Citation Nr: 1329478 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 09-41 865 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus, type II, and/or posttraumatic stress disorder (PTSD). 2. Entitlement to an initial rating greater than 30 percent prior to September 28, 2011 and greater than 70 percent from September 28, 2011 through May 22, 2013, for PTSD. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD C. J. Houbeck, Counsel INTRODUCTION The Veteran had active service from November 1967 to November 1971. He is in receipt of the Combat Action Ribbon and he served in Vietnam from September 1968 to December 1970. This matter comes to the Board of Veterans' Appeals (Board) from a December 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. As discussed in the March 2013 Board decision, the Board took the issue of entitlement to service connection for hypertension pursuant to the Court's holding in Percy v. Shinseki, 23 Vet. App. 37 (2009). The above referenced December 2007 rating decision granted entitlement to service connection for PTSD and assigned a 30 percent rating, effective from September 27, 2006, the date of the claim for service connection. In a January 2012 rating decision, however, the RO increased the rating of the Veteran's PTSD to 70 percent, effective September 28, 2011. Regardless of the RO's actions, the issue remains before the Board because the increased rating was not a complete grant of the maximum benefits available. See AB v. Brown, 6 Vet. App. 35 (1993). The Board remanded the issues for additional development in March 2013. The matter again is before the Board. The Board also notes that after the March 2013 remand, in a May 2013 rating decision the Appeals Management Center (AMC) granted a 100 percent rating for the Veteran's PTSD, effective from May 23, 2013. This decision was a complete grant of benefits with respect to this issue from May 23, 2013. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). As such, the issue on the title page and in the analysis below has been recharacterized to reflect the foregoing. The Board has not only reviewed the Veteran's physical claims file, but also his Virtual VA electronic claims file to ensure a total review of the evidence. The issue of entitlement to service connection for hypertension 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. FINDING OF FACT Prior to March 23, 2013, the Veteran's PTSD was manifested by symptoms such as difficulty sleeping, intrusive thoughts, decreased energy, constricted affect, depression, irritability, concentration problems, flashbacks, nightmares, hypervigilance, avoidance of crowds, survivor guilt, and suicidal ideation, all resulting in deficiencies in most areas, but less than total social and occupational impairment. CONCLUSION OF LAW The criteria for a disability rating of 70 percent, but no higher, for PTSD have been met for the entire appeal period from September 27, 2006 through May 22, 2013. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b), 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's increased rating claim, 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 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VCAA letters dated in May 2007 and August 2011 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio, at 187. The Veteran was advised that it was ultimately his responsibility to give VA any evidence pertaining to the claim. These letters informed him that additional information or evidence was needed to support his claim, and asked him to send the information or evidence to VA. See Pelegrini II, at 120-121. The letters also explained to the Veteran how disability ratings and effective dates are determined. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Furthermore, even if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); 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."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran is represented by an experienced Veterans Service Organization and has submitted argument in support of his claim. These arguments have referenced the applicable law and regulations necessary for a grant of an increased rating. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claim and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. In addition, records from the Social Security Administration (SSA) have been associated with the claims file. Private medical records identified by the Veteran have been obtained, to the extent possible. In that regard, the Board notes that the Veteran claimed treatment with certain private providers that are not of record; however, the Veteran has conceded that records of the claimed treatment are unavailable. The Veteran has at no time otherwise referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. With respect to a claim for increased rating, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). The RO provided the Veteran appropriate VA examinations in June 2007 and May 2013. The examination reports are thorough and supported by the other evidence of record. The examination reports discussed the clinical findings and the Veteran's reported history as necessary to rate the disability under the applicable rating criteria. The examination reports also discussed the impact of the disability on the Veteran's daily living. Based on the examination, the absence of evidence of worsening symptomatology since the examination, and the fact there is no rule as to how current an examination must be, the Board concludes the examination reports in this case are adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Based on the association of VA treatment records, the association of SSA records, the May 2013 VA psychiatric examination, and the subsequent readjudication of the PTSD claim, the Board finds that there has been substantial compliance with its March 2013 remand directives with respect to the increased rating claim. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146- 47 (1999). 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, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Increased Rating Disability ratings are assigned, under a schedule for rating disabilities, based on a comparison of the symptoms found to the criteria in the rating schedule. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. 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 (2012). If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Where the issues involve the assignment of an initial rating for a disability following the initial award of service connection for that disability, as is the case respect to the Veteran's claims for increased initial ratings, the entire history of the disability must be considered and, if appropriate, staged ratings may be applied. Fenderson v. West, 12 Vet. App. 119 (1999). As discussed above, currently the Veteran's disability rating for his service-connected PTSD is 30 percent from September 27, 2006 to September 27, 2011; 70 percent from September 28, 2011 through May 22, 2013; and 100 percent thereafter. The Veteran claims the ratings do not accurately depict the severity of his condition for these periods. The General Rating Formula for Mental Disorders provides, in pertinent part: Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) . . . . . . . . 30 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; difficulty in establishing and maintaining effective work and social relationships . . . . . . . . . . . . . . . . . . . . . . . 50 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 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 name . . . . . . . . . . . . . . . . . . . . . . . . . 100 38 C.F.R. § 4.130, DC 9411 (2012). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to 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). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. Additionally, a Global Assessment of Functioning (GAF) score is often used by treating examiners to reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266 (1996). A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). GAF scores ranging between 61 and 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, and has some meaningful interpersonal relationships. 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). See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV, for rating purposes). 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; child frequently beats up other children, is defiant at home, and is failing at school). A GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). In September 2002, the Veteran reported years of intermittent depression, which included suicidal ideation. He also discussed having a short temper and decreased concentration. In September 2006, the Veteran sought treatment for intrusive thoughts, nightmares, avoidance behavior, depression, irritability, poor concentration, decreased energy, other sleep problems, and recurrent dreams about his combat service. The Veteran also reported passive suicidal ideation, without plans or intent. The diagnosis was major depressive disorder and rule out PTSD verses anxiety disorder not otherwise specified. A lethality assessment the next day found that the Veteran had a history of suicidal ideation without attempt, but no current suicidal ideations and he was not currently a threat for violence. In October 2006, the Veteran reported marital problems and exhibited a restricted or anxious affect. There was no evidence of hallucinations or delusions, memory was intact, and insight, judgment, and impulse control were adequate. The Veteran reported near nightly sleep problems. In January 2007, the Veteran denied suicidal, violent, or homicidal ideation, impulses, or plan. The treatment provider assigned a GAF score of 55. In February 2007, the Veteran's GAF score was 50 and he carried a diagnosis of PTSD. The Veteran was afforded a VA examination in June 2007. The Veteran reported flashbacks, nightmares, poor sleep, hypervigilance, avoidance of crowds, survivor guilt, passive suicidal ideation, and irritability. On examination, the Veteran was fully oriented with an intact memory. Concentration, however, was extremely poor. There was psychomotor slowing of speech and poor judgment. The Veteran denied homicidal ideation, delusions, or hallucinations. The assessment was PTSD and the examiner assigned a GAF score of 30. The examiner noted that the Veteran's symptoms were partly controlled by the structure of his work, but that he currently was in danger of being fired. Unstructured time had significantly increased the Veteran's symptoms. The examiner concluded that the Veteran's PTSD had rendered him "permanently disabled." In July 2007, the Veteran reported that he thought he was going to have to get divorced, although he admitted he had asked for a divorce many times in the past without taking any further action. The Veteran also discussed difficulty socializing and continued financial stress. In August 2007, the Veteran denied thinking about suicide, but did have thoughts wishing he was dead. In February 2008, the Veteran's depression and PTSD were stable. During treatment in June 2008, the Veteran was alert and fully oriented. He was relaxed and smiling without suicidal or homicidal ideation. However, he was easily distracted and forgetful. In June 2009, the Veteran discussed increased irritability and sleep problems. He wanted to quit working due to job stress that he felt was adding to the severity of his PTSD symptoms. In September 2009, the Veteran denied current suicidal ideation, but worried that he would become suicidal if he felt the sadness that he had been blocking. Another June 2009 treatment note indicated increasing stress at work due to job duties, specifically heavy loads, off road driving, and anger at motorists cutting him off. A November 2009 letter from the Veteran's treating VA physician indicated that the Veteran's PTSD diagnosis included a GAF score of less than 50, which resulted in a severe impact on occupational and social functioning. In May 2010, the Veteran reported worsening PTSD symptoms, including avoidance behavior, sleep problems, and nightmares. The Veteran was afforded a general VA examination in August 2011, which noted psychiatric findings to be within normal limits. In September 2011, the Veteran underwent evaluation for a suicide safety plan. In October 2011, the Veteran reported increased rage with other motorists while performing his duties as a truck driver. He also discussed increased suicidal ideation, which included a specific plan. He claimed that he had not committed suicide because he was worried about who would care for his wife and the mess he would make in cutting open his throat. A November 2011 letter from a VA treatment provider noted that the Veteran's PTSD had worsened and that he could no longer safely work. His current GAF score was 45. The Veteran reported nightmares, avoidance behavior, and flashbacks. He denied friends outside of his family. He also described outbursts of anger, sleep problems, hypervigilance, difficulty with crowds, suicidal ideation, and concentration problems. A November 2011 letter from his treating VA physician also noted that the Veteran's current GAF score was 45, which reflected a severe impact on social and occupational functioning. The physician again concluded that the Veteran was unable to pursue gainful employment and that his condition was comparable to permanent and total disability. In an April 2012 document to SSA, the Veteran stated that he had stopped working on October 26, 2011, with work changes from October 3, 2011. A May 2012 SSA psychiatric evaluation indicated moderate restrictions or difficulties in activities of daily living and maintaining social functioning, with mild restrictions on maintaining concentration, persistence, or pace. There were no noted understanding or memory limitations. The ability to maintain concentration and attention for extended periods was moderately limited, as was the ability to work in coordination with or in proximity to others without being distracted by them. The ability to complete a normal workday and work week without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods was markedly limited. The Veteran also had moderate social interaction limitations and moderately to markedly limited adaptation limitations. In a May 2012 document, the Veteran's wife reported severe mood swings and concentration and memory problems. The Veteran spoke with his adult children twice per week and his wife on a daily basis, but did not go to any locations or activities on a regular basis. The Veteran's wife reported that they did not engage in social activities due to physical problems for them both and the Veteran's desire not to be around people. In March 2013, the Veteran's GAF score was 50 to 55. In April 2013, the Veteran denied active suicidal ideation, but did have wishes for death. The Veteran was afforded another VA examination on May 23, 2013. The examiner noted a diagnosis of PTSD and that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported nightmares, irritability leading to violence, hypervigilance, avoiding crowds, passive suicidal ideation, depression, anxiety, flashbacks, mild memory loss, flattened affect, disturbances in motivation or mood, difficulty in establishing and maintaining effective work and social relationships, impaired impulse control, neglect of personal appearance, persistent danger of hurting self or others, sense of foreshortened future, and low motivation, but denied homicidal ideation. The examiner assigned a GAF score of 51 to 55. The Board concludes that the objective medical evidence and the Veteran's and his wife's statements regarding his symptomatology show disability that more nearly approximates that which warrants the assignment of a 70 percent disability rating throughout the appeal period prior to May 23, 2013. See 38 C.F.R. § 4.7 (2012). In reaching that conclusion, the Board notes that throughout the appellate time period the Veteran's symptoms included suicidal ideation, difficulty in adapting to stressful situations, and inability to establish and maintain effective relationships. In addition, multiple treatment providers noted that the Veteran's psychiatric symptoms made continued employment problematic. Such statements preceded the Veteran's ceasing work in October 2011 and began at the time of the first VA examination in June 2007. In addition, the Veteran's GAF scores have ranged from 55 and lower, which would note moderate to severe symptomatology. In light of the foregoing, the Board finds that these symptoms, which have persisted throughout the entire appeal period, are on par with those contemplated by a 70 percent rating. As explained in more detail above, the symptoms throughout the Veteran's treatment and the appellate time period prior to May 23, 2013 are essentially consistent. While the Board recognizes that there is some evidence of worsening symptomatology at times during the appellate time period, for example in November 2011, as will be discussed below the Veteran's symptomatology did not more nearly approximate the criteria for a 100 percent rating either prior or subsequent to November 2011 - at least until May 23, 2013. For this reason, staged ratings are not applicable. See Fenderson, 12 Vet. App. at 119. Therefore, as explained above, the medical evidence supports the Board's conclusion that a 70 percent rating is warranted for the entire appeal period, from September 27, 2006 through May 22, 2013. A rating greater than 70 percent prior to May 23, 2013, is not appropriate for any period of time prior to that date because the Veteran did not have both total social and occupational impairment during that time period. Although the Veteran clearly had a serious disability, he exhibited few of the symptoms noted as applicable for a 100 percent rating. He did not have grossly inappropriate behavior; persistent delusions or hallucinations; gross impairment of thought processes or communication; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. While the Veteran has intermittently expressed suicidal ideation, the majority of treatment providers concluded that the Veteran was not a danger to himself or others and there is little evidence of suicidal intent prior to May 23, 2013. While the Board recognizes that the Veteran may have had one or more intermittent actual plans for suicide contemplated during the appellate time period, which would constitute a danger to himself as contemplated for a 100 percent disability rating, the vast majority of treatment records both prior and subsequent to such reports indicate vague thoughts of suicide or being dead or at most suicidal ideation without plan or intent, which the Board concludes represent symptoms that appear to more closely approximate those for a 70 percent rating, specifically suicidal or homicidal ideation, but without rising to the level required for a 100 percent rating, specifically a persistent danger of hurting self or others. To the extent that the Veteran has demonstrated some impairment of thought processes or communication, during the appellate time period he remained able to communicate despite these problems. The Board recognizes that the June 2007 VA examiner assigned a GAF score of 30, which would indicate behavior considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). Such a GAF score might suggest the applicability of a 100 percent disability rating; however, at that time the Veteran was employed full time, was maintaining a married relationship (as, indeed, he has been throughout the appellate time period), and indicated only passive suicidal ideation. As discussed above, the Board finds the Veteran's suicidal thoughts during the period prior to May 23, 2013 to most closely reflect the criterion for a 70 percent rating and, the GAF score of 30 notwithstanding, the Veteran's subjective complaints during the June 2007 VA examination most closely approximate those contemplated for a 70 percent disability rating under DC 9411. Therefore, the Board assigns the June 2007 GAF score less probative weight than the subjective complaints and objective findings discussed above. As noted above, the Board acknowledges that a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan, 16 Vet. App. at 442; however, as the Court held in Mauerhan, without the examples noted in the rating criteria, differentiating a 50 percent evaluation from a 70 percent evaluation would be extremely ambiguous. By extension to the present case, without the examples, differentiating the 70 and 100 percent ratings would be equally ambiguous. The Board is to consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. If the evidence demonstrates that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the DC, the appropriate equivalent rating should be assigned. Id. In this case, however, the Board concludes that the Veteran's PTSD symptoms do not cause total occupational and social impairment as contemplated for a 100 percent rating. With respect to the Veteran's occupational impairment, the Board acknowledges that his psychiatric symptoms result in a high level of impairment. The Veteran has been unemployed for some of the appellate time period, specifically from October 2011. As noted, however, VA treatment records and other documents suggest significant occupational difficulties prior to October 2011. Moreover, several medical professionals have indicated prior to May 23, 2013, that the Veteran's psychiatric problems either would preclude gainful employment or would make such employment very difficult. As such, for the purpose solely of this decision the Board will not dispute that the Veteran had total occupational impairment prior to May 23, 2013. That said, the Board concludes that prior to May 23, 2013, the Veteran did not have total social impairment. While he did have significant social isolation, he retained relationships with his wife and children. The Veteran did not engage in many activities outside of the home, but this was due in part to physical problems of the Veteran and his wife, as well as the Veteran's avoidance of others. The Veteran did ask his wife for a divorce during the appellate time period, but the record indicates that he had done so on multiple occasions, without ever taking any actual action in the matter. Otherwise, the Veteran maintained relationships with his family throughout the appellate time period and, indeed, expressed concern about who would take care of his wife were he not there. While there certainly were familial difficulties at times prior to May 23, 2013, they did not constitute total social impairment. Thus, the Veteran prior to May 23, 2013 did not have both total social and occupational impairment sufficient to warrant a total schedular rating. He did have some deficiencies in several areas, but the greater weight of evidence demonstrates that it is to a degree that is contemplated by the 70 percent rating assigned herein. Again, in determining that a rating in excess of 70 percent is not warranted, the Board has considered the Veteran's complaints regardless of whether they are listed in the rating criteria, but for the reasons discussed above concludes that prior to May 23, 2013, the Veteran's level of social and occupational impairment did not warrant a rating in excess of the assigned 70 percent rating. While the Veteran may have had some of the criteria for a 100 percent rating, see Mauerhan, 16 Vet. App. at 442, the Board concludes his overall level of disability did not exceed the criteria for a 70 percent rating prior to May 23, 2013. In summary, for the reasons and bases set forth above, the Board concludes that prior to May 23, 2013, an increased rating of 70 percent, but no more, is warranted for any time during the appeal period. See Fenderson, 12 Vet. App. at 119. Extraschedular Considerations 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). 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) (2012). 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 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 Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a 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 evaluations for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the Veteran reports multiple psychiatric symptoms, including anxiety, depression, nightmares, avoidance, sleep impairment, irritability, anger outbursts, concentration problems, hypervigilance, increased startle response, memory problems, suicidal ideation, and other symptoms. The current 70 percent rating contemplates these and other psychiatric symptoms. Thus, the Veteran's current schedular rating under DC 9411 is adequate to fully compensate him for his disability on appeal. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to an initial rating of 70 percent for PTSD from September 27, 2006 through May 22, 2013 is granted, subject to the laws and regulations controlling the award of monetary benefits. REMAND The Veteran also is seeking entitlement to service connection for hypertension, to include as secondary to service-connected diabetes mellitus and/or PTSD. Despite the extensive development already undertaken, another remand is required prior to adjudication of the claim. In that regard, the Board notes that pursuant to the Board's March 2013 remand instructions, the Veteran was afforded a VA examination for his hypertension in May 2013. The examiner diagnosed essential hypertension, but concluded that the Veteran's service-connected diabetes mellitus and PTSD did not cause his hypertension. As to rationale, the examiner concluded that the diabetes was not the cause because the Veteran had normal renal function and the PTSD was not the cause because there was no medical literature supporting such an association. The Board notes, however, that in a February 2013 Informal Hearing Presentation, the Veteran's representative cited to a study claimed to support an association between PTSD and cardiovascular disease, specifically JA Boscarino, Posttraumatic Stress Disorder and Physical Illness: Results from Clinical and Epidemiologic Studies, 1032 ANNALS OF THE N.Y. ACAD. Of SCI. 141-53 (2004) (available online at http://onlinelibrary.wiley.com/doi/10.1196/annals.1314.011/f ull). The examiner failed to discuss the applicability of this study or to otherwise reconcile the assertions of the Veteran's representative that such a study supports the finding of an association between PTSD and hypertension. Moreover, the examiner failed to opine as to whether the diabetes or PTSD aggravated the Veteran's hypertension, as directed in the March 2013 Board remand. As such, the Board concludes that a remand is required to obtain an addendum opinion to the May 2013 VA examination report. Accordingly, the case is REMANDED for the following action: 1. Obtain a supplemental opinion from the examiner who conducted the May 2013 hypertension examination. If the examiner is not available, obtain an opinion from another appropriate medical professional. If the reviewer determines that additional examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The claims file must be made available to and reviewed by the reviewer/examiner. The reviewer/examiner is asked to provide an opinion regarding whether it is as least as likely as not (50 percent probability or more) that any current hypertension disability was (a) caused, or (b) permanently aggravated beyond its natural progression by the Veteran's service-connected PTSD and/or diabetes mellitus, type II. In that regard, the examiner/reviewer is requested to consider, and discuss as necessary, the allegations of the Veteran's representative that the article referenced in the body of this remand suggests a link between PTSD and hypertension. It would be helpful if the examiner/reviewer would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. The examiner/reviewer must provide a complete rationale for any opinion provided. 2. Upon completion of the above requested development and any additional development deemed appropriate, readjudicate the Veteran's claim. All applicable laws and regulations should be considered. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided with an SSOC, and an appropriate period to respond before the case is returned to the Board. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs