Citation Nr: 1337876 Decision Date: 11/19/13 Archive Date: 12/06/13 DOCKET NO. 09-28 470 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent for an acquired psychiatric disorder, diagnosed as posttraumatic stress disorder (PTSD). 2. Entitlement to individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Stephen Eckerman, Counsel INTRODUCTION The Veteran served on active duty from January 1966 to December 1968. He is currently an expatriate living in the State of Israel. This matter is on appeal from a January 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. The Veteran appealed, and in December 2012, the Board granted the claim, to the extent that it increased the Veteran's rating to 30 percent. The RO subsequently assigned an effective date for the 30 percent rating commensurate with the date of service connection, i.e., April 28, 2004. The appellant appealed to the U.S. Court of Appeals for Veterans Claims (Court). In June 2013, while his case was pending at the Court, the VA's Office of General Counsel and appellant's representative filed a Joint Motion requesting that the Court vacate the Board's December 2012 decision, to the extent that it denied an initial evaluation in excess of 30 percent. That same month, the Court issued an Order vacating the December 2012 Board decision. 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 Throughout the course of the appeal, the Veteran's service-connected PTSD has not been characterized by occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for an initial evaluation in excess of 30 percent for an acquired psychiatric disorder, diagnosed as PTSD, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Increased Initial Evaluation The Veteran asserts that he is entitled to an initial evaluation in excess of 30 percent for his PTSD. It has been argued that he has such symptoms as sleep impairment, avoidance of crowds and strangers, and situations he feels are outside of his control, with little tolerance to interference and very little flexibility at work, which warrant an increased initial evaluation. See appellant's brief, dated in November 2012. The Veteran argues that he has social impairment, and that he has "become a recluse," with "constant suspiciousness and anxiety which threaten my work efficiency." See Veteran's appeal (VA Form 9), received in August 2009. In January 2008, the RO granted service connection for PTSD, evaluated as 10 percent disabling, with an effective date for service connection of April 28, 2004. The Veteran appealed the issue of entitlement to an increased initial evaluation for PTSD. In July 2009, the RO denied the claim. The Veteran appealed, and in December 2012, the Board granted the claim, to the extent that it increased the Veteran's rating to 30 percent. The RO subsequently assigned an effective date for the 30 percent rating commensurate with the date of service connection, i.e., April 28, 2004. The appellant appealed to the Court. In June 2013, while his case was pending at the Court, the VA's Office of General Counsel and appellant's representative filed a Joint Motion requesting that the Court vacate the Board's December 2012 decision, to the extent that it denied an initial evaluation in excess of 30 percent. That same month, the Court issued an Order vacating the December 2012 Board decision. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). In cases where the Veteran's claim arises from a disagreement with the initial evaluation following the grant of service connection, the Board shall consider the entire period of claim to see if the evidence warrants the assignment of different ratings for different periods of time during these claims a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). In this case, the Veteran currently has a 30 percent disability rating for his service connected PTSD under the general rating criteria set forth in 38 C.F.R. § 4.130 (2013). The Board notes that service connection is currently in effect for disabilities that include ischemic/atherosclerotic heart disease, diabetes mellitus, and erectile dysfunction. When evaluating a mental disorder consideration will be given to the frequency, severity, and duration of symptoms, the length of remissions and capacity for adjustment during that time. The evaluation will be based on all the evidence of record and not solely an examiner's assessment of the level of disability. 38 C.F.R. § 4.126(a). While social impairment is considered, a rating will not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The RO has evaluated the Veteran's PTSD under 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Under DC 9411, a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactory, 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; or mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted where the disorder is manifested by 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. Id. With regard to the history of the disability in issue, see 38 C.F.R. § 4.1 (2013), the Veteran's service records show that his military occupation specialty was combat construction specialist, and that he served with an engineering unit in Vietnam for about 18 months. The Veteran was not treated for psychiatric symptoms, or diagnosed with a psychiatric disorder, during service. The earliest post-service medical evidence of psychiatric symptoms is dated in January 2005. See statement from R.D.H., Ph.D. The relevant medical evidence is summarized as follows: A statement from R.D.H., Ph. D., dated in January 2005, shows that Dr. H states the following: "The most serious and persistent negative effect on his Vietnam service and experiences is his total sexual impotency that exist[s] to the present." The Veteran is relatively isolated from other people in his community. The Veteran's adjustment on the kibbutz is marked by the interpersonal isolation that his impotency imposes, and a relatively secluded and socially isolated adjustment. He remains an efficient worker, and has a few acquaintances among other single, isolated male peers. He takes no part in most of the kibbutz social or political activities. Dr. H concluded that the Veteran has PTSD "manifested by persistent sexual impotency, social and personal alienation and inability to form any lasting relationships." A statement from Dr. H, dated in February 2006, summarizes the Veteran's inservice and post-service history, and notes that he currently has symptoms such as complete sexual impotence. Dr. H states that the Veteran's "main negative results" of his service are an inability to have a lasting connection with "any woman he sees as 'good.'" Dr. H further notes that the Veteran feels alienated to the American population, had a phobic reaction to his own birthday, and that he may have an underlying sense of failure, as well as "a sense of stress." A statement from J.S., M.D., dated in October 2006, shows that he states that he was the Veteran's primary care physician from 1986 to 1993, and that he has helped him deal with "medical issues" since that time. He notes that the Veteran came to the kibbutz despite not having an ideological, religious, or cultural connection to it. Dr. S states that the Veteran has a history of rejecting women, or pursuing "unattainable women," and that this was an example of destructive behavior. During a recent war with Lebanon, he had symptoms that included anxiety, sleep difficulties, and vivid flashbacks. Dr. S concluded that the Veteran has arrested emotional development and growth since his service, an inability to form loving and trusting relationships with women, and that he has PTSD triggered by the recent war with Lebanon. A statement from a friend of the Veteran's (S.D.B.), dated in October 2006, shows that she states that she is a social worker, and that she has known the Veteran for 39 years. She states that he continues to come to the United States every year or so to visit his family and friends," that he is a productive worker at the kibbutz," and that he "has a personal computer now that enables him to explore what's going on out there and to be in touch with his friends." In a statement, received in February 2007, a social worker (C.G.) noted that she first had contact with the Veteran following rocket attacks on the Galilee "during our recent war" (i.e., in 2006), and that he was exhibiting "the classic symptoms of PTSD," including sleep deprivation and acute anxiety. She recommended a mild tranquilizer, and sleeping pills. However, he refused medication, and insisted on remaining in his "base camp." She states that she conducted regular psychotherapy sessions with him through the end of the war, and that with the cease fire and the cessation of shelling, "he has appeared to have almost returned to his normal routine." A statement from S.B., M.D., a psychiatrist, dated in August 2007, notes that the Veteran was orderly and cooperative, and that he answered questions in a detailed manner with a certain degree of circumstantiality. He reported having anxiety following the Lebanon 2 war the previous summer, to include sensitivity to noise, and sleep difficulties, and apathy. He reported having outbursts of anger. The diagnosis was delayed-onset PTSD. Dr. B stated that he did not exhibit clear depressive characteristics or psychotic symptoms, and that he was not in need of medication. A VA-contracted examination report, by M.L., Ph.D., a psychologist, dated in August 2007, shows that he states that the Veteran experienced a "reawakening of traumatic symptoms" following Lebanese-based rocket attacks in Israel in July and August 2006. Such symptoms included looking for land mines when walking from his home to work, and referring to his home as his "base camp." The report notes the following: the Veteran does not have a history of hospitalization or outpatient care. He complained that he felt that he was in Vietnam most of the time. He was not functioning in his optimum capacity at work due to irritability and severe concentration problems. On examination, there was no impairment of thought process or communication apart from occasional loss of concentration. There were no delusions or hallucinations. There were no suicidal thoughts or serious homicidal thoughts. He was hygienic and clean. He was well-oriented to person, place, and time. There was no memory loss or impairment. With regard to obsessive or ritualistic behavior, he stated that he likes to do things "his way," and that he becomes upset when working outside of his usual routine. He reported getting very angry at changes to his workplace. He had a normal rate and flow of speech, and his speech was relevant. With regard to panic attacks, it was noted that he looked for mines on the side of the road of the kibbutz, and that he could feel highly anxious if things did not go as planned. He slept 3 hours or so at a time, and maybe half an hour during the day. He was impotent in the presence of women that he liked, and could only function sexually with "women of ill repute." He was uncomfortable driving, and won't go to study, because of language difficulties, and due to a dislike of going out. His primary stressors were crowded places, strangers, and situations that he felt were out of his control, as well as any interference at work. He had severe avoidance behavior leading to a limited lifestyle constructed to avoid stress, which has become more severe in the last year. Since the recent war, his concentration levels have become affected and he has been unable to work overtime. The diagnosis was delayed-onset PTSD, exacerbated by Lebanon 2 war in summer 2006. His Global Assessment of Functioning was "good but on a very limited basis." With regard to the effect on occupational and social functioning, it was noted, "Almost no occupational impairment but almost total social impairment due to PTSD signs and symptoms exacerbated by 2006 Lebanon 2 war." The report notes that the Veteran has "an almost total separation between work, where he functions well and his social life which is almost non-existent." A statement from the Veteran's manager, dated in May 2008, shows that he states that the Veteran has worked in the factory since the late 1970s, that he has held a variety of jobs, and that he has performed in an exemplary manner, but that since the Lebanese war, his work attitude and performance has deteriorated. Specifically, he did not work the extra hours that his job requires and he has frequent absences for "health reasons." (quotes in original). The Veteran's floor manager states that the Veteran's proficiency is greatly reduced and his lack of concentration, or forgetfulness, has made him prone to errors. He has also been belligerent towards fellow employees and isolated himself at work. A lay statement from two acquaintances of the Veteran, dated in May 2008, shows that they state that the Veteran has exhibited increased suspiciousness and nervousness since the Lebanon war in 2006. He has also shown increased possessiveness of "everyone in his personal circle," become more remote, isolated himself, and he avoids crowds. A report from A.C., a psychologist, dated in February 2009, appears to have mainly been written in support of the Veteran's claims for service connection for physical disorders, which are not currently in issue. In relevant part, the report shows that Dr. C states the following: the Veteran blamed his smoking and weight gain on "day to day pressure." He complained of being anti-social, and locking himself into his house. He felt stress at work, but remained when not feeling well out of fear of antagonizing management. A second VA-contracted examination report, dated in March 2010, shows that the examination was also performed by Dr. M.L. The report shows that the Veteran stated that he was "still looking for land mines" and experienced triggered stress responses to normal everyday situations. The report notes the following: there had been a greater degree of social withdrawal and lower toleration of changes in work climate. Moreover, the Veteran was still experiencing insomnia, which has caused fatigue at work and has limited his capacity to work regular hours. The Veteran was not taking medication for his symptoms. On examination, there was no impairment of thought process or communication apart from occasional loss of concentration which has deteriorated over the past 3 years. There were no delusions or hallucinations. There were no suicidal thoughts or serious homicidal thoughts. He was hygienic and clean. He was well-oriented to person, place, and time. There was no memory loss or impairment. He slept 3 hours or so at a time, and maybe half an hour during the day. He had not had a relationship with a woman in the past 3 years. He has reported impotence in the presence of women who he likes. He was uncomfortable driving, and won't go to study, because of language difficulties, and due to a dislike of going out. He had increased occupational and social impairment with decrease in work efficiency, and intermittent periods of inability to perform occupational tasks due to increased anxiety and chronic sleep impairment. His primary stressors were crowded places, strangers, and situations that he felt were out of his control, as well as any interference at work. Over the past three years, he has had an increasing intolerance for interference at work. He had severe avoidance behavior leading to a limited lifestyle constructed to avoid stress. He lives in a "dreamworld", described as "film, books, own imagination." The Axis I diagnosis was delayed-onset PTSD, brought on by Lebanon 2 war in summer 2006. His Global Assessment of Functioning was "good but on an increasingly limited basis." With regard to the effect on occupational and social functioning, it was noted, "Since 2009 increasing occupational impairment and almost total social impairment due to PTSD signs and symptoms exacerbated by 2006 Lebanon 2 war." The report notes that the Veteran has "an almost total separation between work, where he functions reasonably well and his social life which is almost non-existent." The report notes that he had a 3-year history of heart disease, and that he had reduced the physical nature of his job but still has to leave to rest to protect his health. A statement from Dr. E, dated in May 2010, shows that he states that he has been the Veteran's family doctor for the past 6 years, and that he is aware of the Veteran's PTSD. Dr. E states, in relevant part, that the Veteran continues to have an inability to sleep and wakes every two to three hours. Sleep medication has had no effect. He has an obsessive behavior to his work to the point where he refused to leave his job in 2009 following a heart attack because he feared repercussions from management. Dr. E had reduced his work day by two hours "for medical reasons." Dr. E states that the Veteran has excluded himself from all social functions or activities remaining in his housed without outside contact. He states that the Veteran has refused counseling. An "industrial doctor's examination report," from L.L., M.D., dated in August 2012, states that the Veteran is incapable of returning to the work force. See also reports from Zivka Riv Hospital, dated in 2009 (showing treatment for a myocardial infarction, to include a percutaneous transluminal coronary angioplasty). A statement from M.E.A., Ph.D., a psychologist, shows that he states the following: There is no evidence of a significant change in his behavior pattern since the detailed assessments previously conducted by [Drs. S.B., A.C., and J.S.]." During the current clinical interview, it became evident that the Veteran continues his physical, social, and occupational impairment which recently has resulted in his mandated retirement. The Industrial Board has ruled him unfit to work. Further, he expressed his experiencing periodic panic attacks which also have been debilitating. I quote as my conclusion from [Dr. S.B.'s] summary: "Delayed onset of PTSD. Increase in anxiety symptoms following the Lebanon 2 war in the summer of 2006 (decompensation) with outstanding traumatic symptoms of social withdrawal and hypervigilance." The Board finds that an initial evaluation in excess of 30 percent is not warranted. The Veteran's symptoms are not sufficiently severe to have resulted in occupational and social impairment with reduced reliability and productivity. The totality of the evidence shows that the Veteran's PTSD more closely resembles the criteria for not more than an initial 30 percent evaluation. As an initial matter, there are no relevant medical records whatsoever from the date of service connection, April 28, 2004, until January 2005. Specifically, the earliest medical evidence is Dr. H.'s January 2005 report shows that he states that the Veteran is relatively isolated from other people in his community, but that he "remains an efficient worker," and that "the most serious and persistent negative effect" is his total sexual impotency. The next medical evidence is dated over a year later, in February 2006. In this report, Dr. H. again stressed the Veteran's social impairment and physical symptoms, i.e., "complete sexual impotence" and that the "main negative results" are an inability to have a lasting connection with "any woman he sees as "good." In October 2006, Dr. J.S. first notes such PTSD symptoms as anxiety, sleep difficulties, and vivid flashbacks, apparently triggered in association with the war with Lebanon that summer. However, he also stressed the Veteran's inability to form lasting relationships with women. The report from a social worker, C.G, dated in February 2007, notes symptoms of sleep deprivation and acute anxiety. She stated that with the cease fire and the cessation of shelling, "he has appeared to have almost returned to his normal routine." In August 2007, Dr. S.B. stated that the Veteran did not exhibit clear depressive characteristics or psychotic symptoms, and that he was not in need of medication. In particular, two VA-contracted examination reports by Dr. M.L., dated in August 2007 and March 2010, contain essentially similar findings. The reports show that on examination, there was no impairment of thought process or communication apart from occasional loss of concentration, there were no delusions, hallucinations, suicidal thoughts, serious homicidal thoughts, memory loss or impairment, or defects of speech. The Veteran was well-oriented to person, place, and time. He slept 3 hours or so at a time, and maybe half an hour during the day. Overall, the Veteran does not have a history of hospitalization for psychiatric symptoms, and apart from medication for sleep symptoms, he does not appear to require medication for control of his symptoms. Of particular note, notwithstanding the Veteran's complaints, there is no evidence to show flattened affect, irregular speech, panic attacks, difficulty in understanding complex commands, impairment of short- and long-term memory, impaired judgment or abstract thinking. See Vazquez-Claudio v. Shinseki, 2012-7114 (Fed. Cir. Apr. 8, 2013) (38 C.F.R. § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas). In this regard, the Board has considered that in October 2006, a social worker stated that the Veteran experiences "acute anxiety and severe panic attacks." However, "severe panic attacks" have not been shown in the record. For example, when addressing panic attacks, the VA-contracted examiner stated in both August 2007 and March 2010 that this included looking for signs of land mines on the road and can feel "highly anxious" when things do not go as planned. Certainly, symptoms such as anxiety and hypervigilance, triggered by certain situations, such as looking for mines, are significant, but the Board does not find that these actions are more accurately characterized as "panic attacks" as contemplated by the rating criteria. The examination reports also note that, with regard to obsessive or ritualistic behavior, he stated that he likes to do things "his way," and that he becomes upset when working outside of his usual routine. However, these symptoms appear to primarily involve triggered anxiety, and the Board does not find that these actions are more accurately characterized as " obsessive or ritualistic behavior" as contemplated by the rating criteria. See 38 C.F.R. § 4.130. In addition, occupational and social impairment with reduced reliability and productivity is not shown. It appears that the Veteran worked full-time until 2012, at which time he retired due to physical symptoms. See August 2012 report from Dr. L.L. The August 2007 examination report notes that, with regard to the effect on occupational and social functioning, there is "Almost no occupational impairment but almost total social impairment due to PTSD signs and symptoms exacerbated by 2006 Lebanon 2 war." The report notes that the Veteran has "an almost total separation between work, where he functions well and his social life which is almost non-existent." The March 2010 report similarly notes that, with regard to the effect on occupational and social functioning, the Veteran has "an almost total separation between work, where he functions reasonably well and his social life which is almost non-existent." (emphasis added). The examiner concluded that the Veteran has increased occupational and social impairment with decrease in work efficiency, and intermittent periods of inability to perform occupational tasks. This closely approximates the criteria for a 30 percent rating under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. The foregoing evidence indicates that the Veteran's symptomatology is primarily manifested by social impairment, with relatively little occupational impairment. In such a case, under 38 C.F.R. § 4.126(b), 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. Here, there is some evidence of decreased concentration, and irritability. He also appears to have had some absences from the workplace. However, it is unclear how much this is due to the Veteran's January 2009 heart attack, rather than his psychiatric symptoms. To the extent that the Veteran's psychiatric symptoms have impacted his job performance, a disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Given the foregoing, the Board finds that the evidence is insufficient to show that the Veteran's symptomatology has resulted in occupational and social impairment to the required degree. As a final matter, the Board has considered the bases for the Joint Motion, and it has fully considered the May 2010 report from Dr. E. However, Dr. E's statement adds little to the clinical picture that was already of record. For example, Dr. E. notes that the Veteran has sleep impairment resulting in 2 to 3 hours of sleep per night. There are similar findings in the August 2007 examination report, in which the Veteran was noted to have sleep impairment resulting in about three hours of sleep per night. Dr. E. also notes the Veteran's inflexibility at work, and his isolating behavior. However, this was already detailed in the previously-dated evidence. The Board further points out that Dr. E.'s report, when considered with the other evidence of record, does not indicate an increase in symptomatology since the Veteran's last examination. See e.g., January 2013 statement from Dr. M.E.A. (stating that there has not been a significant change in the Veteran's behavior pattern since his previous examinations). Accordingly, this evidence is insufficiently probative to warrant an increased initial evaluation. In summary, there is insufficient evidence of symptoms commensurate with the next higher rating of occupational and social impairment with reduced reliability and productivity, which is exhibited by symptoms to include or associated with, but not limited to, the following: as flattened affect; irregular speech; difficulty in understanding complex commands; impairment of short- and long-term memory; and impaired abstract thinking; nor are the other psychiatric symptoms shown to have resulted in such impairment. The Board therefore finds that the Veteran's symptoms are not of such severity to approximate, or more nearly approximate, the criteria for an initial evaluation in excess of 30 percent under DC 9411. See 38 C.F.R. § 4.7. The Board has considered whether referral for an extraschedular evaluation is warranted. The question of an extraschedular rating is a component of a claim for an increased rating. Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The Court of Appeals for Veteran's Claims has clarified the analytical steps necessary to determine whether referral for such consideration is warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). First, VA must determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. In this case, the evidence does not indicate that Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria discussed above. Specifically, the Veteran's PTSD symptoms were applied to the applicable rating criteria, general counsel opinions, and case law. Although the diagnostic code in this case allows for a higher rating, the Board has fully explained why a higher rating is not warranted. Therefore, referral for consideration of extraschedular basis is not for application. II. Veterans Claims Assistance Act of 2000 As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Here, neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 556 U.S. 396 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Rather, the Veteran's claim arises from his disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. Next, VA has a duty to assist a veteran in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records, and private treatment records. The Veteran has also submitted statements from medical professionals, as well as other statements from friends and employers. To the extent it appears that an Industrial Board recently found the Veteran to be unemployable, this report has not been obtained. However, when read in context with the other medical records, it appears that this decision was based on physical symptoms. The Veteran has not asserted that this record is relevant to his claim. Therefore, no additional development is warranted. See e.g., Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) (finding that SSA records are not relevant when a SSA decision is on a completely unrelated medical condition and the Veteran makes no allegations that the records may otherwise be relevant to the claim for which the Veteran seeks VA benefits). Additionally, although the Veteran is does not currently reside in the United States, he was afforded VA-contracted examinations with respect to the issue on appeal in August 2007 and March 2010. 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide a VA examination or, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). While it does not appear that the psychologist who conducted the examinations reviewed the claims file, this does not render examinations inadequate per se. See VAOPGCPREC 20-95, 61 Fed. Reg. 10 ,064 (1996). Rather, the psychologist examiner reported the relevant clinical findings pertaining to the Veteran's PTSD, including psychiatric history and current findings. The Board also notes that that VA-contracted psychologist did not list Global Assessment of Functioning (GAF) scores, which reflect the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. While these scores are typically part of a VA examination, they are not indispensable to the adjudication of the claim. See Brambley v. Principi, 17 Vet. App. 20, 26 (2003). Based upon these facts, the Board finds the examinations were adequate. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Additionally, recognition is given to the fact that the most recent examination is now approximately two years old. However, the duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. Palczewski v. Nicholson, 21 Vet. App. 174 (2007); VAOPGCPREC 11- 95 (1995), 60 Fed. Reg. 43186 (1995). Here, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disability since this VA examination. In this regard, the January 2013 statement from Dr. M.E.A. specifically states that, "There is no evidence of a significant change in his behavior pattern" since his previous examinations. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER A rating in excess of 30 percent for an acquired psychiatric disorder, diagnosed as PTSD, is denied. REMAND With regard to the Veteran's claim for TDIU, in Rice v. Shinseki, 22 Vet. App. 447, 453 (2009) (per curiam) the Court stated that when the issue of entitlement to a TDIU rating for a particular service-connected disability or disabilities is raised in connection with a claim for an increased rating for such disability or disabilities, the Board has jurisdiction to consider that issue. The Court indicated that if the Board determines that further action by the RO is necessary with respect to the issue, the Board should remand that issue. Here, there is an assertion in a medical report that an Industrial Board has determined that the Veteran is unfit to work. See report from Dr. M.E.A., dated in January 2013. Service connection is currently in effect for disabilities that include diabetes mellitus, ischemic/atherosclerotic heart disease, and peripheral neuropathy of the lower extremities. A remand is therefore warranted in order that the Veteran be afforded VCAA notice, and so an opinion may be obtained that is based on a review of the entire claims file which fully discusses the impact of the Veteran's service-connected disabilities on his employability. See Friscia v. Brown, 7 Vet. App. 294, 297 (1994). Accordingly, the Board has no alternative but to defer further appellate consideration and this case is REMANDED to the RO via the Appeals Management Center in Washington DC for the following actions: 1. Send the Veteran a VCAA notice letter with respect to the issue of entitlement to TDIU and enclose the proper claims form and allow and appropriate time for response. 2. When the above is complete take any additional development deemed necessary, including the procurement of medical examinations and/or opinions. 3. The RO should then adjudicate the TIDU issue. If the determination remains unfavorable to the appellant, he should be provided with a supplemental statement of the case (SSOC) that addresses all relevant actions taken on the claim for benefits, to include a summary of the evidence and applicable law and regulations considered. The appellant should be given an opportunity to respond to the SSOC. 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 2002 & Supp. 2012). ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs