Citation Nr: 1323972 Decision Date: 07/29/13 Archive Date: 08/07/13 DOCKET NO. 09-43 613 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for a neck disorder, claimed as degenerative disease. 2. Entitlement to service connection for a back disorder, also claimed as degenerative disease. 3. Entitlement to an initial rating higher than 10 percent for posttraumatic stress disorder (PTSD) from August 30, 2006 through October 25, 2010. 4. Entitlement to a rating higher than 50 percent for the PTSD since October 26, 2010. 5. Entitlement to an initial compensable rating for residuals of a head injury. 6. Entitlement to a total disability rating due to individual unemployability (TDIU). REPRESENTATION Appellant represented by: California Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Harold A. Beach, Counsel INTRODUCTION The Veteran served on active duty from May 1966 to May 1970. He had a tour in Vietnam, and his awards and commendations include the Combat Action Ribbon and Purple Heart Medal. He appealed to the Board of Veterans' Appeals (Board/BVA) from a February 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In November 2012, as support for his claims, the Veteran had a hearing at the RO before the undersigned Veterans Law Judge of the Board. This type of hearing is often and more commonly referred to as a Travel Board hearing. Partly because of his hearing testimony, the Board finds there is a potentially derivative claim of entitlement to a TDIU. See Rice v. Shinseki, 22 Vet. App. 447 (2011). This claim is being REMANDED to the RO via the Appeals Management Center (AMC). FINDINGS OF FACT 1. During his November 2012 hearing, so prior to the promulgation of a decision in this appeal, the Veteran notified the Board that he was satisfied with the higher 50 percent rating assigned for his service-connected PTSD effective October 26, 2010. 2. Also during his November 2012 hearing, so also prior to the promulgation of a decision in this appeal, the Veteran also notified the Board that he was withdrawing his claim for an initial compensable rating for the service-connected residuals of a head laceration. 3. His neck disorder, claimed as degenerative disease, is primarily the result of an August 1968 explosion and consequent injury sustained during his combat service in Vietnam. 4. His back disorder, as well claimed as degenerative disease, is also primarily the result of that August 1968 explosion and consequent injury sustained during his combat service in Vietnam. 5. From August 30, 2006 through September 20, 2009, his service-connected PTSD caused occupational and social impairment due to mild or transient symptoms which decreased his work efficiency and his ability to perform occupational tasks only during periods of significant stress. 6. But from September 21, 2009, through October 25, 2010, his service-connected PTSD caused occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. As concerning the claim for a rating higher than 50 percent for the service-connected PTSD, the criteria are met for withdrawal of the appeal of this claim. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 2. Also as concerning the claim for an initial compensable rating for the residuals of the head laceration, the criteria also are met for withdrawal of the appeal concerning this claim. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 3. The neck disorder, claimed as degenerative disease, is the result of an injury incurred during service in combat. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107(b) (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(d) (2012). 4. The back disorder, also claimed as degenerative disease, is equally the result of an injury incurred during service in combat. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107(b) (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(d) (2012). 5. From August 30, 2006 through September 8, 2009, the criteria were not met for an initial rating higher than 10 percent for the PTSD. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012) 6. From September 9, 2009 through October 25, 2010, however, so even before the current effective date of October 26, 2010, the criteria were met for the higher 50 percent rating for the PTSD. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.2, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Current Rating for the PTSD and the Residuals of the Head Injury (Laceration) The Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2012). Withdrawal may be made by the appellant or by his authorized representative. 38 C.F.R. § 20.204. During his November 2012 Travel Board hearing, so prior to the promulgation of a decision in this appeal, the Veteran notified the Board that he was satisfied with the higher 50 percent rating for his service-connected PTSD that had been granted effective October 26, 2010. He said he resultantly was withdrawing his appeal of this disability's rating as of that date, only instead continuing to appeal for a rating higher than the 10 percent he initially had received for this disability, meaning as of August 30, 2006. He also asked the Board to withdraw his claim for an initial compensable rating for the service-connected residuals of his head injury, referring to his laceration. Hence, with respect to these claims and this portion of them, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review these claims, and they resultantly are dismissed. But, as explained, there remains for consideration whether the Veteran was entitled to an initial rating higher than 10 percent for his PTSD for the immediately preceding period from August 30, 2006 through October 25, 2010. So the Board is still considering this portion of this claim. VA's Duties to Notify and Assist Prior to considering the merits of the Veteran's appeal regarding the claims that remain, the Board must determine whether VA has met its statutory duties to notify and assist him in the development of these claims. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. After reviewing the record, the Board finds that VA has satisfied these obligations. The first point worth noting is that the Board is fully granting the claims of entitlement to service connection for neck and back disorders. The Board therefore need not discuss whether there has been compliance with these duty-to-notify-and-assist obligations, at least as specifically concerning these claims, because even were the Board to assume for the sake of argument there has not been, this still would be inconsequential and therefore at most nonprejudicial, i.e., harmless error. 38 C.F.R. § 20.1102. In Shinseki v. Sanders, 129 S. Ct. 1696 (2009), the U. S. Supreme Court made clear that VCAA notice and assistance errors, even when shown to have occurred, are not presumptively prejudicial, instead, must be judged on an individual case-by-case basis. Moreover, as the pleading party attacking the agency's decision, the Veteran, not VA, has this burden of proof of not only establishing error but also, above and beyond that, of showing how it is unduly prejudicial, meaning outcome determinative of his claim. There simply is no such possibility in this instance. As for the claim concerning the initial rating for his PTSD, in August 2006 VA received his claim of entitlement to service connection for this condition; and there is no issue as to providing an appropriate application form or completeness of the application. Following the receipt of that application, VA notified him of the information and evidence necessary to substantiate and complete his claim, including the evidence to be provided by him versus the evidence VA would attempt to obtain for him. 38 U.S.C.A. § 5103(a) ; 38 C.F.R. § 3.159(b)(1); see also Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Charles v. Principi, 16 Vet. App. 370, 373-74 (2002). VA informed him of the criteria for service connection, as well as for rating service-connected disabilities and for assigning effective dates, should service connection be granted. VA therefore apprised him of all elements of his claim, indeed, even of these "downstream" disability rating and effective date elements. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). In its subsequent February 2008 rating action from which this appeal ensued, the RO granted the Veteran's claim of entitlement to service connection for PTSD and assigned an initial 10 percent disability rating retroactively effective from August 30, 2006, the date of receipt of his claim for this condition. He appealed for a higher initial rating for this condition. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (When a Veteran appeals an initial rating, VA must consider whether to "stage" the rating - meaning assign different ratings at different times since the effective date of the award if there have been occasions when the disability has been more severe than at others; this change in rating over time will compensate the Veteran for this variance.). And, as already alluded to, this is precisely was has occurred here since in March 2012, during the pendency of this appeal, the RO increased the rating for the Veteran's PTSD from 10 to 50 percent as of October 26, 2010, which amounted to a "staging" of the rating for this disability. But inasmuch as these ratings are derived from the initial service-connection claim, these ratings for the PTSD are a "downstream" issue. See Grantham v. Brown, 114 F.3d 1156 (1997) (indicating the Veteran had to separately appeal these ratings, that is, once service connection for his PTSD was established). Although VA has not specifically notified him of the information and evidence necessary to substantiate his downstream increased-rating claim, such notice is not required. In December 2003, VA's General Counsel issued a precedential opinion stating that, if VA received a notice of disagreement (NOD) in response to a decision on a claim for which VA already had sent the Veteran a duty to assist letter, and the NOD raised a new issue, the duty to assist the Veteran did not require VA to provide notice of the information and evidence necessary to substantiate the newly raised "downstream" issue. See VAOGCPREC 8-2003, 69 Fed. Reg. 25180 (2004). The Board is bound by the precedent opinions of VA's General Counsel, as Chief Legal Officer for the Department. 38 U.S.C.A. § 7104(c) (West 2002). If, as here, service connection is granted and, in response, the Veteran appeals a "downstream" issue such as the compensation level assigned for the disability, then VA does not have to provide additional VCAA notice concerning this downstream element of the claim because the initial intended purpose of the notice has been served inasmuch as the claim as it arose in its initial context has been granted, so substantiated. See Goodwin v. Peake, 22 Vet. App. 128 (2008). See also Dunlap v. Nicholson, 21 Vet. App. 112 (2007). According to the holding in Goodwin and its progeny, instead of issuing an additional VCAA notice letter in this situation concerning the downstream disability rating element of the claim, the provisions of 38 U.S.C.A. § 7105(d) require VA to issue a statement of the case (SOC) if the disagreement is not resolved, and this occurred in this particular instance. The Veteran not only received the required SOC but also since has received a supplemental SOC (SSOC). Together, they cite the applicable statutes and regulations governing the assignment of disability ratings and contain discussion of the reasons or bases for assigning an initial 10 percent rating, then a higher 50 percent rating, but no greater rating. VA also fulfilled its duty to assist the Veteran in obtaining identified and available evidence necessary to substantiate his claim. VA obtained or ensured the presence of the following potentially relevant evidence: his service treatment records (STRs); records from P. A. L., D.C. reflecting the Veteran's treatment from January 1987 through March 1989; records from E. B., D.C. reflecting the Veteran's treatment in March and April 1989 and April 1990; records from M. A. M., M.D., reflecting the Veteran's treatment from March through November 1989, as well as a statement dated in December 1989; a June 1989 statement from M. B. Z., M.D.; records from R. G. W., D.C. reflecting the Veteran's treatment from June 1989 through April 1994; statements from M. R. J., D.C. dated in November 1989 and January 1990; a January 1991 statement from G. M., M.D.; an October 1992 statement from S. M., D.C.; a December 2006 statement from R. S., D.C.; records reflecting the Veteran's VA treatment from April 2007 through November 2011; the report of an April 2008 VA Agent Orange Protocol examination; statements from the Veteran's wife; statements, dated in April and July 2008 from D. L. J., D.C.; and the transcript of the Veteran's November 2012 Travel Board hearing before the undersigned Veterans Law Judge. The hearing transcript shows the presiding Veterans Law Judge identified the material issues on appeal, as well as those issues which the Veteran wished to withdraw. With respect to the issue of an increased rating for the PTSD, the Veterans Law Judge asked whether the Veteran had any evidence in addition to the December 2006 VA examination and his wife's statement concerning the treatment or evaluation of his PTSD. The Veterans Law Judge also clarified the evidence on file and whether the Veteran had any additional evidence to submit. As well, the Veterans Law Judge identified a potential issue of entitlement to a TDIU, as a derivative of the increased-rating claim already on appeal. Finally, the Veterans Law Judge asked the Veteran whether he had anything else he wished to say or point out. As such, the conducting of that hearing was in accordance with the provisions of 38 C.F.R. § 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 498 (2010) (citing to 38 U.S.C. § 7261(b)(2); Shinseki v. Sanders, 129 S. Ct. 1696, 1704 (2009)). Also as concerning this additional duty to assist the Veteran with his claim, in December 2006, December 2008, and October 2010 VA had him examined to determine the nature, etiology, and extent of impairment attributable to any neck or back disorders or PTSD found to be present. The reports of those VA examinations show the examiners reviewed his pertinent medical history, interviewed and examined him personally, documented their medical findings, and rendered diagnoses and opinions consistent with the remainder of the evidence of record. Therefore, the Board concludes those VA examinations are adequate for rating purposes, that is, such that additional examination is not needed or required. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure the examination or opinion is adequate). In sum, the Veteran has been afforded a meaningful opportunity to participate effectively in the development of his appeal. He has not identified any outstanding evidence that would tend to support his claim, and there is no evidence of any prejudicial VA error in notifying or assisting him with his claim that could affect the essential fairness of the adjudication of his claim. Accordingly, the Board will proceed to the merits of the appeal. The Service-Connection Claims During his November 2012 hearing before the undersigned Veterans Law Judge, the Veteran testified that his current neck and back disorders are the result an incident during his military service - in particular, while engaged in combat against enemy forces. He alleged that, while stationed in Vietnam, he served aboard a river patrol boat. He said the boat hit a mine and that the resulting explosion caused multiple injuries, including to his neck and back (so all along his spine, both upper and lower). He said that he has had chronic neck and back pain ever since and that he consequently has required and received ongoing treatment for these disorders. He further testified that, from about 1969 to the late 1980s, he had been treated by his wife's uncle, a chiropractor, and that he has continued to receive such care. He noted opinions from D. J., D.C. and R. S., D.C., supporting his claims; and, therefore, he maintained that service connection was warranted for his neck and back disorders. After carefully considering these claims in light of the record and the applicable law, the Board agrees. Accordingly, these claims are being granted. The Applicable Statutes, Regulations and Case Law Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. §§ 1110, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. Service connection may be granted for a disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). So establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a causal relationship, nexus, or linkage between the current disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). If chronicity (permanency) of disease or injury in service is not shown, or legitimately questionable, then a showing of continuity of symptomatology following service is required to support the claim. 38 C.F.R. § 3.303(b). Under § 3.303(b), an alternative method of establishing the second and third Shedden elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. See Hickson v. West, 12 Vet. App. 247, 253 (1999) (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection). In-service notation of a condition does not require medical evidence where the condition is of a type as to which a lay person's observation is competent. However, although prong (3) does not require medical nexus evidence, because it would not necessarily follow that there is a relationship between any present disability and the continuity of symptomatology demonstrated, medical evidence is required to demonstrate such a relationship unless such a relationship is one as to which a lay person's observation is competent. A recent decision of the U. S. Court of Appeals for the Federal Circuit (Federal Circuit Court) clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Court explicitly rejected the argument that a dictionary definition of "chronic" should be used instead, noting that continuity of symptomatology in § 3.303(b) had no other intent than to afford an alternative route to service connection for specific chronic diseases. Id. And while it is true that degenerative joint disease (DJD), i.e., arthritis, is a condition this VA regulation considers chronic, the same cannot be said of degenerative disc disease (DDD). But even as an aside, this notion of continuity of symptomatology also only applies to situations when a condition has been "noted" during service, else, there is no established condition to continue experiencing on a recurrent basis after service. That said, when, for example, a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr, 21 Vet. App. at 310. So medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C.A. § 1154(a) (West 2002 & Supp. 2012). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Federal Circuit Court held in Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010) and in Waters v. Shinseki, 601 F.3d 1274, 1278 (2010), that it is error to suggest that lay evidence can never be sufficient to satisfy the requirement of 38 U.S.C.A. § 5103A(d)(2)(B) that there be a nexus between military service and a claimed condition. But as also observed by the Federal Circuit Court, lay evidence must "demonstrate some competence." See King v. Shinseki (Fed. Cir. 2012) (citing 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.307(b)) (internal quotation marks omitted). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. See 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). Lay evidence is competent if it is provided by a person who has first-hand knowledge of facts or circumstances, or conveys matters that can be observed and described by a lay person. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that appellant was competent to testify as to factual matters of which he had first-hand knowledge, such as experiencing pain in his right hip and thigh in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy). However, lay testimony is not competent with respect to determinations that are "medical in nature" or require medical knowledge due to their complexity. See Barr, 21 Vet. App. at 309. For example, the Court held that a claimant was not competent to determine whether he had rheumatic fever, which was a more medically complex condition. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Jandreau similarly held that a Veteran was incompetent to diagnose a form of cancer or comment on the disease's etiology. See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge); Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (concluding that a Veteran's lay belief that his schizophrenia had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). Competent medical evidence, as opposed to lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Id. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. Id. Whether medical versus lay evidence can establish this required cause-and-effect correlation between the Veteran's claimed disability and his military service, including by way of a service-connected disability, depends entirely on the nature and specific type of disability that he is claiming. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). So in some instances mere lay evidence will suffice, whereas in others it will not, requiring instead supporting medical evidence. Competency of evidence also differs from its ultimate weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, whereas 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 (1997); Layno v. Brown, 6 Vet. App. 465 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted")); Cartwright v. Derwinski, 2 Vet. App. 24 (1991) (although interest may affect the credibility of testimony, it does not affect competency to testify). A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. But even if evidence is determined to be competent, the Board has the additional duty to assess the credibility and ultimate probative weight given to the evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The final determination as to whether these requirements for service connection are met is based on an analysis of all the relevant evidence of record, medical and lay, and the evaluation of its competency and credibility to determine its ultimate probative value in relation to other evidence. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). Reasonable doubt concerning any issue material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 3.102. There is clear indication the Veteran engaged in combat while stationed in Vietnam, as evidenced by his receipt of the Combat Action Ribbon and Purple Heart Medal. These commendations are prima facie evidence of his combat experience. 38 U.S.C.A. § 1154(b) and the implementing VA regulation, 38 C.F.R. § 3.304(d), require that a Veteran have actually participated in combat with the enemy, meaning participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality, and do not apply if he only instead served in a general "combat area" or "combat zone" but did not himself engage in combat with the enemy. See VAOPGCPREC 12-99 (October 18, 1999). But the circumstances, conditions, and hardships of the Veteran's service clearly place him within the realm of a combat Veteran, which is determined on an individual case-by-case basis. In cases, as here, where a Veteran asserts entitlement to service connection for injuries or disease incurred or aggravated in combat, 38 U.S.C.A. § 1154(b) and its implementing regulation, 38 C.F.R. § 3.304(d), are applicable. And this statute and regulation ease the evidentiary burden of a combat Veteran by permitting the use, under certain circumstances, of lay evidence to establish the occurrence of the claimed disease, injury or event in service. If the Veteran engaged in combat with the enemy, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of his service. Id. The Federal Circuit Court has held that in the case of a combat Veteran, not only is the combat injury presumed, but so too is the disability due to the combat injury in service. See Reeves v. Shinseki, 682 F.3d 988, 998-99 (Fed. Cir. 2012). To establish entitlement to service connection, however, there must be the evidence of a current disability and a causal relationship between the current disability and the combat injury. Id. (citing Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). The Board is required to apply the section 1154(b) presumption to whether the claimed injury occurred as well as the separate issue of whether the Veteran suffered the claimed ensuing disability while on active duty. For example, a Veteran would then only have to show that the disability he or she incurred in service was a chronic condition that persisted in the years following active duty. This basically establishes that the injury in service resulted in permanent disability. See generally Reeves. The Factual Background The Veteran's STRs, including the reports of his January 1966 military entrance examination and April 1970 separation examination, are unremarkable for any complaints or clinical findings of a neck or back disorder of any kind. They do however confirm that on August 24, 1968, the river patrol boat to which he was assigned hit a mine. In the subsequent explosion, he sustained a 11/4 by 1/2 inch laceration of the left temporal area of his head. The wound took 4 stitches to close. Thereafter, he was returned to light duty, and the following morning he was transferred to Danang for a period of rest and relaxation. He received the Purple Heart Medal for that combat injury. From April 1970 to December 1986, there were no records of any complaints or clinical findings of a chronic, identifiable neck or back disorder. Records from P. A. L., D.C., show that from January 1987 through March 1989, the Veteran was treated for complaints involving his low back and mid-dorsal spine, as well complaints regarding his right arm. In March 1989, while working for the California State Automobile Association as a vehicle inspector, the Veteran reported that his back was acting up again, and it was noted that it had been a problem for about 4 years. Following an examination, the assessment was somewhat atypical mid-back pain of unclear etiology. In March 1989, X-rays of the Veteran's chest were negative. Those of his thoracic spine revealed minimal degenerative arthritic changes. In April 1989, X-rays of the Veteran's thoracic spine were variously reported as negative or showing minimal degenerative changes of the thoracic spine. The assessment was mid-back syndrome. In June 1989, X-rays of the lumbar spine revealed unilateral lumbarization of S1 on the right. In April and July 1989 state reports of occupational injury or illness, it was noted that in March 1989, the Veteran had experienced a gradual onset of mid-back pain and electric shock-like sensation, while standing at his computer. At that time, he was employed as a Senior Technician for the California State Automobile Association. He reportedly had experienced a mid-back spasm, and his range of cervical and lumbar spine motion was reduced. In June 1989, M. B. Z., M.D., reported that since 1969, the Veteran had been seeing P. L., D.C., primarily for neck symptoms. However, it was noted that the Veteran had had occasional complaints involving his upper, lower, and thoracic spines. Dr. Z. reviewed films of the thoracic and lumbar spines and stated that with the exception of mild asymmetry of the lumbar articulation, the films were unremarkable and showed no degenerative disc disease. There was mild anterior lipping of L2, L3, and L4, but Dr. Z. opined that such findings were insignificant. In November 1989, M. R. J., D.C., a forensic and chiropractic consultant, reviewed the Veteran's history and examined him for insurance purposes. Dr. J. opined that the while working at the California State Automobile Association, the Veteran had sustained some type of thoracolumbar strain. Dr. J. recommended that the Veteran have an MRI. In January 1990, an MRI of the lumbosacral spine revealed 6 lumbar-type vertebral segments with a transitional L6, sacralized on the left. There was some desiccation of the L5-L6 disc without associated disc space narrowing or herniation. Later in January 1990, based on the MRI study, Dr. J.'s impression was that the Veteran had a longstanding congenital problem which was irritated by work. Dr. J. opined that due to that problem he would apportion 50 percent of the Veteran's disability to the natural progression of pre-existing symptomatology, and the remaining 50 percent to an injury related to the Veteran's work at the California State Automobile Association. Dr. J. stated that is appeared that the Veteran could have a cumulative type injury to his lower back but that the Veteran had never filed report. In this regard, Dr. J. noted that the Veteran had a history of chiropractic care since 1969. Dr. J. concluded that the Veteran should be able to return to his normal work activities. In October 1992, S. M., D.C., examined the Veteran and reviewed his claims file for a claims management company. In addition to his March 1989 job-related injury, the Veteran confirmed that in March 1992, he had been involved in a rear-end automobile accident. He received 3 months of chiropractic treatment and returned to his pre-accident levels of thoracic and lumbar spine symptoms. Based on a discussion and records review, Dr. M. noted that since 1969, the Veteran had received chiropractic treatment directed toward his cervical, thoracic, and lumbar regions. In December 2006, R. S., D.C., noted that the Veteran had advanced degenerative changes in his neck which were due to a previous traumatic injury. Dr. S. stated that degenerative changes like the Veteran's did not occur without some form of outside exposure to traumatic. Dr. S. opine that the Veteran's symptoms and spinal changes were due to his 1968 injury in service. In April 2008, following a VA Agent Orange Protocol Examination, the Veteran was found to have post-traumatic degenerative disc disease of the cervical and lumbar spines. Later in April 2008, D. L. J., D.C., stated that in an explosion in service, the Veteran had sustained injuries to his cervical and lumbar spines. Dr. J. further stated that the resulting multiple levels of disc protrusion were certainly responsible for the Veteran's neck, low back, and arm disabilities. In July 2008, the Veteran's wife reported that from approximately 1969 to 1989, the Veteran had been treated by her uncle, P. A. L., D.C. She stated that her uncle had passed away and that none of his old records were available. She further stated that since their marriage in 1969, the Veteran had reported that his neck and back problems were due to an injury in service. Later in July 2008, D. L. J., D.C., stated that he had been treating the Veteran since February 2008 for degenerative joint disease and degenerative disc disease with degrees of disc protrusion at the L4-L5 and C5-C7 levels, as well as extensive bone spurring at the C5-C7 level with spur tissue extending into the spinal canal. Dr. J. opined that the Veteran's symptoms and disability picture were the result of his 1968 boating injury in service. Dr. J. noted that it took many years to achieve the extent of bone spurring and degenerative discs found on the Veteran, and that they were quite consistent with the magnitude of the injuries 40 years earlier. The Veteran denied any significant injury between service and 2008 which would be relevant to his spinal degeneration. In December 2008, during the Veteran's VA examination, it was noted that his treatment records from the late 1980's and early 1990's had not been associated with the claims folder. The Veteran reported intermittent neck and back pain through the 1970's and constant neck and back pain since the 1980's. The history was detailed generally, as above. X-rays taken by VA in April 2007 showed minimal degenerative changes in the cervical and lumbar spines. There was no evidence of fracture or loss of alignment. The disc space at L5-L6 was narrowed. Otherwise, the disc spaces were normal. there was evidence of encroachment by C6-C7 on the intervertebral foramina. Following the VA examination, the diagnoses were degenerative disc disease of the cervical and lumbar spines and cervical and lumbar spine strain. The examiner opined that it was less likely than not the Veteran's cervical and/or lumbar strain were the result of the 1968 mine explosion. In so saying, the VA examiner noted that the Veteran did not remember having neck or back pain at the time of the explosion. The VA examiner also noted that the STRs were negative for any complaints or clinical findings of neck or back disorders in service. There equally were no records from the Veteran's chiropractor confirming the presence of any disc protrusions, and there were no records reflecting his post-service treatment between 1986 and 1992. In August 2009, following the receipt of additional information, the Veteran's claims file was reviewed by a VA health care provider who had not examined him previously, and the VA examiner who had performed the December 2008 VA examination. The additional information included records of the Veteran's treatment from 1989 through 1992, the December 2006 opinion from R. C., D.C., and the April and July 2008 opinions D. L. J., D.C. Following a review of the claims folder, the VA examiners confirmed and continued the December 2008 VA examiner's opinion that it was less likely than not that the Veteran's cervical and/or lumbar strain and DDD were the result of the 1968 mine explosion. The VA examiners indicated the Veteran's back and neck pain and findings of degenerative arthritis, instead, were consistent with his age. Moreover, they noted that R. C., D.C. and D. L. J., D.C. may not have had access to his records. Analysis Given the totality of the evidence, there obviously is no disputing the Veteran has current neck and back disorders, diagnosed primarily as DDD. So resolution of his claims turns, instead, on whether there is the required attribution of his disability to his military service - and, in particular, to the injuries he sustained in the combat explosion in Vietnam. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or a disease incurred in service."). Although the record is unremarkable for any complaints or clinical findings of either disorder in service, the record establishes that this combat Veteran sustained a head injury in the explosion in 1968. He has testified that, in addition to his head injury, he experienced residual pain in his neck and back for which he began receiving treatment in 1969, so relatively contemporaneous to that incident. And while there are no actual records of that treatment from 1969 or even until 1988, there is credible evidence that such treatment was, in fact, rendered. Not only does the Veteran's wife corroborate his testimony, the evidence dated in and after 1989 strongly suggests he began receiving treatment for his neck and back in 1969, as alleged, so while in the military. For example, in March 1989 he reported a history such treatment, and has done so, consistently, since that time. That was more than 15 years prior to his claim for service connection for neck and back disorders; and it begs credulity to conclude that he reported such a history for any reason other than the truth of the matter. Indeed, lay statements found in medical records when medical treatment was being rendered may be afforded greater probative value; statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care. Rucker v. Brown, 10 Vet. App. 67, 73 (1997). When earlier recounting that history of his disability, there was no incentive, financial or otherwise, for the Veteran to fabricate information for his personal gain. There was only instead his best interest in letting his doctors know how long he had been having problems with his neck and back and the potential source or cause of those problems, such as in this instance an injury dating back to his military service. He therefore has presented not only competent but also credible evidence of incurrence of relevant neck and back injury in service and to having experienced residual pain or perhaps other symptoms as a consequence during the many ensuing years up to the present day, but most importantly even before filing these claims. Therefore, according to 38 U.S.C.A. § 1154(b), 38 C.F.R. § 3.304(d) and Reeves, there is a factual presumption that the alleged injury and consequent disability is service connected. The salient question, then, is whether there is clear and convincing evidence to the contrary, and there is not. In addition to the absence of a neck or back disorder in the Veteran's STRs, the December 2008 VA examiner set forth a well-reasoned opinion that it was less likely than not that the Veteran's back and neck disorders were related to service. However, the Veteran has provided evidence of continuing neck and back symptoms and treatment since his service, as well as opinions from R. C., D.C., and D. L. J., D.C., substantiating the posited nexus between his current disability and service. Kahana held that VA adjudicators are precluded from drawing a negative inference from the absence of documentation in the STRs of relevant symptoms or treatment when, as here, the alleged injury is said to have occurred in combat. Kahana cautioned that negative evidence, meaning actual evidence weighing against a party, must not be equated with the absence of substantive evidence. See also Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc). Indeed, even to draw this negative inference in noncombat scenarios, VA adjudicators must have assurances that the STRs are complete or at least substantially complete, in relevant part, and that the symptoms or injury is the type that ordinarily would have been reported. See, too, Bardwell v. Shinseki, 24 Vet. App. 36 (2010) [explaining that, for non-combat Veterans (so unlike here where there is a combat-decorated Veteran), providing non-medical related lay testimony regarding an event during service, Buchanan is distinguishable; the lack of documentation in service records must be weighed against the Veteran's statements]. Therefore, resolving all reasonable doubt in favor of the Veteran, the Board finds that the government has not met its burden of rebutting the presumption of service connection by clear and convincing evidence to the contrary. Thus, the Veteran has met the criteria for service connection for neck and back disorders, primarily diagnosed as degenerative disc disease (DDD). Accordingly service connection for this disorder is warranted. The Increased-Rating Claim During his hearing, the Veteran testified that for the period from August 30, 2006 through October 25, 2010, the 10 percent rating for his service-connected PTSD did not adequately reflect the level of impairment caused by this disorder. He testified that he had held multiple jobs since service, due, in part, to his inability to get along with others. He also testified that he tended to withdraw and that he did not care to socialize. Therefore, he maintained that an increased rating was warranted for the period indicated. After carefully considering the claim in light of the record and the applicable law, the Board agrees in part. Accordingly, the appeal will be granted to the extent indicated. The Applicable Statutes, Regulations and Case Law Disability evaluations are determined by comparing the manifestations of a particular disability with the criteria set forth in the Diagnostic Codes of VA's Schedule For Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity (in civilian occupations) resulting from service-connected disability. 38 C.F.R. § 4.1. PTSD is rated in accordance with a General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 10 percent rating is warranted for PTSD when 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, 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 rating is warranted for PTSD, 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when 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; 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 worklike setting); and inability to establish and maintain effective relationships. Id. Relevant to an evaluation of the level of impairment caused by PTSD is the score on the Veteran's Global Assessment of Functioning (GAF) Scale. That scale is found in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994) (DSM-IV) and reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996). The nomenclature in DSM IV has been specifically adopted by VA in the evaluation of mental disorders. 38 C.F.R. § 4.125, 4.130 (2002). A GAF score of 61 to 70 reflects some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. DSM IV at 32. A GAF score of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. Id.; see Carpenter v. Brown, 240, 242 (1995) While important in assessing the level of impairment caused by psychiatric illness, the GAF score is not dispositive of the level of impairment caused by such illness. Rather, it is considered in light of all of the evidence of record. See Brambley v. Principi, 17 Vet. App. 20, 26 (2003); Bowling v. Principi, 15 Vet. App. 1, 14 (2001). Where 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. All reasonable doubt material to the determination is resolved in the Veteran's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). However, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the claim was filed until a final decision is made. If this occurs, then VA must "stage" the rating to reflect this variance in the severity of the disability. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999) (initially employing this practice only in initial-rating claims). But see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (since additionally employing this practice even in cases that do not involve initial ratings, rather, established ratings). As already mentioned, by initially rating the Veteran's PTSD as 10-percent disabling, but instead higher, as 50-percent disabling as of October 26, 2010, this amounted to a "staging" of his rating for this disability. The Board therefore need only determine whether this was an appropriate staging of the rating. For reasons and bases that will be discussed, the Board concludes that it was not since the Veteran was entitled to the higher 50 percent rating, though no greater rating, at an earlier effective date. The Factual Background The Veteran's wife reports that shortly after her 1969 marriage to the Veteran, she noticed that the his sleep was impaired by nightmares and episodes of yelling out. She reported that during the ensuing 39 years, those episodes decreased in frequency and severity. She also reported that the Veteran demonstrated many signs and symptoms of PTSD, such as anxiety, nervousness, depression, flashbacks, hyperalertness, and a quick temper. The Veteran's wife also noted that following service, the Veteran quit several jobs, because of conflicts or his perception of poor treatment. While she is competent to report her observations, the synthesis of such manifestations to permit a diagnosis is outside the general knowledge of a lay person. Therefore, in December 2006, the Veteran was examined by VA to determine the nature, extent, and etiology of any psychiatric disorder found to be present. During the Veteran's December 2006 VA psychiatric examination, the examiner noted the Veteran's his history of participation in combat. The examiner also noted that since the Veteran's return from Vietnam, he had had periodic memories of his experiences, impaired sleep, avoidance of events which reminded him of Vietnam, and a startle reaction. The Veteran reported that after service, he had held jobs at a service station and an accounting firm and that he also worked as a private investigator, insurance adjuster, and truck driver. Thereafter, he became self-employed in the automotive industry. The Veteran stated, however, that he had never seen a psychiatrist, nor was he taking any psychiatric medication. On examination, the Veteran was properly dressed, and his hygiene was good. His psychomotor activity was within normal limits, and there was no major disorder of speech. His thought processes were coherent with no tangentiality or looseness of association. He demonstrate no delusional thinking or looseness of association, and his intellectual functioning, memory, comprehension, abstract thinking, and calculating ability were judged to be intact and average. His affect was full range, but, when talking about Vietnam, his mood was sad. There was no evidence of homicidal or suicidal ideation. On further examination, it was noted that he was working, able to drive, and able to perform the activities of daily living. Following the VA examination, the relevant diagnosis was PTSD, mild, in partial remission. The examiner assigned the Veteran a GAF of 67. In discussing the diagnosis, the examiner noted that the Veteran had recurrent, intrusive, and distressing recollections and episodes of distressing dreams of Vietnam. The Veteran also manifested avoidance of thoughts, feelings, conversations or activities, places, or people which reminded him of the trauma there. In addition, he had difficulty with hypervigilance and an exaggerated startle response. Due to his symptoms, the examiner opined that the Veteran had experience some limitations on his social and occupational functioning. However, the Veteran reported that over time, his symptoms had gradually become less intense and less frequent, and, therefore less troublesome. As such, the VA examiner concluded that the Veteran's PTSD was in partial remission. In September 2009, after endorsing the presence of anxiety and a depressed mood, the Veteran was evaluated by the VA Mental Health Service. He denied any prior psychiatric or psychological treatment. His history of service in Vietnam was noted, and he reported problems with anger/irritability, intrusive memories, avoidance behavior, and impaired sleep. He expressed a preference to be alone, and it was noted that he had difficulty engaging others, both at work and in a social environment. The Veteran stated that with respect to his Vietnam stressor, he had quite a bit of difficulty with disturbing memories, thoughts or images; disturbing dreams, flashbacks, hyperalertness, and startle response. He reported a moderate amount of difficulty from reminders of his stressful experiences and associated physical reactions, such as a pounding heart, difficulty breathing, or sweating. He also reported a moderate amount of difficulty falling or staying asleep, as well as a moderate difficulty with anger and irritability. The Veteran noted a little bit of difficulty from the following: flashbacks; avoidance of thoughts or activities which reminded him of his stressful experiences; trouble remembering important parts of his stressful experiences; a loss of interest in activities he used to enjoy; distance or estrangement from others; emotional numbing; and impaired concentration. He denied a feeling of a foreshortened future. On examination, the Veteran was alert and oriented. He appeared reserved and dysphoric with a congruent mood and affect. His thought process tended to be perseverative, and he reportedly became angry and worked up over issues that aggravated him. There was no specific evidence of a delusional thought process, and the Veteran denied the presence of auditory or visual hallucinations. He endorsed suicidal ideation without an intent, plan, or history of attempts. He stated that cognitively, he was able to counter such ideation. Following the examination, the relevant diagnosis was PTSD, for which the examiner assigned a GAF of 53. He was to have a follow-up appointment in one month. He was hesitant to start PTSD classes and declined a referral to the VA Psychiatry Service, as well as any medication management of his PTSD symptoms. Analysis In reviewing the foregoing evidence, the Board finds that for the period from the time service connection became effective on August 30, 2006 through September 8, 2009, the Veteran's PTSD was manifested primarily by a sad effect when discussing his experiences in Vietnam, complaints of periodic intrusive memories of those experiences, impaired sleep, avoidance of events which reminded him of Vietnam, and a startle reaction. However, the December 2006 VA examiner found those manifestations to be mild in degree and assigned a congruent GAF of 67. Reportedly, those manifestations did not interfere with the Veteran's ability to perform the activities of daily living, and it was noted that he continued to be employed. Such findings met or more nearly reflected the schedular criteria for a 10 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9411. Indeed, there were no findings of an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), and/or memory loss. As such, the preponderance of the evidence was against an initial rating in excess of 10 percent for the period from August 30, 2006 through September 8, 2009. To that extent, the appeal is denied. In arriving at this decision, the Board has considered the Veteran's argument that his December 2006 VA examination was too brief and inadequate for rating purposes. However, other than his wife's lay statement, the examiner has presented no evidence during the period from August 30, 2006 through September 8, 2009 showing any psychiatric treatment or evaluations with respect to his service-connected complaints or clinical findings of PTSD. Indeed, there was no competent, credible evidence on file to refute the findings on the December 2006 VA examination. In this regard, it is, generally, outside a layman's knowledge as to how to conduct an examination or the time necessary to do so. Absent competent, credible evidence that the December 2006 VA examination was inadequate for rating purposes, an additional examination will not be scheduled. Next, the Board will consider whether a rating in excess of 10 percent is warranted for the period from September 2009 through October 25, 2010. In this case, the evidence suggests that there is. The report of the Veteran's September 9, 2009 consultation with the VA Mental Health Clinic shows a deterioration in the Veteran's PTSD symptoms. In addition to intrusive memories, avoidance behavior, and impaired sleep, he expressed problems with anger/irritability and a preference to be alone. He acknowledged quite a bit of difficulty with disturbing memories, thoughts or images; disturbing dreams; flashbacks; hyperalertness; and startle response. He reported a moderate amount of difficulty from reminders of his stressful experiences and associated physical reactions, such as a pounding heart, difficulty breathing, or sweating. He appeared reserved and dysphoric with a congruent mood and affect. His thought process tended to be perseverative, and he reportedly became angry and worked up over issues that aggravated him. He also endorsed suicidal ideation for the first time, though without plan or intent. The examiner noted that the Veteran's PTSD manifestations caused him difficulty working with others which accounted for his broad variety of post-service occupations. He assigned the Veteran a GAF of 53. On balance the foregoing PTSD symptoms suggest that generally since September 9, 2009, the Veteran has experienced a flattened affect, panic attacks, disturbances in motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Taken together, such manifestations meet or more nearly reflect the schedular criteria for a 50 percent rating for the Veteran's service-connected PTSD. To that extent, the appeal is granted. In arriving at this decision, the Board has considered the possibility of assigning a higher schedular evaluation. However, the Veteran does not demonstrate deficiencies in most areas, such as work, school, family relations, judgment or thinking, 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 worklike setting); and inability to establish and maintain effective relationships. Accordingly, a 50 percent schedular rating and no more is warranted for the period from September 9, 2009 through October 25, 2010. Extra-schedular Consideration Finally, the Board has considered the possibility of referring this case to the Director of the VA Compensation and Pension Service for possible approval of an extra-schedular rating for the Veteran's service-connected PTSD. 38 C.F.R. § 3.321(b)(1) (2012). The question of an extra-schedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). And although the Board may not assign an extra-schedular rating in the first instance, it must specifically adjudicate whether to refer a case for extra-schedular evaluation when the issue either is raised by the claimant or reasonably raised by the evidence of record. See Barringer v. Peake, 22 Vet. App. 242 (2008). Ordinarily, the VA Rating Schedule will apply unless there are exceptional or unusual factors that would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun v. Peake, 22 Vet. App. 111, 114 (2008). However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue 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). See also Fanning v. Brown, 4 Vet. App. 225, 229 (1993). There is a three-step inquiry for determining whether a claimant is entitled to an extraschedular rating. Thun, 22 Vet. App. at 115. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Board must compare 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. Id. If the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular evaluation is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors, such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a claimant's disability picture with such related factors as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. In this case, neither the Veteran nor his representative has expressly raised the matter of entitlement to an extra-schedular rating. The Veteran's contentions have been limited to those discussed above, i.e., that his disability is more severe than is reflected by the currently assigned schedular rating. See Brannon v. West, 12 Vet. App. 32 (1998) (while the Board must interpret a claimant's submissions broadly, the Board is not required to conjure up issues that were not raised by the claimant). The criteria for rating PTSD specifically contemplate the symptoms of the Veteran's service-connected disability: impaired sleep, intrusive thoughts, avoidance of behavior, a startle reaction, a flattened affect, panic attacks, disturbances in motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. §§ 4.130, Diagnostic Code 9411. In short, the Veteran does not have symptoms associated with this disability left uncompensated or unaccounted for by the assignment of the schedular ratings. Thun, 22 Vet. App. at 115. Generally, the degrees of disability specified in the Rating Schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (reiterating that the disability rating, itself, is recognition that industrial capabilities are impaired). So there is no basis for referring this case for extra-schedular consideration. See Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); and VAOPGCPREC 6-96 (August 16, 1996). ORDER With respect to the issue of entitlement to a rating higher than 50 percent for the PTSD, the appeal is dismissed. With respect to the issue of entitlement to an initial compensable rating for the residuals of the head laceration, the appeal is dismissed. Entitlement to service connection is granted for a neck disorder, claimed as degenerative disc disease. Entitlement to service connection is granted for a back disorder, claimed as degenerative disc disease. For the period from August 30, 2006 through September 8, 2009, entitlement to an initial rating higher than 10 percent for the PTSD is denied. But for the succeeding period from September 9, 2009 through October 25, 2010, entitlement to the higher 50 percent rating for PTSD is granted (so from this earlier effective date rather than just as of October 26, 2010), subject to the statutes and regulations governing the payment of retroactive VA compensation. REMAND During his hearing, the Veteran made contentions to the effect that he was unemployable due to his service-connected disabilities. In particular, he said that he "cannot work for someone else" and that he resultantly has had numerous jobs since his service. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a request for a TDIU, whether expressly raised by a Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if a disability upon which entitlement to a TDIU is based already has been found to be service-connected, as part of a claim for increased compensation. In another rather recent case, the Court found that because the claim for a TDIU was received by VA within one year of the grant of service connection based on an initial application for benefits, the TDIU claim was part of the Veteran's initial application for benefits for that disability, not a part of a new claim for increased compensation. See Mayhue v. Shinseki, 24 Vet. App. 273 (2011). A claim for a TDIU is, in essence, a claim for an increased rating. Norris v. West, 12 Vet. App. 413, 420 (1999). See also Hurd v. West, 13 Vet. App. 449 (2000) (indicating that a TDIU claim is also a claim for increased compensation and, therefore, the effective date rules for increased compensation claims apply to a TDIU claim); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001) (a TDIU claim is informally raised when a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest possible rating for that disability; and (3) submits evidence of unemployability); Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (2009) (holding that an inferred claim for a TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). Thus, as the Court explained in this line of cases, the Board should have considered evidence of unemployability as far back as the date of the underlying claim. But there must be cogent evidence of unemployability in the record. See Rice, citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). Consequently, under Rice and this line of precedent cases, the Board has authority to assume jurisdiction over this derivative TDIU claim inasmuch as it is at least partly predicated on the service-connected disability for which the Veteran is requesting a higher rating in this appeal. Since, however, this derivative TDIU claim has not been initially considered by the RO as the AOJ and requires further development before being decided, the Board is remanding it to the RO via the AMC. VA's Office of General Counsel has indicated that remanding the derivative TDIU claim in this circumstance does not preclude the Board from going ahead and deciding the claim for a higher rating for the disability forming the basis of the TDIU claim. See VAOPGCPREC 6-96 (Aug. 16, 1996) and VAOGCPREC 12-2001 (July 6, 2001). The Veteran has not been notified of the information and evidence necessary to substantiate this derivative TDIU claim, much less made argument concerning it. 38 U.S.C.A. §§ 5103, 5103A (West 2002 and Supp. 2012); 38 C.F.R. § 3.159 (2012). Accordingly, this derivative claim is REMANDED to the RO via the AMC in Washington, DC, for the following action: 1. Notify the Veteran of VA's duties to notify and assist him in the development of his derivative claim of entitlement to a TDIU. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. 2. After giving him opportunity to identify or submit evidence and/or argument in response to this notice, schedule him for a comprehensive examination to determine the collective level of impairment due to his service-connected disabilities - which are PTSD, coronary artery disease, tinnitus, bilateral hearing loss, residuals of a tonsillectomy, neck disorder, and back disorder. In particular, the examiner must consider their impact on the Veteran's ability to work, meaning obtain and maintain employment that could be considered substantially gainful versus just marginal in comparison. 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18 and 4.19. All necessary diagnostic testing and evaluation must be performed, and any indicated consultations scheduled. The claims folder must be made available to the examiner for review in conjunction with the examination, and the examiner must acknowledge receipt and review of this file in any report generated as a result of this remand. Following the examination, the VA examiner must render an opinion as to whether the Veteran's service-connected disabilities, either alone or in combination, preclude his ability to secure and follow a substantially gainful occupation (whether sedentary, semi-sedentary, or unrestricted). Any consideration as to whether a Veteran is unemployable is a subjective one, that is, one that is based upon his actual level of industrial impairment, not merely the level of industrial impairment experienced by the average person. So it is not an objective standard. Advancing age and nonservice-connected disability may not be considered in the determination of whether he is entitled to a TDIU. But the sole fact that he is unemployed or has difficulty obtaining employment is not enough. The question is whether he is capable of performing the physical and mental acts required by employment, not whether he can find employment. In rendering this opinion, the examiner must state how and why he or she reached the opinion they did. The Veteran is advised that it is his responsibility to report for the examination and to cooperate in the development of his claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. § 3.655 (2012). In the event that the Veteran does not report a scheduled VA examination, a copy of the notice informing him of the date, time, and location of the examination must be associated with the claims folder. If the notice is returned by the Post Office as undeliverable, that fact must be noted in writing and associated with the claims folder. 3. Then adjudicate this derivative claim of entitlement to a TDIU. If this claim is denied, appropriately apprise the Veteran of the decision and of his right to appeal. If he elects to appeal this claim to the Board, and complete the steps necessary to do this and perfect his appeal, then return this claim to the Board for further appellate consideration. By this remand, the Board intimates no opinion as to the final disposition of this claim. The Veteran need take no action unless he is notified to do so. However, he is advised that he has the right to submit any additional evidence and/or argument concerning this claim the Board is remanding. Kutscherousky v. West, 12 Vet. App. 369, 372-73 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2007). ______________________________________________ KEITH W. ALLEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs