Citation Nr: 1322907 Decision Date: 07/18/13 Archive Date: 07/24/13 DOCKET NO. 10-02 771 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut THE ISSUE Entitlement to an initial rating for posttraumatic stress disorder (PTSD) in excess of 50 percent. REPRESENTATION Appellant (the Veteran) is represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service in the U.S. Marine Corps from June 1967 to July 1969. The Veteran served in Vietnam and was awarded the Combat Action Ribbon and the Purple Heart. This appeal comes before the Board of Veterans' Appeals (Board) from a June 2008 rating decision of the RO in Hartford, Connecticut. In reviewing this case the Board has not only reviewed the physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the appeal has been accomplished. 2. For the entire period of this appeal, the Veteran's PTSD has been manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; there has not been total occupational and social impairment during any period. CONCLUSION OF LAW The criteria for an initial disability rating of 70 percent for PTSD have been met for the entire period on appeal; the criteria for any rating higher than 70 percent have not been met for any portion of that period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION In a June 2008 rating decision, service connection for PTSD was granted. An initial disability rating of 50 percent was assigned, effective February 27, 2008. The Veteran disagreed with the rating assigned and contends that the evidence was not fairly considered. He asserts that he has been unable to have a relationship with his former spouse and children since his divorce in 2000, and that another relationship ended in 2009. He also asserts that he has been unable to maintain effective work relationships, that he has unprovoked irritability, depression, and mood swings. Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When a claimant is awarded service connection and assigned an initial rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). In the process of evaluating a mental disorder, VA is required to consider a number of pertinent factors, such as the frequency, severity, and duration of a veteran's psychiatric symptoms. See 38 C.F.R. § 4.126. After consideration of these factors, and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering. The VA Secretary, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the VA Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). The schedular criteria incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. §§ 4.125, 4.130. In Vazquez-Claudio v. Shinseki, --- F.3d ----, 2013 WL 1395804 (Fed. Cir. April 2013), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Pertinent to the claim on appeal, the General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: A 10 percent rating is warranted for PTSD if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is warranted for PTSD if 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, or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted if it is productive of 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating, may be assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating contemplates 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. 38 C.F.R. 4.130, Diagnostic Code 9411. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). The Board acknowledges that service connection has not been granted for any psychiatric or mental disorder other than PTSD; however, the clinical evidence in this case establishes an additional AXIS I diagnosis of alcohol abuse. While this is not a service-connected disability, and the Board may compensate the Veteran only for his service-connected disability, the Board is legally precluded from differentiating between symptomatology attributed to a non service-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Here, the Veteran was afforded a VA examination in April 2008 and the examiner did not apportion the Veteran's symptoms between service-connected and nonservice-connected disabilities. There is no other medical evidence that attempts to apportion the psychiatric/mental symptoms among service-connected and nonservice-connected disabilities. Accordingly, at this time, the Board will not attempt to do so. However, this fact does not support his claim. After a review of all of the evidence, the Board finds that the evidence in favor of a higher initial rating of 70 percent has attained relative equipoise with the evidence against a higher rating. In essence, while not all of the specific symptom examples are demonstrated in the evidence, the Veteran's symptoms do result in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In particular, the Board notes findings on the April 2008 VA examination that the symptoms of PTSD negatively impact "all areas" of his daily functioning. The examiner also found that the Veteran displays symptoms that represent all symptom clusters of the disorder. In addition, the Board notes that the Veteran's GAF score on the VA examination is in the range from 41 to 50, which is consistent with 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). While the GAF scores do not directly correlate to specific ratings, it is notable that the characterization of scores at this level has a similar structure to the 70 percent rating criteria and includes many of the same symptom examples. This GAF score is also consistent with the VA examiner's finding of "severe symptoms." The examiner described symptoms of avoidance and irritability that have severely impacted the Veteran's social relationships and have negatively impacted his employment as well. This would appear to reflect a level of impairment that is greater than the 50 percent level, which reflects reduced reliability and productivity. Regarding deficiencies in work, the Veteran reported that he has worked for the same construction company for 38 years and has spent the past 20 years running a paving machine; however, he has been losing track of his ability to manage his machine at work and this has been very frustrating for him (April 2008 VA examination report). The Veteran also reported that his level of irritability has caused him to be an outcast from his work crew, many of which he became friends with over the years, and this has made it very difficult for him to work with them on a daily basis. He finds that he is constantly yelling at others at work, and in other situations as well. He stated that the work used to be good, easy, and fun. However, he reported that, after the war in Iraq started, he developed greater problems with his level of irritability and symptoms of avoidance, and reported that he would frequently yell at his work crew, stopped spending time with them after work, and rarely speaks with them (April 2008 VA examination report). The Veteran reported that he also finds that his inability to concentrate on the job has caused problems for him as well. He stated that he has been taking more time off work over the past 3 years. He is going to have a new supervisor and is concerned about how he will manage in his job. He reported limited desire to go to work, as he is frequently aggravated with the others there ("I can't stop yelling") and is also upset that he often feels "all by myself" (April 2008 VA examination report). Regarding deficiencies in family relations, the Veteran reported that he was married from 1970 to 2000 and has 2 daughters and one grandchild. He reported a history of problems with his anger in the marriage, as well as isolative behavior, and stated that he was often "shut off from my family." He indicated that these issues led to his divorce in 2000, and he described a distant relationship with his children currently (April 2008 VA examination). The Veteran reported that he has been seeing the same woman for the past 7 years and lives with her. He believes this relationship is ending, though he is trying to work it out. He reported that "she says I'm too angry and I don't want to do anything." He reported that he also does not show her any love and emotion. He described a history of frequent arguing, yelling at her, and pushing her in the past, when he was drinking. He reported that he will force himself to go out with his girlfriend, on occasion, though frequently feels extremely uncomfortable and wants to leave various situations. The Veteran reported that he is extremely emotionally detached from others, has a limited relationship with his girlfriend and family members, and is highly socially avoidant as well. He prefers to spend most of his time alone at home and has no interest in any leisure activities (April 2008 VA examination report). The Veteran's girlfriend reported that the Veteran becomes depressed, very angry, and displays violent actions, even towards her. He also isolates himself from everything around him (June 2009 letter). Regarding deficiencies in judgment, the Veteran reported that he has road-rage and will frequently scream at others while driving in his car (April 2008 VA examination). Regarding deficiencies in thinking, the Veteran reported significant gaps in his memory for portions of his multiple traumatic experiences. He stated that he has had difficulties with his concentration and that this appears to be worsening over time (April 2008 VA examination). Regarding deficiencies in mood, the Veteran reported chronic problems with irritability. He stated that he feels tense and irritable all of the time and describes involvement in frequent arguments with his girlfriend, and reported a history of some violence in their relationship in the past, particularly when he was drinking (April 2008 VA examination). In addition to the Veteran's level of irritability and his low frustration tolerance, he describes feeling highly anxious and depressed. He stated that there is no point to do anything and describes low motivation, hopelessness, limited appetite, and feelings of guilt (April 2008 VA examination report). The Veteran's girlfriend reported that the Veteran's actions can be explosive. He is always on the defense, looking out the window should a car come up to the house; he is prejudiced towards Asians and has walked out of restaurants on several occasions due to this. His temper is short and he can tolerate very little. When he gets these feelings he shuts off everyone and everything around him, he goes into his own little world as if he is playing out his role in Vietnam again (June 2009 letter). With resolution of all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's PTSD has resulted in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, at this time. Regarding the specific symptomatology contemplated for a 70 percent rating, the evidence demonstrates suicidal ideation, impaired impulse control (such as unprovoked irritability with periods of violence), difficulty in adapting to stressful circumstances (including work or a work-like setting), an inability to establish and maintain effective relationships, and depression affecting the ability to function independently, appropriately and effectively. There is also some evidence of obsessional rituals which interfere with routine activities, as the Veteran described constantly feeling wary of others, and he will look to secure his location (April 2008 VA examination report), at this time. Although there is no evidence consistent with speech intermittently illogical, obscure, or irrelevant, spatial disorientation, or neglect of personal appearance and hygiene, on the whole, the Board finds that the type and degree of symptomatology contemplated for a 70 percent rating are more nearly approximated than they are for a 50 percent rating at this time. The Board has also considered whether a 100 percent rating is warranted. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that the criteria for a 100 percent rating are not more nearly approximated than those for the 70 percent rating. There is no clinical evidence or assertion on the Veteran's part that he demonstrates symptoms like or similar to gross impairment in thought processes or communication, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), or disorientation to time or place. The Veteran's symptomatology is not of the type and degree contemplated by persistent delusions or hallucinations. The Veteran has reported seeing visions of the friend he lost in Vietnam and hearing explosions, including flashback-type experiences, particularly at night time (April 2009 VA examination). However, the examiner found that, although he reported some vivid visions and flashback-type experiences, there were no clear auditory or visual hallucinations. The Veteran's symptomatology is not of the type and degree contemplated by a persistent danger of hurting self or others. The Veteran reported that he has had suicidal thoughts, but stated, "I push it away quick." He reported no homicidal ideation and episodic passive suicidal thoughts. He described a history of pushing his girlfriend in the past when he was drinking. (April 2009 VA examination). The Board also acknowledges the description of the Veteran's girlfriend that the Veteran displays violent actions when he gets irritated; however, she did not describe any harm to her or anyone else (June 2009 letter). Rather, she reported that, when he gets these feelings he shuts off everyone and everything around him; he goes into his own little world as if he is playing out his role in Vietnam again. Based on these descriptions, the Board finds that, while the Veteran's irritability may be frequent and persistent, to the extent that there is ever any danger of harm to others, such danger of harm does not appear to be a persistent. The evidence demonstrates some memory impairment. The Veteran reported significant gaps in his memory for portions of his multiple traumatic experiences (April 2009 VA examination). However, there is no clinical evidence or assertion on the Veteran's part that there is memory loss for names of close relatives, his own occupation, or his own name. The Veteran's symptomatology is also not of the type and degree contemplated by grossly inappropriate behavior. There is no clinical evidence of such symptomatology, and the Veteran has not described such symptomatology. For the reasons described, the Board finds that, while the evidence for and against a 70 percent rating are in relative equipoise, the weight of the evidence is against an initial rating in excess of 70 percent for PTSD. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2012), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the schedular rating criteria contemplate the Veteran's service-connected symptomatology. All the Veteran's PTSD symptoms are either explicitly part of the schedular rating criteria under the general formula for rating mental disorders at 38 C.F.R. § 4.130; are analogous to the schedular rating criteria (see 38 C.F.R. §§ 4.20, 4.21), or are "like or similar to" the schedular rating criteria (see Mauerhan at 442-43). The schedular rating criteria, Diagnostic Code 9411, specifically provide for disability ratings based on a combination of history and clinical findings. The Veteran's symptoms of flashbacks, irritability, social withdrawal, a depressed mood, anxiety, suspiciousness, and loss of concentration and memory are specifically included in the rating schedule, and the assigned 70 percent disability rating specifically rates based on the degree of occupational and social impairment, including due to specific symptomatology. A higher rating is available where symptomatology of the appropriate type and degree is shown. The Board has found that it is not. In addition, the GAF score indicated in the DSM-IV, which reflects the overall degree of impairment due to psychiatric disorders, and which the Board weighed and considered in this case, is part of the schedular rating criteria. It is acknowledged that the Veteran's PTSD symptoms interfere with the Veteran's employment; however, a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In this case, there is nothing unusual regarding the type of symptomatology demonstrated by the Veteran or in the impact it has on employment. He has described his occupational impairment in terms of irritability with co-workers and lack of concentration. These symptoms are contemplated by the rating schedule. Because the schedular rating criteria are adequate to rate the Veteran's service-connected PTSD, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (CAVC) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that 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, including the degree of disability and the effective date of an award. Those five elements include: (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. Because this appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection, no additional notice is required. The Federal Circuit and the CAVC have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for 'downstream' issues following a service connection grant, such as initial rating and effective date claims). The Board is satisfied that VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records and the Veteran's written assertions, and those of his girlfriend. Although notified by letter in March 2008 of the type of evidence necessary to establish a disability rating for PTSD, the Veteran has not identified any VA or private treatment for PTSD. The Veteran was afforded a VA examination to address the manifestations and severity of his PTSD. This examination was adequate because it was performed by a medical professional based on a review of claims file, solicitation of history and symptomatology from the Veteran, and a thorough examination of the Veteran. The examination includes findings pertinent to the rating criteria and is otherwise consistent with the record. Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). The Board acknowledges the Veteran's assertion that his PTSD has worsened (see June 2009 notice of disagreement). The Veteran's girlfriend has also reported a worsening (June 2009 letter). The Board finds that a remand for a new examination is not necessary as the Veteran has not provided even the barest description of the asserted worsening. The Veteran's girlfriend described the worsening as a deeper depression and mood swings. The Board notes that the decision above is an acknowledgment that the Veteran's PTSD is more severe than previously rated. Neither the Veteran nor his girlfriend has described symptoms that would suggest worsening to a degree that would substantiate a total disability rating for PTSD or that would suggest symptomatology associated with the 100 percent rating criteria. Accordingly, the Board finds that additional examination is not necessary. Finally, this decision does not suggest that the Veteran's disability will always be 70 percent disabling. Clearly, the Veteran's use of alcohol plays a role in his disability, which may be a factor that can be distinguished from the Veteran's PTSD in the future. Treatment for this problem is clearly indicated. ORDER An initial rating for PTSD of 70 percent, but not higher, is granted. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs