Citation Nr: 1324382 Decision Date: 07/31/13 Archive Date: 08/07/13 DOCKET NO. 05-02 011 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Entitlement to an effective date earlier than April 29, 2004, for the award of a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 2. Entitlement to an effective date earlier than April 29, 2004, for eligibility to Dependents' Educational Assistance under 38 U.S.C., Chapter 35. 3. Entitlement to an initial disability rating in excess of 10 percent for dysphagia. 4. Prior to April 29, 2004, entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 5. From April 29, 2004, entitlement to an initial disability rating in excess of 70 percent for PTSD REPRESENTATION Veteran represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD D.S. Lee, Counsel INTRODUCTION The Veteran served on active duty from February 1966 through November 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in July 2008, September 2011, and February 2012 by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In the July 2008 rating decision, the RO granted service connection for PTSD, effective from July 30, 2003, and assigned a 30 percent initial disability rating. In an August 2008 NOD, the Veteran expressed his ongoing disagreement with the assigned initial disability rating. After a Statement of the Case (SOC) addressing that issue was mailed to the Veteran in August 2008, the Veteran perfected his appeal in September 2008, via VA Form 9 substantive appeal. After additional evidence was received, the RO issued a January 2012 Supplemental Statement of the Case (SSOC) which awarded a 70 percent disability rating for PTSD, effective from April 29, 2004. In a March 2012 submission, the Veteran expressed his intention to continue his appeal as to the disability ratings assigned for his PTSD. In the September 2011 rating decision, the RO granted service connection for Parkinson's disease and for various separate and distinct manifestations of Parkinson's disease, including dysphagia. The effective date for service connection for dysphagia was August 20, 2008, and a 10 percent initial disability rating was assigned. In a timely October 2011 NOD, the Veteran disputed the assigned effective date and initial disability rating. In a February 2012 rating decision, the RO granted an earlier effective date of February 22, 2008, for the 10 percent evaluation for dysphagia. While the RO assigned an earlier effective date, the RO has yet to address the increased evaluation issue in an SOC. The RO's February 2012 rating decision granted entitlement to a TDIU and eligibility to Dependents' Educational Assistance (DEA) pursuant to 38 USC Chapter 35, both effective from April 29, 2004. A timely NOD disputing the assigned effective dates was received from the Veteran in March 2012. After an SOC addressing those matters was issued in June 2012, the Veteran perfected his appeal as to those issues in July 2012, via VA Form 9 substantive appeal. The issues on appeal were previously remanded by the Board in December 2006, February 2008, November 2008, and May 2011 for various development actions. The Board is satisfied that the previously ordered development actions have been adequately performed, and is prepared to proceed with its de novo consideration of the issues on appeal. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). The issue of whether a February 10, 2012 rating decision should be reversed and revised on the basis that it did not grant special monthly compensation under 38 U.S.C.A. § 1114(s) has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is REFERRED to the AOJ for appropriate action. The issues of increased evaluations for dysphagia and PTSD from April 29, 2004, are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. The Veteran's claim for service connection for PTSD was received on July 30, 2003, and the Veteran did not have any service-connected disabilities prior to receipt of that claim. 2. TDIU has been awarded to the Veteran, effective from April 29, 2004. 3. It could not be factually ascertained, prior to April 29, 2004, that the Veteran's service-connected disabilities, which at that time included PTSD, bilateral hearing loss, tinnitus, and recurrent dermatitis, rendered the Veteran unable to secure or follow a substantially gainful occupation. 4. Prior to April 29, 2004, the Veteran's PTSD was manifested by anxiety and hypervigilence; sleep disturbances marked by frequent nightmares and awakenings; intrusive thoughts; startles responses; isolative behavior marked by a preference of keeping to himself and avoidance of crowds; and physiological responses to reminders of his active duty service in Vietnam. CONCLUSIONS OF LAW 1. The criteria for an effective date earlier than April 29, 2004 for the assignment of a TDIU have not been met. 38 U.S.C.A. §§ 5107, 5110 (West 2002); 38 C.F.R. §§ 3.102, 3.400, 4.16 (2012). 2. The criteria for an effective date earlier than April 29, 2004, for Dependents' Educational Assistance are not met. 38 U.S.C.A. §§ 3500, 3501, 5110 (West 2002); 38 C.F.R. § 3.400, 3.807 (2012). 3. The criteria for an initial disability rating in excess of 30 percent for PTSD prior to April 29, 2004 have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1) , proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In cases that concern the assignment of a disability rating, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. Notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding the Veteran's claims of entitlement to higher initial disability ratings for PTSD and to earlier effective dates for TDIU and Dependant's Educational Assistance, the Board notes that these issues arises from the initial grant of service connection for PTSD and a TDIU. In a November 2003 pre-rating letter, the RO provided notice to the Veteran explaining what information and evidence were needed to substantiate his claim for service connection for PTSD, what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The Veteran's claim for service connection for PTSD was subsequently adjudicated for the first time in a June 2004 rating decision. Subsequently, a January 2007 letter notified the Veteran as to the process by which disability ratings and effective dates are assigned, as well as the type of evidence that impacts those determinations. After issuance of the January 2007 letter, and opportunity for the Veteran to respond, the Veteran's claim for service connection for PTSD was subsequently readjudicated in a July 2007 SSOC. Hence, although full notice in accordance with the VCAA and Dingess was untimely, the Veteran is not shown to be prejudiced by the timing of this notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). Subject to the foregoing, the Board also notes that, in Dingess, the Court also determined that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has not only been substantiated, but proven. Thus, in such instances, section 5103(a) notice was no longer required because the purpose that the notice is intended to serve has already been served. Dingess, 19 Vet. App. at 490-91; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (stating that section 5103(a) notice is no longer required after service-connection is awarded); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Thus, VA's duty to notify the Veteran in connection with his initial disability rating and earlier effective date claims has been satisfied. In addition, VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claims. The Veteran's service treatment records, claims submissions, lay statements, identified and relevant private treatment records, VA treatment records, and social security records have been associated with the record. The Veteran was also afforded VA general examinations for his PTSD and other service-connected disabilities in December 2003, January 2005, June 2008, November 2008, and May 2012. These examinations, along with the other evidence of record, are fully adequate for the purposes of determining the nature, etiology, and severity of the disabilities adjudicated herein. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. I. Earlier Effective Dates By way of history, the Veteran filed a formal application for a TDIU in September 2011. In a February 2012 rating decision, the RO granted the Veteran's application, effective from April 29, 2004, on the basis that the evidence showed that the Veteran was unable to secure or follow a substantially gainful occupation as of that date due to his service-connected PTSD. Specifically, the RO cites April 2004 VA and private treatment records which reflect complaints of irritability, anger, and homicidal ideation. The RO's rationale indicates that it treated the Veteran's TDIU claim as having been raised by the record in connection with his ongoing appeal concerning the initial disability rating assigned for his PTSD. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The rating decision also awarded eligibility to Dependents' Educational Assistance (DEA) pursuant to 38 USC Chapter 35, also effective from April 29, 2004. In his March 2012 NOD and July 2012 substantive appeal, the Veteran disputed the assigned effective dates. Although the Veteran reminds the Board of various laws and regulations governing the Board's role and duties in adjudicating his appeal, he does not assert any specific bases for his appeal or otherwise suggest an alternative effective date. A claim for a TDIU is, in essence, a claim for an increased disability rating. Norris v. West, 12 Vet. App. 413, 420 (1999). Generally, the effective date for an increased rating is the date of receipt of the claim or the date on which entitlement arose, whichever is later. 38 C.F.R. § 3.400(o)(1). If, however, the claim is filed within one year of the date that the evidence shows that an increase in disability has occurred, the effective date is the earliest date as of which an increase is factually ascertainable (not necessarily the date of receipt of the evidence). 38 C.F.R. § 3.157(b)(1); 3.400(o)(2); see also Harper v. Brown, 10 Vet. App. 125, 126-27 (1997). A specific claim in the form prescribed by VA must be filed in order for benefits to be paid to any individual under the laws administered by VA. 38 U.S.C.A. § 5101(a); 38 C.F.R. § 3.151. A "claim" is a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. 38 C.F.R. § 3.1(p). Any communication or action indicating an intent to apply for one or more benefits administered by VA may be considered an informal claim. See 38 C.F.R. § 3.155(a). The benefit sought must be identified, though it need not be specific. See Servello v. Derwinski, 3 Vet. App. 196, 199 (1992). All filings by a claimant must be construed based on a liberal reading. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) (holding that "[i]n direct appeals, all filings must be read 'in a liberal manner' whether or not the veteran is represented"). Once a veteran (1) submits evidence of a disability, (2) makes a claim for the highest rating possible, and (3) submits evidence of unemployability, an informal claim for TDIU is raised. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); 38 C.F.R. § 3.155; see Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (Fed. Cir. 2009) (holding that an inferred claim for TDIU is raised as part of an increased rating claim only when the Roberson requirements are met). A claim for a TDIU may be a freestanding claim, but may also be a claim for an increased rating (a total rating based on individual unemployability) for the underlying disability(ies). Such a claim may be expressly raised (e.g., by filing a VA Form 21-8940) or "reasonably raised by the record," and the claim may be filed as a component of either the initial claim or as a claim for an increased rating for a service-connected disability. If a veteran asserts entitlement to TDIU during adjudication of the issue of entitlement to service connection or during the appeal of the initial evaluation assigned, the issue is part of the underlying claim for an increased initial evaluation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009); see also Norris v. West, 12 Vet. App. 413, 420 (1999). Furthermore, according to 38 C.F.R. § 3.157(b), once a claim for compensation has been allowed, receipt of a VA outpatient or hospital examination or admission to a VA hospital can be accepted as an informal claim for increased benefits. See Servello, 3 Vet. App. at 199. In such instances, the date on the VA outpatient or hospital examination will be accepted as the date of claim. 38 C.F.R. § 3.159(b). When the evidence is from a private physician, the date of receipt of such evidence will be accepted as the date of receipt of an informal claim. 38 C.F.R. § 3.159(b)(2). A "report of examination or hospitalization" under § 3.157(b) should "indicate that [a] veteran's service-connected disability [has] worsened since the time it was last evaluated." Massie v. Shinseki, 25 Vet. App. 123, 134 (2011). Moreover, the term "report of examination" under § 3.157(b) "implies that the medical record in question must describe the results of a specific, particular examination." A letter may qualify if it, for instance, was "generated in connection with any particular VA medical examination" rather than, for example, a "claim for Social Security disability benefits that was pending at the time it was written." Massie, 25 Vet. App. at 133. Other considerations include whether the letter relates "the findings of or treatment provided during a specific VA medical examination, the date of which could possibly serve as the date of an informal claim for increased disability compensation," rather than "present[ing] a very short summation of [the Veteran's general condition, as [the physician] had observed it over" time. Id. Here, the Veteran's TDIU application was received by VA on September 30, 2011. No earlier claim, whether informal or formal, has been identified, and the Veteran does not argue otherwise. Under VA laws and regulations, a TDIU may be assigned upon a showing that a veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a veteran's level of education, special training, and previous work experience; however, age and any impairment caused by non-service-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Marginal employment, defined as an amount of earned annual income that does not exceed the poverty threshold determined by the United States Department of Commerce, Bureau of the Census, shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). A TDIU may be assigned even where the combined rating for the veteran's service-connected disabilities is less than total if the disabled veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purpose of determining the above, the following will be considered as one disability: 1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor set forth under 38 C.F.R. § 4.26, if applicable; 2) disabilities resulting from common etiology or a single accident; 3) disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; 4) multiple injuries incurred in action; or 5) multiple disabilities incurred as a prisoner of war. In exceptional cases, an extra-schedular rating may be assigned on the basis of a showing of unemployability alone. See 38 C.F.R. § 4.16(b). Such cases are referred to the Director of the Compensation and Pension Service for extra-schedular consideration. The Board notes that, prior to April 29, 2004, service connection was in effect for the Veteran for PTSD, rated as 30 percent disabling; tinnitus, rated as 10 percent disabling; recurrent dermatitis, rated as 10 percent disabling; and bilateral sensorineural hearing loss, rated as noncompensable. The effective date for service connection for all of these disabilities was July 30, 2003. Thus, where the regulations expressly provide that a TDIU may be granted for a veteran's inability to secure or follow a substantially gainful occupation due solely to impairment from service-connected disabilities, the effective date for TDIU in this case may not be earlier than July 30, 2003. The Board notes further that the Veteran's combined disability rating during the period from July 30, 2003 through April 29, 2004 was 40 percent, and moreover, did not include at least one disability that was rated as 60 percent disabling or more. As such, the Veteran did not meet the schedular criteria for a TDIU under 38 C.F.R. § 4.16(a). Accordingly, the Veteran is not entitled to an earlier effective date for TDIU unless the evidence pertinent to the period from July 30, 2003 through April 29, 2004 shows that the extent of the Veteran's service-connected disabilities were so exceptional as to warrant consideration of a TDIU on an extra-schedular basis under 38 C.F.R. § 4.16(b). The evidence relevant to the period from July 30, 2003 through April 29, 2004 includes private psychiatric treatment records from the Veteran's therapist, E.G., which are dated from September 2003 through April 2004. The records from September 2003 reflect that the Veteran reported that he was divorced twice but remained close to his two daughters. He indicated some social impairment, reporting that he did not care if he had friends. He endorsed anxiety and stated that he smoked marijuana to reduce his anxiety. He stated that he slept poorly, always felt tired, and that he intermittently had two or three intrusive thoughts per week. He stated that he also often had nightmares and woke with the feeling that rats were running over him. He also reported that he was hypervigilant and had an extreme startle reflex. During follow-up treatment later that month, he continued to report isolation and that his family relationships were strained except for one brother. Treatment records dated December 2003 reflect similar complaints as those noted above. Although subsequent records from March through April of 2004 reflect ongoing complaints of similar symptoms, they also indicate a relatively high level of social functioning. In March 2004, he stated that he was going hunting in Colorado with a close group of friends who, according to the Veteran, provided good support for him. In April 2004, he reported that he visited a friend from high school who is also a Vietnam veteran. The Veteran stated that he was encouraging him to get out more and expressed that he was worried about him. In an April 29, 2004, letter E.G. summarized the Veteran's treatment and symptoms, and related that the Veteran was also having constant anger problems. He noted that the Veteran stated that if he has to go he will leave the world a better place and that he would take out a few people that do not deserve to live, such as people who use others or hurt animals. According to E.G., a series of psychiatric tests indicated significant depression and hostility. Concurrent with the psychiatric treatment above, VA treatment records dated from September 2003 through April 2004 show that the Veteran was also being followed largely for residual symptoms from non-service connected knee and shoulder replacement surgeries, multiple back surgeries, asthma, and hypothyroidism. During a psychiatric history provided by the Veteran in September 2003, he expressly denied having any suicidal or homicidal ideation, depressed mood, anhedonia, insomnia, or anorexia. In December 2003, he was treated for intermittent and seasonal itching on his legs and a rash on his groin. In describing the severity of the reported itching, he acknowledged that though it was "a little bit irritating" during flare-ups, it was "not terribly debilitating" for him. In January 2004, the Veteran was issued hearing aids. Despite the foregoing treatment related to the Veteran's service-connected psychiatric disorder, skin disorder, and hearing loss, there is no evidence in the VA treatment records that these prevented him from securing or following a substantially gainful occupation. In December 2003, the Veteran was afforded VA examinations of his PTSD, hearing loss and tinnitus, and skin. During the psychiatric examination, the Veteran reported symptoms which included nightmares about rats; unpleasant memories related to Vietnam; a reported instance in which he experienced a flashback while driving through Kansas; and getting "heebie jeebies" when seeing rats or smelling scents that remind him of Vietnam. He stated that he was able to think and talk about the war, but appeared to attribute this to the fact that he did not have anyone to talk to about it. He also reported an exaggerated startle response marked by being scared by sounds such as the backfiring of a car. Nonetheless, the Veteran also reported that he was able to go hunting frequently and that this was "not a big deal." The Veteran also reported that he was on guard all of the time. He also described problems related to concentration and that he had gotten more of a short fuse over the past 10 years. He stated that he was sleeping better with medication and that he slept through the night one or two nights per week. Occupationally, he reported that he worked as a truck driver for 30 years and that he was presently disabled from work due to problems related to his back, knee, and shoulder, as well as respiratory problems. Socially, he stated that he had four close friends, all of whom were veterans, and that he was a member of VFW. He stated that he sees his friends on a daily basis during hunting season, had killed three deer that year, and went hunting on a daily basis in Colorado and Nebraska. The examiner further noted that the Veteran's affect was full and broad while discussing the topics of hunting and fishing, but that while discussing the Veteran's mental health, the Veteran's eye contact became distant and possibly evasive. The Veteran also reported that, for three weeks out of the year, he and his friends worked at a cattle ranch. During mental status examination, the Veteran demonstrated an irritable mood but a full and broad affect. Demonstrated speech and language were normal in rate and rhythm. Thought content was appropriate, and no associational disturbance was noted. The Veteran was oriented to place and time. The Veteran's observed attention and concentration were very good, as demonstrated by his ability to complete serial three exercises backward and spelling words forward and backward. Abstracting ability was also noted as being intact to pointing out similarities, differences, and interpreting a proverb. The Veteran's fund of required knowledge was intact for facts such as current and past presidents, and the significance of Martin Luther King, Jr. The Veteran denied any auditory or visual hallucinations, and no evidence of delusions were noted. Overall, the examiner opined that the Veteran was not a danger to himself or others and determined that psychological testing was not indicated by the Veteran's symptoms. The Veteran reported that he smoked marijuana on a daily basis and that it was "the best painkiller in the world." Hence, the examiner noted that the Veteran appeared to be using marijuana for management of pain symptoms. In discussing the findings from the examination, the examiner expressed some concern as to the reliability of the symptoms reported during the examination. Although the examiner declined to provide a PTSD diagnosis at that time, he did provide Axis I diagnoses of depression, NOS and cannabis dependence. In terms of the Veteran's employability, the examiner opined that the Veteran's depression and marijuana use was mildly impacting his ability to maintain gainful employment, while also affecting his attention, concentration, and memory. The examiner did not express any findings of occupational impairment attributable to the depression diagnosis. During the VA examination of the Veteran's skin, the Veteran reported intermittent and seasonal rashes, patches of dry skin, itching on his forearms and legs, and clusters of blisters on his groin. As noted above, the Veteran stated that these symptoms were "a little bit irritating" during flare-ups but "were not terribly debilitating." A physical examination of the Veteran's skin revealed a thin, dry, patchy rash on the Veteran's forearms, but no other abnormal findings at that time. During the Veteran's audiological examination, the Veteran reported that he was experiencing hearing loss and a constant ringing in his ears which was loud at times and described by him as being a "roaring." Audiological testing revealed mild to moderate sensorineural hearing loss in both ears, manifested by speech recognition ability of 90 percent in the right ear and 96 percent in the left ear and the following pure tone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 15 40 55 55 45 LEFT 15 40 45 55 40 Records obtained from the Social Security Administration (SSA) include a May 2002 favorable determination that the Veteran was disabled from employment from December 2001 due to a combination of non-service connected injuries in his left knee and low back. Interestingly, statements provided to SSA in April 2002 by the Veteran's brothers and friend collectively indicate that the Veteran was relatively active socially. In that regard, his friend L.E. noted that she spoke to the Veteran twice a week by phone and met him in person once per week. She stated that the Veteran interacted normally with others, although he did not participate often in social activities, except to go hunting and fishing. His brother R.S. noted that he saw the Veteran two or three times per week and also stated that the Veteran did not have any problems in interacting with others. He elaborated that the Veteran got along well with nearly everyone and stated that the Veteran enjoyed activities such as fishing and hunting. He stated that the Veteran maintained very good grooming, took stressful situations very well, didn't show anger, and took criticism from others in stride. A statement from the Veteran's other brother, L.S. noted that he also saw the Veteran once per week. In his own April 2002 statement, the Veteran also reported that he did not enjoy social activities outside of his family, but nonetheless, stated that he enjoyed fishing and hunting and was able to go on short trips to perform daily errands. He stated that he was able to sleep five to six hours per night with the use of sleeping pills. Overall, the pertinent evidence does not show that any of the disabilities for which service connection was in effect for the Veteran rendered him unable to secure or follow a substantially gainful occupation prior to April 29, 2004. Although the social security records suggest that the Veteran may have been disabled from employment as early as December 2001, SSA's determination was based exclusively upon the extent of disabilities due to the Veteran's non-service connected left knee and low back disorders. In relation to the Veteran's PTSD, the private therapy records from E.G. indicate that the Veteran was experiencing some social impairment marked by isolative behavior, anxiety, and sleep disturbances, these records appear to indicate that the Veteran was able to maintain a relatively high level of social functioning, which included hunting trips with his friends and generally close and enriching relationships with his family. Indeed, the extent of the Veteran's social functioning is supported further by the April 2002 lay statements contained in the social security records and the functioning reported by the Veteran during his December 2001 VA examination. Given the extent of the Veteran's social functioning shown in the evidence, and in the absence of any specific complaints or objective findings of occupational impairment, there is simply no evidence that the Veteran's PTSD prevented him from securing or following substantially gainful employment prior to April 29, 2004. Similarly, there is no evidence in the record that the Veteran was unable to secure or follow substantially gainful employment due to his service-connected skin disorder, tinnitus, or bilateral hearing loss. In that regard, the Veteran acknowledged to the December 2001 VA examiner and during subsequent VA treatment that his intermittent and seasonal skin disorder, although irritating at times, was not debilitating. Indeed, there is no reference in any of the pertinent evidence to any opinion that the Veteran's skin disorder impaired the Veteran's employability in any way, nor does the Veteran make any such arguments. In relation to the Veteran's hearing loss, the Board notes that the Veteran also does not make any express allegation that his hearing loss impaired his employability. Similarly, there is no such finding expressed in the pertinent treatment records or in the December 2001 VA examination report. Although audiological testing performed during the December 2001 examination revealed elevated pure tone thresholds and diminished speech discrimination, it is unlikely that such "mild to moderate" sensorineural hearing loss (as described by the examiner) prevented the Veteran from securing or following a substantially gainful occupation, particularly given the solitary nature of his longstanding occupation as a truck driver. The weight of the evidence does not support a finding that the Veteran's service-connected disabilities, in and of themselves, rendered him unable to secure and follow a substantially gainful occupation at any time during the period from July 30, 2003 through April 29, 2004. As such, the evidence does not show any basis upon which to refer this matter to the Director, Compensation and Pension Service, for consideration of a TDIU on an extra-schedular basis during that period. Accordingly, the preponderance of the evidence is against the Veteran's claim of entitlement to an earlier effective date than April 29, 2004 for the award of a TDIU. As such, that claim must be denied. The Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b). Regarding the Veteran's claim for an earlier effective date for Dependents' Educational Assistance (DEA) benefits pursuant to 38 U.S.C.A., Chapter 35, an earlier effective date is not warranted. The Veteran was awarded eligibility to Dependents' Educational Assistance effective April 29, 2004, based upon the RO's finding that he was permanently unable, as of that date, to secure or follow a substantially gainful occupation, and hence, was entitled to a TDIU. Except as provided in subsections (b) and (c), effective dates relating to awards under Chapter 35 shall, to the extent feasible, correspond to effective dates relating to awards of disability compensation. 38 U.S.C.A. § 5113. Subsection (b) provides that when determining the effective date of an award under Chapter 35 for an individual described in paragraph (b)(2) of 38 U.S.C.A. § 5113, based on an original claim, VA may consider the individual's application as having been filed on the eligibility date of the individual if that eligibility date is more than one year before the date of the initial rating decision. For these purposes, "eligibility date" means the date on which the individual became an eligible person as defined by 38 U.S.C.A. § 3501(a)(1), and "initial rating decision" means a decision by VA that establishes the Veteran's total disability as permanent in nature. 38 U.S.C.A. § 5113(3) . In the case of a veteran who is alive, the conditions for basic eligibility for DEA include: (1) the Veteran's discharge from service under conditions other than dishonorable; and (2) the Veteran has a permanent total service-connected disability. 38 C.F.R. § 3.807(a). Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. 38 C.F.R. § 3.340(a). Permanence of disability will be taken to exist when such impairment is reasonably certain to continue throughout the life of the disabled person. 38 C.F.R. § 3.340(b). The term "total disability permanent in nature" for the purpose of DEA benefits means any disability rated total for the purposes of disability compensation which is based on an impairment reasonably certain to continue throughout the life of the disabled person. 38 U.S.C.A. § 3501(a)(7). In this case, since the effective date for DEA benefits was directly related to a finding that the Veteran had a total disability that was permanent in nature by virtue of his TDIU rating, April 29 2004 is the earliest date at which the Veteran could establish eligibility for Chapter 35 benefits. Accordingly, an earlier effective date for DEA benefits is denied. II. Initial Disability Ratings for PTSD Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. In cases in which a claim for a higher initial evaluation stems from an initial grant of service connection for the disability at issue, multiple ("staged") ratings may be assigned for different periods of time during the pendency of the appeal. See generally Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate when the factual findings show distinct time periods during which the service-connected disability exhibits symptoms that would warrant the assignment of different disability ratings for each distinct period. 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. See 38 C.F.R. § 4.7. As discussed above, service connection for PTSD was granted by the RO, effective July 30, 2003. A 30 percent initial disability rating was assigned pursuant to 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. In his August 2008 NOD and September 2008 substantive appeal, the Veteran disputed the assigned initial disability rating. Based upon additional evidence, the RO subsequently issued a January 2012 SSOC which awarded a 70 percent disability rating for PTSD, effective from April 29, 2004. In a March 2012 submission, the Veteran expressed his desire to continue his appeal as to the disability ratings assigned for his PTSD. Under DC 9411, a 30 percent disability rating is assigned for PTSD that is manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation); due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (i.e., forgetting names, directions, and recent events) A 50 percent disability rating is assigned for PTSD that is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as a 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; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is appropriate where PTSD is manifested by 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 that is 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); or the inability to establish and maintain effective relationships. A 100 percent disability evaluation is assigned where PTSD is productive of 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 himself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; or memory loss for the names of close relatives, own occupation, or own name. A. Prior to April 29, 2004 Based upon the evidence, the Board finds that the Veteran is not entitled to an initial disability rating higher than 30 percent for PTSD prior to April 29, 2004. In this regard, the Board finds that the overall disability picture for the Veteran's PTSD during that period corresponds with the assignment of a 30 percent disability rating. In a July 2003 statement, the Veteran reported symptoms which included nightmares of being buried alive in a bunker and of his service in Vietnam; waking at night while yelling, sweating, and shaking; waking in the middle of the night in his recliner with no memory of having left his bed to go to his recliner; insomnia; fatigue; poor appetite; claustrophobia; dislike of crowds; and apparent social problems marked by two previous failed marriages. Treatment records in the claims file indicate that all psychiatric treatment for the Veteran prior to April 2004 consisted of private therapy with E.G. A September 2003 records show that the Veteran sought treatment from E.G. to "get a handle on this," meaning that residual effects from serving in Vietnam were affecting his life. Regarding his social functioning, he reported that he was twice divorced and that he was close to his two daughters. He stated that he did not care if he had friends. Regarding his symptoms, he reported anxiety and that he smoked marijuana to reduce his anxiety symptoms. He stated that he slept poorly, always felt tired, and had nightmares and woke in the middle of the night with the feeling that rats were running over him. He stated that he intermittently experienced two or three intrusive thoughts per week. He also claimed that he was hypervigilant and that he had an extreme startle reflex. During follow-up treatment later that month, the Veteran added that he was having strained family relationships, that he was isolated, and that his two dogs are his best friends. He reported, however, that he remained close with one of his brothers. During his December 2003 VA examination, the Veteran reported symptoms which included nightmares about rats; both pleasant and unpleasant memories related to Vietnam; an instance in which he had a flashback while driving through Kansas; and getting "heebie jeebies" when seeing rats or smelling scents that remind him of Vietnam. He stated that he was able to think and talk about the war, but attributed this to the fact that he did not have anyone to talk to about it. He reported decreased interest in activities. The Veteran also reported having an exaggerated startle response marked by being scared by the sound of a car backfiring. He also reported that he was on guard all of the time and that he was having problems with concentration. He stated that he had developed more of a short fuse over the past 10 years. Although the Veteran continued to report sleep disturbances, he stated that he was sleeping better with medication and that he was now able to sleep through the night one or two nights per week. He reported instances in which he was woken by his dog, and he wondered whether he was having a nightmare and that this attracted his dog's attention. Occupationally, the Veteran reported that he worked as a truck driver for 30 years and that he was disabled from work due to problems related to his back, knee, and shoulder, as well as respiratory problems. He did not attribute his lack of current employment to his psychiatric symptoms. Socially, he stated that he had four close friends, all of whom were veterans, and that he was a member of VFW. He stated that he saw his friends on a daily basis during hunting season and that he had killed three deer that year and went hunting on a daily basis in Colorado and Nebraska. The Veteran also reported that he and his friends worked on a cattle ranch approximately three weeks out of the year. Interestingly, the examiner noted that the Veteran appeared to strongly downplay his social functioning by emphasizing that his friends stayed in a trailer and hunted different properties independently during the day. Nonetheless, the examiner also noted that the Veteran's affect was full and broad while discussion topics of hunting and fishing, but became distant and possibly evasive while discussing his mental health. During the mental status examination, the Veteran demonstrated irritable mood, but a full and broad affect. Demonstrated speech and language were normal in rate and rhythm. The Veteran's thought content was appropriate, no associational disturbance was noted, and he was oriented to place and time. Demonstrated attention and concentration were very good, as demonstrated by his ability to complete serial three exercises backward and spelling words forward and backward. His abstracting ability was also noted as being intact to pointing out similarities, differences, and interpreting proverbs. The Veteran's fund of required knowledge was intact for facts such as current and past presidents, and the significance of Martin Luther King, Jr. The Veteran denied any auditory or visual hallucinations and no evidence of delusions were observed. The examiner opined that the Veteran was not a danger to himself or others and determined that psychological testing was not indicated by any of the Veteran's symptoms. Notably, the Veteran reported that he smoked marijuana on a daily basis and that it was "the best painkiller in the world." Hence, the examiner noted that the Veteran appeared to be using marijuana for management of his physical pain symptoms. Based upon the foregoing history, symptoms, and objective findings, the examiner declined to diagnose PTSD under the DSM-IV criteria. However, he provided Axis I diagnoses of cannabis dependence and depression, not otherwise specified (NOS). The examiner questioned the reliability of the Veteran's reported history and symptomatology, noting that the Veteran demonstrated a smirk or smile while reporting his intrusive recollections. Also, the examiner commented that some of the Veteran's symptomatology, such as the reported nightmares related to rats, appeared to be "absurd." The examiner also questioned the veracity of the Veteran's reported loss of interest in activities, given his reported interest in hunting and the reported frequency with which the Veteran went hunting. In terms of the Veteran's occupational functioning, the examiner opined that the Veteran's depression and marijuana use was mildly impacting his ability to maintain gainful employment, while also affecting his attention, concentration, and memory. A Global Assessment of Functioning (GAF) scale score of 70 was assessed based upon the findings from the examination. Subsequent treatment records from E.G. dated through April 2004 reflect ongoing complaints of similar symptoms. Despite these symptoms, however, the Veteran continued to indicate a relatively high level of social functioning. In that regard, he reported in March 2004 that he was planning to go hunting with a close group of guys who were also Vietnam veterans and who, according to the Veteran, provided good support. In April 2004, he reported that he had recently visited a friend from high school who was also a Vietnam veteran and stated that he was worried about him and was encouraging him to get out more. The evidence prior to April 29, 2004, shows that the Veteran's PTSD has been manifested by symptoms which include anxiety and hypervigilence; sleep disturbances marked by frequent nightmares and awakenings; intrusive thoughts; startles responses; isolative behavior marked by a preference of keeping to himself and avoidance of crowds; and physiological responses to reminders of his active duty service in Vietnam (i.e. "heebie jeebies" at experiencing certain smells). The Board notes that, other than the subjectively reported symptoms and noted irritability, the Veteran's mental status examination during his December 2003 was grossly normal. Although the evidence is clearly indicative of some social impairment marked by subjective complaints of isolative behavior, history of two prior divorces, and a limited support network, the evidence nonetheless indicates that the Veteran was able to maintain a relatively high level of social functioning. In that regard, he apparently maintained close and meaningful relationships with his daughters and brothers and maintained friendships with a group of Vietnam veterans with whom he regularly went hunting. Although it is unclear as to whether the Veteran always went hunting and fishing in the company of others, he nonetheless reported during his VA examination that he generally went hunting or fishing on a daily basis during the season. Occupationally, the evidence does not show that the Veteran's psychiatric symptoms impaired his employability. In that regard, although the Veteran reported during his VA examination that he was retired after 30 years of service as a truck driver, he appeared to attribute his lack of current employment to physical symptoms attributable to respiratory problems and conditions in his back, knee, and shoulder. Indeed, and as discussed above, social security records show that SSA did determine that the Veteran was unemployable as of December 2003; however, the Veteran's unemployability was attributed to the Veteran's left knee and right shoulder conditions rather than to his psychiatric disorder. As noted above, a GAF score of 70 was assessed during the Veteran's December 2003 VA examination. In assessing the degree of psychiatric disability, GAF scores are for application and reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). According to the DSM-IV, a GAF score ranging from 61 to 70 is interpreted as indicating some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well with some meaningful interpersonal relationships. A GAF score in the range of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). GAF scores in the range of 41 to 50 denote serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging from 31 to 40 indicate PTSD that is marked by some impairment in reality testing or communication (e.g., speech is at times illogical or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). The Board admonishes that GAF scores are not conclusively dispositive as to a veteran's level of psychiatric impairment. Rather, they are merely parts of a whole body of evidence that must be considered by the Board. Overall, the symptoms demonstrated by the Veteran are grossly consistent with the assigned score of 70. In that regard, there is no evidence of flat affect or circumstantial speech; conflicts with co-workers or friends; suicidal ideation; severe obsessional rituals; shoplifting or other legal problems; or impairment of reality, judgment, thinking, or mood marked by avoidance of friends, neglect of family, inability to work due to psychiatric symptoms, or being physically abusive or defiant. Under the circumstances, the GAF score of 70 assigned during the December 2003 VA examination is consistent with the other evidence in the record, and moreover, is also consistent with the assignment of a 30 percent disability rating for the staged period at issue. The Board has considered the potential application of various provisions of Title 38 Code of Federal Regulations, whether or not they have been expressly raised by the Veteran. Schafrath v. v. Derwinski, 1 Vet. App. 589, 594 (1991). In that regard, the Board has also considered the provisions under 38 C.F.R. § 3.321(b)(1), which govern the assignment of extra-schedular disability ratings. However, in this case, the Board finds that the record does not show that the symptomatology associated with the Veteran's PTSD is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular 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. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, 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 and the assigned schedular evaluation is therefore adequate, and no extra-schedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation as "governing norms"(which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that renders inadequate the available schedular ratings for the service-connected disability. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the disability level and symptomatology that are attributable to the Veteran's PTSD. As discussed above, higher schedular disability ratings are available under DC 9411, however, the Veteran's disability simply is not productive of the manifestations necessary to warrant a higher rating. As such, it cannot be said that the available schedular ratings for the Veteran's disability is inadequate. Based on the foregoing, the Board finds that the requirements for an extra-schedular evaluation for the Veteran's service-connected PTSD have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun, 22 Vet. App. 111. The Board has also considered whether further "staged" disability ratings for the Veteran's PTSD are warranted by the evidence. The symptomatology shown upon examination and treatment, however, has been essentially consistent and fully contemplated by the assigned disability ratings. As such, there is no basis for further staged disability ratings for the Veteran's PTSD. Accordingly, the Board finds that the demonstrated symptomatology during the period before April 29, 2004, is consistent with a 30 percent disability rating for PTSD under DC 9411. To that extent, this appeal is denied. ORDER Entitlement to an effective date earlier than April 29, 2004 for award of a TDIU is denied. Entitlement to an effective date earlier than April 29, 2004 for eligibility to Dependents' Educational Assistance under 38 U.S.C., Chapter 35 is denied. Prior to April 29, 2004, entitlement to an initial disability rating in excess of 30 percent for PTSD is denied. REMAND As noted in the introduction above, a September 2011 rating decision awarded the Veteran service connection for Parkinson's disease and for various separate and distinct manifestations of Parkinson's disease, including dysphagia. A 10 percent initial disability rating was assigned for the service-connected dysphagia, effective from August 20, 2008. In a timely October 2011 NOD, the Veteran disputed the assigned effective date and initial disability rating. In a February 2012 rating decision, the RO granted an earlier effective date of February 22, 2008, for the 10 percent evaluation for dysphagia. While the RO assigned an earlier effective date, the RO has yet to address the increased evaluation issue in an SOC. Under Manlincon v. West, 12 Vet. App. 238 (1999), in instances where VA has not issued an SOC despite the timely receipt of an NOD, the Board is compelled to remand the issue to the RO for the issuance of an SOC. For this reason, the Veteran's claim of entitlement to an initial disability rating in excess of 10 percent for dysphagia is remanded so that the Veteran may be provided an SOC as to that issue. With regard to the Veteran's claim for an initial disability rating in excess of 70 percent for PTSD for the period from April 29, 2004, pertinent private and VA treatment records reflect that the Veteran continued to report ongoing symptoms of depression, anxiety, irritability, isolative behavior, and sleep disturbance, as well as new symptoms which include slow rate of speech, frustration, impaired psychomotor function, memory impairment, and pathological gambling. During VA treatment in June 2007, the Veteran reported that he felt as though he was not going to survive much longer due to his medical problems. In December 2007, he was treated following an episode of confusion and demonstrated for the first time an unsteady gait, disheveled grooming, abnormal involuntary movements, poor judgment and insight, and a clouded sensorium. At that time, he was diagnosed with a cognitive disorder that was confirmed by cognitive testing. During a November 2008 VA examination, the Veteran reported symptoms which included difficulty falling asleep and awakening once every two hours. He stated that most of the time, after awakening, he walked through the house. He also reported that he was in a depressed mood on a daily basis and that he felt helpless and hopeless about his medical issues and in relation to his two previous marriages. He continued to report isolative behavior and stated that he felt down about being so isolated. During mental status examination, the Veteran appeared to be restless due to restless leg syndrome. The remaining aspects of the mental status examination apparently did not reveal any other abnormalities. Overall, the examiner confirmed the Veteran's PTSD diagnosis and also diagnosed depressive disorder, NOS. The examiner opined that the Veteran's depressive disorder, NOS was of probable mixed etiology related to sleep apnea, three back operations, one recent neck operation, restless leg syndrome, hypothyroidism, GERD, COPD, emphysema, etc. and was entirely independent of the Veteran's PTSD. Although the VA examiner thus determined that the Veteran's PTSD and depression were entirely separate pathologies with different etiologies, he did not attempt to differentiate the symptoms attributable to depression from those attributable to PTSD. Moreover, the examiner did not offer any discussion as to whether symptoms shown in the record such as slow rate of speech, abnormal involuntary movements, pathological gambling, and clouded sensorium with instances of disorientation were attributable to the Veteran's PTSD or depression, or alternatively, to other previously diagnosed disorders such as Parkinson's or the cognitive disorder that was diagnosed in December 2007. In the absence of the foregoing discussion, the most recent November 2008 VA examination is incomplete and does not permit the Board to determine the current severity of the Veteran's service-connected PTSD. Moreover, the Board notes that nearly five years have passed since the November 2008 VA examination. In view of the length of time since the November 2008 examination and in view of the increasing symptoms which may or may not be attributable to the Veteran's PTSD, the Veteran should be arranged to undergo a new VA examination to determine the current severity of his PTSD and to differentiate those symptoms attributable to his PTSD from any other diagnosed disorder. 38 C.F.R. § 3.159(c)(4); Caffrey v. Brown, 6 Vet. App. 377 (1994) (holding that an examination that is too remote for rating purposes cannot be considered contemporaneous). Prior to arranging the examination, and in order to ensure that the most complete and up-to-date evidence has been associated with the claims file, the Veteran should also be asked to identify any other treatment providers who have rendered psychiatric treatment since June 2012. VA must then make efforts to obtain any treatment records that are identified by the Veteran. 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following actions: 1. Provide the Veteran an SOC addressing the issue of the Veteran's entitlement to an initial disability rating in excess of 10 percent for dysphagia. 2. A letter should be sent to the Veteran explaining, in terms of 38 U.S.C.A. §§ 5103 and 5103A, the need for additional evidence regarding his claim for an initial disability rating in excess of 70 percent for PTSD from April 29, 2004. This letter must inform the Veteran about the information and evidence that is necessary to substantiate his claim, and also, must provide notification of both the type of evidence that VA will seek to obtain and the type of evidence that is expected to be furnished by the Veteran. The letter must also notify the Veteran that VA is undertaking efforts to arrange a new VA examination to assess the symptoms and severity of his PTSD. The Veteran should be advised that it remains his responsibility to report for any scheduled VA examinations and to cooperate with the development of his claim; failure to report without good cause may result in denial of his claim. The Veteran should also be provided a VA 21-4142 release form, and be requested to identify on the release the name(s) and address(es) of any private or VA medical providers who have provided psychiatric treatment since June 2012. 3. Obtain records for any treatment identified by the Veteran. Any records obtained as a result of such efforts should be associated with the claims file. If such efforts yield negative results, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 3. After the above development has been completed to the extent possible, the RO should arrange for the Veteran to undergo a VA examination, to be performed by a psychiatrist or psychologist at a VA medical facility, to assess the current symptoms and severity of the Veteran's PTSD. The entire claims file must be made available to the individual designated to examine the Veteran. All necessary tests and studies, to include an interview of the Veteran and psychological testing, should be performed. The examiner should render specific findings with respect to the existence and extent (or frequency, as appropriate) of any psychiatric symptoms and differentiate those symptoms that are attributable to the Veteran's PTSD from those symptoms that are attributable to any disorder other than PTSD. The examiner shall render a multi-axial diagnosis, including assignment of a Global Assessment of Functioning (GAF) scale score that represents the level of impairment due to the Veteran's psychiatric disability, and an explanation of what the assessed GAF score means. The examiner is also asked to comment on the impact of the claimed increase in severity of the Veteran's disability, if any, on his employment and activities of daily life. A complete rationale for any opinion expressed should be provided. 4. If the Veteran fails to report to the scheduled examination, the RO must obtain and associate with the claims file a copy of any notice(s) of the dates and times of the examinations sent to the Veteran by the pertinent VA medical facility. 5. After completion of the above development, the issue of entitlement to an initial disability rating in excess of 70 percent for PTSD from April 29, 2004 should be readjudicated. If the determination remains adverse to the Veteran, he and his representative should be furnished with a supplemental SOC and be given an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This 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. 2012). ______________________________________________ LANA K. JENG Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs