based upon a showing of clear and unmistakable error (CUE) is premature. See 38 C.F.R. § 3.105(a) (2012) (noting that claims based on CUE request the reversal or amendment of finalized VA decisions). Therefore, the issue of a higher initial rating in excess of 10 percent for residuals of a left leg fracture must be remanded for the issuance of an SOC. See Manlincon v. West, 12 Vet. App. 238 (1999). Thus, this issue has been listed on the title page of this decision. In the October 2010 Decision and Remand, the Board, in pertinent part, remanded the Veteran's claim for a higher initial rating in excess of 20 percent for service-connected diabetes mellitus to the Appeals Management Center (AMC) for further development. As will be discussed in the Remand section below, the AMC did not fully comply with the Board's October 2010 Remand instructions regarding the Veteran's claim for a higher initial rating for diabetes mellitus. Therefore, the Board remands the issue of a higher initial rating for diabetes mellitus for further development. Stegall v. West, 11 Vet. App. 268 (1998). In the October 2010 Remand, the Board also remanded the Veteran's claim for entitlement to a TDIU to the AMC for further development. As the issue of entitlement to a TDIU is inextricably intertwined with the respective claims for higher initial ratings for diabetes mellitus and residuals of a left leg fracture, the issue of entitlement to TDIU is not ready for review and will again be remanded for development. In the October 2010 Remand, the Board also remanded the issue of a higher initial rating in excess of 10 percent for PTSD to the AMC in Washington, DC, for additional development. Following the directed development, the AMC issued a November 2011 rating decision which, in pertinent part, granted a staged rating of 50 percent for PTSD, effective November 4, 2010. Thereafter, the case was returned to the Board for further appellate action. In the October 2010 Decision, the Board also denied the Veteran's claim for service connection for hypertension. The record contains no notation indicating that the Veteran filed an appeal of the Board's October 2010 decision with the U.S. Court of Appeals for Veterans Claims (Court), and the issue is no longer in appellate status and is not before the Board. In an October 2010 letter, the Veteran's spouse stated that the Veteran experienced hypertension related to service; and in April 2013, the Veteran through his representative stated that VA must readjudicate the Veteran's claim for service connection for hypertension. In her October 2010 statement, the Veteran's spouse wrote that the Veteran experienced a heart disorder, a sinus disorder, tooth and jaw disorders, and a prostate disorder, partly related to his service-connected diabetes mellitus and his currently nonservice-connected hypertension. In March 2013, the Veteran submitted a March 2013 VA Agent Orange Exposure examination report, in which a VA examiner wrote that it was her "feeling" that the Veteran had atrial fibrillation and chronic sinusitis related to Agent Orange exposure. In his April 2013 brief, the Veteran's representative wrote that VA should have granted service connection for tinnitus. In previous rating decisions, VA denied the Veteran's respective claims for service connection for ischemic heart disease, atrial fibrillation, a prostate disorder, and residuals of a jaw fracture. The recently-submitted statements are REFERRED to the RO for development. The Veterans Law Judge who conducted the July 2010 Board Videoconference hearing is no longer employed with the Board. In May 2013, the Board offered the Veteran an opportunity to testify at an additional Board hearing before a different Veterans Law Judge, in accordance with 38 C.F.R. § 20.717 (2012). In May 2013, the Veteran notified the Board that he did not wish to testify at an additional Board hearing. The Board will therefore proceed to review the issues on appeal. During the pendency of this appeal, the Veteran submitted additional evidence, in the form of VA treatment records. In June 2013, the Veteran's representative filed a written statement, waiving Agency of Original Jurisdiction (AOJ) review of the newly submitted evidence. The issues of higher initial ratings for diabetes mellitus and residuals of a left leg fracture, and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the AMC in Washington, DC. FINDINGS OF FACT 1. For the initial rating period from January 8, 2007 to November 4, 2010, the Veteran's PTSD was manifested by symptomatology more nearly approximating occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, and chronic sleep impairment. 2. For the initial rating period from January 8, 2007 to November 4, 2010, the Veteran's PTSD was not manifested by symptomatology more nearly approximating occupational and social impairment with reduced reliability and productivity due to such symptoms as 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; and difficulty in establishing and maintaining effective work and social relationships. 3. For the initial rating period from January 8, 2007 to November 4, 2010, the Veteran's PTSD was not manifested by symptomatology more nearly approximating occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. CONCLUSION OF LAW 1. For the initial rating period from January 8, 2007 to November 4, 2010, the criteria for an initial rating of 30 percent, but no greater, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code 9411 (2012). 2. For the initial rating period from January 8, 2007 to November 4, 2010, the criteria for a higher initial rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A.§§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Introductory Matters In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R."), and the precedential rulings of the United States Court of Appeals for the Federal Circuit (Federal Circuit) (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (Court) (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d) (West 2002 & Supp. 2012); see also 38 C.F.R. § 19.7 (2012) (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 ("VCAA") describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify a veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice must be provided to the veteran prior to the initial adjudication of his or her claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA satisfied its duty to notify the Veteran by issuing a notice letter in January 2007. In this notice letter, VA informed the Veteran about the information and evidence not of record that was necessary to substantiate the claim; the information and evidence that VA would seek to provide; and the information and evidence the Veteran was expected to provide. The claim arises from the Veteran's disagreement with an initial rating following the grant of service connection. Once service connection is granted, the claim is substantiated and additional VCAA notice is not required; any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The duty to assist provisions of the VCAA have been met. The claims file contains service treatment records, reports of post-service medical treatment, and reports of respective VA psychiatric examinations provided in October 2007, June 2009, and November 2010. In October 2010, the Board remanded the Veteran's claim to the AMC, requesting that the AMC provide a VA psychiatric examination to determine the current severity of the service-connected PTSD. In November 2010, the AMC provided a VA medical examination, performed by a qualified VA examiner. After a review of all evidence and a thorough mental examination, the VA examiner provided an opinion regarding the severity of the Veteran's PTSD, with references to the evidence reviewed. Therefore, the Board finds that the November 2010 VA medical examination report has probative value in this matter. See Prejean v. West, 13 Vet. App. 444, 448 (2000) (indicating that the Board may determine the probative value of medical opinions based on their detail, the persuasiveness of their opinions, and the physicians' access to a veteran's medical records). Therefore, the Board finds that the AMC complied with the Board's Remand directives. See Stegall, 11 Vet. App. at 268; Dyment v. West, 13 Vet. App. 141, 146-47 (1999). The Veteran has not made the RO or the Board aware of any additional evidence that must be obtained in order to fairly decide the appeal. He has been given ample opportunity to present evidence and argument in support of his claim. Pursuant to 38 C.F.R. § 3.655(2012), all relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. General due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). The Merits of the Case Disability ratings are determined by applying the criteria established in VA's Schedule for Rating Disabilities, which is based upon the average impairment of earning capacity. Individual disabilities are assigned separate Diagnostic Codes. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.20 (2012). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher evaluation is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Consideration must be given to increased evaluations under other potentially applicable Diagnostic Codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1. If there is disagreement with the initial rating assigned following a grant of service connection (i.e., a higher initial rating claim), separate ratings can be assigned for separate periods of time, based upon the facts found. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula for Mental Disorders, a 10 percent rating is warranted where the evidence shows occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. Id. A 30 percent rating is warranted where the evidence shows occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent evaluation is warranted where the evidence shows 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 evaluation is warranted where the evidence shows occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where the evidence shows total occupational and social impairment, with deficiencies such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. In adjudicating a claim for a higher disability rating, the VA adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. In this decision, the Board considered the rating criteria in the General Rating Formula for Mental Disorders not as an exhaustive list of symptoms, but as mere examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has considered the symptoms indicated in the rating criteria as examples or symptoms "like or similar to" the Veteran's PTSD symptoms in determining the appropriate schedular rating assignment, and, although noting which criteria have not been met, has not required the presence of a specified quantity of symptoms in the Rating Schedule to warrant the assigned rating for PTSD. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Global Assessment of Functioning (GAF) score is a scaled rating reflecting the psychological, social and occupational functioning on a hypothetical continuum of mental health-illness. Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994). See Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). A GAF of 71 to 80 is defined as a situation where "if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork)." A GAF of 61 to 70 is defined as "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 generally functioning pretty well, has some meaningful interpersonal relationships." A GAF of 51 to 60 is defined as "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers)." DSM-IV, at 32; Richard v. Brown, 9 Vet. App. 266, 267 (1996). The GAF score and interpretations of the score are important considerations in rating a psychiatric disability. 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. The GAF score must be considered in light of the actual symptoms of a Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, a veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused veteran's death). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert, 1 Vet. App. at 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board has considered all evidence of record as it bears on the question of a higher initial rating. See 38 U.S.C.A. § 7104(a) (West 2002 & Supp. 2012) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. From January 8, 2007 to November 4, 2010 The Veteran filed his claim of service connection for PTSD on January 8, 2007. For the period prior to November 4, 2010, the disability has been rated as being 10 percent disabling under Diagnostic Code 9411, using criteria found at the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. The Veteran essentially claims that, during that period, his PTSD symptomatology more nearly approximated that required for a higher rating under the rating criteria. The Board finds that the Veteran's PTSD symptomatology more nearly approximated the criteria required for a 30 percent rating under Diagnostic Code 9411. Specifically, for the period from January 8, 2007 to November 4, 2010, PTSD was manifested by symptoms more nearly approximating occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, and chronic sleep impairment. 38 C.F.R. § 4.130. In an April 2007 VA psychiatric evaluation, the Veteran stated that a VA examiner and a VA nurse told him that he should start looking into getting disability compensation for psychiatric symptoms. The Veteran reported experiencing flashbacks in the form of nightmares, rather than daytime flashbacks. The Veteran indicated that, soon after returning from Vietnam, he would choke his spouse in his sleep. The Veteran stated that this behavior occurred for three years until he learned to cope with it. The Veteran stated that his dreams about Vietnam at that time were so real that he would become active and run out of the house. The Veteran reported not being able to sleep much as he would toss and turn, and reawaken frequently. The Veteran indicated that the flashbacks had begun reoccurring since he broke his leg about 16 months prior to the interview. The Veteran indicated that the nightmares were particularly severe during a four-month period after the leg injury when he was using opiates. The Veteran indicated that he was able to function at work, had sufficient energy to complete tasks, and was able to concentrate. The Veteran stated that he did not feel hopeless and had not experienced suicidal ideation for many years. The Veteran reported that he did not like to be around Asians or African-Americans due to experiences during the war and a violent incident that occurred after his return to the States. The Veteran indicated that he was depressed or, at least, withdrawn. The Veteran stated that he tended to be at home rather than with others since he returned from Vietnam. The Veteran reported that had experienced chronic feelings of worthlessness, especially since he broke his leg. The Veteran indicated that he tended to avoid crowded places, such as Walmart. The Veteran stated that he startled easily, especially due to loud noises, and that hearing a helicopter at night would render him unable to sleep. The Veteran reported that he currently had three children after losing one 10 months prior to the interview. The Veteran indicated that he intended to return to work. The Veteran stated that he had worked as a coal miner for the previous 18 years and, prior to that job, he had worked in construction. The Veteran reported drinking heavily for three to four years after returning from Vietnam. The Veteran indicated that he practically quit drinking at the age of 40. The Veteran stated that he was now only consuming about one drink per month. After a mental examination, the April 2007 VA examiner diagnosed (Axis I) PTSD related to Vietnam in partial relapse, (Axis III) hypertension, diabetes mellitus type II, obesity in diabetes, atrial fibrillation, long term and current usage of anticoagulants, chronic sinusitis, elevated prostate specific antigen, hyperlipidemia, lower extremity fracture, (Axis IV) on workmen's compensation for lower extremity fracture, and (Axis V) GAF score of 65. In an October 2007 VA psychiatric examination report, the Veteran indicated that he had been drinking to excess partly to aid him in sleeping at night and partly due to the idle time he now experienced. The Veteran stated that he now drank a 12-pack of beer every other day. The Veteran reported sleeping about three hours per night. The Veteran stated that he still had difficulties being around African-Americans and Asians. The Veteran stated that his temper had worsened since he stopped working. The Veteran indicated that he had a short temper, especially for people who were late, and reported "cussing" at such individuals. The Veteran stated that he startled at loud noises. The Veteran indicated that he felt anxious around crowds and avoided them. The Veteran reported being unable to watch movies about warfare and being unable to enjoy conversations about combat. The Veteran indicated that he felt distant from others, including his wife. The Veteran indicated that he had worked consistently until he was laid off due to a leg injury in February 2006. However, the Veteran reported that his PTSD symptomatology did not interfere with his work. He stated that he attended church with his wife on a weekly basis. The Veteran indicated that he had a few friends, but also reported that he was not close to them. The Veteran stated that he had a daughter who lived across the street from him who had five children. The Veteran reported enjoying hunting and fishing, but indicated that he had not been able to hunt since his leg injury. The Veteran stated that he was fully competent with his activities of daily living, including bathing, dressing, grooming, and caring for himself. During a separate interview, the Veteran's spouse told the October 2007 VA examiner that the Veteran "rattled around" in his sleep. She also indicated that the Veteran attacked her in his sleep on occasion. The Veteran's spouse stated that the Veteran had a tendency to hang up on people and was increasingly "crabby" around others, to include his grandchildren. During a mental examination, the October 2007 VA examiner noted that the Veteran was casually and appropriately dressed. The VA examiner reported that the Veteran's communication skills were appropriate as the Veteran, for example, made good eye contact; however, the VA examiner also reported that there was a "definite sense of distance" in the Veteran's communications. The VA examiner noted that the Veteran had difficulty elaborating his symptomatology and problems in any detail, and required many questions before he would divulge information. The VA examiner wrote that the Veteran was mildly sad; and that the Veteran would demonstrate a greater range of facial expressions when describing a traumatic event. The VA examiner reported that the Veteran's voice was soft and that he spoke at a normal pace; his thought process was coherent and logical, without any loose associations, thought blocking, or derailment. The VA examiner reported that attention and concentration were normal throughout the interview. While the VA examiner indicated that he did not test the Veteran's short-term and long-term memory formally during the examination, he noted that the Veteran's recall appeared normal. The VA examiner reported finding no delusional ideation and indicated that the Veteran denied experiencing hallucinations. The VA examiner noted that the Veteran specifically denied having any suicidal ideation. The October 2007 VA examiner diagnosed (Axis I) chronic PTSD with recent exacerbation, episodic alcohol abuse, (Axis III) a history of a recent leg injury, cardiac problems, hypertension by history, diabetes mellitus type II by history, (Axis IV) leg injury, laid off from work, death of daughter, and (Axis V) GAF score of 65 for the current and previous year. The VA examiner noted the loss of the Veteran's occupation had apparently caused an increase in the Veteran's PTSD symptomatology, namely irritability, isolation, and increased frequency of nightmares. The VA examiner stated that, at that point, the evidence indicated that the Veteran's PTSD symptomatology was not severe enough to interfere with occupational functioning; however, the VA examiner also opined that the Veteran's PTSD symptomatology was severe enough to interfere with social functioning. In a June 2009 VA psychiatric examination report, the Veteran described his social life as being satisfactory but reported not associating with many other people. The Veteran indicated that he had few friends and described going to The American Legion hall where he had a few friends. The Veteran reported playing bingo in the evening and spending time with his wife. The Veteran indicated that his wife was not an outgoing person. The Veteran stated that he would drink 15 to 20 cans of beer per week. The Veteran reported that his most prevalent PTSD symptoms were nightmares and poor sleep. The Veteran described having flashbacks during which he believed that he was in Vietnam. The Veteran indicated that he did not have dreams until he underwent a sinus and uvula surgery approximately 10 years prior to the examination. The Veteran reported last attempting to choke his wife in her sleep in approximately 2006, but indicated that he had not done so since that time so he believed that he was getting better. The Veteran stated that he did not have patience with people. The Veteran described himself as being opinionated and prejudiced against Asians. He indicated that he once had taken medication for his PTSD, but had since stopped. He stated that since his last PTSD examination, his nightmares and drinking had increased, but his mood had not changed during that period. The Veteran indicated that he was too judgmental and too quick to pass opinions that were none of his business. The June 2009 VA examiner noted that the Veteran was alert, oriented to time, place and person; and cooperative. The VA examiner reported that the Veteran's speech was loud and at times abrupt. The VA examiner noted that the Veteran had no overt delusions, paranoia, or hallucinations and his insight and judgment were fair. The VA examiner diagnosed (Axis I) chronic PTSD, cyclothymia, alcohol dependence, (Axis III) a history of a recent leg injury, cardiac problems, hypertension by history, diabetes mellitus type II by history, and (Axis V) GAF score of 75. The VA examiner noted that while the Veteran had been diagnosed as having PTSD, the disability did not have an impact on his life. The VA examiner noted that the Veteran had a good marriage and that he was still working until he sustained a physical injury. The VA examiner indicated that the Veteran maintained social ties with friends at the American Legion hall. The VA examiner noted that the Veteran was not seen by a psychiatrist and have never mentioned his insomnia or PTSD symptomatology to a primary care physician. The VA examiner reported that cylcothymia was a very likely possibility, but that the condition did not have an impact on the Veteran's PTSD. The VA examiner found that the Veteran's mental disorder would not cause any difficulties either socially or with the Veteran's occupation. The VA examiner found that the Veteran's mental disorder symptomatology was not severe enough to require continuous medication. The June 2009 VA examiner diagnosed the Veteran as having chronic PTSD, cyclothymia, and alcohol dependence. The June 2009 VA examiner further stated that the cyclothymia disorder did not cause or affect the Veteran's PTSD, and stated that it "appeared" that the Veteran's alcohol dependence was related to his cyclothymia rather than his PTSD. The June 2009 VA examiner's finding, indicating an appearance of relationship between a diagnosed cylcothymia and the Veteran's alcohol addiction, is speculative and cannot establish such a relationship under VA regulations. See, e.g., 38 C.F.R. § 3.102 (2012) (stating that VA findings of service connection may not be based on a resort to speculation or even remote possibility). Moreover, reviewing the entire record of evidence under appeal, the evidence does not contain any other diagnosis for a cyclothymia disorder, casting some doubt on the probative value of the sole cyclothymia disorder diagnosis. See Owens v. Brown, 7 Vet. App. 429, 433 (1995) (finding that it was the Board's responsibility to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same). Finally, the Board notes that the June 2009 VA examiner did not differentiate between the psychiatric disorder symptomatology caused by the Veteran's service-connected PTSD and that caused by the diagnosed cyclothymia. The Board is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence that does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Therefore, in analyzing the severity of the Veteran's mental disorder symptoms, the Board cannot and will not attempt to discern what psychiatric disorder symptoms were attributable to the diagnosed PTSD and what was attributable to the diagnosed cyclothymia. In a November 2009 VA treatment record, the Veteran reported drinking about eight to 10 beers or more per day. The Veteran also indicated drinking whiskey occasionally. The Veteran stated that he would quit drinking at about eight P.M. and sleep fitfully at night, resulting in very little sleep. The Veteran indicated that his mood was depressed most of the time, and that he had been feeling anxious, possibly in response to his legal situation. For the period from January 8, 2007 to November 4, 2010, the Veteran's PTSD was manifested by symptomatology more nearly approximating the criteria for a 30 percent initial rating under Diagnostic Code 9411. Specifically, for that period, the Board finds that the Veteran's PTSD was manifested by symptomatology more nearly approximating occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, and chronic sleep impairment. See 38 C.F.R. § 4.130. For the period, the Veteran has reported experiencing depression and some degree of anxiety, as listed in the criteria for a 30 percent rating under Diagnostic Code 9411. See id. Moreover, throughout this record of evidence, the Veteran has described chronic sleep impairment, related to his PTSD, as listed in the criteria for the next higher 30 percent rating. See id. The Board notes that both the October 2007 and June 2009 VA examiners respectively indicated that the Veteran's psychiatric disorder symptomatology would not cause any difficulties with the Veteran's occupation. In the October 2007 VA psychiatric examination report, the October 2007 VA examiner opined that the Veteran's PTSD symptomatology was severe enough to interfere with social functioning; however, in the June 2009 VA psychiatric examination report, the June 2009 VA examiner found that the Veteran's PSTD symptomatology would not cause any social difficulties. Considering these findings, for the period prior to November 4, 2010, the Board finds that the Veteran's PTSD symptomatology more nearly approximates the mild social impairment contemplated by the criteria listed for a 30 percent rating under Diagnostic Code 9411. See id. For the period prior to November 4, 2010, the Board notes a variance in the GAF scores assigned by the respective VA examiners. The GAF scores have varied with the highest GAF score, assigned in the June 2009 VA psychiatric examination report, being 75, and the lowest, assigned in both the April 2007 VA psychiatric evaluation and the October 2007 VA psychiatric examination report, being 65. A GAF score of 65, the lowest assigned during the initial rating period, is considered to be consistent with mild symptoms with difficulty in social functioning, consistent with the symptomatology contemplated by a 30 percent rating. See id. For the period prior to November 4, 2010, the PTSD was not manifested by symptomatology more nearly approximating the criteria for a 50 percent initial rating under Diagnostic Code 9411. Specifically, for that period, the Board finds that the Veteran's PTSD was not manifested by symptomatology more nearly approximating occupational and social impairment with reduced reliability and productivity due to such symptoms as 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; and difficulty in establishing and maintaining effective work and social relationships. See id. In the October 2007 VA psychiatric examination report, the examiner reported that there was a "definite sense of distance" in the Veteran's communications. The October 2007 VA examiner also noted that the Veteran had difficulty elaborating his symptomatology and problems in any detail, and required many questions before he would divulge information. Subsequently, in the June 2009 VA psychiatric examination report, the examiner noted that the Veteran's speech was loud and at times abrupt. The Board notes that such notations, indicate some abnormalities in the Veteran's responses to the respective VA examiner's questions; however, such notations do not indicate PTSD symptomatology more nearly approximating the circumstantial, circumlocutory, or stereotyped speech listed in the criteria for a 50 percent rating. See id. For the period prior to November 4, 2010, the record of evidence contains no report indicating that the Veteran experienced difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); or impaired abstract thinking, all criteria required for a 50 percent rating under Diagnostic Code 9411. See id. For the period prior to November 4, 2010, the Board finds that the Veteran's PTSD symptomatology was not manifested by symptomatology more nearly approximating that which would cause difficulty in establishing and maintaining effective work and social relationships. As noted above, the October 2007 and June 2009 VA examiners, having reviewed the evidence of record, determined that the Veteran's PTSD symptomatology did not cause any difficulties with the Veteran's occupational functioning; however, in the October 2007 VA psychiatric examination report, the October 2007 VA examiner opined that the Veteran's PTSD symptomatology was severe enough to interfere with social functioning. Although the Veteran reported some difficulties with anger and patience, the evidence indicates that the Veteran has managed to maintain social relationships with his wife and family. Moreover, although the Veteran reported that he did not feel close to the few friends he had outside of his family, the record indicates that the Veteran was able to maintain those friendships. Therefore, for the period prior to November 4, 2010, the Board finds that the Veteran's PTSD symptomatology was not manifested by symptomatology more nearly approximating that which would cause difficulty in establishing and maintaining effective work and social relationships, as listed in the criteria for a 50 percent rating under Diagnostic Code 9411. See id. As noted above, the lowest GAF scores for the period prior to November 4, 2010, specifically GAF scores of 65, are consistent with the mild symptoms contemplated by a 30 percent rating, rather than the moderate symptomatology contemplated by a 50 percent rating, under Diagnostic Code 9411. See id. For the initial rating period prior to November 4, 2010, the Board finds that the disability picture for the Veteran's PTSD more nearly approximates that required for a 30 percent rating under Diagnostic Code 9411. See id. As the preponderance of the evidence is against the granting of a rating in excess of 30 percent for the period prior to November 4, 2010, the benefit of the doubt rule is not applicable as to that aspect of the Veteran's appeal. See 38 U.S.C.A. § 5107(b); Gilbert, at 54-56. From November 4, 2010 For the period from November 4, 2010, the Veteran's service-connected PTSD has been rated as being 50 percent disabling under Diagnostic Code 9411. The Veteran's PTSD symptomatology did not more nearly approximate that required for a next higher 70 percent rating under Diagnostic Code 9411. Specifically, for the period from November 4, 2010, PTSD was not manifested by symptoms more nearly approximating occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. See id. The evidence for the period from November 4, 2010 consists entirely of a November 2010 VA psychiatric examination report, written on the date in question. In the November 2010 VA psychiatric examination report, the Veteran reported taking medication for treatment of sleep problems related to his PTSD symptomatology. The Veteran reported drinking alcohol more heavily than he did four years prior to the interview. He stated that he usually drank every other night; however, the Veteran also stated that he would consume 18 to 20 beers every day for five or six consecutive days occasionally. However, the Veteran indicated that he was not alcohol-dependent and reported that he could "quit any time I want." The Veteran denied using drugs recreationally. The Veteran stated that the police had arrested him in the summer of 2009 for the crime of fraudulent gambling. The Veteran indicated that a court sentenced him to probation and that he had a couple of weeks left on his probation. The Veteran reported being married for about 40 years; that he had one daughter by his marriage, but that she had died about five years prior to the interview, possibly due to drug use. The Veteran indicated that he had three stepchildren through his wife, that he had been involved in their upbringing, and that he currently had good relationships with all three. The Veteran stated that he remained a member of the American Legion, but was ambivalent towards his membership. The Veteran reported having one or two close friendships, and a couple of friends with whom he passed time. The Veteran indicated attending church on a weekly basis. Regarding his activities and leisure pursuits, the Veteran reported gambling occasionally and playing cards with friends. The Veteran stated that he would become verbally aggressive, often when provoked by others, and that he had had experienced two or three such incidents within the previous month. The Veteran indicated that he was in an incident involving physical violence about two years ago, but did not offer further details. Upon mental examination, the November 2010 VA examiner noted that the Veteran was appropriately dressed in casual clothing. The VA examiner reported that the Veteran's psychomotor activity and speech were unremarkable and that the Veteran's attitude toward the examiner was cooperative, friendly, and relaxed, and that he did not behave inappropriately. The Veteran's affect was constricted, and his mood was good, but anxious. The VA examiner reported that the Veteran's attention and orientation were normal, and his thought process and thought content were unremarkable. The VA examiner noted no evidence of delusional thinking or hallucinations. The VA examiner indicated that the Veteran understood the outcome of his behavior and, at least partially, understood that he had a problem. The VA examiner noted that the Veteran experienced nightmares once or twice a week, and that he slept from two to five hours per night. The VA examiner reported that the Veteran did not have panic attacks, obsessive/ritualistic behavior, homicidal thoughts, or suicidal thoughts. The VA examiner indicated that the Veteran did not interpret proverbs appropriately, but did not offer further detail. The VA examiner reported that the Veteran's impulse control was fair and his memory was normal. The examiner noted that the Veteran experienced recurrent and intrusive distressing recollections of traumatic in-service events, including images, thoughts, or perceptions and recurring distressing dreams of the stressor events. The VA examiner indicated that the Veteran's report that he would sometimes act or feel as if the stressor events were recurring. The VA examiner also noted that the Veteran would experience intense psychological distress or physiological reactivity to exposure to internal or external cues that symbolized or resembled aspects of the traumatic events. The VA examiner noted that the Veteran experienced remarkably diminished interest in participating in significant activities; that the Veteran had reported feelings of detachment or estrangement from others, and a sense of a foreshortened future. The Veteran indicated that the Veteran experienced difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and an exaggerated startle response. The examiner diagnosed (Axis I) chronic PTSD, alcohol dependence, (Axis III) chronic medical issues, (Axis IV) ongoing medical complications, spouse diagnosed with cancer a couple of years prior to examination, and (Axis V) GAF score of 63. Regarding the Veteran's diagnosed alcohol dependence, the VA examiner noted that the Veteran's drinking changed after the Veteran became medically disabled in 2006, secondary to the workplace incident in which he broke his left leg. The examiner found that the Veteran's PTSD sign and symptoms were mild or transient, causing decreased work efficiency and an inability to perform occupational tasks only during periods of significant stress and that the Veteran was clearly coping with chronic PTSD symptomatology. The VA examiner noted that the Veteran's PTSD symptomatology would have a limited impact on his work overall as the Veteran had a good work history prior to leaving the workforce in 2006 due to medical disability. The examiner also reported that the Veteran's ongoing medical problems could stimulate an escalation of symptomatology which the Veteran reported were moderate to severe at the present time. The examiner also noted that the Veteran had a very limited treatment history and had no notable intention to seek further treatment; the Veteran had good relations with his family and meaningful social relationships. For the period after November 4, 2010, the preponderance of the evidence is against a finding that PTSD symptomatology met or nearly approximated that required for a next higher 70 percent rating, either explicitly under the examples under Diagnostic Code 9411 or as tantamount to these symptoms under Mittleider. See id. PTSD was not manifested by symptoms more nearly approximating occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. See id. There is no evidence in this period indicating suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; or neglect of personal appearance and hygiene, all criteria for the next higher 70 percent rating under Diagnostic Code 9411. See id. Impaired impulse control (such as unprovoked irritability with periods of violence) is listed in the criteria for a higher 70 percent rating. When asked if he had any episodes of violence, the Veteran reported becoming verbally aggressive, often when provoked by others, and stated that he had had experienced two or three such incidents within the previous month. The Veteran indicated that he was involved in an incident in which physical violence occurred about two years prior to the interview, but did not offer further details. While the record for the entire initial rating period indicates that the Veteran has experienced irritability, verbal aggression is not equivalent to violence. Moreover, the Veteran claims that he was aggressive verbally to people who provoked him. Such incidents are not indicative of the unprovoked irritability contemplated by the criteria listed for a 70 percent rating at Diagnostic Code 9411. The Veteran claims to have experienced a violent incident in approximately 2008. However, the record contains no other notations regarding it. The evidence does not indicate impaired impulse control with multiple episodes of violence. Therefore, for the rating period from November 2010, the Veteran's PTSD was not manifested by symptomatology more nearly approximating impaired impulse control (such as unprovoked irritability with periods of violence), as listed in the criteria for a 70 percent rating under Diagnostic Code 9411. See id. For this period, PTSD was also not manifested by symptomatology more nearly approximating that which would cause difficulty in adapting to stressful circumstances (including work or a worklike setting), or an inability to establish and maintain effective relationships. The November 2010 VA examiner reported that the Veteran's PTSD symptomatology would cause only decreased work efficiency and an inability to perform occupational tasks only during periods of significant stress. The VA examiner indicated that the Veteran's PTSD symptomatology would have a limited impact on his work overall as the Veteran had a good work history prior to leaving the workforce in 2006 due to medical disability and that the Veteran had good relations with his family and meaningful social relationships. While the November 2010 VA examiner observed the Veteran's PTSD symptomatology was moderate to severe, an examiner's description of the severity of a disorder is not dispositive of the Board's inquiry. The evidence of record for this period does not indicate the presence of the severe symptomatology contemplated by the next higher 70 percent rating under Diagnostic Code 9411, either under the specific examples under of the Diagnostic Code or similar symptoms. See id. and Mittleider. For the initial rating period from November 4, 2010, the disability picture for the Veteran's PTSD does not more nearly approximate a next higher 70 percent rating under Diagnostic Code 9411. See id. The preponderance of the evidence is against the claim so the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, at 54-56. Extraschedular Ratings The Board has considered whether referral for consideration of extraschedular ratings is warranted for the Veteran's PTSD. In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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 a veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe a veteran's disability level and symptomatology, then the veteran'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 a veteran's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the veteran'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) (stating that related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the Rating Schedule is inadequate to evaluate a veteran'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 the Compensation and Pension Service for completion of the third step, specifically a determination of whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Id. Regarding the Veteran's service-connected PTSD, turning to the first step of the extraschedular analysis, the impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria (38 C.F.R. § 4.130, Diagnostic Code 9411), and no referral for extraschedular consideration is required. The schedular rating criteria at Diagnostic Code 9411 specifically provides for disability ratings based on a combination of history, symptoms, and clinical findings. In this case, for the initial rating period under appeal prior to June 4, 2010, the Veteran's PTSD was manifested by symptomatology more nearly approximating occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, and chronic sleep impairment. For the rating period from November 4, 2010, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect and disturbances of motivation and mood. The schedular rating criteria specifically provide for ratings based upon occupational and social impairment related to cognitive disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. As the schedular evaluations contemplate the symptomatology of the Veteran's PTSD during the entire initial rating period, the Board need not determine whether there are exceptional disability pictures that exhibit other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1). In the absence of evidence that the schedular rating criteria are inadequate to rate the Veteran's PTSD, the Board is not required to remand this issue to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1). See also Bagwell v. Brown, 9 Vet. App. 237, 238-39 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER For the initial rating period from January 8, 2007 to November 4, 2010, an initial rating of 30 percent, but no greater, for PTSD is granted. For the initial rating period from November 4, 2010, a higher initial rating in excess of 50 percent for PTSD is denied. REMAND Additional development is required before the issues of respective higher initial ratings for diabetes mellitus and residuals of a left leg fracture, and entitlement to a TDIU are ready for appellate review. 38 C.F.R. § 19.9 (2012). The evidence indicates that the Veteran's diabetes mellitus may be causing a secondary neurological disorder, for which service connection could be granted, either on a secondary (causal) or aggravational (worsening) basis. In a December 2006 VA medical examination report, the Veteran reported experiencing numbness in the feet and hands, with onset beginning about 12 years prior to the examination. After an examination, the December 2006 VA examiner diagnosed peripheral neuropathy. After a review of the record, the December 2006 VA examiner opined that the Veteran's peripheral neuropathy was not caused by the Veteran's service-connected diabetes mellitus because the onset of the neuropathic disorder predated the 2000 onset of diabetes mellitus. In a November 2010 VA medical examination report, the Veteran was diagnosed as having peripheral neuropathy as a complication of diabetes. In explaining the opinion, the November 2010 VA examiner wrote "duration of the diabetes - this could be aggravated by his diabetes since it was noted in his records that he had peripheral neuropathy prior to being diagnosed with diabetes mellitus." (Italics added). In a December 2011 VA medical examination report, the examiner reported finding no evidence of any neuropathic disorder; however, the December 2011 VA examiner did not provide any report of what tests he ran in making that particular determination. In a November 2011 rating decision, the RO assigned a 10 percent initial rating for the residuals of the Veteran's left leg fracture. In April 2012, the Veteran indicated that he experienced constant pain and a lack of flexion related to his service-connected residuals of a left leg fracture. The Veteran's April 2012 statement is essentially a timely-filed notice of disagreement with the initial 10 percent rating assigned for the service-connected residuals of a left leg fracture. The RO did not subsequently issue an SOC regarding this issue. Therefore, the issue of a higher initial rating in excess of 10 percent for residuals of a left leg fracture must be remanded for the issuance of an SOC. See Manlincon, 12 Vet. App. 238. The evidence suggests that the Veteran has outstanding records with the SSA that provides disability benefits. In the December 2011 VA medical examination report, the Veteran indicated that he was in receipt of SSDI payments for his service-connected left leg disability. VA has an obligation to secure SSA records if there is a reasonable possibility that the records would help to substantiate the Veteran's claim. Golz, 590 F.3d at 1317. As the issue of entitlement to a TDIU is inextricably intertwined with the claims for higher initial ratings for diabetes mellitus and residuals of a left leg fracture, the issue of entitlement to a TDIU is not ripe for final appellate consideration. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO must ask the Veteran to identify the names, addresses, and approximate dates for all VA and non-VA health care providers who provided treatment for his diabetes mellitus and left leg disability. The AMC/RO must request release forms to allow the AMC/RO to acquire all treatment records not currently associated with the claims file. At a minimum, the AMC/RO must procure all VA treatment records dated since December 2011, the date of the last treatment record procured by VA for the claims file. The AMC/RO must attempt to obtain all records regarding the Veteran's application for private disability benefits from his employer for his left leg disability. The AMC/RO must request release forms to allow the AMC/RO to acquire all records regarding the private disability benefits, including any administrative decision(s) and the underlying medical records relied upon in making the decision(s). 2. The AMC/RO must contact SSA and obtain and associate with the claims file copies of the any records pertaining to the Veteran regarding any claim for SSA benefits, including any SSA administrative decision(s) (favorable or unfavorable) and the underlying medical records SSA relied upon in making its decision(s). 3. The AMC/RO must schedule the Veteran for a VA medical examination, provided by a qualified VA physician, to ascertain the current severity and manifestations of his service-connected diabetes mellitus. The claims file must be provided for the VA examiner's review prior to writing the examination report. The VA examiner must conduct all testing required, to include any neurological testing, and review the results of any testing prior to completion of the examination report. Although the examiner must conduct a review of the claims folder, the examiner's attention is called to the following evidence of record: a. In a December 2006 VA medical examination report, the Veteran reported experiencing numbness in the feet and hands, with onset beginning about 12 years prior to the examination. During an examination, the December 2006 VA examiner noted decreased sensation to monofilament and painful stimuli over both feet, and diagnosed peripheral neuropathy of unknown etiology. The VA examiner stated that the neuropathy disorder was not caused by diabetes mellitus as it predated the 2000 onset of diabetes. b. In a November 2010 VA medical examination report, a November 2010 VA examiner noted decreased sensation to vibration on the lower anterior legs, and decreased sensation to pinprick and light touch on the feet. The VA examiner diagnosed peripheral neuropathy as a complication of diabetes. In explaining the opinion, the November 2010 VA examiner wrote "duration of the diabetes - this could be aggravated by his diabetes since it was noted in his records that he had peripheral neuropathy prior to being diagnosed with diabetes mellitus." c. In a December 2011 VA medical examination report, the examiner reported finding no evidence of any neuropathic disorder, to include any related to diabetes mellitus; however, the December 2011 VA examiner did not provide any report of what tests he ran in making that particular determination. The VA examiner must provide a fully explained opinion as to whether any current neurological disorder (i.e. neuropathy) was caused or permanently worsened in severity by the service-connected diabetes mellitus or any medication prescribed for that disability. The VA examiner must also comment on the Veteran's current level of social and occupational impairment due to his service-connected diabetes mellitus. Any indications that the Veteran's complaints or other symptomatology are not in accord with the objective findings on examination must be directly addressed and discussed in the examination report. If no opinion can be rendered, an explanation must be set forth. If peripheral neuropathy is detected, the VA examiner must opine as to whether the Veteran's peripheral neuropathy disorder was either caused or permanently worsened by the Veteran's service-connected diabetes mellitus. If the VA examiner is unable to render the requested opinion without resort to speculation, he or she must so state. However, a complete explanation for such a finding must be provided, such as whether there is inadequate factual information, whether the question falls within the limits of current medical knowledge or scientific development, whether the cause of the condition in question is truly unknowable, and/or whether the question is so outside the norm of practice that it is impossible for the clinician to use his or her medical expertise and training to render an opinion. 4. After the above-listed development and any development deemed necessary by the AMC/RO, the AMC/RO must issue the Veteran an SOC, accompanied by notification of his appellate rights, which addresses the issue of entitlement to a higher initial rating for residuals of a left leg disorder. The Veteran must be advised that, for the Board to have jurisdiction in the matter, he must file a timely substantive appeal responding to the SOC. If the Veteran submits a timely substantive appeal, the matter must be returned to the Board for appellate review. 5. After completion of the above and all other necessary development, the AMC/RO must re-adjudicate the claims for an increased rating for diabetes mellitus and entitlement to a TDIU. If the benefits sought remain denied, the Veteran and the representative must be furnished a supplemental statement of the case, and must be given an opportunity to submit written or other argument in response before the claims file is returned to the Board for further appellate consideration. The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claims. See 38 C.F.R. § 3.655 (2012). The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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). ______________________________________________ VITO A. CLEMENTI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs