Citation Nr: 1319980 Decision Date: 06/20/13 Archive Date: 07/02/13 DOCKET NO. 07-32 571 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating for individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from January 1963 to October 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. Subsequently, jurisdiction of this matter was transferred to the RO in Jackson, Mississippi. The Board remanded this matter for additional development in January 2013. A TDIU claim is part of an increased disability rating claim when that claim is raised by the record. When evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for a TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). There is evidence of the Veteran's unemployability which may be due to his service-connected PTSD disability, specifically during the pendency of the claim for increase and prior to the assignment of a 100 percent schedular disability rating for prostate cancer, effective April 6, 2009. Therefore, the issue of entitlement to a TDIU is before the Board. The following determination is based on review of the Veteran's claims file and his electronic Virtual VA file. The issue of entitlement to service connection for glaucoma, to include as secondary to service-connected diabetes, has been raised by the Veteran's representative in an April 2013 written submission, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over that issue, and it is referred to the AOJ for appropriate action. The issue of a TDIU is REMANDED to the RO via the Appeals Management Center, in Washington, DC. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his PTSD is manifested by occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for a disability rating of 70 percent, but not higher, for PTSD, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 3.159, 4.1-4.14, 4.125-4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ), of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice requirements apply to all five elements of a service connection claim, to include veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Neither the Veteran nor his representative has alleged prejudice with respect to notice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. The Veteran was notified via letters dated in November 2006 and May 2007 of the criteria for establishing a higher rating for PTSD, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates in this same correspondence which was issued before the August 2007 rating decision now on appeal was issued. VA also has a duty to assist a Veteran in the development of a claim. As a result of the Board's January 2013 remand, the RO scheduled a VA PTSD examination in February 2013. While the remand had requested an examination by a psychiatrist, the Board notes that the February 2013 VA examiner was a VA psychologist. Nevertheless, the Board finds that represented substantial compliance with the remand request. The first page of the examination report lists the types of persons who are qualified to conduct a VA mental examination, and that list includes a licensed doctorate-level psychologist. Thus, the Board finds that the duty to assist has been fulfilled as VA and private medical records relevant to this claim have been requested or obtained and the Veteran has been provided with several VA examinations of his higher rating claim for PTSD. Information in the claims file shows that the Veteran's medical records from the Social Security Administration (SSA) are unavailable because there are no SSA medical records. The Board finds that the available medical evidence is sufficient for an adequate determination of this claim. There has been substantial compliance with all pertinent VA laws and regulations and to adjudicate this claim would not cause any prejudice to the Veteran. Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). To rate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will consider entitlement to staged ratings to compensate for any times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204 (1994). Rating of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses are prohibited. 38 C.F.R. § 4.14 (2012). When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7 (2012). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2012). Service connection for PTSD was granted in a November 2005 rating decision and a 50 percent rating was assigned, effective August 30, 2004, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Under Diagnostic Code 9411 and the General Rating Formula for Mental Disorders, a 50 percent rating requires 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 (such as retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires 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 work like setting); and inability to establish and maintain effective relationships. A 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411, General Rating Formula for Mental Disorders (2012). The symptoms recited in the criteria in the rating schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When rating a mental disorder, the rating must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2012). Further, when rating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). Reports of psychiatric examination and treatment frequently include a Global Assessment of Functioning (GAF) score. The GAF scale includes scores ranging between zero and 100 which represent the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV). The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. Richard v. Brown, 9 Vet. App. 266 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder, which provide the primary basis for the rating assigned. 38 C.F.R. § 4.126(a) (2012). A GAF score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates 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 61 to 70 indicates 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, and has some meaningful interpersonal relationships. American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV). In September 2006 the Veteran filed a claim for a higher rating, essentially contending that his service-connected PTSD had worsened. VA treatment records dated from September 2005 to March 2013 associated with the claims file or found in the Veteran's Virtual VA electronic claims file show medication management for PTSD. They also show that group therapy at a California VA facility was followed years later by individual therapy with a licensed social worker in Mississippi after the Veteran relocated. The Veteran underwent a VA mental examination in December 2006. It was noted that the Veteran was a helicopter chief in Vietnam, was never wounded, and attended group therapy at VA regularly. He complained of recurrent recollections of trauma, nightmares after which he woke up sweaty and agitated, disturbed sleep, ringing in his ears, and panic attacks. He avoided watching the news and recently left a basketball game early because he could not be around crowds. He reported doing better since his medications were recently changed. He was currently taking Remeron, Depakote, and Wellbutrin. While he used to enjoy sports and walking, he no longer did those activities. He also complained of detachment and estrangement from others and an exaggerated startle response when he heard planes flying overhead. He said that he thought they would hit his building. His residence was under the flight path to the Los Angeles airport. He endorsed hypervigilance, said he had very few friends, was estranged from two adult children whom he had not seen in 20 years, and had never seen his two grandchildren. It was noted that the Veteran currently worked part-time at Goodwill and was living at a Veterans' Center for two years since his release from prison. He said that he had been free from substance abuse problems for six years after a long history of cocaine and alcohol abuse and was able to take care of personal hygiene. On mental status examination, the Veteran was oriented to time, place, person, and the reason for the examination. He presented wearing slightly dirty clothes, but with no abnormal movements or agitation. His speech was regular and affect was full and reactive. Insight and judgment were reasonable and there was no indication of paranoia or delusions or suicidal or homicidal ideation. Some mild memory, concentration, and calculation problems were noted. Diagnosis was chronic PTSD and a GAF score of 50 was assigned. A functional assessment noted that the Veteran had occasional interference in performing activities of daily living, had difficulty establishing and maintaining effective work and social relationships, and was unable to maintain family role functioning. There was an intermittent inability to pursue recreation or leisure. His psychiatric prognosis was recorded as good. The Veteran underwent a VA mental examination in June 2007. The Veteran complained of occasional panic attacks, sleeping difficulties at night and feeling tired during the day, flashbacks once or twice a week, difficulty concentrating, impatience with people, nightmares related to Vietnam two to three times a week, receiving shrapnel wounds in Vietnam, and auditory hallucinations during flashbacks when he heard others talking about him and hearing pounding and ringing sounds. He said that a specialist told him he did not have any hearing problems. The Veteran said that he was no longer working after foot surgery and was not sure he would be able to work due to poor eyesight. It was noted that he had kitchen duties at the veterans' center where he lived and got along well with the people there. It was unclear from the report of examination whether he still slept with guns due to fear. He currently took Citalopram, Mirtazapine, and Lamotrigine. On mental status examination, the Veteran was oriented to four spheres. He was neat and well-groomed and generally cooperative. There was no evidence of exaggeration or manipulation. He was relevant and non-delusional and denied any suicidal or homicidal ideation. He reported a past history of suicidal ideation with no history of suicidal action. He also denied recent auditory or visual hallucinations. He did not report anxiety symptoms and his affect was appropriate, full, and euthymic. Insight or judgment were intact or fair. Diagnosis was chronic PTSD and full remission of long-term polysubstance dependence. A GAF score of 52 was assigned. While the Veteran reported that he still had a feeling of detachment from others and had significant difficulties dealing with others in the past, the VA examiner noted those difficulties had improved over time. The examiner also noted that his past substance abuse was due in part to PTSD. The examiner commented that he appeared to have a significant impairment in daily activities with being tired during the day, flashbacks, and feeling tense. However, the examiner found that he was able to establish and maintain effective work and social relationships. In a June 2007 signed statement, L.B., a VA staff psychologist, stated that the Veteran was then a patient in the PTSD Outpatient Services Program (POST) at VA and had sought treatment there since about June 2004. That psychologist noted that the Veteran had presented with chronic symptoms including: nightmares with combat-related themes, intrusive recollections, avoidance of reminders of his combat experiences, and dissociative-like symptoms. The Veteran attended a weekly support group and was followed for medication management by a psychiatrist. He reported benefits from participation in group therapy and from medication, but in the past two years had experienced periods of increased dysphoria, irritability, nightmares, and intrusive experiences. Those diminished with adjustments in medications and increased psychotherapeutic intervention. The psychologist stated that the Veteran continued to manifest serious symptoms of PTSD with a co-morbid disorder, both of which affected his occupational and social functioning. The diagnosis was PTSD, bipolar disorder, and cocaine and alcohol dependence in full sustained remission. A GAF score of 55 was assigned. Private medical records from a Mississippi department of Mental Health dated from March 2008 to September 2008 show that the Veteran was treated for an unstable mood, with irritability and aggressive behavior, and was easily frustrated. Axis I diagnoses included PTSD and mixed bipolar disorder. A GAF score between 55 and 60 was assigned. A March 2008 record noted that the veteran would revert to violence if under extreme pressure. A June 2008 record noted auditory hallucinations. A September 2008 record noted that the Veteran had panic symptoms two to three times a day and still had flashbacks and nightmares. In an April 2009 signed statement, the Veteran complained of nightmares, flashbacks, panic attacks, and night sweats. He stated that it was stressful for him to socialize with people. He also noted that he was recently diagnosed as bipolar. A December 2010 VA mental health clinic record shows that a VA staff psychiatrist had assigned a GAF score of 65. A March 2011 VA mental health clinic record shows that a nurse practitioner had assigned a GAF score of 70. An April 2011 VA optometry record shows that the Veteran took exercise with neighbors who lived in his apartment complex and that he had family in the area with whom he was in contact. It was also noted that the Veteran went to church, Bible study, and meetings of the NAACP. An August 2011 VA medical record noted that the Veteran was about to give up driving because of his declining vision, but that he had gone on a cruise to Italy and Spain with his sister. The Veteran underwent a VA mental examination in November 2011. The examiner, a VA staff psychiatrist, noted that the Veteran continued to experience recurrent and intrusive distressing recollections of his Vietnam combat experiences along with nightmares with combat themes. Hyperarousal symptoms included insomnia, irritability, anger, impaired concentration, and hypervigilance. Avoidance symptoms included a sense of feeling detached from others and a preference to be alone. He also struggled with depression which the examiner said was encompassed in the PTSD diagnosis. The examiner found that substance abuse was not currently a factor in the Veteran's condition. The November 2011 VA examiner noted that the Veteran lived alone in an apartment in Mississippi after moving from Los Angeles in 2007. He was divorced, his ex-wife was dead, and while he had a good relationship with his son, that was not true of his daughter who had a drug problem. He was not currently in therapy and did not see a psychiatrist. He was prescribed Divalproex and Remeron. His PTSD symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, nightmares with combat content once every several months, occasional crying spells, and feelings of hopelessness and helplessness. He denied any current suicidal thinking. On mental status examination, the Veteran presented somewhat disheveled and was significantly overweight, but was alert and oriented to four spheres. His affect was restricted. He denied auditory hallucinations, but experienced visual hallucinations at times and sometimes saw shadows of something not there. He denied paranoia and there was no overt sign of psychoses or of any cognitive defects. Insight and judgment were intact. The diagnosis was PTSD with a GAF score of 52 assigned, which the examiner found indicated moderate impairment in social and industrial functioning. However, the examiner thought the Veteran's prognosis for improvement or stabilization was guarded. The examiner estimated that the Veteran's level of occupational and social impairment showed occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. A December 2011 VA medical record noted that a social worker had recorded that the Veteran told him he often invited his cousin's kids over and enjoyed their company, that the Veteran was still actively involved in the church, and that he volunteered at the senior community center. A February 2012 VA medical record showed that a psychiatric nurse practitioner had assigned a GAF score of 70. A November 2012 VA mental health clinic record noted that a nurse practitioner had assigned a GAF score of 65. The Veteran underwent a VA mental disorders examination in February 2013 as a result of the a Board remand. The report of examination noted that since the November 2011 VA examination, the Veteran had purchased a house where he lived alone. While the Veteran isolates somewhat, the examiner noted that family came by and checked on him and that he was in touch with other family members by telephone. Since the last VA examination, one of his closest friends, also a veteran, had died, and another close friend was in the hospital. With their absence, the examiner noted that the Veteran struggled more. The Veteran was prescribed Depakote and Mirtazepine and saw a licensed social worker for therapy. PTSD symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and occasional thoughts of suicide. The Veteran was judged to be of low risk of suicide with no plan or available means and no intent. He was given the telephone number of a crisis hotline and said that he would follow-up with his VA therapist. The diagnosis was PTSD with some depressive symptoms secondary to PTSD and exacerbated by his recent decrease in vision. A GAF score of 51 was assigned. The VA examiner also found that the level of occupational and social impairment due to his PTSD represented impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. Resolving all reasonable doubt in favor of the Veteran, for the period of this appeal, the Board finds that the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas, warranting a 70 percent rating. Based on the observations made in the several VA examinations of record and in the other medical evidence of record, the Board finds that the evidence is in relative equipoise as to whether the Veteran's PTSD symptoms met the criteria for the 70 percent rating during the appeal period. Therefore, the Board finds that a 70 percent rating is warranted. Evidence from the four VA mental disorders examinations of record in 2006, 2007, 2011 and 2013 show the Veteran manifested chronic PTSD with such symptoms as sleep difficulties, depression, anxiety, nightmares, panic attacks, impaired concentration, hypervigilance, and estrangement from others. In addition, the June 2007 VA examination noted auditory hallucinations and a past history of suicidal ideation. The November 2011 VA examination noted visual hallucinations, but that the Veteran had denied auditory hallucinations. The February 2013 VA examiner noted that the Veteran had occasional thoughts of suicide and gave him the telephone number of a crisis hotline and arranged follow-up with his therapist. The November 2011 VA examiner estimated the Veteran's level of occupational and social impairment as meeting the criteria for only a 30 percent disability rating when the Veteran was already rated at 50 percent, while the February 2013 VA examiner estimated the level of occupational and social impairment as meeting the criteria for a 70 percent disability rating. Moreover, GAF scores assigned to the Veteran during the appeal period ranged from 50 to 70, which represent symptomatology ranging from mild to moderate to serious symptoms. However, the Board notes that the GAF scores for all four VA mental examinations (50, 52, 52, and 51) were in the low 50s on the borderline between moderate and serious symptoms. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, reasonable doubt will be resolved in favor of the claimant. By reasonable doubt is meant one that exists because of an approximate balance of positive and negative evidence which satisfactorily proves or disproves the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 C.F.R. § 3.102 (2012); 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board finds that the evidence in this appeal is, at the very least, in equipoise as to the question of whether the Veteran is entitled to a 70 percent rating for the entire period of appeal, especially because after his move to Mississippi he does not see a psychiatrist or attend group therapy. He has also reestablished some family relationships. However, resolving reasonable doubt in favor of the Veteran, the Board finds that under the circumstances of this case, the other evidence of serious PTSD symptoms, especially thoughts of suicide and some evidence of hallucinations, are sufficient to provide support for the award of a 70 percent disability rating for the period of this appeal. The Board finds that the evidence of record does not show that the Veteran's PTSD symptoms met the criteria for the next higher rating of 100 percent, which requires total occupational and social impairment. The Veteran did not exhibit symptoms synonymous with those listed under the criteria for the assignment of a 100 percent rating in the General Rating Formula. There was no objective evidence of gross impairment in thought processes or communication; persistent delusions; an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. The evidence does not show total occupational and social impairment. The Board finds that the symptomatology described in the medical and lay evidence for the period of this appeal is more consistent with the rating criteria for the 70 percent rating. Therefore, the Board will resolve all reasonable doubt in this matter and find that a 70 percent rating for PTSD, but no higher, is warranted for the period of this appeal. The Board has considered the Veteran's assertions that his PTSD disability warrants a higher rating. The Board has considered the statements of the Veteran as to the extent of his PTSD over the entire course of this appeal. He is competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465 (1994). However, in rating a claim for an increased schedular disability rating, VA must consider the factors as enumerated in the rating criteria, which involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204 (1994). While he is competent to report that his symptoms are worse, the training and experience of medical personnel makes the medical findings found in treatment notes and examinations more probative as to the extent of the disability. Cromley v. Brown, 7 Vet. App. 376 (1995). Thus, while the Board has sympathetically considered the Veteran's appeal and increased his disability rating for the period on appeal, it has not awarded a 100 percent rating for the total occupational and social impairment that the Veteran contends he is entitled to on appeal. Consideration has been given to assigning a staged rating. However, a 70 percent rating has now been assigned for the entire rating period on appeal. At no other time during the appeal period has the evidence and the Veteran's PTSD symptoms warranted the assignment of a rating higher than herein assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). Finally, the Board finds that the Veteran's PTSD disability does not warrant referral for extraschedular consideration. In exceptional cases where schedular ratings are found to be inadequate, referral for consideration an extraschedular evaluation may be made. 38 C.F.R. § 3.321(b)(1) (2012). There is a three-step analysis for determining whether referral for consideration of an extraschedular rating is appropriate. First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as governing norms such as marked interference with employment and frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1) (2012). If so, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds that the rating criteria are not inadequate in this case. The Veteran does not meet the schedular criteria for a 100 percent rating in the time period examined in this appeal. However, there is evidence of interference with employment in this case and the Veteran's representative has argued that the issue of a TDIU was raised by the record in the Veteran's appeal for a higher rating for his service-connected PTSD. Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, the TDIU claim is part of the Veteran's higher rating claim for his service-connected PTSD and is discussed further in the remand section below. ORDER Entitlement to a 70 percent rating, but not higher, for PTSD is granted. REMAND Unfortunately, a remand is required for the Veteran's TDIU claim. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide his claim so that he is afforded every possible consideration. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. §§ 5107(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c) (2012). The issue of entitlement to a TDIU is raised by the record as part of the Veteran's increased rating claim. Rice v. Shinseki, 22 Vet. App. 447 (2009). Information in the record indicates that the Veteran had a part-time job at a senior citizens center, but now doubts whether he could get a job because of his poor eyesight. VA examiners have provided differing opinions over the years on whether the Veteran's service-connected PTSD prevented gainful employment. The Board cannot currently determine, based on the medical evidence found within the claims file, whether the Veteran is unable to secure and follow substantially gainful employment by reason of his current service-connected disabilities to meet the requirements for TDIU. Thus, further development of the claim is needed. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran and his representative with a notice letter pertaining to his TDIU claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). 2. Obtain all VA treatment records since March 2013, from either the Memphis VAMC in Tennessee or the Smithville or Tupelo VA clinics in Mississippi. All attempts to procure records should be documented in the claims file. 3. After the Veteran's claim for service connection for glaucoma is adjudicated, adjudicate the Veteran's claim for TDIU. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. 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 or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ HARVEY P. ROBERTS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs