Citation Nr: 1319860 Decision Date: 06/20/13 Archive Date: 07/02/13 DOCKET NO. 09-29 615 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for erectile dysfunction. 2. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to September 15, 2011. 3. Entitlement to an initial disability rating in excess of 70 percent for PTSD from September 15, 2011. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D.S. Lee, Counsel INTRODUCTION The Veteran served on active duty from August 2005 through November 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which denied the Veteran's claims for service connection for PTSD and erectile dysfunction. A timely Notice of Disagreement (NOD) as to those issues was received in May 2008. After a Statement of the Case was issued in June 2009, the Veteran perfected his appeal in August 2009, via VA Form 9 substantive appeal. In a January 2010 disability rating, the RO granted service connection for PTSD, effective from November 5, 2006, and assigned a 50 percent initial disability rating. In a June 2010 submission, the Veteran expressed his ongoing disagreement with the assigned initial disability rating. After receipt of additional evidence, the RO granted a 70 percent disability rating for the Veteran's PTSD, effective from September 15, 2011. The Veteran has not expressed satisfaction with the assigned disability ratings for his service-connected PTSD. As such, the Board presumes that the Veteran is seeking the maximum available benefit for his PTSD and maintains jurisdiction over the issues concerning the disability ratings assigned for the Veteran's PTSD. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35, 38 (1993). This appeal also initially included the issues of entitlement to service connection for left knee pain, temperomandibular joint disorder, cervicalgia, low back pain, myopia, bilateral hearing loss, diarrhea, skin disorder, and cephalgia. Although appeal as to those disabilities was initially preserved by the Veteran's May 2008 NOD, the Veteran has not filed a substantive appeal as to the issues of service connection for cervicalgia, low back pain, myopia, bilateral hearing loss, diarrhea, skin disorder, and cephalgia. In November 2011, the Veteran withdrew his appeal as to the issues of service connection for left knee pain and temperomandibular joint disorder. Accordingly, those issues do not remain before the Board on appeal. The issue of the Veteran's entitlement to service connection for erectile dysfunction is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to September 15, 2011, the Veteran's PTSD was manifested by symptoms consistent with occupational and social impairment with reduced reliability and productivity; occupational and social impairment with deficiencies in most areas is not shown during this period 2. For the period from September 15, 2011, the Veteran's PTSD more closely approximates deficiencies in most areas than reduced reliability and productivity; total occupational and social impairment as a result of PTSD is not shown. CONCLUSIONS OF LAW 1. The criteria for an initial disability in excess of 50 percent for PTSD, prior to September 15, 2011, have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an initial disability rating in excess of 70 percent for PTSD, for the period from September 15, 2011, have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010) and 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 the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1) , proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. Such notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Insofar as the issues concerning the Veteran's entitlement to higher initial disability ratings for his service-connected PTSD, a pre-rating August 2007 letter provided the Veteran with notice of the information and evidence needed to substantiate his claim for service connection for PTSD. This letter included notice of the process in which VA assigns disability evaluations and effective dates. This notification would also apply to the "downstream" issue of entitlement to a higher initial disability rating for PTSD. In that regard, the United States Court of Appeals for Veterans Claims (Court) has held that once service connection is granted, the claim is substantiated. In such instances, additional VCAA notice is not required and any defect in the notice is not deemed prejudicial to the Veteran. Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007); Dingess, 19 Vet. App. at 491. Thus, because the VCAA notice that was provided before service connection for PTSD was granted was legally sufficient, VA's duty to notify in this case has been satisfied. In addition, VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claims. His service treatment records, claims submissions, lay statements, identified and relevant private treatment records, VA treatment records, and social security records have been obtained and associated with the record. VA examinations of the Veteran's PTSD were conducted in October 2007, November 2009, and November 2011. Moreover, VA has not received any additional evidence since that time which indicates that the Veteran's condition has changed such as to warrant the scheduling of a new VA examination to reassess the symptoms and severity of his PTSD. Hence, these examinations, along with the other evidence of record, are fully adequate for the purposes of determining the extent of the Veteran's disability in light of the applicable diagnostic criteria. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Higher Disability Ratings Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations applies, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Moreover, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. The relevant 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). In instances where the rating being appealed is the initial disability rating assigned with a grant of service connection, the entire appeal period is for consideration, and again, staged ratings may be assigned as warranted, based upon the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. §§ 3.102, 4.3. Once the evidence is assembled, the Board is responsible for determining whether the preponderance of the evidence is against the claim. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). For all periods relevant to this appeal, the Veteran's PTSD has been rated in accordance with 38 C.F.R. § 4.130, DC 9411, which provided the rating criteria specifically for PTSD and requires that PTSD be rated under the General Rating Formula for Mental Disorders (General Formula). Under the General Formula, a 50 percent disability rating encompasses PTSD that is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as a 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; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is appropriate for PTSD that is manifested by 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 that is 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); or the inability to establish and maintain effective relationships. A 100 percent disability evaluation is granted where PTSD is productive of total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting himself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; or memory loss for the names of close relatives, own occupation, or own name. A. Initial Disability Rating Higher than 50 Percent for PTSD, Prior to September 15, 2011 As discussed above, service connection for PTSD was established by the RO, effective from November 5, 2006. For the period from November 5, 2006 through September 14, 2011, the Veteran's PTSD has been rated as being 50 percent disabling. Upon review and consideration of the evidence of record, the Board finds that the criteria for an initial disability rating higher than 50 percent for PTSD during the staged period identified above, have not been met, either on a schedular or extraschedular basis. VA treatment records show that the Veteran initially sought psychiatric treatment in March 2007. During the initial intake interview, he reported an array of symptoms which included anxiety; depression; mood swings; problems with anger; sleeping problems marked by nightmares and difficulty falling asleep; confusion; racing and intrusive thoughts; fatigue; changes in appetite and loss of 25 pounds; loss of motivation; difficulty getting along with others marked by marital problems; constant worry; having his feelings hurt easily; inability to express himself; being suspicious of others; loneliness; stress; and a desire to avoid others. The Veteran reported that he had previously taken medications including Prozac (for depression), Ambien (for sleep difficulty), Trazadone (for sleep difficulty), and Ritalin (for pre-service ADD). During the mental status examination the Veteran demonstrated a disheveled appearance and was tearful and visibly upset. He was also hyper-alert and confused; dysthymic; anxious; and demonstrated a fearful affect. The Veteran was agitated and restless. His short-term memory was mildly impaired. The Veteran was oriented to person, place, and time, and demonstrated logical, goal-directed, pressured, and productive speech. Demonstrated insight, judgment, and intelligence were average. There was no evidence of homicidal or suicidal ideation. A multi-axis diagnosis included Axis I diagnoses of depression, attention deficit disorder, and PTSD. A Global Assessment of Functioning (GAF) score of 60 was assessed. During a follow-up VA evaluation and treatment later that month, the Veteran reported similar symptomatology to that noted above. Occupationally, he reported that he was working in an audio/video store and that he was enrolled in school to become an industrial electrician. He also reported that he maintained custody and care for his two year old son. A mental status examination performed at that time revealed that the Veteran was alert, cooperative, fairly dressed, and groomed. Demonstrated affect at that time was appropriate, although mood was anxious and depressed. Once again, there was no evidence of suicidal or homicidal ideation, paranoia, hallucinations, or delusions. The Veteran remained oriented to person, time, and place and his speech remained clear, coherent, goal-directed, and rational with normal rate and volume. Subsequent VA treatment records from August through September of 2007 reflect essentially unchanged symptomatology. The Board notes, however, that the Veteran was reporting increased irritability. During treatment in September 2007, he reported pervasive anxiety, frustration, and anger marked by a desire to hit something. A GAF score of 50 was assigned at that time. During an October 2007 VA examination, the Veteran reported that his nightmares and flashbacks were occurring four to five times per week. He also reported frequent nervousness and depression; panic; poor concentration; irritability; frequent trouble falling and staying asleep; feelings of guilt; anger; and isolation. He stated that he avoided crowds and noises, as well as war movies and activities or situations that aroused recollections of his combat experiences. During the mental status examination, the Veteran answered questions and was coherent and relevant. Thought processes were intact and the Veteran was able to communicate. His demonstrated mood was nervous and depressed with reported panic symptoms from time to time. Demonstrated affect was constricted. The Veteran denied having any hallucinations or homicidal or suicidal thoughts. His orientation and memory were preserved, and Insight and judgment were intact. The examiner did not observe any inappropriate behavior and stated that he was able to perform activities of daily living. Overall, the examiner characterized the Veteran's PTSD as being "moderate to severe" and assessed the Veteran's GAF score as falling within the range of 50 to 60. Although the Veteran reported that he was unemployed, this appeared to be attributable to a recent work-related accident in which he fractured his wrist and forearm after falling from a roof while working as a carpenter. Subsequent treatment records through August 2009 demonstrate periodic changes in the Veteran's symptomatology. During VA treatment in January 2008, the Veteran reported that he was having terrifying nightmares on a nightly basis. A GAF score of 50 was assigned. During a mental status examination performed in April 2008, the Veteran cried and continued to demonstrate sad, tense, and frustrated mood. During treatment in February 2009, the Veteran reported that he was having racing thoughts and that he was unable to concentrate. In March 2009, the Veteran reported ongoing anger and was noted by his treating physician as being intense and complaining in the office. An improved GAF score of 57 was assessed at that time. In July 2009, the Veteran continued to report the symptoms noted previously and added that he was having daily crying spells, was easily angered, and had the sense that he "can't do anything right." Still, he indicated some degree of social functioning, as he identified "protective factors" which included his children and fiancée and stated that he had become actively involved with his church and that he was recently baptized. During an August 2009 evaluation, the Veteran reported ongoing crying episodes and endorsed memory problems marked by constant forgetfulness and forgetting what he is supposed to do. A mental status examination at that time revealed that the Veteran was casually attired and demonstrated fair grooming and hygiene. The Veteran was alert and oriented, however, demonstrated a labile mood. The Veteran became more teary as the interview continued. A GAF score of 50 was assessed. In November 2009, the Veteran was afforded a new VA examination to reassess his PTSD. During mental status examination, the Veteran presented as casually but appropriately dressed; demonstrated a cooperative attitude toward the examiner; normal speech and psychomotor activity; constricted affect; mood that was grossly within normal limits; oriented to person, time, and place; able to spell backward and forward, but inability to perform serial seven exercises; unremarkable thought content and process; no evidence of delusions; normal insight and judgment marked by awareness of his problem and an ability to understand the outcome of his behavior; normal memory; and no evidence of homicidal ideation. He continued to report sleep impairment that was marked by difficulty attaining sleep and nightmares that occurred once or twice per week; inappropriate behavior marked by impatience, irritability, and deficits with anger management; inability to interpret proverbs; panic attacks when being among crowds. For the first time in the record, he reported suicidal ideation, albeit fleeting and without specific plan. The Veteran also reported persistent re-experiencing of in-service traumatic events, marked by recurrent and intrusive distressing recollections; recurrent dreams; acting or feeling as though the traumatic event was recurring; intense psychological distress at exposure to external and internal cues that symbolize or resemble an aspect of the traumatic event; and physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. He also reported persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness marked by efforts to avoid thoughts, feelings or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; and restricted range of affect. Also reported persistent symptoms of increased arousal, which include difficulty falling or staying asleep, irritability and outbursts of anger; difficulty concentrating; hypervigilance; and exaggerated startle response. Overall, the examiner determined that the Veteran was capable of maintaining minimum personal hygiene and remained independent in his activities of daily living. An improved GAF score of 67 was assessed. Records obtained from the Social Security Administration (SSA) include VA treatment records which pertain to psychiatric treatment received by the Veteran in 2010. Overall, these records continue to reflect the same symptomatology as that noted above. January 2010 records show that the Veteran was taking Temazepam to manage his ongoing sleep problems. Occupationally, he reported that he was working a swing shift at a yarn manufacturing factory. A GAF score of 45 was assigned. During treatment in February 2010, the Veteran indicated that he was attending school. A GAF score of 50 was assessed. In September 2010, the Veteran indicated that he was still attending technical school three days a week and that he spent the rest of his time with his son. He reported that he previously medicated with Zoloft, Effexor, Depakote, and Prazosin and that he was currently taking Seroquel, which makes him groggy in the mornings and unable to concentrate during classes. A GAF score of 55 was assigned. During a December 2010 treatment, the Veteran reported that he had gotten into a fight the night before. During this treatment, the Veteran was tearful and stated that he was unable to control his anger and that he was unable to sleep due to ongoing nightmares. During a mental status examination performed during VA treatment in March 2011, the Veteran demonstrated a normal appearance and appropriate behavior. There was no evidence of abnormal involuntary movements, psychomotor retardation, or hyperactivity. Demonstrated speech was logical, clear, and relevant. There was also no evidence of any overt suicidal or homicidal ideation or active perceptual distortions. The Veteran was able to think abstractly and his demonstrated mood was mildly anxious with congruent affect. The Veteran was oriented to person, place, and time and he demonstrated attention, concentration, memory, insight, and judgment that were grossly intact. The SSA records also include a favorable disability finding that the Veteran was disabled as of January 15, 2010 due to a combination of his PTSD symptoms and work-related right wrist and arm fractures. Indeed, the Veteran's application for social security disability benefits reflects complaints of symptoms as noted above. A psychiatric evaluation performed for SSA by Dr. P.W.L. reflects findings of anxiety and recurrent and intrusive recollections of traumatic experiences. During the evaluation, the Veteran continued to report the occurrence of disturbing dreams; thoughts and images related to his in-service combat trauma; becoming upset at reminders of his trauma; loss of interest in activities that he previously enjoyed; keeping to himself; feeling numb emotionally; difficulty sleeping; memory problems; difficulty with concentration; becoming confused at written and spoken instructions; difficulty handling stress; and panic attacks. In view of the foregoing evidence, for the period before September 15, 2011, the Veteran's PTSD has been manifested consistently by symptoms that are consistent with a 50 percent disability rating under DC 9411. In that regard, the Veteran experienced anxiety; depression; impaired short-term memory and forgetfulness; disturbances of motivation and mood marked by consistently labile mood, mood swings, crying spells, and difficulty managing anger; sleep disturbances marked by nightmares and difficulty falling asleep; racing and intrusive thoughts; confusion and difficulty in following complex commands; and difficulty in establishing and maintaining effective work and social relationships, marked by frequent marital and domestic problems, being suspicious of others, desire to avoid others, and reported inability to express himself and loneliness. The Veteran's symptoms have been managed by constant psychiatric medication, to include Prozac, Ambien, Trazadone, Zoloft, Effexor, Depakote, Prazosin, and Seroquel. As noted above, the Veteran was noted as demonstrating a disheveled appearance during his May 2007 VA treatment. Nonetheless, the remaining evidence prior to September 15, 2011 shows that the Veteran was generally able to maintain appropriate dress and hygiene. Similarly, the Board notes that the Veteran was reportedly involved in a fight concerning his property in December 2010; nonetheless, the remaining evidence shows that the Veteran consistently denied having any homicidal or suicidal ideation. In that regard, there does not appear to be any evidence that the Veteran was a threat to himself or others during the period before September 15, 2011. As indicated above, the Veteran's symptomatology has also been marked by difficulty in establishing and maintaining relationships. In that regard, the evidence shows that the Veteran experienced marital problems and a general propensity to avoid others. Nonetheless, the evidence does not support a finding that the Veteran experienced an outright inability to establish and maintain effective relationships. Toward that end, the evidence shows that the Veteran maintained an enriching relationship with his son, was able to establish a new relationship with a new fiancée, and became actively involved with his church. The Board also notes that the Veteran appeared to be able to maintain employment and attend classes The Board also notes that, generally, the Veteran's GAF scores prior to September 15, 2011 appear to range consistently from 50 to 57. The Board notes that the Veteran was assessed a high GAF score of 67 during his November 2009 VA examination; nonetheless, the high score assessed at that time appears to be an isolated anomaly in comparison to the other GAF scores shown by the evidence. In assessing the degree of psychiatric disability, GAF scores are for application and reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). According to the DSM-IV, a GAF score falling in the range of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). The Board admonishes that GAF scores are not conclusively dispositive as to a veteran's level of psychiatric impairment. Rather, GAF scores are merely parts of a whole body of evidence that must be and has been considered in arriving at a decision. Overall, the GAF scores reflected in the evidence appear to be consistent with the reported and objectively observed symptoms that are discussed above. Accordingly, the Board finds that the Veteran's symptomatology is consistent with a 50 percent disability rating under DC 9411 for the period before September 15, 2011. To that extent, this appeal is denied. In reaching this conclusion, the Board acknowledges the judicial holding in Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In that decision, the United States Court of Appeals for Veterans Claims held that a request for a total rating based on individual unemployability (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate 'claim' for benefits, but rather, can be part of a claim for increased compensation. In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue whether a TDIU is warranted as a result of that disability. In the present case, the RO issued a decision in August 2012 awarding TDIU effective September 15, 2011. The record does not reflect that the Veteran filed a timely notice of disagreement with the effective date assigned for this total evaluation. Accordingly, the Board declines to apply Rice and take jurisdiction over a TDIU claim for the period prior to September 15, 2011. B. Initial Disability Rating Higher than 70 Percent for PTSD, from September 15, 2011 As noted previously, the Veteran's PTSD has been rated as being 70 percent disabling since September 15, 2011. After review and consideration of the evidence of record, the Board finds that the Veteran is not entitled to a disability rating higher than 70 percent for the identified staged period. The effective date for the increased 70 percent disability rating appears to be fixed to a September 15, 2011 VA hospitalization for psychiatric treatment and evaluation. On that date, the Veteran admitted himself for reported depression and "overpowering" suicidal ideation with plan. During mental status examination, the Veteran was alert and active and demonstrated good eye contact, full affect, neutral mood, and clear and coherent speech. There was no evidence of thought disorder or delusions and the Veteran denied having any hallucinations. The Veteran's memory, judgment, and insight were intact and the Veteran was oriented in all spheres. Overall, the Veteran was hospitalized for four days and reported improving symptoms over the course of the hospitalization. During that time, he stated that he was not working but that he intended to return to school in January. In November 2011, the Veteran was afforded a new VA examination to assess the severity of his PTSD symptoms. Socially, he reported that he had been dating the same person for the past eight to nine months and that he was continuing to care for his six year old and three year old sons. He described his relationship with his girlfriend as being impacted by his erectile dysfunction (which is discussed below). Occupationally, he stated that he had been searching for employment but had not worked for two years. He reported legal problems which included a charge of domestic violence approximately two or three months before the examination. He stated that he was sentenced to six months of probation and mandatory completion of a VA administered anger management course. Symptoms identified during the examination included ongoing depressed mood, anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; and suicidal ideation. The examiner opined that the Veteran was persistently re-experiencing traumatic experiences through recurrent and distressing recollection of the traumatic events; dreams; acting or feeling as though the traumatic event were recurring; intense psychological distress at exposure to internal and external cues that symbolize or resemble an aspect of the traumatic event; and physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. The examiner opined further that the Veteran demonstrated persistent avoidance of stimuli associate with the trauma and numbing of general responsiveness, as marked by efforts to avoid thoughts, feelings, or conversations associated with the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; markedly diminished interest or participation in significant activities; and feelings of detachment or estrangement from others. The examiner also opined that the Veteran was experiencing persistent symptoms of increased arousal, marked by difficulty falling or staying asleep; irritability and outbursts of anger; difficulty concentrating; hypervigilance; and exaggerated startle responses. Overall, the examiner concluded that the noted symptoms caused clinically significant distress or impairment of social, occupational, and other important areas of functioning. Notwithstanding the foregoing symptoms, the examiner opined that the Veteran remained capable of managing his own finances. A GAF score of 48 was assigned. During VA treatment in March 2012, the Veteran reported that he was having problems managing his anger and that he had pushed his girlfriend down earlier that day. He continued to complain of the symptoms noted in the November 2011 VA examination report, and also reported that he was crying all the time and that he was having suicidal thoughts every day. He stated that he felt useless and reported that he was having difficulties in school marked by panic attacks. He stated that he was having panic attacks and arguments with his girlfriend which sometimes became violent and resulted in his pushing and yelling at his girlfriend. He stated that his nightmares were occurring every night sometimes felt so real that he could not differentiate his dreams from reality. During mental status examination, the Veteran continued to demonstrate adequate grooming and hygiene. He was calm and cooperative during the interview and was able to maintain eye contact. Demonstrated mood remained labile with dysphoric affect marked by crying and becoming emotional. The Veteran spoke in a relevant and coherent manner without flight of ideas or ideas of reference. Demonstrated insight and judgment were intact. A GAF score of 55 was assessed. Later that month, the Veteran returned for further psychiatric follow-up, complaining that he was having intrusive thoughts about death and that he had an incident in which he could not recall attending his son's birthday party. A mental status examination at that time was grossly unchanged from that performed earlier that month. The following month, in April 2012, the Veteran reported depression and anxiety related to his recent breakup with his girlfriend. During follow-up later than month, he stated an instance in which he was angry and punched a wall. He stated that he was afraid he would hurt somebody. Although he denied current suicidal ideation, he admitted that he had put a gun to his head in the past. The foregoing evidence shows that the Veteran's PTSD symptoms have been essentially consistent with a 70 percent disability rating for the period from September 15, 2011. Over that period, the Veteran has experienced ongoing depressed mood; anxiety; chronic sleep impairment marked by nightly nightmares; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; suicidal ideation with definite plan; frequent panic or depression affecting the Veteran's ability to function independently, appropriately, and effectively; impaired impulse control marked by periods of uncontrolled anger and physical violence. The Veteran continued to demonstrate difficulty in establishing and maintaining effective relationships, as evidenced by his break-up with his girlfriend. The Board notes, however, that the Veteran appears to maintain responsibility for his children and continues to care for them. The evidence appears to suggest that the Veteran had an instance in which he may have been disoriented to his surroundings, as evidenced by his recollection that he could not recall being in attendance at his son's birthday party. Nonetheless, there is no indication in any of the mental status examinations performed since September 15, 2011 that the Veteran was disoriented to person, place, or time at any other time. Although, as discussed above, the Veteran has demonstrated persistent suicidal ideation and periods of uncontrolled anger marked by violence and domestic abuse, the evidence does not show that the Veteran is a persistent danger to others. In that regard, and as noted above, the Board points out that the Veteran continues to provide care for his young children. Overall, the evidence does not establish that the Veteran has experienced actual spatial disorientation. Certainly, there is no evidence that the Veteran has experienced any delusions or hallucinations, been unable to perform his activities of daily living, unable to maintain minimal hygiene, or experienced memory loss for the names of his close relatives, his own occupation, or his own name. Overall, although the Veteran has exhibited constant suicidal ideation which indicates that he may be a persistent danger of hurting himself, the constellation of symptoms associated with the Veteran's PTSD does not correspond to the assignment of a 100 percent disability rating under the General Formula. As noted above, the Veteran's GAF scores since September 15, 2011 range from 48 to 55. As noted above, the DSM-IV characterizes a GAF score falling in the range of 51 to 60 as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). Once again, the GAF scores since September 15, 2011 are consistent with the PTSD symptoms that are discussed above and do not suggest the presence of symptomatology which warrants a 100 percent disability rating under the General Formula. Accordingly, the Board finds that the Veteran's symptomatology is consistent with a 70 percent disability rating under DC 9411 for the period from September 15, 2011. To that extent, this appeal is also denied. C. Other Considerations The Board has also considered the provisions under 38 C.F.R. § 3.321(b)(1), which govern the assignment of extra-schedular disability ratings. However, in this case, the record does not show that the severity of the Veteran's PTSD is so exceptional or unusual such as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2012). The threshold factor for extra-schedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and, no extra-schedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular rating does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation (38 C.F.R. § 3.321(b)(1) ) as "governing norms"(which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show that the Veteran's PTSD presents an exceptional disability picture that renders inadequate the available schedular ratings. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. As discussed above, there are higher ratings available under the applicable diagnostic code; however, the Veteran's PTSD is not productive of the manifestations required for a higher disability rating. As such, it cannot be said that the available schedular ratings for the Veteran's PTSD are inadequate. Based on the foregoing, the Board finds that the requirements for an extra-schedular evaluation for the Veteran's service-connected PTSD, under the provisions of 38 C.F.R. § 3.321(b)(1), have not been met. Thun, 22 Vet. App. 111; Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). The Board has also considered whether "staged" disability ratings, beyond those already provided, are warranted by the evidence. The symptomatology shown upon examination and treatment, however, has been essentially consistent and fully contemplated by the assigned disability ratings. As such, there is no basis for further staged disability ratings in connection with the Veteran's PTSD. ORDER Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to September 15, 2011 is denied. Entitlement to an initial disability rating in excess of 70 percent for PTSD from September 15, 2011 is denied. REMAND In support of his claim for service connection for erectile dysfunction, the Veteran has alleged generally that he is entitled to service connection. In October 2007, he was afforded a VA examination which confirmed an erectile dysfunction diagnosis, but determined that its etiology remained undetermined. In December 2011, the Veteran underwent a new VA examination which once again confirmed the prior diagnosis of erectile dysfunction. The examiner opined that it was less likely than not that the erectile dysfunction was due to or a result of the Veteran's service-connected PTSD. However, the examiner did not offer an opinion as to whether it was at least as likely as not that the Veteran's erectile dysfunction was sustained during his active duty service, or, was related in any other way to his active duty service, to include to an injury or illness sustained therein or to the Veteran's documented service in Iraq. In the absence of such an opinion, the opinions expressed in the December 2011 VA examination report are incomplete. The Veteran should be arranged to undergo a new VA examination of his erectile dysfunction to determine whether it was sustained during his active duty service; is related to an injury or illness sustained during his active duty service; has been due to or a result of his service-connected disabilities, to include PTSD, tinnitus, and/or right knee osteoarthritis; and/or has been due to or a result of medications taken for any of his service-connected disabilities. 38 C.F.R. § 3.159(c)(4). Prior to requesting the examination ordered above, and in order to insure that the most complete and up-to-date evidence has been associated with the claims file, the Veteran should also be asked to identify any other private or VA treatment providers who have rendered treatment for his erectile dysfunction since June 2012. VA must then make efforts to obtain any treatment records that are identified by the Veteran. 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following action: 1. A letter should be sent to the Veteran explaining, in terms of 38 U.S.C.A. §§ 5103 and 5103A, that he may submit or identify any additional evidence regarding his claim of entitlement to service connection for erectile dysfunction. This letter must also inform the Veteran about the type of information and evidence that is necessary to substantiate his claim and provide notification of both the type of evidence that VA will seek to obtain and the type of evidence that is expected to be furnished by the Veteran. The letter must also notify the Veteran that VA is undertaking efforts to arrange a new VA examination of his erectile dysfunction. The Veteran should be advised that it is his responsibility to report for the scheduled VA examination and to cooperate with the development of his claim; failure to report without good cause may result in denial of his claim. The Veteran should also be provided a VA 21-4142 release form, and be requested to identify on the release the name(s) and address(es) of any private or VA medical providers who have provided treatment for his erectile dysfunction since June 2012. 2. Make efforts to obtain the records of any treatment identified by the Veteran. Any records obtained as a result of such efforts should be associated with the claims file. If such efforts yield negative results, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 3. After the above development has been completed to the extent possible, the Veteran should then be afforded a VA examination, with an appropriate examiner, to determine the nature and etiology of the Veteran's erectile dysfunction. The claims folder must be made available to the examiner, and, the examiner must review the entire claims file in conjunction with the examination. All tests and studies deemed necessary by the examiner should be performed. The examiner should provide a diagnosis pertinent to the claimed erectile dysfunction. The examiner should also provide an opinion as to whether it is at least as likely as not (i.e. is at least a 50 percent probability) that any diagnosed disorders were initially sustained during the Veteran's active duty service; are related to an injury or illness sustained during service; are due to or a result of his service-connected disabilities, to include PTSD, tinnitus, and/or right knee osteoarthritis; and/or has been due to or a result of medications taken for any of his service-connected disabilities. A report of the examination should be prepared and associated with the Veteran's VA claims file. A complete rationale which includes citation to any relevant facts, evidence, or medical principles must be provided for all opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to what additional information is necessary and why the opinion sought cannot be given without resorting to speculation. 4. If the Veteran fails to report to the scheduled examination, the RO must obtain and associate with the claims file a copy of any notice(s) of the dates and times of the examinations sent to the Veteran by the pertinent VA medical facility. 5. After completion of the above development, the issues of the Veteran's entitlement to service connection for erectile dysfunction should be readjudicated. If the determination remains adverse to the Veteran, he and his representative should be furnished with a supplemental SOC and be given an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs