Citation Nr: 1333802 Decision Date: 10/25/13 Archive Date: 11/06/13 DOCKET NO. 13-22 837 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Newark, New Jersey THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). ATTORNEY FOR THE BOARD C. E. de Jong, Associate Counsel INTRODUCTION The Veteran (appellant) served on active duty from March 1969 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2012 rating decision of the RO in Newark, New Jersey, which granted service connection for PTSD and assigned an initial evaluation of 30 percent effective April 8, 2011. The initial evaluation was subsequently increased to 50 percent in a June 2013 Decision Review Officer decision. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's service-connected PTSD has been manifested by occupational and social impairment with reduced reliability and productivity, but not total impairment or deficiencies in most areas at any time during the period on appeal. CONCLUSION OF LAW The criteria for an initial evaluation in excess of 50 percent for PTSD are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Increased Evaluation The Veteran contends that he is entitled to an initial rating in excess of 50 percent for his PTSD. For the reasons that follow, the Board concludes that a rating of 50 percent most closely reflects the Veteran's symptoms and that no increased rating is warranted. Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2013); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14 (2013). The Veteran's service-connected PTSD is evaluated as 50 percent disabling under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). 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). Under the provisions for rating psychiatric disorders, a 50 percent disability rating requires evidence of the following: 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. The criteria for a 70 percent rating are: 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.) The criteria for a 100 percent rating are: 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. The Board notes that the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the VA must consider all symptoms of a claimant'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)). See Mauerhan, supra. Within the DSM-IV, Global Assessment 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). While not determinative, 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). According to DSM-IV, a score of 51-60 represents "[m]oderate 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. Several GAF scores have been assigned in the evidence, the lowest of which was a 54, assigned at the Veteran's March 2012 VA examination, and the highest of which was a 60, assigned at a March 2011 treatment session at the East Orange VA Medical Center (VAMC). As noted above, according to the DSM-IV both of these scores are indicative of moderate symptoms or moderate difficulty in social or occupational functioning. They do not tend to show deficiencies in most areas or total impairment. In the Veteran's April 2011 statement in support of his claim, he indicated that he has experienced PTSD symptoms since 1971 and that his primary symptom has been nightmares related to incidents during his service onboard the U.S.S. Ranger as an Aviation Boatswain's Mate. The Veteran reported that he suffered "a lot of memory loss" and that he heard "the voice of my mother and a cat around me." The Veteran also asserted that he lived alone because his PTSD symptoms caused his relationships to end quickly, and that he was unable to concentrate at work due to his symptoms. The evidence of record reflects that the Veteran first began receiving treatment for PTSD at the East Orange VA Medical Center (VAMC) in February 2011. He presented at that time with chronic sleep problems as a result of his service-related nightmares and reported that his symptoms were causing frustration, irritability, and negatively affecting his work performance. In February 2011 he was assigned a GAF score of 57, indicating moderate symptoms or moderate difficulty in social or occupational functioning. At this initial treatment session, the Veteran reported that he was experiencing nightmares 2-3 times per week, and that his sleep problems had contributed to missing many days at work. The Veteran reported that he was irritable at work and that he had lost his temper with a co-worker 3 months earlier. The Veteran stated that he had worked as a lawyer until 2000, when he lost his law license due to angry outbursts directed at clients. He had since been employed as a risk manager and was satisfied with his job, although he was concerned about how much longer his employer would put up with his recent problems at work. At this time, the Veteran asserted that his PTSD symptoms had factored into his two divorces, and reported that he had not spent much time with friends in recent years. He reported having good relationships with his children. The Veteran also reported that he had a daughter from his second marriage who was born prematurely and with severe health problems. She was institutionalized for her entire life and died at age 11. The Veteran noted that he was not able to visit his daughter for much of the last year of her life. The Veteran presented with an anxious/frustrated mood, constricted affect, clear speech and relevant and organized thoughts. He denied suicidal or homicidal ideation. He had consistent eye contact, average insight, and his judgment was intact. At his March 2011 VAMC treatment session, the Veteran denied suicidal, homicidal, or paranoid ideation, and also denied auditory or visual hallucinations. The Veteran presented with an appropriate affect and preoccupied mood, and had logical and goal-directed thought processes, as well as fair insight and judgment. The Veteran reported having problems at work and said he had notified his boss that he might quit if his sleep problems continued. However, the Veteran also reported that if his symptoms improved he would try to continue working. At this session the Veteran was assigned a GAF score of 60, which as noted above indicates moderate symptoms or moderate difficulty in social or occupational functioning. The Veteran was prescribed Prazosin at this time to treat his PTSD symptoms, as well as Hyroxyzine to treat his sleep problems. In April 2011, a VA treatment note states the Veteran reported feeling better with the aid of the medication. At that time the Veteran presented as calm and relaxed, stable and in good control. He continued to deny suicidal, homicidal or paranoid ideation, as well as auditory or visual hallucinations. He reported that his mood was better, and presented with appropriate affect, logical and goal-oriented thought processes, and fair insight and judgment. Throughout May and June 2011, the Veteran continued to report improvement in his symptoms with medication, and the Veteran was also prescribed Zoloft. The Veteran continued to deny suicidal, homicidal or paranoid ideation, and also continued to deny auditory or visual hallucinations. In July 2011, the Veteran continued to report a decrease in his PTSD symptoms, with fewer nightmares and better sleep. However, the Veteran did continue to report irritability and relational problems at work. In August 2011, the Veteran reported feeling "really good" and stated that his children had noticed a significant positive change in him. He reported decreased irritability at work, but stated that he still planned to quit his job in about a year. The Veteran also reported that his memory had improved since he began medication, but was scheduled for a neurology consultation due to his continuing complaints of memory and concentration impairment. Records from any such consultation are not included in the Veteran's claims file. September and October 2011 VA treatment notes show that the Veteran continued to report improvement in his PTSD symptoms with medication. In October 2011, the Veteran reported that his symptoms were worse without medication, and that he almost lost his job after an argument with his boss when he was not on his medication. At his October 2011 treatment session, he reported his mood as good, and continued to present with appropriate affect, logical thought process, and good insight and judgment. He continued to deny any type of hallucinations, as well as suicidal or homicidal ideations, and reported feeling well on his medication regimen. The Veteran was assigned a GAF score of 55 at this session, again indicating moderate symptoms or moderate social or occupational impairment. The Veteran continued to present with appropriate affect, good or "ok" mood, fair insight and judgment, and no suicidal or homicidal ideations nor any type of hallucinations throughout his treatment at the East Orange VAMC. In March 2012, the Veteran reported having an angry outburst at work, and in April 2012, the Veteran reported that his boss had asked him to take an early retirement in August 2012. In September 2012, the Veteran reported that he had not been able to go to work for a week because he had run out of his medications and his PTSD symptoms had worsened. He also reiterated that he was considering early retirement. In December 2012, the Veteran reported that he had left his job in October. He stated that he felt pressured to leave and was getting into too many arguments with his boss. The Veteran was afforded a VA examination in March 2012. Upon examination, the Veteran was assigned a GAF score of 54, which as noted above indicates moderate symptoms or moderate social or occupational impairment. The examiner indicated that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although the Veteran was generally functioning satisfactorily with normal routine behavior, self-care and conversation. The VA examiner noted that the Veteran was unable to form, maintain, and sustain social relationships due to his angry outbursts, and that the Veteran reported his two long-term marriages had both ended in divorce due to his PTSD symptoms. At examination, the Veteran reported good relationships with his children. The examiner noted that the Veteran had conflicts with his boss at his current job, and that the Veteran's law license had been revoked in 2000 because of his angry outbursts directed at clients. The examiner indicated the Veteran's PTSD symptoms as follows: anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, inability to establish and maintain effective relationships, and impaired impulse control. The Veteran reported he had been experiencing these PTSD symptoms for 40 years, but did not seek treatment until 2011. The examiner noted that the Veteran's PTSD symptoms appeared to have had the greatest impact on the Veteran's social functioning, particularly with regard to maintaining relationships and frequent conflicts with co-workers and clients. In the Veteran's May 2012 Notice of Disagreement, he asserted that he was unable to work due to his severe PTSD symptoms. The Board notes that the Veteran remained employed in his position as a risk manager until October 2012. The Veteran reported that he was unable to cope with his job obligations, was unable to communicate with his superiors because of his mood, and isolated himself at work. He stated that "the most I can stay asleep is 1 to 2 hours due to nightmares and panic attacks" and that "my mood is so bad that I stay alone in order to avoid confrontations." The Veteran further asserted that his condition impaired his judgment to the point of ending both his marriages and losing jobs, and that he was unable to remember simple things. In his August 2013 statement, the Veteran reported that his PTSD symptoms had caused him to stop working in October 2012. He stated that his relationships with his co-workers and superiors had deteriorated such that he was no longer able to communicate or interact with them without having a confrontation, and that he was afraid these confrontations would become violent. The Veteran reported that one of his superiors had told him that he was crazy and should leave the company. The Veteran stated, "I know in my heart that staying there could cause an unfortunate event of violence and decided to leave." He also reported that he only had a relationship with his children by phone or on certain occasions, and that he had not lived with his children since they were small. The Board has respectfully considered the Veteran's statements. However, his statements are inconsistent with his VA treatment records in several respects. Although the Veteran asserted in his May 2012 Notice of Disagreement that he was unable to work due to his PTSD symptoms, he was employed in a high-level position as a risk manager at that time and had been since 2000. Prior to his work as a risk manager, the Veteran worked as an attorney. The Veteran remained employed until October 2012. In his VA treatment records, the Veteran reported leaving his job at that time because he felt pressured to retire. However, the Veteran was not fired from his job due to his PTSD symptoms, and he had held his position for 12 years at the time he retired at age 65. In his Notice of Disagreement, the Veteran reported only being able to sleep 1-2 hours per night because his sleep was disrupted by nightmares and panic attacks. This statement is inconsistent with statements the Veteran made to his VA healthcare providers during the same time period. At his treatment sessions, the Veteran reported that his sleep had improved significantly and that he was sleeping about 4 hours per night. He also reported that his nightmares had decreased significantly with the aid of his medication regimen. Furthermore, although the Veteran reported impaired judgment that caused his two divorces, as well as the loss of his law license, his VA treatment records consistently noted that the Veteran possessed fair to good judgment. The Veteran also reported substantial memory loss in his statements, but such memory loss was never found throughout the course of his treatment or on his VA examination, despite multiple tests to assess memory loss. The inconsistency of the Veteran's statements submitted to VA in support of his claim with the statements he made to his healthcare providers for purposes of treatment tends to lessen the credibility of the Veteran's statements submitted in support of his claim. The Board finds that the Veteran's PTSD is productive of social and occupational impairment with reduced reliability and productivity, but not with deficiencies in most areas or total impairment. Of those symptoms suggestive of a 50 percent rating, the Veteran does not have circumstantial, circumlocutory or stereotyped speech, difficulty in understanding complex commands, or impaired abstract thinking. The Veteran did assert in his May 2012 Notice of Disagreement that he experienced panic attacks, although he did not report experiencing panic attacks at any of his VA treatment sessions or during his VA examination. The Veteran has also asserted that he has memory loss. At his initial February 2011 VA treatment session, the Veteran presented with flattened affect, although in all subsequent treatment sessions and at his VA examination he presented with appropriate affect. The Veteran has asserted that he has impaired judgment that impacted his marriages and his prior jobs, although at all of his VA treatment sessions and his VA examination he was found to have fair to good judgment. The Veteran has reported disturbances of motivation and mood, which are clearly reflected in the clinical evidence of record. He has also reported difficulty in establishing and maintaining effective work and social relationships, and this is also reflected by clinical evidence, including his VA treatment records and his VA examination. The preponderance of the evidence shows that the Veteran does not have deficiencies in most areas. The Veteran has impaired impulse control and inability to establish and maintain effective relationships. The Veteran does not have suicidal ideation, obsessional rituals, speech which is intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting his ability to function independently, appropriately and effectively, spatial disorientation, neglect of personal appearance and hygiene, or difficulty in adapting to stressful circumstances. As noted above, the Veteran has deficiencies in mood, as evidenced by his own reports and the clinical evidence of record. The Veteran has reported deficiencies in judgment, although this is not shown by any other evidence of record. The Veteran does not have deficiencies in thinking. The Veteran asserted in his August 2013 statement that his relationship with his children consisted of phone calls and certain occasions, and that he had not lived with his children since they were small. At all of his VA treatment sessions and his VA examination he reported having good relationships with his children. The Veteran has also asserted his belief that his PTSD symptoms led to his two divorces. Both of the Veteran's marriages were long-term, with the first lasting from 1977 to 1995, and the second lasting from 1995 to 2008. The Board also notes that on multiple occasions during the Veteran's VA treatment, the Veteran took extended trips to Puerto Rico to visit with family members there. Based on the Veteran's ability to sustain good relationships with his children, his ability to sustain successive long-term marital relationships, and his ability to visit with family members in Puerto Rico for extended periods of time, the Board finds that the Veteran is not deficient in the area of family relations. The Board further finds that the Veteran is not deficient in the area of work. The Veteran worked as an attorney for many years after his separation from service. Although the Veteran unfortunately lost his law license in 2000, he was able to immediately secure a high-level position as a risk manager, which entails stressful and complicated work. The Board acknowledges the Veteran's reports of irritability and frustration at work, the effect of his chronic sleep impairment on his work performance, and confrontations with co-workers and repeated arguments with superiors. The Board also acknowledges that the Veteran reported leaving his job in October 2012 due to his conflicts with his superiors, and that the Veteran was afraid he might become physically violent in a workplace confrontation. However, the Veteran was never violent and was able to competently complete his job duties in his risk manager position for 12 years. The Veteran also reported in an August 2011 treatment note that he planned to retire in one year, and he in fact stayed at his job for another 14 months. The Veteran also reported throughout his VA treatment sessions that his PTSD symptoms were decreasing and his workplace mood and behavior improving with the aid of his medication regimen. In a July 2011 VA treatment note, the Veteran attributed his work impairment to sleep disruption, not to interpersonal conflict. The Veteran reported continued improvement in his sleep problems throughout the course of his treatment with the aid of medication. The Veteran's ability to stay employed in a high-level, stressful position for over a decade, and the improvement in his workplace mood and behavior that resulted from his medication regimen, tends to show the Veteran is not deficient in the area of work. Although the Veteran is deficient in the area of mood and has asserted a deficiency in the area of judgment, he is not deficient in the areas of thinking, family relations or work. Therefore, he is not deficient in most areas as described by the rating criteria. The Veteran's GAF scores ranging from 54 to 60 also do not indicate deficiencies in most areas. As the Veteran does not have deficiencies in most areas, the Board finds that the criteria for a 70 percent rating are not met. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (holding that a veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration). The Veteran does not have any of the symptoms suggestive of a 100 percent rating. The Veteran does not have gross impairment in thought processes or communications. The Veteran asserted in his April 2011 statement in support of his claim that he heard the voice of his mother and a cat around him. However, the Veteran denied both auditory and visual hallucinations in all of his VA treatment sessions and at his VA examination. As the Veteran only reported experiencing hallucinations on one occasion in a statement to VA and has never reported hallucinations during the course of his medical treatment and evaluation, the Board finds the Veteran does not have persistent delusions or hallucinations. The Veteran does not have grossly inappropriate behavior, intermittent inability to perform activities of daily living, or disorientation to time or place. The Veteran has expressed concern that he might become violent during a workplace confrontation. However, the Veteran has never become violent and has consistently denied any suicidal or homicidal ideation. Therefore, the Board finds the Veteran does not have a persistent danger of hurting himself or others. The Veteran has asserted memory loss on several occasions during the period on appeal. However, memory loss has never been documented in any clinical evidence of record, despite multiple tests of memory during his VA treatment sessions and his VA examination. The Veteran has at no time asserted an inability to remember his own name, his occupation, or the names of close relatives. The Veteran's GAF scores ranging from 54 to 60 do not indicate total impairment. As the Veteran has none of the symptoms suggestive of a 100 percent rating and there is no other evidence of total impairment, the Board finds that the Veteran does not have total social or occupational as a result of his PTSD symptoms. The Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). 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. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extraschedular consideration referral). The schedular evaluation for the Veteran's PTSD is not inadequate. The Veteran's reported symptoms are squarely within the anticipated symptoms of the General Ratings Formula for Psychiatric Disabilities. Although the Veteran endorses some of the symptoms for a rating in excess of 50 percent, such as impaired impulse control, the application of the ratings schedule is not thwarted. There is no reason that mere endorsement of symptoms associated with a higher rating invalidates the balancing test used by the Formula. The Veteran does not argue such and there is no other evidence to suggest that the schedular rating is defeated by the presence of these symptoms. The Veteran merely disagrees with the assigned evaluation for his level of impairment. In other words, he does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is moot. See Thun, supra. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." Fenderson v. West, 12 Vet. App. 119 (1999); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered the possibility of staged ratings. The Board, however, concludes that the criteria for a rating in excess of 50 percent have at no time been met. Accordingly, staged ratings are inapplicable. See id. As such, the Board finds that the preponderance of the evidence is against the Veteran's increased rating claim for an initial evaluation higher than 50 percent on a schedular basis, and on an extraschedular basis. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). II. Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claim for an initial evaluation in excess of 50 percent for PTSD. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). A. Duty to Notify When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Id. The initial rating appeal arises from a granted claim of service connection. Compliance with the first notice element requires notice of the five service connection elements in initial ratings cases: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See Dunlap v. Nicholson, 21 Vet. App. 112 (2006). Prior to initial adjudication of the Veteran's claim, an April 2011 letter fully satisfied the duty to notify provisions, including notice of the degree of disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). B. Duty to Assist The Board also concludes VA's duty to assist in obtaining records has been satisfied. The Veteran's service treatment records and VA medical records are in the file. The Veteran's VA treatment records indicate that a neurology consultation was scheduled for October 2011. However, no record of any such consult has been associated with the file. The Veteran has at no time referenced a VA neurology consultation and no reference appears in the Veteran's subsequent VA treatment records. Furthermore, a CAPRI check performed in June 2013 did not find a report of any such consultation. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. 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. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2013). The RO provided the Veteran an appropriate VA examination in March 2012. The Veteran has not reported receiving any recent treatment specifically for this condition (other than at VA, records of which are in the file), and there are no records suggesting an increase in disability has occurred as compared to the prior VA examination findings. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disorder since he was last examined. 38 C.F.R. § 3.327(a). The examination report provides sufficient evidence to apply the ratings schedule and to determine that the schedular rating is adequate to rate the disability. The Veteran's claims file was not available for the examiner to review. However, the examiner did review the Veteran's medical chart prior to the examination, and this review provided all the information necessary to accurately evaluate the Veteran. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination); see also VAOPGCPREC 11-95. The March 2012 VA examination report is thorough and supported by VA outpatient treatment records. The examination in this case is an adequate basis on which to adjudicate the claim. 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 Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). ORDER Entitlement to an initial evaluation in excess of 50 percent for PTSD is denied. REMAND The Veteran has reported that he is unable to work due to the severity of his PTSD symptoms, and that his PTSD symptoms led to workplace arguments and confrontations which caused him to leave his job as a risk manager. This evidence of occupational impairment may indicate, interpreted liberally, a claim for total disability based on individual unemployability (TDIU). See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). A request for TDIU, whether expressly raised by a Veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim, or, as part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Here, the Veteran was not provided notice of the regulations that govern TDIU in the Statement of the Case. Accordingly, the Veteran should be provided with appropriate notice as to how to substantiate a claim for TDIU and afforded a general medical examination to determine whether it is at least as likely as not (fifty percent or greater) that the Veteran's service connected disabilities alone, without reference to any non-service connected disabilities, prevents him from maintaining substantially gainful employment. Accordingly, this matter is REMANDED for the following action: 1. Provide to the Veteran all notification action required by VA's duty to notify with respect to TDIU. Any notice given, or action taken thereafter, must comply with current, controlling legal guidance. 2. After appropriate notice with respect to TDIU has been provided, schedule the Veteran for a VA examination to obtain an opinion as to the effect of the Veteran's service-connected disabilities on his ability to secure or follow a substantially gainful occupation. The Veteran is service-connected for PTSD and chronic allergic rhino sinusitis. The claims file must be made available to the examiner for a review of the Veteran's pertinent medical history. The examiner should be provided a full copy of this remand, and he or she must indicate that he or she has reviewed the claims file. The examiner should provide a rationale for all opinions. 3. Then, the RO/AMC should adjudicate TDIU on the merits. If the benefits sought are not granted, the Veteran and his representative should be furnished a SSOC and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran 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). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655 (2013). 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. 2013). ____________________________________________ M. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs