Citation Nr: 1326486 Decision Date: 08/20/13 Archive Date: 08/26/13 DOCKET NO. 08-29 726 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for hypertension, including as secondary to posttraumatic stress disorder (PTSD). 2. Entitlement to an initial evaluation greater than 30 percent for PTSD. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran, Veteran's spouse ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran served on active duty from November 1973 to August 1983. This appeal arises before the Board of Veterans' Appeals (Board) from a rating decision rendered in January 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Veteran testified before the undersigned Acting Veterans Law Judge in May 2010. A transcript of the hearing is associated with the claims file. In an August 2010 decision, the Board remanded this issue for additional development. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's currently diagnosed hypertension disability was not manifest in service, was not manifest within one year of separation, is not related to service and is not directly related to, or aggravated by his service-connected PTSD disability. 2. The Veteran's PTSD symptoms are indicative of occupational and social impairment with no more than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSIONS OF LAW 1. Entitlement to service connection for hypertension disability to include as secondary to service-connected PTSD, is not warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. The criteria for entitlement to an initial disability evaluation in excess of 30 percent for PTSD have not been met or approximated. 38 U.S.C.A. § 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 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 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). 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); 38 C.F.R. § 3.159(b); 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. Notice should be sent prior to the appealed rating decision or, if sent after the rating decision, before a readjudication of the appeal. A Supplemental Statement of the Case, when issued following a notice letter, satisfies the due process and notification requirements for an adjudicative decision for these purposes. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided notice to the Veteran in an October 2007 letter, prior to the date of the issuance of the appealed January 2008 rating decision. The October 2007 letter explained what information and evidence was needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The October 2007 letter also provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Furthermore, for initial rating claims or claims for an earlier effective date, where, as here, service connection has been granted for PTSD and the initial rating and effective date have been assigned, the claim of service connection has been more than substantiated, as it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement (NOD) with the rating or the effective date of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matters on appeal. Pertinent medical evidence associated with the claims file consists of service, VA treatment records and the reports of November 2007, August 2010 and September 2010 VA examinations. The November 2007, August 2010 and September 2010 VA examination reports reflect that the VA examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted an appropriate evaluation of the Veteran, and rendered an appropriate diagnosis and opinion consistent with the remainder of the evidence of record. As such, the Board finds that the November 2007, August 2010 and September 2010 VA examination reports are sufficient upon which to base a decision with regard to these claims. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Also of record and considered in connection with the appeal are the various written statements provided by the Veteran and by the Veteran's representative on his behalf, to include the Veteran's May 2010 hearing testimony. The Board finds that no additional RO action to further develop the record on the claims is warranted. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Entitlement to Service Connection for Hypertension, including as Secondary to PTSD Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden for certain chronic disabilities such as hypertension is through a demonstration of continuity of symptomatology. In relevant part, 38 U.S.C.A. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Certain diseases, to hypertension, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service- connected disease or injury. Such permits a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation to a nonservice- connected disability by a service- connected disability. Id. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). Effective October 10, 2006, 38 C.F.R. § 3.310 was amended to implement the holding in Allen v. Brown, 7 Vet. App. 439 (1995) for secondary service connection on the basis of the aggravation of a nonservice-connected disorder by service- connected disability. See 71 Fed. Reg. 52744 (2006). The amendment essentially codifies Allen with language that requires that a baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation. Factual Background The Veteran asserts that he has a current hypertension disability that was either caused or aggravated by his service-connected PTSD disability. A review of his service treatment records discloses no complaints or assessments regarding hypertension or elevated blood pressure. An October 2007 Agent Orange Registry examination noted a diagnosis of hypertension. Per the August 2010 Board remand instructions, the Veteran underwent a VA examination in September 2010. The Veteran reported that he had been first diagnosed with hypertension 4 to 5 years ago by a private physician. The examiner noted that there was no evidence in the Veteran's service treatment records that the Veteran was treated for hypertension in the military. There was no evidence in the claims file that the Veteran was diagnosed with hypertension within 1 year of discharge from the military. Therefore, the examiner opined that it was less likely than not that the Veteran's hypertension had its onset during the Veteran's active service. The examiner also noted that while it was well-known than stress transiently elevates blood pressure in all individuals, this was a normal response to catecholamine release and such temporary elevation did not aggravate or cause the underlying condition of hypertension. Therefore, the examiner opined that the Veteran's hypertension was less likely than not secondary to his service-connected PTSD. It was also less likely than not that the PTSD aggravated the condition beyond its normal progression. The examiner noted that the Veteran was service-connected for PTSD, a spine condition, impaired hearing and tinnitus and that none of these conditions was etiologically related to the Veteran's hypertension. There was no evidence in the Veteran's claims file that the Veteran's hypertension was etiologically related to the Veteran's military service or any incidents. The examiner concluded that it was less likely than not that the Veteran's hypertension was etiologically related to his service-connected disability including PTSD. When considering the pertinent evidence of record in light of the above-noted legal authority, the Board finds that service connection for hypertension as secondary to service-connected PTSD is not warranted. As noted above, there is a current diagnosis of hypertension; hence, the first element of service connection is satisfied. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000). Initially, as noted above, service connection may be granted on a presumptive basis for certain chronic diseases, including hypertension, if such diseases are shown to be manifest to a degree of 10 percent or more within one year following the Veteran's separation from active military service. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). In this instance however, service connection for hypertension on a presumptive basis is not warranted as the first evidence of hypertension is the October 2007 Agent Orange Registry. Additionally, the record does not demonstrate elevated blood pressure complaints or a diagnosis of hypertension within a year of the Veteran's service separation and the Veteran himself at his September 2010 VA examination reported first being diagnosed with hypertension only 4 to 5 years ago. As the record does not show manifestations of hypertension within one year of the Veteran's service separation, service connection for hypertension on a presumptive basis is not warranted. With regard to service connection on a direct basis for the Veteran's hypertension, the Board notes that the Veteran's service treatment records are entirely negative for hypertension complaints or diagnoses. On the contrary, as noted above, the first post-service evidence of a hypertension disability is the October 2007 VA Agent Orange Registry. As the Veteran was not diagnosed with a hypertension disability until many years after service and there was a significant period between his service and his post-service diagnosis where the medical record was silent for complaints or a diagnosis of hypertension, the Board concludes that the weight of the evidence is against a finding of continuity of symptomatology since service. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000). The Board also finds that the weight of the evidence is against a finding that the Veteran's current hypertension is etiologically related to the Veteran's military service on a direct or secondary basis. In fact, the only medical opinion addressing the etiology of the hypertension disability weighs against the claim as the September 2010 VA examiner concluded that it was less likely than not that the Veteran's hypertension disability was etiologically related to his military service to include as secondary to his service-connected PTSD. The VA examiner also opined that it was less likely than not that the PTSD aggravated the Veteran's hypertension condition beyond its normal progression. None of the competent medical evidence currently of record refutes these conclusions, and the Veteran has not presented or identified any such existing medical evidence or opinion. In reaching this conclusion, the Board has considered the lay evidence offered by the Veteran to VA. This includes his statements and the statements of his representative in which they asserted their belief that the Veteran's hypertension disability is related to his service-connected PTSD. A layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995). However, lay persons are generally not competent to opine as to medical etiology or render medical opinions. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998), Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed.Cir. 2007) ("Sometimes the layperson will be competent to indentify the condition where the condition is simple, for example a broken leg, and sometimes not, for example a form of cancer."). That is, the Veteran is competent to report symptoms that he can perceive through his senses; however, he is not competent to state that his hypertension disability is the result of his service or his service-connected PTSD. Accordingly, the Board has placed greater probative weight on the conclusions reached by the VA examiner, who, as medical professional, is competent to render opinions regarding medical matters. As the preponderance of the evidence is against the Veteran's claim, service connection must be denied. 38 C.F.R. §§ 3.1(m) & (n), 3.102, 3.301. Entitlement to an Initial Evaluation Greater than 30 Percent for PTSD Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during active service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where the Veteran timely appealed the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to "staged" ratings to compensate him for times since filing his claim when his disability may have been more severe than at other times during the course of his appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). In this case, the Veteran is currently assigned an initial 30 percent rating for PTSD under Diagnostic Code 9411. The Board notes that psychiatric disabilities other than eating disorders are rated pursuant to the criteria for General Rating Formula. See 38 C.F.R. § 4.130. Under the general rating formula, a 30 percent rating requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversion normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires 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. A 70 percent rating requires 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 affected the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Board notes that in accordance with the general rating formula, a maximum 100 percent rating is applicable if the manifestations of the service-connected psychiatric disorder result in total occupational and social impairment. Although the rating formula lists specific symptoms that are indicative of total impairment, the Court has held that the symptoms listed in the rating formula are only examples, and that evidence of those specific symptoms is not required to show that the veteran is totally disabled. In rating a mental disability, VA is required to consider all symptoms that affect her social and occupational functioning, and not limit consideration to those symptoms listed in the rating formula. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In other words, the primary consideration is whether the manifestations of the service-connected psychiatric disorder result in total social and occupational impairment, regardless of whether the Veteran demonstrates the symptoms listed in the rating formula. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect 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 (e.g., depressed man avoids friends, neglects family, and is unable to work). While the rating schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. In addition to PTSD, for which service connection has been established, the record shows an additional diagnosis of recurrent major depressive disorder. It is now well-settled that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability, in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The medical evidence in the instant case does not differentiate between the symptomatology associated with the Veteran's PTSD and that resulting from his nonservice-connected psychiatric disorders. Accordingly, for the purposes of this decision, the Board will attribute all of the Veteran's psychiatric symptoms to his service-connected PTSD. Factual Background and Analysis The Veteran underwent a VA examination in November 2007. His current symptoms at the time were initiating and maintaining sleep, yelling and screaming and hitting the tables with his fists. The symptoms described occurred constantly. The effect that the symptoms had upon total daily functioning was noted to be an avoidance of social activities. He reported having difficulty sleeping for over 40 years with his sleeping problem consisting of prolonged sleep latency and decreased sleep time. Since leaving the military, he worked in a warehouse for a year with a good relationship with his supervisors and coworkers. He then worked in the Post Office for 24 years with his relationship with his supervisor described as fair and the relationship with his coworkers described as good. Prior to his mental disorder, he had a good relationship with his parents and his sibling and had a good relationship with his wife and children. There have been major changes in his daily activities such as no motivation or interest; however, there had not been any major social function change since he developed his mental condition. At the time of the examination, he was working as a letter carrier with the Post Office and had been doing so since 1983. In 2006 he was off of work for 8 weeks because of stress. He experienced a persistent, recurrent, distressing dream of his stressor event and it was as if the traumatic event was recurring. The feeling of the recurring event was triggered by loud noises. He avoided stimuli associated with the trauma which included avoidance of thoughts and feelings associated with the trauma. There were persistent efforts to avoid activities, places or people that arose recollections of the event. There was a persistent inability to recall an important aspect of the event. There was a persistent, markedly diminished interest or participation in significant activities including avoidance of social activities and having no friends. His wife of 25 years divorced him. Due to the traumatic event, he had increased arousal including difficulty falling and staying asleep, an erratic sleep pattern, persistent irritability or outbursts of anger and persistent, exaggerated startle response. He reported using alcohol 6 to 8 times a day since 1965. There were no consequences of his substance abuse. On examination, his orientation was within normal limits. His appearance and hygiene were appropriate. His behavior was appropriate. Affect and mood were abnormal with depressed mood which occurred near-continuously and affected his ability to function independently as he had no motivation or interest. He was not interested in interacting with people. He had no friends and no hobbies. He had no motivation at work. His communication was within normal limits. Speech and concentration were within normal limits. He did not have panic attacks. There were signs of suspiciousness as he thought everyone was out to get him which was unprovoked. There were no delusions or hallucinations. Obsessional rituals were absent. Thought processes were appropriate and judgment was not impaired. Abstract thinking was normal. Memory was within normal limits. There was no suicidal or homicidal ideation. The diagnosis was PTSD. The examiner noted that the Veteran's substance abuse disorder was due to a non-service related mental disorder and the effects of the substance abuse could be separated from the non-service connected depressed mood because PTSD was an anxiety disorder while alcohol abuse is a substance abuse disorder. A GAF score of 60 was assigned. The examiner noted that the Veteran was capable of managing benefit payments in his own best interest. Mentally, he did not have difficulty performing activities of daily living. The best description of the Veteran's current psychiatric impairment was psychiatric symptoms causing occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally the Veteran was functioning satisfactorily with routine behavior, self-care and normal conversation. The above description was supported by the following symptoms: depressed mood, anxiety, suspiciousness, and chronic sleep impairment. He had no difficulty understanding commands and appeared to pose no threat of persistent danger or injury to himself or others. Per the August 2010 remand instructions, the Veteran underwent a VA examination in August 2010. The examiner noted that there had been no periods of remission of the Veteran's PTSD since his last examination. He reported symptoms such as having recurrent and intrusive distressing recollections of the stressor event at the rate of 3 to 4 times a year. Twice a year he had recurrent dreams of the stressor event. He had flashbacks about 1 or 2 times a year. He reported intense stress at exposure to internal and external cues. He also reported efforts to avoid thoughts, feelings or associations associated with the trauma. He reported diminished interests in significant activities and noted that he did not go hunting as much as he used to. He noted being always detached and estranged from others. He chose a job as a letter carrier with the Post Office as he preferred to work alone. He indicated that he had a restricted range of affect and his wife "accepts it". He had symptoms of arousal including difficulty sleeping. He noted a lot of irritability and anger and he estimated having approximately 1 episode at work and 1 episode at home a week. He described historically volatile relationships with his wife and sons. His relationship with his wife had become increasingly volatile and affected by his anger, agitation and outbursts. He denied any difficulty concentrating. He was always hypervigilant and aware of his surroundings. He had exaggerated startle response and reported significant depression symptoms which manifested in isolation, loss of interest in activities, loss of appetite and being self-critical. He had 3 to 4 sessions with a psychologist to work on anger management and coping skills. He reportedly used alcohol and drank 8 to 12 beers a day. He used alcohol daily for approximately 26 years. On examination, he was cooperative and polite. His grooming was fair to good as was his personal hygiene. He was oriented to person and place, time and circumstances. His level of consciousness was within normal limits. His mood was depressed with congruent affect. His thought process was logical and sequential and he indicated no apparent delusions or impairment of the immediate, recent or remote memory. He reported no extensive difficulties with cognitive functioning. His speech was within normal limits with regard to volume and clarity. Judgment and insight were within normal limits and he appeared to be a reliable informant. He denied any past, present or future suicidal ideation. His sleep was disrupted and he did report a history and current alcohol use. The depression scale indicated severe depression. He had severe symptoms of pessimism, self-criticalness, agitation, loss of interest in activities and a decrease in appetite. His moderate symptoms included loss of pleasure, irritability and tiredness. A GAF score of 60 was assessed. The examiner noted that the Veteran had re-experiencing symptoms, avoided stimuli associated with the trauma and had persistent symptoms of arousal that were distressing to him. The Veteran reported that his symptoms had not changed significantly since his last examination. He also presented with symptoms of depression and an ongoing alcohol use disorder which both appeared to be related to his PTSD and contributed to his overall social impairment. He reported that he had an occasional decrease in work efficiency and intermittent periods of inability to perform his occupational tasks but that he generally considered himself functionally well at work. Most of his impaired function appeared to be related to interpersonal relationships with his supervisors at work and irritability and conflict in his marital relationship. He had only missed two days of work since surgery in May 2009 and he described routinely being able to function on most days. He was able to manage his VA benefits. Based on the record, the Board finds that initial rating in excess of 30 percent for the Veteran's PTSD disability is not warranted. The pertinent medical evidence collectively reflects that the Veteran's PTSD was primarily characterized by, depressed mood, anxiety, suspiciousness, chronic sleep impairment, irritability, loss of pleasure, tiredness and by having few friends. The Board finds that these symptoms more nearly approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, the level of impairment contemplated in the initial 30 percent disability rating. The medical evidence does not show the Veteran to have flattened affect; panic attacks more than once a week; difficulty in understanding complex commands; impaired judgment; impaired abstract thinking; or other symptoms that are characteristic of the next higher, 50 percent rating. Rather, the November 2007 and August 2010 VA examinations both determined that the Veteran's thought process and association was unremarkable, normal and coherent with no unusual thought content. Additionally, the November 2007 examiner also specifically found that the Veteran had occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally the Veteran was functioning satisfactorily with routine behavior, self-care and normal conversation. The August 2010 VA examiner also noted that the Veteran had occasional decrease in work efficiency and intermittent periods of inability to perform his occupational tasks but that he generally considered himself functionally well at work. These descriptions actually correspond squarely with the schedular requirements for the assignment of a 30 percent disability rating. The Board notes that the GAF scores of 60 on the November 2007 and August 2010 VA examinations. While the GAF score of 60 reflects 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), the Board again notes that the Veteran's overall symptoms during this time period more nearly approximate occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, the level of impairment contemplated in the initial 30 percent disability rating. Additionally, the Board notes that GAF scores are only one indication of the severity of a given service-connected mental disorder. 38 C.F.R. § 4.130, Diagnostic Code 9411; see also Carpenter, supra. Accordingly, the aforementioned discussion makes clear that the Veteran's PTSD symptomatology has resulted in a disability picture that approximates no more than the level of occupational and social impairment contemplated in the assigned 30 percent rating under the applicable rating criteria. As the preponderance of the evidence is against the claim for an increased rating, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Considerations The Board has considered the question of whether an extraschedular rating may be appropriate for the Veteran's service-connected PTSD. See Bagwell v. Brown, 9 Vet. App. 157 (1966). Ordinarily, the VA Rating Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent period of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.21(b) (1) (2012). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the level of disability and symptomatology and is found to be inadequate, the Board must then determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. The Veteran has not identified any factors which may be considered to be exceptional or unusual, and the Board has been similarly unsuccessful. There is no evidence in the medical records of an exceptional or unusual clinical picture. The record demonstrates that the Veteran has not required hospitalization as a result of his service-connected PTSD disability. Further, the record does not demonstrate any other reason why an extraschedular rating should be assigned. Accordingly, the Board therefore has determined that referral of the case for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b) (1) is not warranted. ORDER Entitlement to service connection for hypertension, including as secondary to PTSD is denied. Entitlement to an initial evaluation greater than 30 percent for PTSD is denied. REMAND As noted in the August 2010 Board remand, during his May 2010 hearing, the Veteran and his witness testified that he had had difficulties with his employer as a result of his PTSD symptoms, and that his family physician had put him off work for six to ten weeks at a time for stress. The Veteran therefore raised the issue of a TDIU. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (once a veteran submits evidence of medical disability and additionally submits evidence of unemployability, VA must consider total rating for compensation based upon individual unemployability). The Court recently held 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, either as part of the initial adjudication of a claim or, if a disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). 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. Id at 455. Accordingly, the Board in its August 2010 decision instructed that the RO's readjudication of the Veteran's claim for a higher initial disability evaluation for PTSD should include the issue of TDIU. While, pursuant to the August 2010 Board remand instructions, the Appeals Management Center (AMC) in a November 2011 supplemental statement of the case (SSOC) readjudicated the Veteran's claim for an initial evaluation in excess of 30 percent for PTSD and for service connection for hypertension as secondary to service-connected PTSD, the AMC did not adjudicate the Veteran's claim for a TDIU. As a result, the AMC did not comply fully with the Board's August 2010 instructions. The United States Court of Appeals for Veterans Claims has held that a remand confers on the veteran, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). On remand, the RO or AMC should adjudicate the Veteran's claim for a TDIU in accordance with the Board's August 2010 directives cited herein. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be provided appropriate notice in response to the claim of entitlement to a TDIU. 2. The RO or the AMC also should undertake any other development it determines to be warranted before the Veteran's claim for a TDIU is decided, including referral of the claim to the Director, Compensation and Pension Services, for extra-schedular consideration. 3. Then, the RO or the AMC should readjudicate the Veteran's claim of entitlement to TDIU. If any benefit sought on appeal is not granted to the Veteran's satisfaction, the RO or the AMC should furnish to the Veteran and his representative an SSOC and afford them the requisite opportunity to respond. Thereafter, if indicated, the case should be returned to the Board for further appellate action. The appellant has the right to submit additional evidence and argument on the matter or 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). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs