Citation Nr: 1324831 Decision Date: 08/05/13 Archive Date: 08/13/13 DOCKET NO. 04-40 027 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder for the time period from July 17, 1997, to May 13, 2008. 2. Entitlement to an increased evaluation for posttraumatic stress disorder, currently evaluated as 70 percent disabling for the time period from May 14, 2008. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The Veteran served on active duty from April 1971 to February 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 1997 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The issue of entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. From July 17, 1997, to May 13, 2008, the medical evidence of record shows that the Veteran's PTSD was manifested by occasional sleep impairment, occasional nightmares, mild intrusive thoughts, mild short-term memory impairment, occasional isolative behavior, anxiety, occasional impaired impulse control, and occasional depressed mood and affect, that results in occupational and social impairment with reduced reliability and productivity. 2. From May 14, 2008, the medical evidence of record shows that the Veteran's PTSD was manifested by a depressed mood, social withdrawal, nightmares, fatigue, low self esteem, low sex drive, suicidal ideation, impaired impulse control, obsessive rituals, hypervigilance, flashbacks, intrusive thoughts, sleep impairment, memory impairment, and almost total social impairment, that results in occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood; total occupational and social impairment has not been shown. CONCLUSIONS OF LAW 1. From July 17, 1997, to May 13, 2008, the criteria for an initial evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 2. From May 14, 2008, the criteria for an evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Increased Evaluation Claims for Service-Connected PTSD With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The Veteran's claims of entitlement to initial increased evaluations for PTSD arises from his disagreement with the initial evaluation assigned following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed. The duty to assist the Veteran has been satisfied in this case. The RO has obtained the Veteran's service treatment records, service personnel records, and his identified private and VA outpatient and inpatient treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Moreover, the Veteran has been afforded multiple VA examinations in July 1998, August 1999, April 2002, April 2003, March 2004, August 2008, and October 2012 that are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Specifically, the VA examiners took into account the Veteran's statements and treatment records, which allowed for fully-informed evaluations of Veteran's service-connected PTSD during the appeal period. Id. As such, there is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Historically, the RO granted entitlement to service connection for PTSD in an April 2002 rating decision, assigning an initial 30 percent evaluation under 38 C.F.R. § 4.130, Diagnostic Code 9411, effective July 17, 1997. The same rating decision also assigned temporary total ratings for the Veteran's PTSD in accordance with the provisions of 38 C.F.R. § 4.29 for the periods from October 7, 1997, to October 31, 1997, March 4, 1998, to March 31, 1998, and December 2, 1998, to December 31, 1998. The 30 percent evaluation was resumed after each temporary total rating. An April 2003 rating decision granted an additional temporary total rating for the Veteran's PTSD in accordance with the provisions of 38 C.F.R. § 4.29 for the period from February 28, 2003, to March 31, 2003. The 30 percent evaluation was resumed after the temporary total rating. A September 2004 rating decision assigned a 50 percent evaluation for the Veteran's PTSD, effective from July 17, 1997. The 50 percent evaluation was resumed after each temporary total rating. A February 2006 rating decision granted a further temporary total rating for the Veteran's PTSD in accordance with the provisions of 38 C.F.R. § 4.29 for the period from November 9, 2005, to December 31, 2005. The 50 percent evaluation was resumed after the temporary total rating. In June 2008, the Board remanded this matter for additional development, to include obtaining a VA examination. Thereafter, in a May 2010 decision, the Board granted temporary total rating for the Veteran's PTSD in accordance with the provisions of 38 C.F.R. § 4.29 for the period from July 29, 1997, to September 31, 1997. While it continued the previously assigned initial 50 percent evaluation for PTSD for the time period prior to May 14, 2008, the Board granted entitlement to a 70 percent evaluation for service-connected PTSD, effective May 14, 2008. The RO effectuated the Board's order in a June 2010 decision, assigning a 70 percent rating for PTSD, effective from May 14, 2008. Thereafter, the Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In December 2010, based on a Joint Motion for Partial Remand (Joint Motion), the Court issued an Order remanding this case for compliance with the Joint Motion. In a January 2013 rating decision, the RO granted an additional temporary total rating for the Veteran's PTSD in accordance with the provisions of 38 C.F.R. § 4.29 for the period from June 1, 2009, to June 30, 2009. The 70 percent evaluation was resumed after the temporary total rating, effective July 1, 2009. After issuing a supplemental statement of the case in April 2013, this matter was returned to the Board for adjudication. Where a Veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous. . . ." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id.; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). Pursuant to Diagnostic Code 9411, PTSD is rated 50 percent 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. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 70 percent disability 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); inability to establish and maintain effective relationships. Id. A 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition, in Mittleider v. West, 11 Vet. App. 181 (1998), the U.S. Court of Appeals for Veterans Claims (Court) held that VA regulations require that when the symptoms and/or degree of impairment due to a veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF of 31 to 40 is defined as some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. Id. A GAF of 41 to 50 is defined as 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). Id. A GAF of 51 to 60 is defined as moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Id. A GAF of 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful relationships. Id. When evaluating a mental disorder, consideration shall be given to the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation will be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. It is the responsibility of VA to interpret examination reports in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. §§ 4.2, 4.126 (2012). From July 17, 1997 to May 13, 2008 In VA outpatient medical reports dated in July 1997, the Veteran reported a history of PTSD, depression, and polysubstance abuse. He noted feeling suicidal and homicidal, detailing that the previous day he took a mixture of heroin, crack cocaine, marijuana, and Tylenol #3 in attempt to commit suicide by drug overdose. The Veteran reported experiencing blackouts, auditory hallucinations, and recurrent recollections of distressing events. He reported that his mood was sad and that he experienced some anger, flashbacks, startle response, avoidance behavior, sleep impairment, impaired impulse control, and hypervigilance. A September 1997 VA hospital discharge report stated that the Veteran had been hospitalized from July 29, 1997, to September 15, 1997, with diagnoses of continuous chemical dependence to opiates and PTSD. The examiner assigned a GAF score of 75. Treatment was noted to be primarily for his problem with substance abuse and for his problems related to PTSD symptoms. The Veteran was noted to respond will to Trazodone and to have no suicidal or homicidal behavior. An October 1997 VA hospital discharge report stated that the Veteran had been hospitalized from October 7, 1997, to October 29, 1997, with a diagnosis of PTSD. The examiner assigned a GAF score of 45 with a GAF score of 48 during the past year. It was indicated that the Veteran sought admission for flashbacks, nightmares, sleep disturbance, depressed mood, problems controlling anger, isolating himself, and fear of thunder and lightning. Mental status findings on admission were listed as decreased in short term memory and abstract reasoning, mild deficit with concentration, normal speech, and no suicidal or homicidal ideation. A March 1998 VA hospital discharge report stated that the Veteran had been hospitalized from March 4, 1998, to March 31, 1998, with a diagnosis of PTSD. The examiner assigned a GAF score of 47 with a GAF score of 49 during the past year. It was indicated that the Veteran continued to have symptoms of flashbacks, nightmares, intrusive thoughts, sleep disturbance, anger, irritability, hypervigilance, avoidance, social isolation, and dysthymia. On discharge, it was indicated that the Veteran was now returning to the Flint area for independent living. An April 1998 VA medication management note revealed diagnoses of chronic PTSD, alcohol abuse in remission, opioid dependence in remission, cannabis abuse in remission, and antisocial personality disorder. In a July 1998 VA PTSD examination report, the Veteran complained of being addicted to heroin, cocaine, and alcohol, with sobriety over the previous year. He reported having a "fine" mood; sleeping "extremely well"; and being employed as a prep cook. The Veteran reported experiencing occasional nightmares but denied experiencing flashbacks, suicidal ideation, homicidal ideation, auditory hallucinations, hyperarousal, a sense of a foreshortened future, and a sense of isolation, or recurrent, intrusive, or distressing recollections. The Veteran discussed his personal history, indicating that he was divorced and that his two children were being raised by his sisters. On mental status examination, the Veteran was alert, oriented, cooperative, and had good hygiene and grooming. There was no motor agitation and the Veteran did not have any formal thought disorder. The Veteran's affect had a normal range and intensity. He was euthymic and reactive, without suicidal or homicidal ideation. There were no psychotic symptoms and the Veteran did not have any cognitive impairment. The examiner listed diagnoses of heroin dependence in remission, cocaine and alcohol abuse in remission, and antisocial personality disorder. The examiner assigned a GAF score of "about 65", noting that the Veteran did not experience flashbacks, avoidance behavior, hyperarousal, or sleep impairment when on medication. A December 1998 VA hospital discharge report stated that the Veteran had been hospitalized from December 2, 1998, to December 30, 1998, with a diagnosis of PTSD. The examiner assigned a GAF score of 49/49. It was indicated that the Veteran complained of depression, isolation, anger problems, nightmares, flashbacks, and intrusive thoughts. On mental status examination, the Veteran was well oriented times three, alert, feeling depressed without complaints of fatigue or anhedonia, and had poor short term memory but good concentration, fair insight, and normal speech content. There were no complaints of suicidal ideation, homicidal ideation, or visual or auditory hallucinations. An August 1999 VA PTSD examination report stated that the Veteran's medical records had been reviewed. The Veteran denied experiencing a depressed mood, auditory hallucinations, visual hallucinations, suicidal ideation, and homicidal ideation. He reported sleeping well, good energy, able to control his anger, and having intrusive thoughts of traumatic incidents that were not distressing, as he was able to control his feelings due to medication. The Veteran stated that he was currently employed as a truck driver and maintenance person as well as held the position of treasurer for Narcotics Anonymous (NA). He reported "good contact" with his sister. It was noted that he was currently on probation until 2000 for assault and battery which occurred in October 1998. His previous probation was noted to be for carrying a concealed weapon, heroin, and retail fraud. The Veteran denied experiencing sleep impairment, impairment of impulse control, and impairment of concentration. On mental status examination, the Veteran was in no acute distress and had no abnormal body movements. He was cooperative, his mood was euthymic, and his affect was appropriate. The Veteran's speech was spontaneous, coherent, and relevant. There were no signs of psychosis, suicidal ideation, or homicidal ideation. The Veteran was alert and oriented to person, place, and time. He was able to remember "one out of three after 5 minutes." The Veteran's general fund of knowledge, insight, and judgment were fair. He did well with abstract reasoning and proverb interpretation. The examiner diagnosed polysubstance dependence in full sustained remission and assigned a GAF score of 65. The examiner highlighted that the Veteran was currently employed, functioning pretty well, had a meaningful relationship with his sister, and was participating actively in NA. The examiner indicated that the Veteran did not meet the full criteria of PTSD. The Veteran reported that his symptoms had subsided since he stopped using illicit drugs two years before. It was noted that the Veteran's condition may be due to his substance abuse problems and personality when he was having anger outbursts and behavioral problems which started before he went to the service. During a March 2000 Board hearing, the Veteran asserted that he suffered from nightmares and flashbacks but was a little "more at ease with it now". He reported having trouble getting along with people and being currently employed as a truck driver. Records from SSA listed a primary diagnosis of mixed drug dependence with no established secondary diagnosis. In an April 2002 VA mental disorders examination report, the examiner stated that the Veteran's claims file and medical records had been reviewed. The Veteran reported that he got along well with all three of his siblings, had a poor relationship with his eldest daughters, and had a distant but amicable relationship with his younger daughters. He stated that he was currently employed and worked 40 hours per week as a truck driver in the "family business." The Veteran stated that he had held that job for the previous three years, which was his longest period of stable employment, and that he had purchased a home six months before. He reported that he had not taken psychoactive medication for the previous 1.5 years. The Veteran reported nightmares approximately once every two months, anxiety during thunderstorms due to memories of combat, and avoidance of war movies and Veterans' organizations. It was unclear whether the Veteran had blocked memories of traumatic events. The Veteran denied experiencing sleep impairment and reported that he had not had difficulty with impulse control since becoming sober five years before. He experienced strong, intrusive angry thoughts but was able to control them with a conscious effort. The Veteran denied difficulty with concentration and there was no evidence of hypervigilance. He reported being uncomfortable in crowds when he was alone, but not when accompanied by friends or family members. The examiner stated that the Veteran's PTSD symptoms were "significantly distressing to him, but they do not appear to be causing social or vocational impairment at this time." The Veteran reported that he held several positions of responsibility in NA, including sponsor for multiple people, treasurer, and another leadership position. On mental status examination, the Veteran was neatly dressed, groomed, and fully cooperative. His mood was euthymic and his affect was consistent and within normal limits. The Veteran's eye contact was good and he was oriented to person, place, time, and purpose. There were no abnormalities of speech and the Veteran denied experiencing auditory hallucinations, visual hallucinations, suicidal ideation, and homicidal ideation. He denied experiencing obsessive or ritualistic behaviors that interfered with routines activities. He denied short term memory impairment, but reported "questionable" long term memory. No memory deficiencies were noted by the examiner. The examiner stated that the Veteran did not appear to be exaggerating his symptoms and was managing many of his previous symptoms such as anger control, social estrangement, and a negative outlook. The examiner stated that the Veteran experienced clinically significant symptoms of anxiety, listed diagnoses of PTSD as well as opioid dependence in remission, and assigned a GAF score of 70. A March 2003 VA hospital discharge report stated that the Veteran had been hospitalized from February 28, 2003, to March 28, 2003, with a diagnosis of PTSD. The examiner assigned a GAF score of 44/46. The Veteran was noted to complain of nightmares, intrusive thoughts, guilt feelings, and having feelings of anger. At admission, the Veteran did not voice any suicidal or homicidal ideations. VA treatment records dated in March 2003 showed the Veteran was attending individual as well as group psychology therapy; was working on his anger; remained employed full time in the family business; and volunteered with NA. An additional treatment record dated in March 2003 showed an assigned GAF score of 50/52. In an April 2003 VA PTSD examination report, the examiner stated that the Veteran's claims file and medical records had been reviewed. The Veteran reported that he had been employed as a truck driver at his nephew's business for the previous four years and presently worked about 40 hours per week. The Veteran reported that he was doing well at his job. He reported that he was heavily involved with NA, both locally and nationally, and it was his main activity outside work. The Veteran complained of nightmares, intrusive thoughts, and isolative behavior. He reported difficulty with anger, irritability, environmental triggers for symptoms, and sleep impairment. The Veteran reported an increase in symptoms since the start of the Iraq war. On mental status examination, the Veteran was neatly dressed and articulate with speech of normal form and rate and anxious mood. The Veteran's affect was appropriate and he had no hallucinations or delusions. The Veteran did not have any thought disorder or suicidal ideation, and he had good insight. The examiner diagnosed PTSD and opioid dependence in remission for six years as well as assigned a GAF score of 65. The examiner stated that the Veteran's symptoms caused "some mild social impairment, but in general the [Veteran] is able to work well and has some meaningful interpersonal relationships and has been very active in NA." In a March 2004 VA PTSD examination report, the Veteran complained of often feeling frustrated and angry. He reported that he did not like or get along with people. The Veteran reported occasional sleep impairment and described his mood as a three on a scale from one to ten, with ten being the worst. The Veteran denied feeling worthless and any sustained sad mood. He reported experiencing nightmares. He reported that he'd been working for the previous six years at a family business owned by his nephew. The Veteran stated that he was not on any psychiatric medications. On mental status examination, the Veteran was alert, oriented, and mesomorphic. He was in no acute distress, had no motor agitation, and exhibited fluent speech, somewhat dysphoric affect, fair insight, and fair judgment. The Veteran did not have suicidal ideation, homicidal ideation, psychotic symptoms, or gross cognitive defects. The examiner diagnosed polydrug dependence in remission and PTSD by history as well as assigned a GAF score of 70. The examiner stated that the Veteran had some nightmares and anxiety symptoms, but was "able to hold a job and [was] able to interact with people, with some impairment in his social interaction." During a May 2005 RO hearing, the Veteran reported that he continued to have anger, flashbacks, dreams, and sleeplessness. He indicated that he had not seen his two eldest daughters in many years but that he was in the lives of his four children but "not on a daily basis". He commented that he had recently had a "pretty bad" accident at work, did not often miss work even when he didn't want to go because of his responsibilities, lived with his parents, and was experiencing irritability and mood swings. A November 2005 VA hospital discharge report stated that the Veteran had been hospitalized from November 8, 2005, to December 2, 2005, with a diagnosis of PTSD. The examiner assigned a GAF score of 38/40. The Veteran was noted to complain of being depressed, experiencing anxiety, having sleeping problems, having problems controlling his anger, and isolating himself. He denied any homicidal ideation, suicidal ideation, or auditory or visual hallucinations. The Veteran was also noted to have chronic left ankle pain secondary to a crushing injury to the ankle. A November 2005 VA psychiatric note stated that the Veteran had been working 60 hours per week as a family-owned business until his ankle was crushed in March 2005 in a work-related accident. He reported that the injury made him unable to work and that he was feeling more depressed with a lot of time on his hands. The Veteran complained of more frequent and intense nightmares and flashbacks since his injury with fewer activities with NA. A December 2005 VA treatment record showed a diagnosis of PTSD. It was noted that the Veteran was feeling better with improved attitude and awareness. He discussed some thoughts about suicide without intent or plan but denied homicidal ideation and auditory hallucinations. The examiner assigned a GAF score of 55 on admission and on discharge. A May 2006 VA outpatient neuropsychology consultation report stated that the Veteran had been employed until a crush injury to the right ankle, for which he had since been determined to be medically disabled. On clinical interview and mental status examination, the Veteran was cooperative, compliant, and responded with coherent and goal-directed responses. The Veteran had no difficulty understanding directions. The examiner detailed that the Veteran became increasingly angry as the neuropsychological evaluation progressed, being aware of failed performances and responding to them with frustration. His affect was broad, and his mood was typically angry, expansive, and irritable. On testing, the Veteran had mild impairment of short-term memory, particularly when the material lacked structure or context. He reported minimal distress or difficulty in coping with stressors. The examiner stated that testing showed the Veteran was agitated, depressed, confused, withdrawn, and likely psychotic, with tangential thinking. It was noted that individuals with this profile were unpredictable and may rely on alcohol and drugs to face the world, otherwise feeling ruminative and doubtful. The examiner summarized that the Veteran's overall abilities fell into the low average range, with impairment of new learning, memory, complex problem solving, and emotional functioning. In an April 2008 Informal Hearing Presentation, the Veteran's representative asserted that the Veteran had sought treatment for his service-connected PTSD in support groups, individual therapy, and numerous month-long stays in VA hospitals since 1997. It was indicated that the Veteran had experienced increased symptoms in the last four to five months, including intrusive thoughts, depression, nightmares, flashbacks, and suicidal thoughts. The representative reported that the Veteran was on a waiting list to receive another 30 days of inpatient care for PTSD. It was noted that the Veteran requested a disability rating of at least 70 percent for PTSD or wanted the matter remanded for VA to obtain additional records as well as a new examination. Regarding the time period from July 17, 1997, to May 13, 2008 (excluding those period of time a 100 percent temporary total rating was assigned to the Veteran's service-connected PTSD under the provisions of 38 C.F.R. § 4.29), the Board finds that the service-connected PTSD disability symptomatology does not meet the severity of occupational and social impairment contemplated for a rating in excess of 50 percent. 38 C.F.R. § 4.130, Diagnostic Code 9411. As noted above, a 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood due to certain symptoms; however, the Board finds that that level of occupational and social impairment has not been shown during this time period, other than those periods of time that a 100 percent evaluation has previously been assigned under the provisions of 38 C.F.R. § 4.29. The clinical evidence of record during this time period does not show 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; or an inability to establish and maintain effective relationships at work and at home. While the Veteran has asserted that his service-connected PTSD caused him to at times be socially isolative, depressed, irritable, and had conflicts with his family members and at work, the evidence of record indicates that the Veteran was able to maintain full-time employment for many years during this time period until medically disabled due to an ankle injury in 2005; to sustain relationships with multiple members of his family and at least one friend; to attend and benefit from individual and group therapy; and to pursue volunteer activities. While the Veteran described having difficulty controlling his anger and was shown to have been put on probation after an assault and battery charge in 1998, his descriptions of what this entailed did not indicate recurrent periods of actual violence. In fact, the Veteran has repeatedly indicated that he found ways to cope and control his anger and intrusive thoughts. Also, the few isolated complaints of suicidal ideation were described as without plan or intent. Moreover, the Board has also considered the assigned GAF scores of 65 in July 1998, August 1999, and April 2003, and of 70 in April 2002 and March 2004, during this time period which are indicative of mild symptomatology and mild impairment in social and occupational functioning due to service-connected PTSD. The Board in no way seeks to minimize the strides the Veteran has taken toward recovery or the severity of his chronic PTSD symptoms. It is the responsibility of VA to interpret examination reports in the light of the whole recorded history as well as reconcile all evidence of record into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. §§ 4.2, 4.126, (2012). The evidence of record clearly reflects that the Veteran sought voluntary VA hospital admission for VA inpatient treatment on six occasions from 1997 to 2008 whenever he felt his symptoms increasing beyond his control. VA has already fully compensated the Veteran during those times of increased PTSD symptomatology. See 38 C.F.R. § 4.29 (2012). While the Board has not used the actual findings during those periods of hospitalization in considering the Veteran's claim for an initial evaluation in excess of 50 percent for PTSD during the time period from July 17, 1997, to May 13, 2004, it has considered the effects from and totality of those hospitalizations in conjunction with evaluating the Veteran's PTSD during this time period. The Board is fully cognizant that the repeated inpatient VA treatment during this time period shows the chronic nature of the Veteran's service-connected PTSD. However, once discharged to independent living after each hospitalization, the Veteran's capacity for adjustment during many lengthy periods of remission was shown to be generally robust. The Veteran has revealed himself to be of strong conviction, resilient character, and to be deeply invested in maintaining his sobriety, as well as attuned to managing his PTSD symptomatology. While there have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence shows no other distinct periods of time from July 17, 1997, to May 13, 2008, during which the Veteran's PTSD has varied to such an extent that a rating greater or lesser than the initial 50 percent evaluation assigned would be warranted. Cf. 38 C.F.R. § 3.344 (2012) (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). Consequently, there is no basis for assignment of an initial evaluation in excess of 50 percent for PTSD during the time period from July 17, 1997, to May 13, 2008. From May 14, 2008 In a May 14, 2008, VA outpatient psychiatric note, the Veteran reported that he was able to cope with his symptoms without psychiatric medication. He reported significant financial stressors since his leg was crushed, resulting in an inability to work. The Veteran stated that thunderstorms frightened him. He reported experiencing depression, social withdrawal, nightmares, fatigue, low self esteem, low sex drive, and feelings of worthlessness. The Veteran also reported suicidal ideation without any plans or intent as well as racing thoughts, tension, angry outbursts, worries, fears, social anxiety, obsessive thinking, and flashbacks. On mental status examination, the Veteran was neat, clean, casually dressed, pleasant, and cooperative, but his mood was depressed. No abnormalities were noted in affect, speech, thought content, thought process, or cognitive abilities. The Veteran denied auditory or tactile hallucinations, but reported "seeing shadows." The examiner diagnosed PTSD and assigned a GAF score of 60. VA outpatient mental health notes dated from June to October 2008 stated that the Veteran behaved appropriately and was active in group therapy and also joined a VA Compensated Work Therapy Program (CWT). In an August 2008 VA PTSD examination report, the Veteran reported that his PTSD symptoms had become worse since a work-related injury in March 2005. He reported that as he was no longer working; usually stayed by himself all day; had intrusive thoughts three times per week; had nightmares two times per week; and suffered from sleep impairment. The Veteran stated that he experiencing flashbacks about three to four times per week, with chronic anxiety, hypervigilance, and irritability. He reported depression since March 2005 with fleeting suicidal ideation approximately four to five times per week, but with no plans to act on them. The Veteran complained of memory impairment. It was noted that he currently lived with his parents; stayed in his room for most of the day; attended Alcoholics Anonymous and NA meetings for 1.5 hours each day; and ran a NA group at a prison once per month. He reported that he also attended a PTSD group once per week, but otherwise did not go out, did not have a social life, and did not like crowds. On mental status examination, the Veteran looked anxious and hypervigilant. His mood was depressed and his affect was congruent, mildly depressed, and constricted. The Veteran's thoughts were logical and goal-directed, and he did not experience auditory or visual hallucinations. He reported fleeting suicidal ideations, but denied any at the time of the examination, and denied homicidal ideation. The Veteran was noted to have a good fund of knowledge was good, impaired memory, intact concentration, good insight, and fair judgment. After reviewing the claims file and examining the Veteran, the examiner diagnosed chronic PTSD and assigned a GAF score of 50. The examiner stated that the Veteran's depressive symptoms had increased since his March 2005 work accident, due to an inability to work. The Veteran was noted to continue to have sleep impairment, flashbacks, panic attacks, intrusive thoughts, and be socially isolative with no friends or significant relationships. However, the Veteran was noted to be logical and oriented. It was indicated that he did not have any obsessional rituals; stereotyped or circumlocutory speech; illogical, obscure, or irrelevant speech; delusions; hallucinations; disorientation to time or place; and was not in persistent danger of hurting himself or others. A March 2009 VA psychology telephone contact note, the Veteran was noted to work at a VA CWT; attend near daily NA meetings; live with his parents; and works mostly alone in a warehouse or "safe haven" six days a week from 0730 to 1300. He complained of hypervigilance, difficulty sleeping, flashbacks, depression, thoughts of suicide, and nightmares two to three times a week. The interviewer noted that the Veteran denied any recent suicidal ideation/homicidal ideation or any plan or intent to harm himself or anyone else. On mental status evaluation, there was no evidence of impaired orientation. The Veteran was noted to have grossly intact memory; clear and coherent speech; and logical thought process with no evidence of thought disorder. There was no evidence of paranoia, delusional thought system, or audio/visual hallucinations. The Veteran was noted to request admission to residential treatment to enhance his coping skills and improve functioning. The examiner diagnosed PTSD and assigned a GAF score of 50. A June 2009 VA hospital discharge report stated that the Veteran had been hospitalized from June 3, 2009, to June 25, 2009, with a diagnosis of PTSD. The examiner assigned a GAF score of 45/47. The Veteran was noted to complain of being depressed, isolating himself, having sleeping problems with nightmares and night sweats, hypervigilance, anxiety, relationship problems, increased startle response, short term memory problems, flashbacks, problems controlling his anger, concentration problems, emotional numbing, and intrusive thoughts. The Veteran again received group and individual therapy during inpatient admission. On discharge, the Veteran was returning to daily living; considered competent; and was free of any suicidal or homicidal ideation or delusions. The Veteran's memory, concentration, attention span, impulse control, insight, and judgment were all noted to be fair. A July 2009 VA treatment record showed an assessment of PTSD with some mood instability but no suicidal ideation. The examiner assigned a GAF score of 80. In a February 2010 Informal Hearing Presentation, the Veteran's representative asserted that the Veteran's symptoms had worsened since his last examination and he was entitled to an increased rating. It was further noted that the Veteran had not worked for over five years and that his symptoms were severe enough to indicated that he may be unemployable due to his PTSD. VA treatment notes dated in 2010 showed continued findings of anxiety and chronic PTSD. A January 2010 CWT individual note showed an assigned GAF score of 70. In a November 2010 VA psychiatric progress note, the examiner listed an assessment of PTSD and assigned a GAF score of 85. In an October 2012 VA Initial PTSD VA examination report, the examiner listed diagnoses of anxiety disorder, not otherwise specified, recurrent major depressive disorder in partial remission and polysubstance dependence in sustained remission. However, the examiner indicated that the Veteran did not have a diagnosis of PTSD that conformed to DSM-IV criteria based on the current evaluation. The examiner indicated that depressive symptoms included some guilt feelings, periodic poor sleep maintenance (but eight hours sleep with medication), and sadness. It was further noted that anxiety symptoms included avoidance of some crowds (but attends baseball games), nightmares two times a week, angry reactions (but does not act out), and startle reaction. The examiner marked that the Veteran suffered from occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. It was further noted that it was not possible for the examiner to differentiate what portion of the Veteran's occupational and social impairment was caused by each diagnosed mental disorder. The examiner assigned a GAF score of 61. The Veteran described having a good relationship with two of his children; living with his parents; maintaining a friendship with his NA sponsor; going to jails to talk with inmates about recovery; attending NA five to seven times per week; attending baseball games; and being "pretty easy to get along with" at work. He discussed his occupational history, noting that starting in December 1997 he worked for Waste Management hauling garbage as temporary worker for a couple of months. He reported that he then found work at a steakhouse for six months before transferring to another steakhouse for two months before was fired because of anger problems. The Veteran indicated that his nephew then hired him to work at his granite company for three to four years before he had an accident resulting in his left leg being crushed. He reported that he did not work from 2004 to 2009 until he completed the CWT Program at VA, becoming a Supply Technician for 16 months. He indicated that he was then offered full-time employment and has worked in that job for almost three years. For VA rating purposes, the examiner found that the suffered from depressed mood, anxiety, panic attacks that occurred weekly or less often, periodic guilt, disappointment at lack of life partner, and decreased joy or pleasure in life due to his diagnoses. It was again indicated that the Veteran had some symptoms of PTSD but did not meet full criteria. After reviewing the Veteran's claims file and VA medical records, the examiner listed the following mental status examination findings: focused; articulate in interview; displayed appropriate speech, flow of ideas, and social skills; and pleasant, wide ranging, and appropriate affect. The examiner specifically noted that the Veteran's primary focus during the interview was on the difficulty in obtaining his compensation from VA, which appeared to be his main, current stressor. It was indicated that the Veteran did not suffer from disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances, impairment in thought processes or communication, delusions, hallucination, grossly inappropriate behavior, inability to perform activities of daily living, danger of hurting himself or others, or disorientation to time or place. Regarding the Veteran's present functioning, the examiner noted that the Veteran was presently working with reports of good performance and attendance record. The Veteran was noted to report satisfactory relationships with friends, family, and co-workers. He discussed continued volunteer work and frequent attendance of NA meetings, maintaining a relationship with a sponsor. Although the Veteran continued to have some symptoms, the examiner indicated that he is functioning fairly well with some meaningful activities and personal relationships. In a May 2013 Informal Hearing Presentation, the Veteran's representative asserted that there were no additional arguments to present regarding the Veteran's scheduler rating for service-connected PTSD. Regarding the time period from May 14, 2008 (excluding the period of time a 100 percent temporary total rating was assigned to the service-connected PTSD under the provisions of 38 C.F.R. § 4.29), the Board finds that the service-connected PTSD disability symptomatology does not meet the severity of occupational and social impairment contemplated for a rating in excess of 70 percent. 38 C.F.R. § 4.130, Diagnostic Code 9411. As noted above, a 100 percent rating requires total social and occupational impairment; however, the Board finds that this level of occupational and social impairment has not been shown during this time period, other than that period of time that a 100 percent evaluation was previously assigned under the provisions of 38 C.F.R. § 4.29. While the Veteran complained of depressed mood and fleeting suicidal ideation without plan or intent during this time period, he has maintained current employment, familial relationships, leisure activities, and volunteer work. The Board further points out that the assigned GAF scores of 60 (May 2008), 50 (August 2008 and March 2009), 70 (January 2010), 85 (November 2010), and 61 (October 2012) during this time period are indicative of mild to serious symptomatology and mild to serious but not total impairment in social and occupational functioning due to service-connected PTSD. While there have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence shows no other distinct periods of time from May 14, 2008, to the present during which the Veteran's PTSD has varied to such an extent that a rating greater than the 70 percent evaluation previously assigned would be warranted. Cf. 38 C.F.R. § 3.344 (2012) (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). The Board has also considered the effects of the June 2009 VA inpatient treatment during this time period. However, once discharged to independent living after the June 2009 hospitalization, the Veteran's capacity for adjustment was again shown to be strong. The Board is cognizant that the Veteran seeks increased compensation for his PTSD symptomatology. Based on the foregoing discussion, the Board finds that there is no basis for assignment of an evaluation in excess of 70 percent for PTSD during the time period from May 14, 2008. However, the Board again wishes to emphasize that the Veteran's proactivity in his recovery; his continued tenacity in creating opportunities for himself; his ability to provide for his family; and his inspiring volunteer work are commendable. Additional Considerations for Both Time Periods In this case, the Veteran's statements are competent evidence to report his increased PTSD symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is also credible in his belief that he is entitled to higher ratings. However, the more probative evidence of record does not indicate that the assignment of any additional increased evaluation is warranted. In so finding, the Board notes that it weighed the lay and medical evidence and finds more probative certain opinions rendered by medical professionals given their expertise in evaluating mental disorders. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. Nonetheless, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available scheduler evaluations for that service-connected disability are inadequate. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned scheduler evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the assigned ratings inadequate. The Veteran's service-connected PTSD is evaluated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. During the appeal period, evidence of record shows that the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity from July 17, 1997, to May 13, 2008, and by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood from May 14, 2008. When comparing these disability pictures with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability pictures represented by the assigned 50 percent and 70 percent disability ratings. Higher ratings are provided for by the regulations for certain manifestations of PTSD, but the medical evidence for the time periods from July 17, 1997, to May 13, 2008, and from May 14, 2008, demonstrates that those manifestations are not present. The criteria for the assigned 50 percent and 70 percent evaluations reasonably describe the Veteran's disability levels and symptomatology throughout the pendency of this appeal. Consequently, the Board concludes that the scheduler evaluations are adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). Finally, in reaching this decision the Board considered the doctrine of reasonable doubt; however, as discussed above, the preponderance of the evidence is against the assignment of an initial evaluation in excess of 50 percent from July 17, 1997, to May 13, 2008, and the assignment of an evaluation in excess of 70 percent from May 14, 2008, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); see also Fenderson, 12 Vet. App. at 126; see also Hart, 21 Vet. App. at 507. ORDER Entitlement to an initial evaluation in excess of 50 percent for PTSD for the time period prior to May 14, 2008, is denied. Entitlement to an evaluation in excess of 70 percent for PTSD for the time period from May 14, 2008, is denied. REMAND The Board's review of the claims file reveals that further development on the issue of entitlement to a TDIU is warranted. A longitudinal review of the claims file showed that the Veteran was initially employed as a prep cook at various steakhouses in 1998 before he worked as a truck driver for his nephew's granite company starting in 1999. Evidence of record detailed that the Veteran experienced an ankle crush injury while on that job in March 2005 and was then considered "medically disabled". VA treatment notes dated in 2008 showed that the Veteran joined a CWT group. In a March 2009 VA psychology telephone contact note, the Veteran was noted to work in a CWT program at the Detroit VA. It was indicated that he worked mostly alone in a warehouse or "safe haven" six days a week from 0730 to 1300. In July 2012, the Board determined that the issue of entitlement to a TDIU was part and parcel of the determination of the evaluation for the Veteran's service-connected PTSD and was properly before the Board. See Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009) (holding that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities; if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability as a result of that disability is warranted). It remanded this matter to obtain updated treatment records and to obtain an opinion as to whether the Veteran's service-connected PTSD precluded him from securing and following substantially gainful employment consistent with his education and occupational experience. In a September 2012 statement, the Veteran reported that he had been unemployed and unable to work from July 2004 through December 9, 2009. In an October 2012 VA Initial PTSD VA examination report, the Veteran discussed his occupational history, noting that starting in December 1997 he worked for Waste Management hauling garbage as temporary worker for a couple of months. He reported that he then found work at a steakhouse for six months before transferring to another steakhouse for two months before was fired because of anger problems. The Veteran indicated that his nephew then hired him to work at his granite company for three to four years before he had an accident resulting in his left leg being crushed. He reported that he did not work from 2004 to 2009 until he completed the CWT Program at VA, becoming a Supply Technician at VA for 16 months. He indicated that he was then offered full-time employment and has worked in that job for almost three years. Regarding the Veteran's present functioning, the examiner noted that the Veteran was presently working with reports of good performance and attendance record. In a May 2013 Informal Hearing Presentation, the Veteran's representative argued that VA continues to lack the medical evidence necessary to determine the pending TDIU claim. While acknowledging that the Veteran had become employed as of December 2009, it was asserted that the October 2012 VA examiner's opinion as to unemployability was inadequate, as no opinion was offered concerning employability at any time during the pendency of the claim. The representative requested a remand in order to address the matter in the form of a retrospective medical opinion. Chotta v. Peake, 22 Vet. App. 80 (2008). An April 2013 supplemental statement of the case continued the denial the Veteran's claim for entitlement to TDIU, and the matter was returned to the Board for appellate review. Based on the cumulative evidence of record, the Board finds that a retrospective medical opinion addressing the effects of the Veteran's service-connected PTSD on his ability to obtain and maintain substantially gainful employment consistent with his education and occupational experience for the time period from July 17, 1997, to the present is necessary to effectively adjudicate the claim for entitlement to a TDIU on appeal. See Chotta v. Peake, 22 Vet. App. 80 (2008); see also Vigil v. Peake, 22 Vet. App. 63 (2008) (holding that the duty to assist may include development of medical evidence through a retrospective medical evaluation where there is a lack of medical evidence for the relevant time period). Accordingly, the case is remanded for the following actions: 1. The RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claim for entitlement to TDIU. Regardless of the Veteran's response, the RO must obtain and associate with the claims file all of the Veteran's pertinent VA treatment records, to include all treatment records from the Detroit VAMC dated from October 2012 to the present. If, after making reasonable efforts to obtain this information the RO is unable to secure any of the identified records, the RO must notify the Veteran and his representative and (a) identify the information the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain that information; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that the Veteran is ultimately responsible for providing information. The Veteran and his representative must then be given an opportunity to respond. 2. Thereafter, the RO must obtain a supplemental medical opinion, from an appropriate VA examiner, preferably a psychiatrist, to determine the effects of the service-connected PTSD on the Veteran's ability to obtain and maintain employment consistent with his education and occupational experience for the time period from July 17, 1997 to the present. The claims file and all electronic records, to include on Virtual VA, must be made available to the examiner, and the examiner must specify in the examination report that these records have been reviewed. The examiner must specify the dates encompassed by the Virtual VA records that were reviewed. The examiner must compile a full work and educational history. Following a thorough review of all pertinent medical records and the lay statements of record, the examiner must provide an opinion as to whether the Veteran's service-connected PTSD precluded him from securing and following substantially gainful employment consistent with his education and occupational experience during the time period from July 17, 1997, to the present. This opinion must be provided without consideration of his nonservice-connected disabilities or age. The examiner must discuss whether the Veteran's prior employment at his nephew's granite company as well as his current VA CWT position constitutes substantially gainful employment. The examiner is advised that substantially gainful employment is considered employment that is available within the employment market that would provide sufficient remuneration to allow the Veteran to support himself financially on the income derived from that employment. Marginal employment that is of limited remuneration or that is in a sheltered environment, protected from demands of employment in the general marketplace (such as a special position within a family business sheltered from productive requirements of general employment), is not to be considered substantially gainful employment. A complete rationale for all opinions must be provided. If the examiner cannot provide the requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. The report must be typed. Another examination of the Veteran must only be performed if deemed necessary by the person providing the opinion. 3. The RO must notify the Veteran that it is his responsibility to report for any examination scheduled, and to cooperate in the development of the claim. The consequences for failure to report for any VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained and associated with the Veteran's claims file that shows that notice scheduling the examination was sent to his last known address. Documentation must be also be obtained and associated with the Veteran's claims file demonstrating any notice that was sent was returned as undeliverable. 4. After the development requested has been completed, the RO must review any medical opinion and/or examination report to ensure that it is in complete compliance with the directives of this Remand. If the opinion and/or report is deficient in any manner, the RO must implement corrective procedures at once. 5. Once the above actions have been completed, and any other development as may be indicated by any response received as a consequence of the actions taken above, the RO must re-adjudicate the Veteran's claim on appeal. If the benefit remains denied, a SSOC must be provided to the Veteran and his representative. After he has had an adequate opportunity to respond, the appeal must be returned to the Board for further appellate review. No action is required by the Veteran until he receives further notice; however, he may present additional evidence or argument while the case is in remand status at the RO. Kutscherousky v. West, 12 Vet. App. 369 (1999). ______________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs