Citation Nr: 1333108 Decision Date: 10/22/13 Archive Date: 10/24/13 DOCKET NO. 06-08 363 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a lung condition. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Murray, Associate Counsel INTRODUCTION The Veteran served as a member of the United States Navy, with active service from April 1974 to June 1976. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions rendered by the Department of Veterans Affairs (VA) Regional Office in New York, New York (RO). In a September 2006 rating, the RO denied the claim for service connection for a lung condition. By the way of a December 2007 rating decision, the RO awarded service connection for PTSD and assigned a 30 percent evaluation, effective from June 12, 2006. In a July 2008 rating decision, the RO reconsidered the effective date for the award of service and assigned an earlier effective date of June 24, 2005. Then in a July 2013 rating decision, the Appeals Management Center (AMC) increased the initial assigned rating from 30 to 50 percent disabling, effective from the date of claim, June 25, 2005. Regardless of the RO/AMC's actions, the issues remain before the Board because the increased ratings were not a complete grant of the maximum benefits available. See AB v. Brown, 6 Vet. App. 35 (1993). The Veteran testified at a Travel Board hearing before the undersigned at the New York RO in September 2009. A copy of the hearing transcript has been associated with the claims folder. The Travel Board hearing was sufficient to fulfill his right to a hearing under 38 C.F.R. § 20.700(a) (2013). The Veteran's claims were remanded by the Board for additional development in August 2010, December 2012, and June 2013. The case has since been returned to the Board for further appellate consideration. A review of the Veteran's virtual VA electronic claims file reveals that additional relevant VA treatment records have been associated with the record. These records have been reviewed and considered by the Board. The issue of entitlement to an earlier effective date for eligibility to disability pension has been raised by the Veteran's representative in a March 2013 statement. As this issue has been raised by the record but it has not been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. The issue of entitlement to service connection for a lung condition to include as due to in-service chemical exposure 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. During the entire period under appeal, the Veteran's disability due to PTSD has been manifested by symptoms consistent with occupational and social impairment that involves deficiencies in most areas, including work, family relations, judgment, concentration, and mood. 2. At no point during the period under appeal has the Veteran's PTSD disability resulted in total occupational and social impairment. CONCLUSION OF LAW The criteria for a 70 percent rating, but not higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Stegall Concerns In August 2010, the Board remanded this claim and ordered the agency of original jurisdiction (AOJ) to obtain outstanding VA and private medical records as well as schedule the Veteran for a VA psychiatric examination. The Veteran's claim was then to be readjudicated. Pursuant to the Board's remand instructions, VA mental health treatment records were obtained and associated with the Veteran's claims folder. Additionally, the Veteran was afforded a VA psychiatric examination in November 2010 and a report of the examination was associated with his claims folder. The Veteran's PTSD claim was readjudicated via the February 2012 supplemental statement of the case (SSOC). Subsequent to that SSOC, the Veteran submitted a February 2012 statement, in which she attached information that she claimed to have provided the AMC in December 2011 that included an updated VA Forms 21-4142, for private mental health records from CM (a VA turned private clinical psychiatric nurse) since 2009 and an undated letter from a private treatment provider detailing the Veteran's PTSD symptoms and treatment. The Veteran's February 2012 statement indicated that she did not believe that this information had been considered in rendering the February 2012 SSOC and she desired initial consideration of the additional treatment records. In December 2012, the Board remanded the matter again in attempt to obtain the identified private treatment records and for initial consideration of the additional evidence. The AMC sent the Veteran a notice letter in December 2012 to request that the Veteran to submit separate VA Form 21-4142s Authorization and Consent to Release Information for any treatment provider other than CM. As noted in a February 2013 SSOC, the Veteran failed to respond to the AMC's request for such information. Since it appeared that the Veteran was not notified that that private treatment records from CM have not yet been obtained, the Board, in June 2013, remanded the matter again to attempt to obtain those outstanding private treatment records from CM since 2009. Also, the Board instructed that the Veteran should be provided with a new VA psychiatric examination to evaluate the severity of her disability. In June 2013, the AMC specifically requested that the Veteran submitted a completed VA Form 21-4142 for Authorization and Consent to Release Information to the VA for CM as well as any other provider. The Veteran failed to respond. The duty to assist is not a one-way street. If a veteran wishes help in developing her claim, she cannot passively wait for it in those circumstances where she may or should have information that is essential in obtaining putative evidence. Wood v. Derwinski, 1 Vet. App. 190 (1991). The RO has substantially complied with the Board's June 2013 instructions. Additionally, the Veteran was afforded a VA psychiatric examination in July 2013 and a report of the examination was associated with his claims folder. The Veteran's PTSD claim was readjudicated via the July 2013 supplemental statement of the case (SSOC). Accordingly, the Board's remand instructions have been substantial compliance with the Board's 2010, 2012, and 2013 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board imposes upon the Secretary of Veterans Affairs a duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008) (indicating that substantial compliance is the applicable standard for review of Board remands); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). VA's Duty to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. In the notice, VA will inform the claimant which information and evidence, if any, that the claimant is to provide to VA and which information and evidence, if any, that VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159 (2008); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Notice should also address the rating criteria and effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In the case at hand, the record reflects that the originating agency provided the Veteran with the required notice by a letter dated in September 2006, as well as notices with respect to the effective-date element of the claim, by a letter dated in September 2010 and June 2013, prior to the most recent adjudication of her claim in July 2013. See 38 U.S.C. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2011); Mayfield v. Nicholson, 19 Veteran. App. 103, (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In short, the record indicates the Veteran received appropriate notice pursuant to the VCAA. Accordingly, with respect to VCAA notice, there is no prejudice to the Veteran in the Board's proceeding with the issuance of a decision on the merits as to his increased rating claims. Concerning VA's duty to assist, the Board notes that the VA has obtained the Veteran's service personnel records, post-service VA and private treatment records, and his testimony and lay statements. The Veteran was afforded VA psychiatric examinations in November 2010 and July 2013. The examination reports reflect that the examiners interviewed and examined the Veteran, reviewed her claims folder, reviewed her past medical history, documented her current medical condition, and rendered appropriate diagnoses consistent with the remainder of the evidence of record. Furthermore, these examination reports contain sufficient information to rate the Veteran's PTSD under the appropriate diagnostic criteria. The Board therefore concludes that the VA examination reports are adequate for evaluation purposes. See 38 C.F.R. § 4.2 (2011); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) [holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate]. In short, the Board has carefully considered the provisions of the VCAA, in light of the record on appeal and, for the reasons expressed above, finds that the development of the Veteran's claims has been consistent with said provisions. The Board is satisfied that any procedural errors in the originating agency's development and consideration of the claims were insignificant and nonprejudicial to the Veteran. The Veteran has been accorded ample opportunity to present evidence and argument in support of his claims. See 38 C.F.R. § 3.103. She has retained the services of a representative, and she has had the opportunity for a personal hearing before a member of the Board. Accordingly, the Board will address the claims on appeal. Increased Rating Disability ratings are assigned in accordance with the VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1. Separate diagnostic codes identify the various disabilities. See 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. The Court has held that an appeal from an initial rating is a separate and distinct claim from a claim for an increased rating. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007) [holding, "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"]. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). The Veteran's psychiatric disorder is currently rated under 38 C.F.R. § 4.130, Diagnostic Code 9411 [PTSD]. Diagnostic Code 9411 is deemed by the Board to be the most appropriate because it pertains specifically to the primary diagnosed disability in the Veteran's case (PTSD). In any event, with the exception of eating disorders, all mental disorders including PTSD and bipolar disorder are rated under the same criteria in the rating schedule. Therefore, rating under another diagnostic code would not produce a different result. Moreover, the Veteran has not requested that another diagnostic code be used. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 9411. PTSD is to be rated under the general rating formula for mental disorders under 38 C.F.R. § 4.130. The pertinent provisions of 38 C.F.R. § 4.130 concerning the rating of psychiatric disabilities read in pertinent part as the following. A 50 percent evaluation 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. 38 C.F.R. § 4.130. A 70 percent rating may be assigned where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessed 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 work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted where 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging from 51 to 60 reflect more 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 (2011) [incorporating by reference the VA's adoption of the DSM-IV for rating purposes]. In this case, the Veteran seeks an initial evaluation in excess of 50 percent for her PTSD disability. A review of the record shows that the Veteran began receiving VA mental health treatment in 2006. She underwent an initial VA mental health clinic assessment in May 2006. That mental health treatment note shows that the Veteran complained of flashback and intrusive thoughts about sexual assault and harassment during her military service. The Veteran also reported a history of alcohol and drug abuse. On Mental status examination, the treating VA psychologist observed that the Veteran was cooperative and reasonable and her appearance was appropriate. Her mood and affect were anxious and dysphoric. Her thought process, speech, and language were intact, but her insight was limited. Her judgment was evaluated as good. She denied any suicidal or homicidal thoughts. She was oriented and her memory was intact. She was diagnosed with PTSD and she was assigned a GAF scaled score of 50. In a December 2006 statement from her treating VA mental health provider, CM, who later turned into a private clinical psychiatric nurse, she stated that the Veteran had PTSD related to her history of in-service sexual assault and harassment. The Veteran's current symptoms included nightmares, depressed mood, anxiety, and resent towards her military experiences. CM stated that due to the severity of her mental health symptoms, the Veteran was "unable to cope at times especially in situations where there may be a group of men." CM also noted that the Veteran's mental health symptoms had led her to engage in substance and alcohol abuse in the past. Similar statements by CM were dated in March 2007 and September 2007. A February 2007 VA mental health treatment note shows the Veteran complained of feeling tired and having panic attacks in close spaces, but she denied any suicidal or homicidal thoughts. The Veteran was assessed with a GAF scaled score of 60. An April 2007 VA mental health treatment note shows the Veteran complained of intrusive thoughts, sleep disturbances, irritability, and depressed mood. She denied any suicidal or homicidal thoughts. A September 2008 VA mental health treatment record shows a GAF scaled score of 55. The record also contains several subsequent statements from CM regarding the severity of the Veteran's PTSD disability. In these statements, CM consistently concluded that the Veteran had difficulty establishing and maintaining employment because of her PTSD disability. See June 2008, September 2008, October 2008, September 2009 VA medical statements. CM noted that the Veteran is easily distracted and she has difficulty accomplishing her assignments. In an October 2008 statement, CM stated that her PTSD disability "is impeding her ability to work" and resulted in her leaving her job because of increase in nightmares and panic attacks. In each statement, CM noted that the Veteran's condition had worsened both mentally and physical because of her service connected disabilities. Subsequent VA mental health treatment records dated from November 2009 to March 2010 show that the Veteran reported feeling depressed, anxious and upset about her work conditions. She reported that she enjoys her work helping returning veterans, but she finds that her work causes her stressful dreams. She also reported that she has difficulty working with others at her job and she felt that her superiors were attacking her. In an October 2010 statement, CM noted that she had left VA in June 2010, but the Veteran decided to continue her treatment with CM outside of VA because she found the transition to a new therapist was too difficult. CM noted a strong correlation between the deterioration of the Veteran's mental status and her physical health due to her hepatitis C disability. CM opined that the Veteran is "disabled and unable to function at her optimum level." CM concluded that the Veteran's disability had worsened. In November 2010, the Veteran underwent a VA psychiatric examination to evaluate the severity of her PTSD disability. That examination report shows that the Veteran complained of nightmares, intrusive thoughts, anxiety, decreased physical intimacy with her partner, irritability, anger outbursts, sleep impairment, low energy, depressed mood, and being tearful. The Veteran also reported that she avoids situation where there are too many men or crowds. The examiner noted that the Veteran had waited in the compensation administration office prior to her scheduled examination time, because she was unable to wait in the waiting room because she felt anxious around the other men who were seated in there. The Veteran reported that she was currently employed at a college as a teacher and veteran's specialist, but she had lost numerous jobs at different schools because of difficulty with supervisors and peers. She reported that she continues to have difficulty with her superiors at her current work position. She also felt that working with veterans exacerbated her PTSD symptoms. It was noted that although she had obtained a law degree, she failed to pass the legal bar six times because she "couldn't focus to get it done." On mental status examination, the November 2010 VA examiner observed that the Veteran had appropriate appearance, behavior, and hygiene. She was oriented. Her mood and affect were characterized as depressed and anxious. The Veteran's speech, thought process, thought content were evaluated as normal. She had preoccupation with worrying that she will be attack. She denied any suicidal or homicidal ideations. Her judgment and insight were assessed as good. A diagnosis of PTSD was confirmed. The Veteran was assigned a GAF scaled score of 74, however, the examiner concluded that Veteran's psychiatric impairment was moderate to severe at times as evidenced by her history employment and social functioning. The examiner stated that "although she had maintained employment over last years, she has changed up quite a bit due to the fact that she struggles interpersonally particularly with superiors and bosses... she ends up having difficulty coping, having lashes out and either loses her job or goes change jobs." The examiner also noted that the Veteran's PTSD symptoms affect her personal relationship with her partner. The VA examiner conclude that the Veteran's PTSD symptoms are moderate to severe level and her current work position have exacerbated some of her symptoms by making it harder for her to avoid intrusive thoughts. As noted above, VA attempts to obtain the private mental health records since June 2009 have been unsuccessful. The Veteran's treating private psychiatric nurse, CM, previously VA medical professional, provided another medical statement in December 2011. In that statement, CM noted that the Veteran was employed helping veterans obtain a college education, but the Veteran found her work stressful and triggers nightmares. The Veteran also felt that she was "being at times attacked by her administrators and is overwhelmed." The Veteran suffered from depression association with her PTSD and hepatitis C disabilities. CM felt that the Veteran "becomes self destructive," which compounds her mental and physical health. CM concluded that the Veteran's disability has not improved and her mental and physical health had deteriorated. CM opined that the Veteran was "100% disabled." In July 2013, the Veteran underwent another VA psychiatric examination to evaluate the severity of her PTSD disability. The July 2013 VA examiner found that the Veteran's PTSD disability was manifested by depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, flattened affect, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. The Veteran also complained of low energy, loss of libido, reduced appetite, and the feeling that she has not "adequately fulfilled her life goals." The Veteran reported that her relationship with her partner of 12 years was affected by her PTSD symptoms of anxiety, sleep impairment, and sexual intimacy difficulties. She reported that she often feels like isolating herself from others, and despite her efforts to "get out and socialize with friends," she is unable to do so frequently. She stated that she spends most of her leisure time at home watching TV and movies. With regard to her occupational history, the Veteran reported that she stopped teaching in 2010 because it "got to be too overwhelming" but she continues to work as a director for a returning veterans program and helps veterans connect with services. She reported having difficulty with her superiors and she does not have a good relationship with her direct supervisor who has stated that she is "being defensive." The Veteran also reported that she does not feel protected at her work place due to a sexual harassment incident with a student and the lack of supportive response from her supervisor. The Veteran complained of some difficulty with multi-tasking at work and she has difficulty focusing on and completing her tasks. She reportedly enjoys her work with veterans, but she wants to seek work in a more supportive environment. The Veteran reported that she has missed work approximately one day per week due to symptoms of increased anxiety and elevated blood pressure. The Veteran reported that she continues to seek treatment from her private psychiatric nurse, C.M., about twice a month. On mental status examination, the July 2013 VA examiner observed that the Veteran was appropriately dressed and she was cooperative during the clinical interview. She made good eye contact with the examiner and she became tearful at times. Speech and motor evaluation were within normal limits. With respect to her mood, the Veteran stated that "I've had better days; I've been somewhat distressed and depressed." She had full affect and appropriate thought content. Her thought process was logical and goal-oriented and there was no evidence of suicidial or homicidal ideations, hallucinations or delusions. She was oriented and her judgment and insight were assessed as good. With regard to PTSD diagnostic criteria, the examiner noted that the Veteran exhibited recurrent and distressing recollections of trauma, she had nightmares, and she had intense psychological distress at exposure to internal or external cues. The Veteran exhibited avoidance of remainders of her trauma, she had markedly diminished interest, she had feelings of detachment from others, and she had restricted range of affect. She complained of sleep impairment, irritability and outburst of anger, difficulty concentrating, hypervigilance, and exaggerated startled responses. The July 2013 VA examiner opined that the severity of the Veteran's PTSD disability resulted in occupational and social impairment with reduced reliability and productivity. The record also contains the testimony and statements from the Veteran as well as statements from her partner, in which the Veteran's PTSD symptoms are described. Collectively, the Veteran reported that she experiences symptoms of depression, sleep impairment, anxiety, strained personal and work relationships, lack of motivation, mood swings, irritability, avoidance of crowds, and withdrawal from others. She testified that she feels "unstable" at times, and she reported that she has changed addresses and jobs frequently over the years. She also testified that she had difficulty with concentration and understanding complex assignments, and she failed her tests for certification for teaching and for bar licensing. See September 2009 statement in support of the case. Her partner observed that the Veteran has suffered from panic attacks, anxiety, depressed mood, nightmares, flashbacks, fatigue, nausea and emotional mood swings for years. See September 2009 statement in support of the case. Here, the Veteran seeks a higher evaluation for her PTSD disability. She asserts that her disability is manifested by symptomatology that is more severe than associated with a 50 percent evaluation under Diagnostic Code 9411. In this case, the Board notes that while there has been some variation in the severity of the Veteran's PTSD symptoms during the appeal period, the severity of the Veteran's symptomatology has been relatively constant throughout the period of this appeal; therefore, "staged" ratings are not warranted. 38 C.F.R. § 4.71a; Hart, 21 Vet. App. 505. By this decision, the Board is resolving any doubt in the Veteran's favor to award an increased rating for disability due to PTSD to 70 percent over the entire appeal period. The medical evidence of record does not indicate that the Veteran's symptomatology had worsened to a level more severe than 70 percent disabling at any point during this appeal period. See 38 C.F.R. § 4.1. Collectively, the aforementioned medical evidence reflects that throughout the appeal period, the Veteran's PTSD was manifested predominantly by symptoms no more severe than the following: depressed mood, flattened affect, impaired concentration and insight, memory impairment, irritability, anger outburst, panic attacks, sleep impairment, decreased physical intimacy with her partner, avoidance of crowds and groups of men, social withdrawal, preoccupied thought content on sexual harassment, and difficulty in establishing and maintaining effective work and social relationships. The Board acknowledges that the November 2011 VA examiner assigned a GAF scaled score of 74, however, the examiner later concluded that the Veteran's disability was moderate to severe in severity. In addition, CM, the clinical psychiatric nurse has consistently concluded that the Veteran's PTSD disability causes her difficulty with maintaining employment due to her difficulty in getting along with her supervisors and completing her work task. It is apparent that the Veteran's symptomatology affected her ability to maintain employment, as demonstrated by her history of frequent job turn-over. These symptoms are directly consistent with a 70 percent evaluation, and a 70 percent evaluation is warranted for the entire period under appeal. See 38 C.F.R. § 4.130, Diagnostic Code 9411. That being said, the evidence of record does not demonstrate that the Veteran's PTSD disability is manifested by total occupational and social impairment. The Board has considered CM's medical conclude that the Veteran is "100% disabled," but it appears that her medical conclusion was based on the severity of both the Veteran's PTSD and Hepatitis C disabilities. Pertinently, both the November 2010 and July 2013 VA examiners found that the Veteran's PTSD symptomatology only created difficulty at her place of employment, and not that it has caused her total occupational impairment. Moreover, the objective findings from clinical evaluations are insufficient to warrant a rating to the next higher, 100 percent, rating for PTSD. See 38 C.F.R. § 4.130, Diagnostic Code 9411. In this regard, there is no evidence that the Veteran's PTSD results in symptoms consistent with such severe criteria as the following: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. Also, the Veteran has consistently received a GAF scale score range of that falls into the category that suggests serious symptomatology, but not scores indicative of totally disabling symptomatology. These findings indicate that the Veteran's PTSD disability does no more than contribute to her difficulty functioning at work and in social situations with others. These objective findings approximate the criteria for a 70 percent disability rating, and are insufficient to warrant a rating to the next higher, total disability, rating for PTSD. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Accordingly, the next higher rating of 100 percent is not warranted for any period under appeal. The objective medical findings recorded and tracked throughout the appeal period support the criteria for the 70 percent disability rating. The GAF scores assigned are consistent with such a conclusion. Accordingly, an increased disability rating of 70 percent, and no higher, is warranted from the beginning of the appeal period. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board notes that in reaching these conclusions, the benefit of the doubt doctrine has been applied to resolve the matters on appeal in a manner favorable to the Veteran. See 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has also considered whether an extraschedular rating is warranted, noting that if an exceptional case arises where ratings based on the statutory schedules are found to be inadequate, consideration of an "extra-schedular" evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). The Court has held that the determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service. Thun v. Peake, 22 Vet. App. 111 (2008). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. This means that initially there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is adequate, and no referral is required. If the criteria do not reasonably describe the claimant's disability level and symptomatology, a determination must be made whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). See id. However, in this case, the medical evidence fails to show anything unique or unusual about the disability at issue that would render the schedular criteria inadequate. The Veteran's main symptoms are contemplated in the assigned 70 percent rating. A rating in excess of that assigned is provided for certain manifestations of her PTSD but the probative evidence reflects that those manifestations are not present in this case. The rating criteria adequately describe the severity and symptomatology of the Veteran's service-connected mental health disability. Therefore, the Veteran's disabilities are contemplated by the rating schedule and no extraschedular referral is required. Additionally, there is no showing that the disabilities cause any significant functional impairment. As such, it would not be found that they meet the "governing norms" of an extraschedular rating. Accordingly, an extraschedular rating is not warranted. Finally, the Board has considered whether a remand for consideration of total disability benefits based on individual unemployability (TDIU) is warranted. The Court has held that TDIU is an element of an increased rating claim. Rice v. Shinseki, 22 Vet. App. 447 (2009). Although the Veteran has asserted that her symptomatology has impacted her ability to work, at no time during the pendency of this claim has the Veteran alleged that she is unemployable as a result of her PTSD. Despite her treating private clinical psychiatric nurse opinion that the Veteran is "totally disabled", the evidence of record shows that the Veteran continues to work on a regular basis. Therefore, further consideration of this matter is not necessary. ORDER Entitlement to an evaluation of 70 percent, and not higher, for PTSD disability is granted. REMAND Unfortunately, another remanded is needed prior to adjudication of the Veteran's claim for service connection for a lung disorder. In June 2013, the Board remanded the Veteran's claim for a VA respiratory examination to determine the nature and etiology of her claimed lung condition. Pursuant to the Board's remand instruction, the Veteran was afforded with a VA examination in July 2013. In the examination report, the VA examiner noted that the Veteran had a current diagnosis asthma, and the examiner noted that there was evidence of minimal interstitial changes noted on the 2013 chest x-ray. The VA examiner provided negative medical nexus opinions regarding the etiology of the Veteran's asthma and diagnostic evidence of minimal interstitial changes as related to her period of service or as proximately caused by her service-connected hepatitis disability (and treatment). In support of the medical conclusion regarding minimal interstitial changes, the VA examiner noted that a review of the chest x-ray reports from the 1990s to the present all revealed normal findings, except the one from 2013 which showed minimal interstitial changes. However, the Board's review of the claims folder shows that a VA chest x-ray in January 1999, when compared to VA chest x-rays dated in October 1996, October 1997, and December 1997, demonstrated findings that "chronic interstitial lung disease persists." Although subsequent VA and private chest x-ray failed to demonstrate similar findings, it is apparent from the earlier 1996, 1997 and 1999 chest x-rays showed interstitial changes well before 2013. As such, the VA examiner's statement that there was no evidence of interstitial changes prior to 2013 may be inaccurate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). An addendum medical statement should be obtained from the July 2013 VA examiner, in which the VA examiner considered the previous VA chest x-ray findings of chronic interstitial lung disease prior to 2013. The VA examiner then should reconsider the medical conclusion on whether the Veteran's current lung condition is etiologically related to her period of service, to include presumed exposure to chemicals while performing her duties on the flight lines, or proximately caused or aggravated by her service-connected hepatitis C, to include treatment for her disability. Accordingly, the case is REMANDED for the following action: 1. Arrange for the examiner from the July 2013 VA respiratory examination to review the claims folder and provide an addendum medical statement on the etiology of the Veteran's current lung conditions. The examiner should review the claims file, to include the July 2013 VA respiratory examination as well as any relevant records in Virtual VA, and a copy of this REMAND in conjunction with the examination. (If the examiner who conducted the July 2013 VA respiratory examination is unavailable, then arrangements should be made for an appropriate specialist to review the claims folder and provide a supplemental VA medical opinion.) The VA examiner should provide an addendum medical statement to the July 2013 VA respiratory examination, in which the examiner notes consideration of the previous VA chest x-ray findings of chronic interstitial lung disease in 1999. Then, the VA examiner should reconsider the previous medical conclusion on whether the Veteran's current lung condition is: (a) etiologically related to her period of service to include her presumed exposure to jet fuel (daily) and unknown cleaning chemicals while cleaning jet engines and fuel tanks which resulted in dizziness during service as alleged); or (b) proximately caused or aggravated (permanently worsened beyond normal progression) by her service-connected hepatitis C, to include at least two courses of Interferon/Ribavirin antiviral treatment, to include from 2003 through 2004. If aggravation is shown, the examiner should specify what permanent, measurable increase in the severity of the lung condition is attributable to service-connected hepatitis C and/or treatment thereof. Any and all opinions must be accompanied by a complete rationale. If the VA examiner is unable to reach an opinion, he or she should explain the reasons for this inability and comment on whether any further tests, evidence or information would be useful in rendering an opinion. 2. Then, after ensuring that any other necessary development has been completed, readjudicate the issues on appeal. If the benefits sought on appeal are not granted, issue a supplemental statement of the case, and afford the Veteran and her representative an opportunity to respond. Thereafter, the case should be returned to the Board, if in order. 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