Citation Nr: 1320985 Decision Date: 06/28/13 Archive Date: 07/05/13 DOCKET NO. 08-29 939A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a right knee disorder. 2. Entitlement to service connection for a left knee disorder. 3. Entitlement to service connection for a back disorder. 4. Entitlement to an initial evaluation in excess of 30 percent and an evaluation in excess of 50 percent from December 8, 2008 for service-connected posttraumatic stress disorder (PTSD). 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD A. G. Alderman, Counsel INTRODUCTION Please note 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 Veteran served on active duty from December 2003 to March 2005 and from February 2012 to August 2012. He served with the U.S. Army Reserves from January 1988 to August 2012, including periods of active duty for training from January to April 1988 and from June 1990 to October 1990. He also had periods of inactive duty for training. These matters come before the Board of Veterans' Appeals (Board) on appeal from March 2008 (service connection issues) and January 2009 (increased rating issue) rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In January 2009, the RO increased the evaluation assigned for the Veteran's service-connected PTSD to 50 percent, effective from December 8, 2008. As the Veteran is in receipt of less than the maximum schedular rating for this disorder, the matter remains in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran provided testimony at a hearing conducted via videoconference in February 2011. A transcript of this hearing, conducted by the undersigned Veterans Law Judge, is of record. In June 2011, the Board remanded this matter to obtain service treatment records, schedule VA examinations, issue proper notice, and obtain private treatment records. As discussed below, the Board finds that the requested development has not been substantially completed; therefore, a remand of the service connection claims is necessary for additional development. See Stegall v. West, 11 Vet. App. 268 (1998). The issue of entitlement to service connection for a cervical spine disability has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for bilateral knee disorders, a back disorder, and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to August 2010, the Veteran's PTSD symptoms did not cause impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking or mood due to symptoms such as suicidal ideation, obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships 2. As of August 2010, the Veteran's PTSD symptoms did not cause 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; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name CONCLUSION OF LAW The criteria for an initial evaluation of 50 percent and for a 70 percent rating from August 2010 for service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Duties to Notify and Assist Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Notice must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103(a); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Veteran filed claims seeking service connection for PTSD, bilateral knee disorders, and a back disorder in November 2007. The duty to notify was satisfied by way of a letter sent to the Veteran in December 2007 that fully addressed all notice elements and was sent prior to the initial RO decision in this matter. The letter informed the Veteran of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. In March 2008, the RO granted service connection for PTSD, assigned a 30 percent rating, and denied the claims seeking service connection for the knees and back. The Veteran submitted a notice of disagreement (NOD) for the service connection claims but not for PTSD. Instead, in December 2008, prior to the expiration of the one-year appeal period, the Veteran filed a claim for an increased rating for PTSD. He also submitted new evidence showing a worsening of his PTSD, i.e. losing his job allegedly due to PTSD symptoms, within the one-year appellate period. New and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim that was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Therefore, the March 2008 rating decision did not become final and the Board will consider whether the Veteran is entitled to an initial evaluation in excess of 30 percent and an evaluation in excess of 50 percent from December 8, 2008. The duty to assist was also met in this case. Available service treatment records are in the claims file. Notably, service treatment records for all periods of active service have not been obtained and associated with the claims file and the RO has not made a formal finding of unavailability of records; however, since service connection for PTSD has been granted, the Veteran is not prejudiced by this oversight in as much as it pertains to the PTSD claim. VA and private medical records have been secured. VA examinations for PTSD were obtained in February 2008, January 2009, and July 2011. 38 C.F.R. § 3.159(c) (4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations obtained in this case are adequate as the examination reports contain descriptions of the symptomatology related to the service-connected PTSD. While the February 2008 and January 2009 examiners did not indicate review of the Veteran's claims file, the July 2011 examiner did review the claims file and provide a detailed report. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486. Increased Ratings Generally, disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered because of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1 , 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where a veteran appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of the veteran's disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). However, where VA's adjudication of a claim for increase is lengthy and factual findings show distinct periods where the service-connected disability exhibits symptoms, which would warrant different ratings, different or "staged" ratings may be assigned for such different periods. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). In determining the applicable disability rating, pertinent regulations do not require that all cases show all findings specified by the Rating Schedule; rather, it is expected in all cases that the findings be sufficiently characteristic as to identify the disease and the resulting disability, and above all, to coordinate the impairment of function with the rating. 38 C.F.R. § 4.21 (2012). Therefore, with respect to each of the claims herein, the Board will consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The RO granted an initial 30 percent evaluation and a 50 percent evaluation from December 8, 2008 for Veteran's service-connected PTSD. The disability is rated under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411. Evaluations are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase 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. Under the provisions for rating psychiatric disorders, a 30 percent evaluation is contemplated when there is 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). Id. A 50 percent evaluation is warranted where 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; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is 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; intermittently illogical obscure, or irrelevant speech; 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. A 100 percent evaluation is warranted where there is 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; memory loss for names of close relatives, own occupation, or own name. Id. The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown , 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). While not determinative, a GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Under the DSM-IV, GAF scores ranging between 61 to 70 reflect 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. Scores ranging from 51 to 60 reflect more 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). Scores ranging from 41 to 50 reflect 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). The evidence shows that in June 2006, the Veteran reported anger and difficulty controlling his emotions. He was stressed about keeping his job because he was paid well and his wife did not work. In February 2008, the Veteran had a VA Compensation and Pension examination. The report indicates that the Veteran experienced distressing recollections, dreams, and nightmares involving in-service traumatic events. When exposed to internal or external cues relating to the traumatic events, he reexperienced the events and had psychological distress. He avoided triggers such as people, places, and activities, and he avoided crowds. He also avoided talking about the traumatic events, and in fact, could not recall important aspects of the events. His interest and participation in activities had diminished and at times, he felt detached or estranged from others. The examiner observed restricted range of affect. The Veteran said he had become more irritable, angry, and distrustful of people. He also reported increased arousal, including difficulty falling or staying asleep, increased irritability and anger, hypervigilence, and exaggerated startle response. He said he becomes upset easily and has scared people. He also had considerable difficulty concentrating. The examiner observed that the Veteran's mood was "so-so". See Examination Report, February 27, 2008, page 5. No abnormalities of affect, thinking, recall, speech, or memory were observed. The Veteran denied homicidal, suicidal and paranoid ideation as well as hallucinations. He did not respond to imperceptible stimuli. The examiner said his attention span and concentration were fair while social judgment, formal judgment, insight, and reliability were good. The examiner opined that the Veteran's stressors had affected his emotional wellbeing and his ability to interact adequately with his environment and enjoy life. The examiner noted that the Veteran held a well-paying job, had a good occupational history, and had a successful marriage and raised two children. The examiner said PTSD did not interfere with the Veteran's ability to perform activities of daily living. He had no difficulty establishing and maintaining effective work, school and social relationships and had no difficulty maintaining effective family role functioning. The examiner noted occasional interference with recreation or leisurely pursuits because of his medical problems. A GAF score of 80 was assigned. November and December 2008 VA treatment records document the Veteran's complaints of memory changes and indicate that he lost his job in May 2008. The Veteran's supervisor did not tell him why his employment was terminated; however, he heard rumors that he lost his job because he threatened the owner - an allegation that he denied. The Veteran had a consult with a speech pathologist in December 2008. Neurobehavioral symptoms included headaches; hearing and vision problems; noise and light sensitivity; fatigue; sleep difficulty; poor concentration, attention and memory; difficulty making decisions; anxiety and tension; and depression and sadness. Examples of memory problems included misplacing items and forgetting why he walked into certain rooms. The Veteran said he lost his job but was involved with the Lions Club. The provider found that the memory deficits were possibly related to PTSD and anxiety other than PTSD. Traumatic brain injury could not be determined. The provider was unable to tell if the Veteran lost his job due to cognitive factors. She observed that the Veteran was on edge In January 2009, the Veteran reported that his PTSD symptoms were causing severe problems at home, especially with his son. His son hated living with him and accelerated his schooling so that he could graduate early and leave home. Regarding his former employment, the Veteran said he had conflict with another local executive; however, he said his termination was a surprise. The Veteran had another VA Compensation and Pension examination in January 2009, which was performed by QTC. The Veteran reported sleep problems, nightmares, intrusive thoughts, hypervigilence, and flashbacks. He said the symptoms were constant and affected his total daily functioning, causing irritability and anger outbursts. He had a job but lacked motivation to go to work and had trouble getting along with coworkers. The examiner noted a disturbance of motivation and mood and that the Veteran lacked motivation to help his wife with everyday chores. Panic attacks occurred weekly. The examiner did not observe abnormalities with orientation, appearance, hygiene, behavior, communication, speech, concentration, thought process, thinking, memory or judgment. He did not express suicidal or homicidal ideations or delusions. The examiner assigned a GAF score of 56 and said that the Veteran had difficulty establishing and maintaining effective work/school and social relationships because he was irritable, making it difficult to get along with others. He also had difficulty maintaining effective family role functioning because he was often in conflict with his children due to his PTSD symptoms. The examiner found that the Veteran had occasional interference with recreation or leisurely pursuits. A March 2009 VA treatment record shows the Veteran reported occasional depression and suicidal ideation without intent. He said he was unemployed and had been since May 2008. The provider observed adequate insight and judgment. The provider diagnosed major depression in connection with PTSD and assigned a GAF score of 50. A March 2009 VA outpatient assessment shows sleep problems; hypervigilence; depression; anxiety; stress; irritability; anger outbursts; occasional nightmares, flashbacks; intrusive thoughts; avoidance of thoughts, feelings, or talks about the trauma; diminished interest in activities; feelings of detachment or estrangement from others; restricted range of emotions; feelings of foreshortened future; difficulty concentrating; and crying spells. The Veteran said he was hypervigilent, withdraws, and disliked large crowds and new experiences. He said he withdrew from his education program because he was unable to deal with stress. He had been unemployed for about a year and had difficulty maintaining employment. He was active with the Lions Boys' Ranch. He said his energy level had significantly decreased after returning from Iraq and that he was no longer interested in things, such as his former employment, yard work, or going to the lake. He had thoughts of suicide but no intent to act. The provider observed labile, anxious, and tense mood and affect. No other abnormalities were noted. A GAF score of 58 was assigned. A June 2009 VA treatment record indicates that the Veteran went on vacation but experienced increased hyper arousal. His stress level had increased because he had to complete a psychiatric evaluation for the U.S. Army after filling out a form endorsing occasional suicidal ideation. In August 2009, the Veteran said he experienced increased depression and asked for an increase in one of his medications. He interviewed for a job but did not get it. The provider observed that the Veteran had a positive attitude towards job hunting, but still struggled with a sense of foreshortened future, relationship difficulties, and ongoing irritability. A December 2009 VA psychiatry note indicates that the Veteran was getting along well with his family. He was less irritable. The provider noted improvement of symptoms with medication. A GAF score of 60 was assigned. February 2010 psychiatry notes indicate that the Veteran quit his consulting job due to questionable practices on the part of the owner of the business. He said his depression and anxiety had remained stable but that his family conflict was a concern. His wife started seeing a counselor and was considering a separation. He reported a decline in intimacy and acknowledged that his anger had been problematic. A GAF score of 58 was also assigned in February 2010. See VA Psychiatry Note, February 22, 2010. In March 2010, the Veteran reported that he and his wife were divorcing. The provider said his mood was mildly dsyphoric and that affect was consistent with this. August 2010 treatment records show increased depression and note his struggle to deal with his divorce and future employment prospects, i.e. taking a deployment or trying to find a job. The Veteran reported increased distance from his children. The provider said his mood was mildly dsyphoric and affect was consistent with this. In October 2010, the Veteran said he was working but felt stress due to the divorce and being separated from his kids. His mood was good and the Veteran said he was ready to discontinue treatment. In January 2011, the Veteran said he felt sad. He was still in the process of divorcing from his wife. He was also working a temporary job. Since going through the divorce, he reported worsening of his PTSD symptoms. He noted frequent thoughts of Iraq and survivor's guilt as well as an increase in alcohol intake to self-medicate. The provider noted tearful, dsyphoric affect and fair insight and judgment. A GAF score of 55 was assigned. During his Board hearing, the Veteran testified that he should be rated 70 percent disabled. He said he was never informed of the reasons why he was terminated from his regular employment in 2008. He had heard that his coworkers were on edge and that they could tell when he was upset or angry. He said he has not had a job in five years and cannot not handle the anger and stress. He and his wife divorced and his children were distant because they were afraid of him. Prior to Iraq, he and his family had a good relationship. After returning from deployment, he said he secluded himself at home but tried to get out in public. He said he does not have personal relationships outside of a few people he served with. He described suicidal tendencies but swore that he would not follow through. Regarding memory loss, he reported incidents where he would start to do something at his temporary job but forget why he left his desk. The Veteran had a VA Compensation and Pension examination in July 2011. He told the examiner that his family felt like he did not come back from his deployment. He said he experienced intrusive thoughts and recollections of events two to three times daily, nightly distressing dreams, and flashbacks once or twice per week. He tried to avoid, thoughts, conversations, and feelings related to the in-service trauma and forced himself to do normal activities, such as shopping. He continued to have difficulty with crowds and avoided family and social get-togethers. He felt detached and estranged from others and felt like he was already dead. He thought a lot about suicide but did not have intent, plans, or self-directed violence. His anger and irritability had improved but he continued to have problems concentrating. Since his divorce in 2010, he had been living out of his vehicle. He had been working for a company for about a year but was having difficulty showing up for work. His supervisor had reprimanded him because of his behavior with customers, including two instances when he became angry, irritable, and inappropriate. He also reported that he was having performance problems in his management of soldiers, particularly during maneuvers. His relationship with his kids was strained and he was not involved in a personal relationship. The examiner observed that the Veteran arrived early, was willing to talk, and had logical and sequential thought process. He had some tangential storytelling. His mood was depressed with congruent affect and he became tearful and wept openly on five occasions when describing current functioning and military trauma. The examiner did not observe impairment of immediate, recent, or remote memory but noted suicidal ideation without intent. Sleep problems were also indicated. The examiner noted recurrent alcohol abuse that appeared to be self-medication. Included in the report are summarized psychological testing results which indicate stressful dreams, disturbing memories, reexperiencing symptoms, physical reaction to reminders of the in-service trauma, avoidance of thinking and talking about the in-service trauma, avoidance of activities that remind him of the trauma, and feeling of distance from others. Answers to the questions indicate that he was extremely emotional with irritability and anger outbursts and difficulty concentrating. He was also super alert and jumpy. The depression testing showed severe depression with feelings of pessimism, past failure, guilty feeling, self dislike, agitation, indecisiveness, worthlessness, loss of energy, irritability, changes in appetite, and loss of interest in sex. Moderate symptoms include sadness, loss of pleasure, self-criticalness, suicidal thoughts, loss of interest, changes in sleeping pattern, concentration difficulties, tiredness, and fatigue. Mild symptoms include crying. The examiner diagnosed PTSD; major depression, recurrent, moderate; alcohol abuse, continuous; and nicotine dependence in early remission. A GAF score of 55 was assigned. In the discussion, the examiner noted the Veteran's difficulties at work, homelessness, and problems with family and relationship functioning and that the Veteran needed ongoing medication and psychosocial treatment for PTSD. In August 2012, upon returning from deployment, the Veteran said he did not perform as well in Afghanistan. His memory and focus were worse, making it difficult to handle stress. He said he performed poorer than he would have liked and that his evaluations were average. The provider said he was managing with the disappointment in himself well. Prior to deploying, the Veteran started a relationship and moved in with her upon returning. His children were adapting to the divorce and he was on positive terms with them. In October 2012, the Veteran told his provider that he was having anger problems. In November 2012, the Veteran reported stress related to the effect of his medical issues on work and that the stress had exacerbated his symptoms. The provider noted anxious mood and affect consistent with mood. In December 2012, the Veteran reported mild increase in depression related to the holidays as well as continued stress about his medical conditions. His mood was dsyphoric with consistent affect. By January 2013, he had determined that complaints of dizziness and vertigo-like symptoms were related to stress. He reported an increase in anxiety over the holidays and said he continues to struggle with anxiety symptoms, such as increased tension, irritability, and difficulty managing stress. The provider observed euthymic mood and consistent affect. In a March 2013 statement, the Veteran pointed out that his 22-year marriage ended and that he was unemployed for two years because of his PTSD. He lost a career that had spanned 30 years and earned in excess of six figures per year. He now struggles to keep a job for more than nine months and make more than fifteen thousand dollars per year. He also said he was not examined by VA in July 2011 and was told that the appointment was cancelled upon arrival. He noted his impairments in thought processes and communication, and that his attempts to block thoughts have caused him to lose momentary thought. His loss of filter, or inappropriate behavior has almost caused him to lose his job twice in the past nine months. He is now on permanent probation at work. He noted an increase in his persistent thoughts to hurt himself and others; the thoughts are constant. He is intermittently unable to perform activities of daily living and work. His personal hygiene has suffered and he finds himself stopping and standing still for periods. He has daily episodes of disorientation as to times and places. He also forgets to complete tasks, even once he has started them. His girlfriend, children and employer have started to notice his behavior. He said his anger and obsessional rituals interfere with his ability to work with others and interact with his family. He reported an inability to maintain a relationship with his former wife, his kids, or his mother. The Board has reviewed all of the evidence, and finds that an initial evaluation of 50 percent is warranted. While the February 2008 VA examination indicates that the Veteran was employed and exhibited only occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, his condition either quickly deteriorated or was not accurately portrayed in February 2008, evidenced by the Veteran's loss of employment in May 2008 due to allegedly threatening a supervisor. Thus, the Board finds that the Veteran's disability picture more closely resembles the criteria for a 50 percent rating for occupational and social impairment with reduced reliability and productivity. Consequently, an initial 50 percent disability evaluation is warranted. A rating in excess of 50 percent is not warranted prior to August 2010, discussed below, because the Veteran's symptoms did not cause impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking or mood due to symptoms such as suicidal ideation, obsessional rituals which interfere with routine activities; intermittently illogical obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; inability to establish and maintain effective relationships. Id. While the Veteran may have experienced some of these symptoms, such as occasional suicidal ideation, depression, stress, and difficulties with work and relationships, the Board notes that the symptoms for a 50 percent and 70 percent rating overlap and finds that the symptoms are not of the severity to warrant a 70 percent rating, or higher, prior to August 2010. The Board finds that a 70 percent rating is warranted from August 2010. Records from this period show worsening depression, increased strain between the Veteran and his kids, increased stress due to the divorce process, survivor's guilt, and more importantly, the onset of alcohol abuse to self-medicate. Notably, the January 2011 provider observed only fair insight and assigned a GAF score of 55. The records also show an increase in suicidal thinking as well as continued bouts of anger and irritability, which manifested at his place of employment, resulting in his permanent probation. Moreover, testing conducted during the July 2011 VA examination indicates that the Veteran is extremely emotional with irritability and anger outbursts, as well as difficulty concentrating. Testing also showed severe depression. Consequently, the Board finds that a 70 percent rating is warranted from August 2010. A rating in excess of 70 percent is not warranted at any time during the pendency of the claim because the evidence does not show that the Veteran's PTSD causes total occupational and social impairment. He has not endorsed and the medical evidence does not show gross impairment in thought processes or communication, persistent delusions or hallucinations, or memory loss for names of close relatives, own occupation, or own name. While suicidal ideation has been frequently noted in the medical records, the Veteran has continually asserted that he has no intent to kill himself. In his March 2013 statement, he said he had an increase in thoughts to hurt others; however, he did not indicate intent to do so. He also notes that his personal hygiene is suffering; however, he does not indicate that he is unable to maintain minimal personal hygiene. While he has endorsed symptoms of inappropriate behavior at work, the Board cannot find that the levels described rise to the level of "grossly inappropriate" at this time. Even if the Board considers the described behavior "grossly inappropriate", this symptom alone is not sufficient to support a total rating. The Board has also considered his current claims of momentarily losing thought, episodes of disorientation as to times and places, memory complaints, and difficulties with his family relationships; however, these symptoms are more appropriately rated under the 70 percent rating criteria. The Board has also considered whether a referral for extra-schedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, 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. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993)(a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extra-schedular consideration referral). The evaluation for the Veteran's PTSD is adequate as the schedular criteria adequately encompass the Veteran's symptoms, as described in detail above. Moreover, the Veteran has submitted no evidence showing that this disorder has markedly interfered with his employment status beyond that interference contemplated by the assigned evaluation, and there is no indication that this disorder has necessitated frequent, or indeed any, periods of hospitalization during the pendency of this appeal. As such, the Board is not required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1), which concern the assignment of extra-schedular evaluations in "exceptional" cases. See Thun, 22 Vet. App. 111. ORDER An initial evaluation of 50 percent is granted for service-connected PTSD and a 70 percent evaluation is granted from August 2010. REMAND Reasons for Remand: To obtain service treatment records; to obtain adequate VA etiology opinions; to obtain private treatment records; and to adjudicate the TDIU claim. First, in the June 2011 remand, the Board ordered the RO/AMC to attempt to obtain all available service treatment records not yet associated with the claims file. The claims file includes electronic mail correspondence between VA personnel dated November 2012 concerning the Veteran's service treatment records. The final correspondence indicates that the Veteran's records could not be located and that the filing system had been "FLAGGED" to show VA's interest in the records in case the records are located in the future. See Electronic Mail Correspondence, November 15, 2012. Unfortunately, the RO/AMC did not issue a formal finding of unavailability of records. 38 C.F.R. § 3.159(c)(2); M21-1MR, Part I, Subpart 1, C.5.f. Since this claim must be remanded for other matters, the Board finds that the RO should make another attempt to obtain these records or make a formal finding that a request for such records would be futile. Second, the February 2013 VA examination reports addressing the etiology of the bilateral knee disabilities and spine disability are inadequate for rating purposes. Notably, the initial examiner, a nurse practitioner, addressed only whether the Veteran's bilateral knee disabilities and back disability are related to his parachute jumps. Her opinions are supported by adequate rationale. The RO/AMC obtained addendum opinions from a medical doctor addressing the issue of whether the bilateral knee disabilities and back disability were caused or aggravated by an in-service injury, event, or illness. Unfortunately, these opinions are not supported by adequate rationale. In this case, the Veteran has consistently stated that he initially injured his knees when performing his parachuting duties. Personnel records show he was awarded the parachute badge. He has also consistently maintained that he initially injured his back in 2004 while completing an obstacle course run and reinjured his back and knees in 2012 when he fell down a set of stairs. Very few service treatment records have been obtained for review. The available records show that the Veteran was placed on medical profile in March 2004 for a rib contusion and strain. A copy of the Physical Profile was submitted with a notation that the disability was later determined to be low neck, mid-back, and lower "5L". The note states that the Veteran had pain in the mid-back, which caused pain when breathing. The pain was originally thought to be due to his ribs. A January 2005 personnel record indicates that the Veteran was injured in the line of duty. A February 2005 Post-Deployment Health Assessment form shows that the Veteran checked the box indicating swollen, stiff or painful joints and the box for back pain. A check box specifically addressing the knees was not provided on the form. A Statement of Medical Examination and Duty Status, dated September 2007, shows that the Veteran experienced painful joints and back pain, among other symptoms. The document indicates that the Veteran needed further medical evaluation. Also of record is a Post Deployment Health Reassessment form, dated April 2007. This document shows that the Veteran checked the box indicating swollen, stiff or painful joints and box indicating back pain related to his deployment. He also said he was physically injured while deployed. Notably, the form did not provide a check box addressing the knees. In the addendum opinions, the medical doctor opined that the Veteran's bilateral knee disabilities and back disability were less likely as not incurred in or caused or aggravated by the claimed in-service injury, event, or illness. The examiner said the active duty medical records did not contain evaluations for complaints or injuries to the Veteran's thoracolumbar spine. He noted the 1987 enlistment physical, which shows a history of a left knee injury, and a July 1989 record, which shows treatment of a right knee injury that occurred prior to airborne training and was assessed as normal. The examiner found no subsequent history of knee problems documented in the available service treatment records while on active duty. He did not address the February 2005 or September 2007 Post-Deployment Health Assessment forms, the line of duty determination, the medical profile, or the parachute badge. Further, and more importantly since service treatment records have not been obtained, the examiner did not address the Veteran's complaints of painful knees due to parachute jumps, his reports of injury to his back when falling on an obstacle course, or his reports of injuring his back and knees when falling down stairs in Afghanistan. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). In this case, the Veteran is competent to report his in-service injuries. Thus, the examiner had a duty to consider his statements when rendering the opinions. Where a medical examination does not contain sufficient detail to decide the claim on appeal, the Board must return the report as inadequate for evaluation purposes. Hayes v. Brown, 9 Vet. App. 67, 73 (1996); 38 C.F.R. § 4.2. In this case, since the VA examiner did not address the Veteran's lay statements and the limited available service treatment records, such as the post deployment questionnaires, the line of duty determination, and the physical profile form, a remand is necessary to obtain adequate opinions. Third, in the June 2011 remand, the Board instructed that attempts should be made to obtain treatment records from private provider, T.Y., D.C. In March 2011, the Veteran submitted three treatment records that pertain to the spine; however, the records do not indicate the provider of medical care. Thus, the Board cannot determine if these records are from T.Y., D.C. or another provider. Accordingly, the Board finds that another attempt should be made to obtain treatment records from T.Y., D.C. Finally, while the appeal was pending, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a TDIU claim is part and parcel of an increased-rating claim when raised by the record. The Board has jurisdiction to consider the Veteran's possible entitlement to TDIU in this circumstance when the issue is raised by assertion or reasonably indicated by the evidence and is predicated at least in part on the severity of the service-connected disability in question, regardless of whether the RO has expressly addressed this additional issue. See VAOPGCPREC 6-96 (Aug. 16, 1996). See also Caffrey v. Brown, 6 Vet. App. 377 (1994); Fanning v. Brown, 4 Vet. App. 225, 229 (1993); EF v. Derwinski, 1 Vet. App. 324 (1991). In this case, in March 2013, the Veteran specifically said he was unemployed for two years due to his PTSD symptoms and insinuates that he has been otherwise unable to maintain substantially gainful employment due to the condition. Therefore, the Board finds that the issue of TDIU has been raised and that it must be remanded for initial development. Accordingly, the case is REMANDED 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 RO/AMC should consider whether the Veteran is entitled to TDIU under the provisions of 38 C.F.R. § 4.16, based on impairment attributable to his service-connected disabilities, to include sending the Veteran an application for TDIU and an appropriate notification letter. In so doing, the RO may decide to pursue further development of the Veteran's employment history, or obtain additional medical evidence or medical opinion, as is deemed necessary. 2. The RO/AMC should obtain updated treatment records from the Oklahoma City VA Medical Center and associate them with the claims file. 3. The RO/AMC should attempt to obtain service treatment records (particularly related to the periods of active service from December 2003 to March 2005 and February 2012 to August 2012) not yet associated with the claims folder. If the records are not obtained after search possibilities have been exhausted, make a formal finding of the unavailability of service treatment records. The formal findings must detail all actions undertaken in the records search. 38 C.F.R. § 3.159(c)(2). Inform the Veteran about the missing service treatment records, of the efforts made to obtain the records, and of any additional efforts that will be made with regard to his appeals. 4. The RO/AMC should obtain copies of medical records pertaining to all chiropractic treatment provided to the Veteran by T.Y., D.C. To assist in this development, the Veteran should be supplied a VA Form 21-4142 (Authorization and Consent to Release Information). If the records cannot be obtained, the attempts to obtain them should be documented for the record, and the Veteran informed in writing. 5. After completing the above requested development, the RO/AMC should refer the Veteran's claims file, copies of pertinent records on Virtual VA, and a copy of this remand to the examiner that provided the February 2013 VA addendum opinion or, if he is unavailable, to another suitably qualified physician, for an addendum opinion indicating whether it is at least as likely as not (50 percent probability or more) that the Veteran's bilateral knee disabilities and spine disability had onset during, were caused by, or were aggravated by his periods of active service. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a conclusion as it is to find against it. The examiner is also informed that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The examiner must be informed that the Veteran is competent to report his in-service injuries and that the Veteran's statements must be considered and addressed in the rationale. The examiner should specifically address the 2005 and 2007 post deployment health assessment forms as well as the January 2005 line of duty determination and March 2004 physical profile. If another VA examination is deemed necessary in order to provide the requested opinions, such should be scheduled. 6. The Veteran is hereby notified that if he is scheduled for a VA examination, it is his responsibility to report and to cooperate in the development of the claims. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for any scheduled examination, documentation should be obtained which shows that notice scheduling the examination was sent to the last known address. It should also be indicated whether any notice that was sent was returned as undeliverable. 7. Thereafter, the RO/AMC must review the claims folder and ensure that the foregoing development actions, as well as any other indicated development, have been conducted and completed in full. If the response is deficient in any manner, the RO/AMC must implement corrective procedures. Stegall v. West, 11 Vet. App. 268 (1998). 8. Thereafter, and following any other indicated development, the RO/AMC should readjudicate the issues on appeal in light of all the evidence of record. If the appeal is denied in any respect, the Veteran and his representative should be provided a supplemental statement of the case in accordance with 38 U.S.C.A. § 7105 (West 2002) which includes a summary of any additional evidence submitted, applicable laws and regulations, and the reasons for the decision. The Veteran should then be afforded an applicable time to respond. The purpose of this REMAND is to ensure due process. The Board does not intimate any opinion as to the merits of the case, either favorable or unfavorable, at this time. No action is required of the appellant until he is notified. The case should then be returned to the Board, if in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ KATHLEEN K. GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs