Citation Nr: 1329261 Decision Date: 09/12/13 Archive Date: 09/20/13 DOCKET NO. 07-28 368 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Shamil Patel, Counsel INTRODUCTION The Veteran served on active duty from March 1965 to March 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas, which, in part, continued the 50 percent disability evaluation for PTSD. In December 2008, the Veteran and his wife testified before the undersigned Acting Veterans Law Judge at a Travel Board hearing at the RO. A copy of the transcript has been associated with the claims file. The appeal was then remanded in May 2011 for additional development. A portion of the Veteran's records are contained in the Virtual VA system. Instead of paper, a highly secured electronic repository is used to store and review every document involved in the claims process. The use of this system allows VA to leverage information technology in order to more quickly and accurately decide a Veteran's claim for benefits. Because the current appeal was processed as part of the Virtual VA system, any future consideration of this appellant's case should take into consideration the existence of this electronic record. 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, D.C. FINDINGS OF FACT 1. Prior to October 19, 2010, the Veteran's PTSD was manifested by impaired impulse control with periods of violence, but was not manifested by suicidal ideation, obsessional rituals, speech abnormalities, a near-continuous panic or depression, or neglect of personal appearance and hygiene. 2. From October 19, 2010, the Veteran's PTSD was manifested by passive suicidal ideation, angry and aggressive thought content, and significant impairment in social and occupational relationships. CONCLUSIONS OF LAW 1. Prior to October 19, 2010, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. From October 19, 2010, the criteria for a 70 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 and Supp. 2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 A. Duty to Notify Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159 (2012). Such notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). Prior to the initial adjudication of the Veteran's claim, a letter dated March 2006 was sent to the Veteran in accordance with the duty to notify provisions of the VCAA. 38 U.S.C.A. § 5103; 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The Veteran was notified of the evidence that was needed to substantiate his claim; what information and evidence that VA will seek to provide and what information and evidence the Veteran was expected to provide, and that VA would assist him in obtaining evidence, but that it was his responsibility to provide VA with any evidence pertaining to his claim. See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). B. Duty to Assist The Veteran's service treatment records, VA treatment records, Social Security Administration (SSA) records, lay statements, and hearing transcript have been associated with the claims file. The Veteran was also afforded VA examinations. 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations obtained in this case are adequate as they are collectively predicated on a review of the claims file; contain a description of the history of the disabilities at issue; document and consider the relevant medical facts and principles; and record the relevant findings for rating the Veteran's PTSD. VA's duty to assist with respect to obtaining a VA examination or opinion for the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Veteran testified at a Board hearing in December 2008. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. 3.103(c)(2) requires that the Decision Review Officer (DRO) or Veterans Law Judge (VLJ) who chairs a hearing must fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the Acting VLJ elicited testimony to support the Veteran's claim and sought to identify any pertinent evidence not currently associated with the claims folder that might substantiate the claim. Moreover, the Veteran has not asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) or identified any prejudice in the conduct of the hearing. By contrast, the hearing focused on the elements necessary to substantiate the claim and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. See Dalton v. Nicholson, 21 Vet. App. 23, 30-31 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative demonstrating an awareness of what is necessary to substantiate the claim). As such, the Board finds that, consistent with Bryant, the Acting VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claim based on the current record. VA has provided the Veteran with the opportunity to submit evidence and argument in support of his claim. The Veteran has not made the Board aware of any additional evidence that needs to be obtained prior to appellate review, and no further action must be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Increased Rating A. Applicable Law Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). Where entitlement to compensation has already been established and increase in disability rating is at issue, present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Therefore, although the Board has thoroughly reviewed all evidence of record, the more critical evidence consists of the evidence generated during the appeal period. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2008). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Generally, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). The Veteran is currently assigned a 50 percent rating under Diagnostic Code 9411. A 50 percent rating is assigned for 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 9435 (2012). A 70 percent disability rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned 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; and memory loss for names of close relatives, or for the Veteran's own occupation or name. Id. Within the DSM-IV, Global Assessment Functioning (GAF) scale scores ranging from 1 to 100, reflect "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). DSM-IV at 46-47. GAF scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. Id. 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). Id. Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). Id. GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which 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., a depressed patient who avoids friends, neglects family, and is unable to do work). Id. The evidence in this case reflects other diagnosed psychiatric disorders in addition to PTSD. Except where noted below, the evidence does not differentiate symptoms attributable to these conditions versus those due to PTSD. Therefore, all potentially service-connected symptoms have been attributed to the Veteran's service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181, 182 (1998)(the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition). B. Evidence VA treatment records dated January 2006 show the Veteran received 42 days of rehabilitation for substance abuse. At admission, the Veteran was bright in mood and cheerful in affect. He reported good sleep and appetite. He was alert and oriented, with coherent thoughts and behaviors. His mood was euthymic and his affect was consistent with mood. There were no signs of psychosis or suicidal or homicidal ideation. His GAF score was 40. Additional records show the Veteran reported significant periods in which he could not get along with anyone. He also had difficulties with depression and anxiety. However, he denied being bothered by any recent family or social problems. The Veteran underwent a VA examination in April 2006. He reported current symptoms consisting of nightmares, confusion, intrusive thoughts of Vietnam with associated heightened arousal, and an increased propensity to get violent and angry at people. He had sleep difficulties. He enjoyed reading and listening to music, and did not watch as much television as he used to. He also enjoyed fishing with his wife. He was able to handle his personal care, and he performed chores around the house. He reported a history of drug abuse which ended in January 2006. On examination, the Veteran was appropriately dressed and groomed. His speech was moderate in tone and pace. Thought content was rational and goal-directed. His mood was congenial, and his affect was predominantly euthymic. No delusions, hallucinations, or suicidal or homicidal ideation were elicited, though the Veteran reported sensory anomalies as part of his PTSD. The examiner stated that the Veteran was moderately impairment in social and industrial capacity, and assigned a GAF score of 51-55. VA records dated June 2007 was trying to cope with the death of his grandson. On examination, he was appropriately dressed and groomed. His mood was euthymic and his affect was appropriate. There was no indication of delusions, hallucinations, or suicidal or homicidal ideation. Additional records from July 2007 through September 2007 show the Veteran attended group therapy sessions, and reflect GAF scores of 55. In a September 2008 statement, the Veteran reported that he could not talk to anyone without thinking of hurting them if they provoke or irritate him. He also got disoriented as to time and place when driving. In records dated November 2008, the Veteran reported that he had been doing "OK," but continued to have some problems. He still felt that when he was "right" about something that he should press things and "flare-up." He stated that it had been over a year since anything had happened, but he still "thought about it." Generally, he felt that he had good control over himself. On examination, the Veteran was alert and oriented. Speech and psychomotor activity were normal. His mood was fair and his affect was euthymic. There was no overt anxiety or suicidal or homicidal ideation. His GAF score was 50. An additional visit in January 2009 noted a depressed mood and affect, and a GAF score of 45. The Veteran and his wife testified at a Board hearing in December 2008. He reported a prior history of suicidal ideation, and recounted an instance in 1999 or 2000 which he tried to overdose with pills. His wife testified regarding an incident 4 or 5 months earlier between the Veteran and his son, in which the Veteran pulled a knife out and she had to calm him down. They also recounted earlier incidents in which the Veteran shot another man. The Veteran stated that he did not like to deal with or be around people. This helped him avoid conflicts and getting angry. He described previous instances of fighting with co-workers. VA records dated February 2009 show the Veteran could not attend Alcohol Anonymous or Narcotics Anonymous meetings because of his temper and aggression. He generally stayed in his house. Examination revealed normal mood and affect. No psychosis or suicidal or homicidal ideation was present. Additional records in June 2009 noted the Veteran was non- compliant with his medication, and he admitted to use of cocaine and alcohol. He denied any mood problems. On examination, the Veteran had appropriate dress and grooming. Speech was normal. His mood was euthymic and his affect was bright. He denied any delusions, hallucinations, or suicidal or homicidal ideation. His judgment was noted to be impaired, and his insight was poor. His GAF score was 45. In July 2009, his GAF score was 47. In November 2009, the Veteran had normal grooming and hygiene. His speech and thought processes were normal. His mood was euthymic, though his affect was blunted. There was no indication of any thought disorder or suicidal or homicidal ideation. His GAF score was 52. Additional records dated April 2010 reflect reports by the Veteran's wife that he did not sleep well, and thrashed about at night. He also had periods where he was very irritable. The Veteran reported feeling very fulfilled at home, and enjoyed fishing with his wife. On examination, the Veteran had appropriate dress and grooming. Speech was normal. His mood was euthymic and his affect was bright. He denied any delusions, hallucinations, or suicidal or homicidal ideation. Insight and judgment were fair. In October 2010, the Veteran presented with depressed mood, lack of interest, decreased sleep, and lack of energy. He also had nightmares and intrusive thoughts. He had passive thoughts of death. Examination revealed a dysphoric mood and mildly dysphoric affect. There were no hallucinations, paranoid or grandiose thoughts, or suicidal or homicidal ideation. Additional records from December 2010 show the Veteran reported decreased frequency of nightmares, but had struck out at his wife while sleeping, which had not occurred previously. He denied any suicidal ideation. On examination, the Veteran was appropriately dressed and groomed. Speech was clear and coherent, but somewhat loud. Mood was nondepressed and affect was full. There were no perceptual disturbances. Thought processes were linear and goal directed. No delusions, hallucination, or suicidal or homicidal ideation was noted. The Veteran's GAF score was 55. Additional records dated May 2011 also revealed a GAF score of 55. A VA examination was conducted in July 2011. He reported having a disorderly conduct charge in 2008 arising from an incident with a man in his church and a police officer. He denied any current charges or probation. He denied harming his wife since 2006, but reported pulling a knife on her and their sons in 2010. They described another incident in which the Veteran was driving with the intent to harm his son, but was involved in an accident along the way. There was continued verbal and emotional abuse. The Veteran reported needing "more space" than he did previously. His wife reported that she had to "tiptoe" around him. He stopped working in 2008 due to continuing conflicts with other people. The Veteran used to go fishing but now spent most of his time watching television. The examiner noted that the Veteran had significant anger and judgment problems that exacerbated his general level of assaultiveness. On examination, the Veteran was appropriately groomed and dressed. His speech and psychomotor activity were unremarkable. His mood was agitated and irritable, and his affect was full. He as fully oriented, and able to complete serial 7's and spell a word forward and backward. His thought processes were unremarkable, but thought content was noted to be angry and aggressive. There were no delusions present. There was no obsessive or ritualistic behavior. The Veteran reported some suicidal ideation but denied any intent. The examiner noted that he was a low risk for immediate harm. Memory was fully intact. His GAF score was 48. The examiner stated that the Veteran did not have total occupational or social impairment due to PTSD, but there were deficiencies in judgment, thinking, mood, and family relations. VA records dated January 2012 show the Veteran reported occasional nightmares, but was in good spirits and enjoyed making people laugh. On examination, the Veteran had appropriate dress and grooming. Speech was normal. His mood was euthymic and his affect was congruent. He denied any delusions, hallucinations, or suicidal or homicidal ideation. His GAF score was 55. C. Analysis Based on the evidence of record, the Board finds that staged ratings are appropriate for the Veteran's PTSD. Prior to October 19, 2010, a rating in excess of 50 percent is not warranted. As noted above, a higher 70 percent rating contemplates symptoms such as suicidal ideation; obsessional rituals, speech abnormalities, a near-continuous panic or depression, impaired impulse control, spatial disorientation, and neglect of personal appearance and hygiene. The evidence during this period reflects reports from the Veteran and his wife of instances of impaired impulse control, such as incidents involving a knife or an intent to harm their son. However, none of the symptoms contemplated by the higher 70 percent rating were noted to be present during this period. Although the Veteran testified regarding instances of suicidal ideation, those occurred prior to the period on appeal. In addition, the Veteran had GAF scores of 50 or below prior to October 19, 2010, and the Court has recognized that certain scores may demonstrate a specific level of impairment. Richard, 8 Vet. App. at 267; Bowling v. Principi, 15 Vet. App. 1, 14-15 (2001) (both recognizing that a GAF score of 50 indicates serious impairment). However, GAF scores are just one factor to be considered in assigning an evaluation. In this case, although the Veteran had some GAF scores indicating serious impairment, symptoms associated with those scores, such as suicidal ideation or obsessive rituals, were not demonstrated. For these reasons, the Veteran's PTSD is most closely approximated by the assigned 50 percent rating for the period prior to October 19, 2010. From October 19, 2010, a 70 percent rating is warranted. VA records from that date reflect passive thoughts of death. The July 2011 VA examination noted passive suicidal ideation, as well as angry and aggressive thought content and manner. The Veteran also reported that he no longer engaged in recreational activities such as fishing. For this examination, his GAF score of 48 reflects serious impairment and is supported by accompanying symptoms of suicidal ideation. A 100 percent rating is not warranted from October 19, 2010. The Veteran's PTSD has not been manifested by 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 personal hygiene, or memory deficiencies for basic concepts such as his own name or occupation. GAF scores reflect serious impairment, but not the marked impairment consistent with symptoms such as reality testing or communication. The July 2011 examiner clearly stated that the Veteran did not have total occupational or social impairment due to PTSD. D. Extraschedular Consideration In evaluating the Veteran's claims for higher ratings, the Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA 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). As part of the evaluation for an extraschedular rating, the Board has considered the provisions of Mittleider v. West, 11 Vet. App. 181, 182 (1998), which holds that the benefit of the doubt applies to determinations of whether a symptom should be attributed to a service-connected condition. The Board has attributed all potentially service-connected symptoms to the Veteran's service-connected conditions in considering if the Veteran is entitled to an extraschedular rating. According to the regulation, an extraschedular disability rating is warranted based 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 periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). 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 claimant's level of disability and symptomatology and is found inadequate, the Board must 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. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected disabilities is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria found in the rating schedule for that condition shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology, as discussed above. In other words, Diagnostic Code 9411 contemplates additional symptoms and a higher degree of impairment that has not been demonstrated in this case. There is no indication that the Veteran's PTSD results in any symptoms that fall so far outside the rating schedule as to render it inadequate. ORDER A rating in excess of 50 percent for PTSD prior to October 19, 2010 is denied. A 70 percent rating for PTSD from October 19, 2010 is granted, subject to the laws and regulations governing the award of monetary benefits. REMAND In a July 2013 brief, the Veteran's representative raised the issue of entitlement to a TDIU. Although the issue of TDIU has not been certified on appeal, the Board does have jurisdiction to decide the claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (a TDIU claim is part of an increased rating claim when such claim is raised by the record). In a claim for TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that a veteran's service-connected disability or disabilities do not prevent him from performing work that would produce sufficient income to be other than marginal. See Friscia v. Brown, 7 Vet. App. 294 (1995). The Court stressed that VA has a duty to supplement the record by obtaining an examination which includes an opinion on what effect the appellant's service-connected disabilities have on his ability to work. Friscia, at 297, citing 38 U.S.C.A. § 5107(a); 38 C.F.R. §§ 3.103(a), 3.326, 3.327, 4.16(a)(b). In this case, the July 2011 VA examiner stated that it was as likely as not that the Veteran was unemployable. This was not exclusively due to his PTSD, but also his physical decline and "argumentative, aggressive style." Notably, the Veteran is also service-connected for a right knee injury and residuals of a right leg gunshot wound. Therefore, an opinion as to the impact of the Veteran's service-connected disabilities, alone, on his employability must be obtained. He should also be sent VCAA notice on the matter of entitlement to a TDIU. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran and his representative a VCAA letter addressing the matter of entitlement to a TDIU. 2. Schedule the Veteran for a VA examination to determine if his service- connected disabilities render him unable to secure and follow a substantially gainful occupation. In making this determination, the examiner must NOT consider the effect of any nonservice- connected disabilities and advancing age. (a) The examiner must review the claims folder, and; (b) The examiner is advised that the Veteran alleges that he is unemployable due to his service-connected PTSD. He is also service-connected for a right knee injury and residuals of a right leg gunshot wound. 3. The RO/AMC must review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing physician for corrective action. 4. The RO/AMC must consider all of the evidence of record and adjudicate the TDIU claim on both a schedular basis and an extra-schedular basis under 38 C.F.R. § 4.16(a) and 4.16(b). If the benefit sought is not granted, issue a Supplemental Statement of the Case and allow the Veteran and his representative an opportunity to respond. Thereafter, subject to current appellate procedure, the case must be returned to the Board for further consideration, if otherwise in order. No action is required of the Veteran until he is otherwise notified by the RO/AMC. By this action, the Board intimates no opinion, legal or factual, as to any ultimate disposition warranted in this case. 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). ______________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs