Citation Nr: 1320224 Decision Date: 06/21/13 Archive Date: 07/02/13 DOCKET NO. 10-45 602 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to a higher initial evaluation for posttraumatic stress disorder (PTSD), rated as 30 percent disabling from November 4, 2009, and as 70 percent disabling from November 1, 2011. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Massachusetts Department of Veterans Services WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran served on active duty from October 1952 to October 1954. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2010 and June 2012 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island. In the June 2010 decision, the RO awarded the Veteran service connection for PTSD and assigned a 30 percent disability rating, effective November 4, 2009. The Veteran disagreed with the disability rating assigned. In the June 2012 rating decision, the RO denied entitlement to TDIU. In a November 2011 supplemental statement of the case (SSOC), a decision review officer increased the Veteran's PTSD disability rating to 70 percent, effective November 1, 2011. Because less than the maximum available benefit for a schedular rating was awarded and because the increase was not awarded for the entire claims period, the claim remains properly before the Board. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35 (1993). On November 26, 2012, the Veteran testified at a Board hearing via videoconferencing before the undersigned Veterans Law Judge. A transcript of that proceeding is of record. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). (The decision below addresses the issue of entitlement to higher initial ratings for service-connected PTSD. The issue of entitlement to TDIU is addressed in the remand that follows the Board's decision.) FINDINGS OF FACT 1. Prior to November 9, 2009, the Veteran's PTSD was manifested by symptomatology resulting in a moderate level of overall social and occupational impairment without regard to the ameliorative effects of medication. 2. Total impairment has not been shown. CONCLUSIONS OF LAW 1. Prior to November 1, 2011, the criteria for a 50 percent disability rating for service-connected PTSD were met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9441 (2012). 2. From November 1, 2011, the criteria for a rating in excess of 70 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9441 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that VA's General Counsel has held that VCAA notice is not required for downstream issues. VAOPGCPREC 8-2003. Additionally, the Court held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess, 19 Vet. App. at 490. In this case, the Veteran's claim of service connection for PTSD was granted in June 2009. He was also assigned a disability rating and an effective date. As the Veteran's current appeal stems from a disagreement with a downstream element, no additional notice is required because the purpose that the notice is intended to serve has been fulfilled. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also June 2008 VCAA Letter (outlining requirements to establish a higher rating for a service connected disability). The Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate his claim. The Board finds that all available evidence pertaining to the matter decided herein has been obtained. The evidence includes the Veteran's VA treatment records, VA examination reports, and lay statements from the Veteran and his family members. The Veteran was also afforded a hearing in connection with his case. The Veteran has also not indicated that there are outstanding relevant and available records that VA should have obtained, and the Board is aware of none. Further, the Veteran has been afforded several examinations in connection with his claim of service connection and appeal of the disability ratings assigned. The VA examiners indicated that the claims folder had been reviewed and they took into account the Veteran's subjective complaints associated with his service-connected disability. All appropriate testing was conducted, and the examiners made all findings necessary to apply the rating criteria. Upon review of the examination reports, and in light of the VA treatment records, the Board is satisfied that the record contains sufficient evidence by which to evaluate the Veteran's service-connected PTSD throughout the appeal period. Accordingly, the Board has properly assisted the Veteran by affording him adequate VA examinations. II. Analysis The Veteran has been in receipt of VA disability compensation for PTSD since November 4, 2009, which disability has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411, as 30 percent disabling from November 4, 2009, and as 70 percent disabling from November 1, 2011. Under DC 9411, a 30 percent rating is assigned for 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; mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9411 (2012). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting 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 work-like setting); inability to establish and maintain effective relationships. Id. Lastly, a 100 percent evaluation is warranted for 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation 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. See 38 C.F.R. § 4.126(a) (2012). When evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2012). Further, "[w]here there is a question as to which of two evaluations shall be applied, 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 (2012). A review of the evidence relevant to the determination of the appropriate rating for the Veteran's service-connected PTSD shows that the Veteran was seen in the geriatric mental health clinic (GMHC) on November 17, 2009, at which time he reported increased irritability and issues with sleep. It was noted that the he been followed in the GMHC since 2007. In February 2010, the Veteran was afforded a VA PTSD examination. The Veteran reported becoming easily enraged over small things, which was lessened somewhat by medication. The Veteran endorsed occasional fitful sleep, avoidance of crowds and triggers that reminded him of the war, irritability and road rage, slightly diminished concentration, hypervigilance, a heightened startle response, and a depressed mood and/or feelings of guilt on occasion. The Veteran indicated that most symptoms had improved with medication. He denied nightmares, significant sleep problems, feelings of worthlessness, suicidal or homicidal impulse or ideation, symptoms of mania, panic disorder, agoraphobia, delusions, and hallucinations. The Veteran was noted to be able to handle daily living skills and maintain personal hygiene. It was noted that he was living with his wife of 52 years in an addition to his son and daughter-in-laws house. He indicated spending time with family members who lived in the house and stated that his days consisted of watching the news in the morning, going shopping or to the mall to meet friends, going to appointments, and spending time with his grandchildren. The Veteran stated that he used to like to fish, but no longer did so because he felt empathy for the fish. He still enjoyed camping and outdoor activities, and reported having a large number of friends, neighbors, and family with whom he and his wife socialized. Regarding his occupational functioning, the Veteran reported an extensive work history prior to his retirement in 1993. He denied having had any disciplinary action taken against him and stated that he was consistently promoted. On examination, the Veteran was appropriately dressed and groomed and his demeanor was pleasant and cooperative. His speech was logical, fluent, and goal-directed. He was oriented times three and his thought processes were coherent and organized. The Veteran reported a euthymic mood, which was consistent with his presentation. Delusions, hallucinations, and homicidal and suicidal ideation were denied. His insight and judgment were adequate. It was noted that the Veteran had arrived with his son and wife and appeared to have a good relationship with both of them. Diagnoses of anxiety disorder, not otherwise specified (NOS), with features of PTSD, and depressive disorder, NOS, were recorded and the Veteran was assigned a Global Assessment of Functioning (GAF) score of 62. The examiner stated that the Veteran's symptoms had exacerbated over time, until he was placed on medication a year and a half prior, and indicated that the Veteran's symptoms had a mild impact on social and occupational functioning, but stated that it was likely that the Veteran experienced more severe symptoms prior to be placed on medication. Another examination was conducted in April 2010, at which time the Veteran reported hypervigilance and a heightened startle response. He reported doing better with his irritability and argumentativeness, but indicated having traumatic nightmares and difficulty concentrating. Orientation and intellectual functioning were intact and insight and judgment were good. A VA treatment note dated in June 2010 recorded a GAF score of 65. The Veteran underwent a VA PTSD review examination on November 1, 2011. At that time, Veteran reported that he began seeking treatment for his anger outbursts and irritability due to strained family relationships. He indicated that treatment and medication helped to alleviate these episodes. The Veteran's PTSD symptoms were noted to include recurrent and distressing recollections of the event; distressing dreams; psychological distress and reactivity in response to internal or external cues; efforts to avoid thoughts, feelings, or conversations associated with the trauma; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement; flattened affect; sleep difficultly; irritability; hypervigilance; exaggerated startle responses; depressed mood; anxiety; disturbance of mood and motivation; difficulty establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; and obsession rituals. The examiner determined that the Veteran's symptoms caused clinically significant distress or impairment in social, occupation, and other important areas of functioning and resulted in occupational and social impairment with reduced reliability and productivity. A GAF score of 60 was assigned. Based on the November 2011 VA examination report, the Veteran's disability rating was increased to 70 percent, effective November 1, 2011. The DRO indicated that the increase in disability evaluation was based on the evidence showing difficulty adapting to stressful circumstance and obsessional rituals that interfered with routine activities. In expressing his disagreement with the effective date of the 70 percent evaluation, the Veteran stated his belief that he was as disabled by his PTSD at the time of examination as he was at the time that he filed his initial claim for benefits. A VA psychiatry outpatient treatment note dated on November 28, 2011, contained a GAF score of 65. At that time, the Veteran's speech and behavior were normal, his cognition was okay, he had no hallucinations or delusions, his thoughts were logical and goal directed, his insight and judgment were good, and his mood was a 7 to 8 on a scale of 10. It was noted that he had down moments when he missed his friends and that he missed his former dog. The Veteran reported that he and his wife still enjoyed camping. An addendum to the November 2011 VA examination report was obtained in January 2012, which included the examiner's opinion that although the Veteran's PTSD had caused significant distress to his and his family, there was no evidence that it rendered him unable to work. A psychiatry outpatient treatment note dated in April 2012 indicated a GAF score of 65. At that time, the Veteran reported nightmares once a month, flashbacks, and jumpiness. Examination of the Veteran showed that he was neatly dressed and groomed. His speech and behavior were normal. There was some decrease in short term memory. The Veteran denied voices, visions, and paranoia. He reported his mood to be a 7 or 8 on a scale to 10 and stated that his anger was less. In November 2012, the Veteran testified at a Board hearing, during which he asserted that the PTSD symptoms had worsened since his medication was decreased due to its effect on his heart condition. The Veteran also alleged an inability to work on account of his PTSD and his representative indicated that the Veteran avoided large crowds, was hypervigilant, had few close friends, slept during the day, and had a short tempter. The Veteran was provided with another VA examination in February 2013. He reported an increase in symptoms since November 2011, and stated that in the last year he had experienced an increase in the frequency and severity of his startle response, nightmares, and anger outbursts. The Veteran endorsed intrusive thoughts, but stated that they consisted of regret over how he had handled past friendships. The examiner was unable to obtain clear evidence that the Veteran experienced spontaneous and unwanted thoughts of war. The Veteran reported traumatic dreams several times a week and flashbacks on occasion. The Veteran was unable to identify any specific emotional or physical response to cues, and his family could not identify any specific reactions to reminders of combat, other than a startle response. The Veteran was noted to speak openly and freely about his combat experiences without apparent distress. He reported experiencing heightened anxiety in cities, supermarkets, and crowded events, but denied actively avoiding the supermarket or cities. The Veteran also stated that he no longer enjoyed hunting or fishing because he found it distressing to kill. Feelings of detachment and an inability to have pleasant or loving feelings were improved since treatment and the Veteran's sense of a foreshortened future was noted to be due to his history of heart attack and obstructive pulmonary disorder. The Veteran endorsed nightmares one to two times month, after which he had trouble falling back to sleep. He reported increased anger, but denied having had episodes of physical aggression since 2011. He stated that his anger was due to frustration over sensory impairments and diminished physical capabilities. He denied hypervigilance, but endorsed an exaggerated startle response and difficulty concentrating. The Veteran's wife reported avoiding confrontation with the Veteran, stating that she would bend over backwards to keep him calm. She indicated that his temper was not as bad as was before he sought treatment, but she continued to make efforts to avoid triggering his irritability and anger, which placed a significant strain on their relationship. The Veteran also indicated that while he was working, his irritability and anger outbursts impacted his work relationships, stating that he was formally reprimanded for being abrasive with a secretary and also that he had threatened a co-worker whom he perceived to be making fun of him. He stated that management, however, continued to like his work and that he was not formally reprimanded. The Veteran alleged that his PTSD symptoms caused him to take an early retirement in 1993. The Veteran reported the presence of a down and depressed mood on a daily basis, which he attributed to difficulties contending with his physical limitations and sensory impairments. The Veteran denied thoughts of death and suicide, but endorsed decreased energy, due to mood and cardiac difficulties, difficulty making decisions, decreased interest in hunting, anxiety, and difficulty in adapting to stressful circumstances. He indicated, however, that he continued to enjoy pleasurable activities, such as accompanying his wife on errands. The Veteran also reported a good relationship with his four sons and the daughter-in-law with whom he resides and stated that he had three or four good friendships. Overall, the examiner determined that the Veteran's PTSD resulted in occupational and social impairment with reduced reliability and productivity. A GAF score of 60 was assigned, and the examiner indicated that the severity of the Veteran's PTSD appeared to be unchanged relative to his most recent VA examination in 2011, noting a worsening of some symptoms, but amelioration of others. Upon review of the evidence, the Board finds that prior to November 1, 2011, the Veteran's PTSD more nearly approximated the criteria required for a 50 percent rating. Although the relevant evidence suggests that the Veteran's symptoms were mild, as evidenced by GAF scores of 62 and 65, a closer review of the record demonstrates that the severity of the Veteran's symptoms, and their resulting impact on his social and occupational functioning, was diminished due to an increased dosage of medication used to treat his PTSD. As recently held by the United States Court of Appeals for Veterans Claims (Court), "the Board may not deny entitlement to a higher rating on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria." Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). As the current version of DC 9411 does not contemplate the effects of medication in alleviating symptoms of PTSD, the Board is now precluded from considering the relief afforded by the Veteran's medication in evaluating the severity of his PTSD and its effect on his social and occupational functioning. Id. As noted by the VA examiner in February 2010, it was likely that the Veteran experienced more severe symptoms prior to being prescribed medication for his PTSD. A review of the Veteran's VA treatment records shows that his dosage of Citalopram was increased sometime around November 2009. Prior to that time, the Veteran's VA treatment records suggest that his symptoms were moderate in nature, as evidenced by GAF scores of 60. The record also shows that the Veteran's medication was decreased sometime in or around November 2011, after which the Veteran has testified that he experienced an increased in symptom severity. Notably, the November 2011 VA examiner also assigned a GAF score of 60. In assessing the evidence of record, it is important to note that the GAF is a scale 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) (DSM-IV). A GAF score of 51-60 is defined as: "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 61-70 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." In this case, the Board finds probative the GAF scores recorded before and after the Veteran's medication was increased and decreased, which scores suggest that the apparent mild impact of the Veteran's PTSD on his social and occupational functioning prior to November 1, 2011, was indeed due to the ameliorative effects of his medication. Further, the Veteran's reported symptomatology has remained relatively consistent throughout the appeal period, which symptomatology VA examiners in November 2011 and February 2013 found to cause clinically significant distress or impairment in social, occupation, and other important areas of functioning and to result in occupational and social impairment with reduced reliability and productivity, which is the criteria for a 50 percent rating. Accordingly, when reasonable doubt is resolved in the Veteran's favor and when the ameliorative effects of the Veteran's medication are disregarded, the Board finds that the Veteran's overall symptomatology, as evidenced by the relevant VA examination reports, treatment records, and GAF scores reflects a moderate disability warranting the assignment of a 50 percent disability rating prior to November 1, 2011. The Board cannot, however, find that the evidence of record supports a rating greater than 50 percent during this time. Indeed, entitlement to a 70 percent rating "requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation." Vazques-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). During the relevant time period, the Veteran exhibited few symptoms of like kind to those associated with a 70 percent disability rating, save for unprovoked irritability and some difficulty adapting to stressful situations. The Veteran specifically denied suicidal or homicidal impulse or ideation, symptoms of mania, panic disorder, agoraphobia, delusions, and hallucinations. Further, he was noted to be able to handle daily living skills, maintain personal hygiene, maintain good relationships with his wife and family, and maintain a network of friends. His insight and judgment were also described as adequate or good. Accordingly, because the evidence fails to show total impairment, or deficiencies in most areas due to symptoms equivalent in severity to those listed in the rating criteria for a 70 percent rating, the Board finds that a rating is excess of 50 percent is not warranted. The Board also finds that total impairment has not been shown at any point since November 1, 2011. Accordingly, there is no basis upon which to assign a rating greater than the currently assigned 70 percent. Notably, the Veteran has maintained a relationship with his wife for over 50 years, reports several close friends with whom he associates, and stays in contact with his children and grandchildren. The Board acknowledges that the Veteran has reported strained familial relationships due to his PTSD symptoms, but finds that overall the evidence fails to demonstrate total social impairment, as it is clear that the Veteran has the ability to maintain relationships, evidencing a level of social functioning. Thus, regardless of whether the Veteran's PTSD results in total occupational impairment, because the evidence fails to establish that it has caused total impairment, a rating greater than 70 percent is not warranted for the period since November 1, 2011. See 38 C.F.R. § 4.130, DC 9411 (requiring "[t]otal occupational and social impairment" to establish entitlement to a 100 percent disability evaluation under the general rating formula for mental disorders) (emphasis added). In making the above findings, the Board has considered the doctrine of reasonable doubt, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The Board is unable to identify a reasonable basis for granting a rating in excess of 50 percent for the Veteran's PTSD prior to November 1, 2011, or in excess of 70 percent thereafter. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990); 38 C.F.R. § 3.102 (2012). The above determinations are also based upon consideration of applicable rating provisions. The Board also finds that the Veteran's disability level and symptomatology is adequately described by the rating criteria. Indeed, the Veteran's symptomatology, to include irritability, sleep issues, anger outbursts, depressed mood, diminished concentration, hypervigilance, heightened startle response, and decreased concentration, are exactly the type of symptomatology contemplated by the rating criteria set forth in DC 9411. Without sufficient evidence reflecting that the Veteran's disability picture is so "exceptional or unusual," such that the "the available scheduler evaluation for [his service-connected psychiatric disability] are inadequate," referral for a determination of whether the Veteran's disability picture requires the assignment of an extra-schedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008); 38 C.F.R. § 3.321(b)(1) (2012). ORDER Entitlement to a disability rating for PTSD of 50 percent from November 4, 2009, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an evaluation for PTSD in excess of 70 percent from November 1, 2011, is denied. REMAND In January 2013, the Board remanded the issue of entitlement to TDIU for further development. Specifically, the Board directed that the Veteran was to be afforded a VA examination for the purpose of determining, among other things, whether the Veteran was unemployable on account of his psychiatric disability. As part of the February 2013 VA examination, the examiner considered the Veteran's work history, which was described as a 30 plus year history of stable and consistent employment prior to retirement in 1993. The examiner noted that the Veteran acknowledged some difficulties managing co-worker relationships on account of irritability due to PTSD, but indicated that management was quite happy with his performance and that he was only reprimanded once. Based on this work history, the examiner stated that there was no evidence to suggest that the Veteran is incapable of employment based on his history of PTSD alone. The examiner opined, rather, that it was likely that the Veteran's advanced age, current health, and sensory impairment would represent a greater barrier to gainful employment. Upon review of the VA examiner's opinion, the Board finds that it is inadequate to rely upon in this case. This is so because it does not appear as though the examiner considered the current level of severity of the Veteran's PTSD in opining that he would not be incapable of employment. Rather, the examiner seeming based his opinion on the fact that the Veteran's PTSD did not impact his work performance while he was still working. However, the Veteran ceased working in 1993 and has consistently maintained that his PTSD symptoms have worsened in the recent past, which assertion is supported by the assignment of staged ratings in this case. Thus, because it cannot be concluded that the VA examiner considered the Veteran's current level of disability when forming her opinion regarding the Veteran's employability, the Board finds that the matter must be remanded for a new opinion that takes into consideration all of the relevant evidence, which includes evidence regarding the current level of disability. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Further, because the examiner indicated that the Veteran's "sensory impairments," previously noted in the examination report to consist of vision and hearing loss, and because the Veteran is service connected for hearing loss and tinnitus, the examiner must consider all of the Veteran's service-connected disabilities in rendering the opinion regarding employability. Accordingly, the case is REMANDED to the agency of original jurisdiction (AOJ) for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The AOJ should request that the examiner who provided the February 2013 examination in connection with the Veteran's claim for a higher initial rating for PTSD, if she is still available, provide an addendum that addresses whether the Veteran's service-connected disabilities (PTSD, hearing loss, and tinnitus), in combination with one another, renders him unable to secure or follow substantially gainful employment consistent with his education and occupational experience. Such opinion should be based on a review of the claims folder, to include the information regarding the Veteran's employment and educational history contained therein. In setting forth the addendum opinion, the examiner must discuss the current level of severity of the Veteran's service-connected disabilities. In other words, the examiner may not rely solely on the occupational impact of the Veteran's PTSD at the time that he was working. (If the February 2013 is no longer available, the AOJ should refer the claims file for review by a VA clinician with the appropriate expertise for an opinion on this question. The Veteran's claims file, including a copy of this remand, must be made available to the reviewer for review in connection with the requested opinion.) 2. The AOJ must ensure that the medical examination report complies with this remand and the questions presented in the request, especially with regard to the request that the VA examiner consider the current level of severity of the Veteran's service-connected disabilities. If the report is insufficient, it must be returned to the examiner for necessary corrective action, as appropriate. 3. After undertaking any other development deemed appropriate, the AOJ should readjudicate the issue of entitlement to TDIU. If the benefit sought is not granted, the Veteran should be furnished with a supplemental statement of the case (SSOC) and afforded an opportunity to respond before the record is returned to the Board for further review. Thereafter, the case should be returned to the Board for further appellate review. No action is required of the Veteran until he is notified. 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). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs