Citation Nr: 1338520 Decision Date: 11/22/13 Archive Date: 12/06/13 DOCKET NO. 07-37 081 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to an initial rating (or evaluation) in excess of 50 percent for posttraumatic stress disorder (PTSD) with depressive disorder, not otherwise specified (NOS). 2. Entitlement to service connection for hypertension, claimed as secondary to service-connected PTSD. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Patricia Kingery, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had active service from March 1968 to November 1970. This appeal comes to the Board of Veterans' Appeals (Board) from an October 2006 rating decision Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California, which, in part, granted service connection for PTSD and assigned an initial 50 percent disability rating. In a September 2007 Substantive Appeal (VA Form 9) for the claim for an initial rating in excess of 50 percent for PTSD with depressive disorder, NOS, the Veteran requested a Board hearing to be held at the local VA office (Travel Board hearing). In a December 2007 written statement, the Veteran requested a Board hearing to be held by live videoconference. In a February 2009 written statement, the Veteran, through his representative, withdrew the hearing request. The hearing request is withdrawn. 38 C.F.R. § 20.704 (2013). In reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also the file on the "Virtual VA" system to insure a total review of the evidence. The issues of TDIU and entitlement to service connection for hypertension are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's PTSD with depressive disorder, NOS, has been manifested, for the entire appeal period, by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: depression, agitation, intrusive thoughts, almost daily suicidal ideation, short term memory loss, sleep disturbance, hypervigilance, inability to concentrate, severe distractibility, mental confusion, mood lability, and panic attacks that occur weekly or less often. 2. The Veteran's PTSD with depressive disorder, NOS, has not more nearly approximated total occupational and social impairment due to acquired psychiatric disorder signs and symptoms for any period. CONCLUSION OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for an initial rating of 70 percent, but no higher, for PTSD with depressive disorder, NOS, have been met for the tire rating period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2013). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied with respect to the initial rating issue decided herein. The RO sent the Veteran a letter in April 2006 that informed him of the requirements needed to establish service connection for PTSD, including information regarding the assignment of ratings and effective dates. As this case concerns an initial rating and comes before the Board on appeal from the decision which also granted service connection, there can be no prejudice to the Veteran from any alleged failure to give adequate 38 U.S.C.A. § 5103(a) notice for the service connection claim. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice arises from receipt of a notice of disagreement). VA satisfied its duty to assist the Veteran in the development of the claim. First, VA satisfied its duty to seek, and assist in the procurement of, relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include service treatment records, VA treatment records, private treatment records, a copy of the Board's September 2009 remand, VA examination reports, articles submitted by the Veteran, and lay statements from the Veteran and others. Additionally, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Thus, the Board concludes that VA has made every reasonable effort to obtain all records relevant to the Veteran's claim. Second, VA satisfied its duty obtain a medical opinion when required. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran was provided with VA examinations (the reports of which have been associated with the claims file) in May 2006 and October 2011. The Board finds the VA examinations were thorough and adequate and provide a sound basis upon which to base a decision for the Veteran's claim for an initial rating in excess of 50 percent for PTSD with depressive disorder, NOS. The VA examiners personally interviewed and examined the Veteran, fully reviewed all medical evidence of record, and specifically addressed the symptoms listed in the relevant criteria in the potentially applicable diagnostic code. Neither the Veteran nor his representative has questioned the adequacy of these examinations with respect to the initial rating claim. The Veteran was offered the opportunity to testify at a hearing before the Board, but withdrew his hearing request in a written statement received February 2009. As VA satisfied its duties to notify and assist the Veteran, the Board finds that there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. § 5103(a), § 5103A, or 38 C.F.R. § 3.159. Initial Rating for PTSD with Depressive Disorder, NOS, in Excess of 50 Percent Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4 (2013). Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1 (2013). Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2013). Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Where, as here, the question for consideration is the propriety of the initial evaluations assigned, evaluation of the evidence since the grant of service connection and consideration of the appropriateness of staged ratings is required whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran is in receipt of a 50 percent disability rating for PTSD with depressive disorder, NOS, under Diagnostic Code (DC) 9411. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped, speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. A 70 percent disability rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent disability rating is assigned total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the veteran's own occupation or name. Id. In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (hereinafter DSM- IV). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. Id. Within the DSM-IV, one factor for consideration is the Global Assessment Functioning (GAF) score, which is a scale ranging from 1 to 100 and reflecting "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). However, while the rating schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). DSM-IV at 46-47. GAF scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. Id. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Id. Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). Id. GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which is at times illogical, obscure, or irrelevant) or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood (e.g., a depressed patient who avoids friends, neglects family, and is unable to do work). Id. In an October 2006 Notice of Disagreement, the Veteran asserted that his service-connected PTSD with depressive disorder, NOS, warrants a higher rating. After a review of all the evidence, lay and medical, the Board finds that, for the entire appeal period, the Veteran's PTSD with depressive disorder, NOS, has been characterized by occupational and social impairment, with deficiencies in most areas consistent with the criteria for a 70 percent disability rating, but no higher, under Diagnostic Code 9411. 38 C.F.R. § 4.130. The Veteran's PTSD with depressive disorder, NOS, has been manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood due to such symptoms as: depression, agitation, intrusive thoughts, almost daily suicidal ideation, short term memory loss, sleep disturbance, hypervigilance, inability to concentrate, severe distractibility, mental confusion, mood lability, and panic attacks that occur weekly or less often. At a February 2006 private counseling intake/assessment, the Veteran reported depression, agitation, extremely explosive anger, almost daily intrusive thoughts of suicide with no plan, short term memory loss, daily intrusive flashbacks of Vietnam, insomnia and night sweats, and hypervigilance. The private social worker noted that the Veteran was not currently homicidal, suicidal or a behavioral risk. The private social worker opined that the Veteran's symptoms adversely affect all contacts and virtually precludes his ability to establish or maintain trust and intimacy with others to the extent that the Veteran is virtually isolated in the community. The private social worker found that the Veteran's anxiety, suspiciousness, strong resentment of authority figures, and mood lability impair almost all of his daily activities. The private social worker also noted that the Veteran's inability to concentrate and focus on tasks at hand was severely compromised by his distractibility and mental confusion. The Veteran was assigned a GAF score of 38. In May 2006 the Veteran underwent a VA PTSD examination. The Veteran reported his mood as a little depressed and somewhat anxious; that he has restless sleep, averaging four to six hours a night; and, that he has had suicidal thoughts for years in passing. The Veteran reported periodically getting angry enough to have assaultive thoughts, but that he is always able to control that. The Veteran reported intrusive thoughts at least every two weeks and nightmares at least once every month or two. The Veteran reported he is very uncomfortable around crowds and generally tends to isolate. The Veteran reported retiring from his job because the job had become much more stressful and he was afraid that, if he did not retire, he would end up getting into trouble of some kind. The VA examiner noted the Veteran has a long history of sleep problems, issues with irritability though pretty well controlled anger, some difficulty in concentration, and hypervigilance. The VA examiner noted that, since the Veteran had these symptoms for years, his PTSD has caused a clinically significant impairment in the Veteran's ability to function in normal life. The VA examiner noted that the Veteran was not seen as dangerous to self or to others. The VA examiner opined that the Veteran's current moderate range of symptoms had caused impairment in his work and relationships over the years. The Veteran was assigned a GAF score of 55. In an October 2006 private treatment record, the private social worker noted that the Veteran had PTSD symptoms including depression, anxiety, sleep disturbance with nightmares, flashbacks of wartime events, avoidance of people, several inability to trust, daily suicidal thoughts with no plan. The Veteran reported an inability to show any intimacy towards his spouse or children. The private social worker opined that the Veteran's symptoms adversely affect most contacts and have virtually precluded his ability to establish or maintain trust and intimacy with others to the extent that he is isolated from the community. The private social worker noted that the Veteran has a long history of difficulty maintaining stability and relationships and that the Veteran's severe distractibility, brooding, and preoccupation with PTSD issues, coupled with severe mood lability severely impair all of the Veteran's daily activities. The Veteran was assigned a GAF score of 38. In a September 2007 private treatment record, the private social worker noted the Veteran's PTSD symptoms had significantly increased over the prior six months. The Veteran reported continuing to withdraw from his spouse and "just everyone," but did report participating actively as a member of a veteran's support group. The Veteran continued to report difficulties in establishing and maintaining meaningful relationships. The Veteran was assigned a GAF score of 42. An April 2009 VA treatment record notes that the Veteran reported an increase in his PTSD related symptoms of anxiety and depression. In a June 2009 statement, the Veteran reported daily mood swings and depression. In February and September 2010 and August 2011, as reflected on VA treatment records, the Veteran was assigned GAF scores of 65. In October 2011 private treatment record, the private social worker notes that the Veteran been treated since February 2006 and that she has observed a number of extreme increases in his PTSD symptomatology including severe increase in nightmares, flashbacks, sleep disturbance, self-isolation, and almost daily suicidal ideation with no plan, with the Veteran experiencing significant emotional deterioration over the prior 12 months. The private social worker noted that the Veteran's ability concentrate and focus is severely compromised, more so than when the social worker first started seeing him. The Veteran reported that he has felt like he is walking around in a "fog" for the past 12 to 15 months. The private social worker opined that, if the Veteran were not in therapy and without his spouse's support, he would more likely than not be in a long term locked psychiatric facility. The Veteran was assigned a GAF score of 34. At an October 2011 VA PTSD examination, the Veteran reported serious symptoms of PTSD including frequent recollections of events, images and distressing dreams; occasional suicidal ideation and depressed mood. The VA examiner noted that the Veteran has a long-term marriage and participates in two veteran volunteer groups. The Veteran reported that he did some contract work for about one and one half years after retirement, but that the work was too stressful causing him to quit. The VA examiner noted that the Veteran had difficulty falling or staying asleep; irritability or outbursts of anger; and hypervigilance. The VA examiner noted that the Veteran displayed the following symptoms: depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; mild memory loss, such as forgetting names, directions or recent events; difficulty in establishing and maintaining effective work and social relationships; and, suicidal ideation. The Veteran was assigned a GAF score of 45. Based on the foregoing, the Board finds that, for the entire rating period, the Veteran's PTSD with depressive disorder, NOS, has been characterized by symptoms of depression, agitation, intrusive thoughts, almost daily suicidal ideation, short term memory loss, sleep disturbance, hypervigilance, inability to concentrate, severe distractibility, mental confusion, mood lability, and panic attacks that occur weekly or less often, many symptoms of which are associated with the 70 percent rating. The Board finds that throughout the rating period the Veteran's PTSD with depressive disorder, NOS, results in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, which more nearly approximates the criteria for a 70 percent disability rating under DC 9411. 38 C.F.R. §§ 4.3, 4.7. As noted above, the symptoms recited in the criteria in the rating schedule for evaluating mental disorders 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, supra. Thus, a finding that there is occupational and social impairment with deficiencies in most areas is sufficient to warrant a 70 percent disability rating for the entire period on appeal even though all the specific symptoms listed for a 70 percent rating are not manifested. The Board also finds the weight of the lay and medical evidence demonstrates that the criteria for a disability rating of 100 percent have not been met or more nearly approximated for any part of the rating period on appeal. The evidence does not show that the Veteran experiences total occupational and social impairment or displayed symptoms of 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; or memory loss for names of close relatives, own occupation, or own name. In the October 2011 private treatment record, the private social worker noted that the veteran had significant impairment of almost all of his daily activities, but did not note total impairment. VA treatment records dated from April 2009 through May 2011 note that the Veteran denied suicidal or homicidal ideation, intent, or plans. The VA treatment records note the veteran was oriented to time, place, person, and situation. The May 2006 VA examination report notes that the Veteran was appropriately groomed; had logical speech; was oriented to time, place, person, and situation; and, had fair to good insight. At the May 2006 VA examination, the Veteran denied hallucinations or delusions. At the October 2006 VA examination, the VA examiner noted that the Veteran has a long-term marriage and participates in two veteran volunteer groups. The October 2011 VA examination shows that there was mild memory loss but did not show symptoms of 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; or memory loss for names of close relatives, own occupation, or own name. While the Veteran reported had some problems with one of his sons, he indicated that he got along with another son and that he was also involved with two groups that assist veterans. He also indicated that his 15 year old grandson lived with him and that they got along well. In the February 2006 private treatment record, the Veteran was assigned a GAF score of 38. At the May 2006 VA PTSD examination, the Veteran was assigned a GAF score of 55. In the October 2006 private treatment record, the Veteran was assigned a GAF score of 38. In the September 2007 private treatment record, the Veteran was assigned a GAF of 42. In February and September 2010 and August 2011 VA treatment records, the Veteran was assigned GAF scores of 65. In the October 2011 private treatment record, the Veteran was assigned a GAF score of 34. At the October 2011 VA examination, the Veteran was assigned a GAF score of 45. The Board finds that the Veteran's GAF scores, when read together, reflect occupational and social impairment with deficiencies in most areas and do not reflect that the Veteran experiences total occupational and social impairment. While the Veteran was assigned GAF scores in the 30s, as reflected in the February and October 2006 and October 2011 private treatment records, the Board finds that these scores are not supported by the contemporaneous findings, and are highly inconsistent with the Veteran's psychological presentation during the course of this appeal. While GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which is at times illogical, obscure, or irrelevant) or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood (e.g., a depressed patient who avoids friends, neglects family, and is unable to do work, see DSM-IV at 46-47, such general characterization of overall impairment due to psychiatric disorders suggested by the assignment of GAF scores in the 30s is inconsistent with the more specific and detailed social and occupational impairment and symptoms the Veteran has actually experienced during the course of the appeal, as reflected in both lay reports and clinical findings of symptoms and degree of occupational and social impairment. For these reasons, the Board finds that the Veteran's disability picture more nearly approximates the criteria for a 70 percent evaluation, as a reflection of both the Veteran's symptoms and the social and occupational impairment. See 38 C.F.R. §§ 4.3, 4.7. Extraschedular Considerations The Board has considered whether an extraschedular evaluation would have been warranted for PTSD with depressive disorder, NOS. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). 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. Therefore, 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. Thun v. Peake, 22 Vet. App. 111 (2008). 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, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine 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"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD with depressive disorder, NOS, are specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DC 9411, specifically provide for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD with depressive disorder has been manifested by depression, agitation, intrusive thoughts, almost daily suicidal ideation, short term memory loss, sleep disturbance, hypervigilance, inability to concentrate, severe distractibility, mental confusion, mood lability, and panic attacks that occur weekly or less often. These symptoms are part of the schedular rating criteria. The level of occupational and social impairment is explicitly part of the schedular rating criteria. The GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Moreover, all the Veteran's psychiatric symptomatology is contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan at 443. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] 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." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with the acquired psychiatric disorders, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial disability rating of 70 percent, but no higher, for PTSD with depressive disorder, NOS, is granted. REMAND The veteran contends that his current hypertension is secondary to his service-connected PTSD. As a result of the September 2011 Board remand, the Veteran was afforded a VA hypertension examination in October 2011. An August 2012 addendum opinion was also obtained. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the October 2011 VA hypertension examination opinion and August 2012 VA addendum opinion obtained in this case were not adequate. In the October 2011 VA examination opinion, the VA examiner did not opine as to whether the Veteran's hypertension was secondary to his service-connected PTSD. The VA examiner did opine that the Veteran's nonservice-connected hypertension was aggravated by the service-connected PTSD based on the rational that, with flare-ups of PTSD, caused by the news, television, and talk of war, the Veteran will have a 10 to 20 point elevation predominantly in the systolic blood pressure. However, in the August 2012 addendum opinion, the same VA examiner found that the Veteran's mild hypertension was not secondary to, aggravated beyond normal progression, or permanently worsened by the service-connected PTSD because the Veteran's blood pressure has been well controlled on a very low dose of an ACE inhibitor. The VA examiner did not provide a rationale for changing her opinion as to whether the Veteran's nonservice-connected hypertension was aggravated by the service-connected PTSD. Based on the inconsistencies in the VA examiner's opinions, the Board finds that the Veteran should be scheduled for a new VA examination by a different examiner that can render the appropriate medical opinions regarding any nexus of the claimed disability to service or service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In a September 23, 2013 rating decision, the RO denied TDIU. In a September 27, 2013 written brief presentation, the Veteran's representative stated "we insist the Board grant . . . total disability based on individual unemployability benefits." Any written communication from a claimant or his or her representative expressing dissatisfaction or disagreement with an adjudicative determination by the agency of original jurisdiction and a desire to contest the result will constitute a notice of disagreement. 38 C.F.R. § 20.201. Generally a notice of disagreement must be filed with the VA office from which the claimant received notice of the determination being appealed unless notice has been received that the applicable VA records have been transferred to another VA office. In that case, the notice of disagreement must be filed with the VA office which has jurisdiction over the applicable records. 38 C.F.R. § 20.300. While the September 2013 written brief presentation was filed with the Board and not the RO, the Board finds that the applicable records had been transferred to and the Board had jurisdiction over the Veteran's claims file; thus, the filing of the notice of disagreement with the Board was proper under 38 C.F.R. § 20.300. As such, the Board finds that this was a timely filed notice of disagreement. Where a statement of the case has not been provided following the timely filing of a notice of disagreement, a remand, not a referral to the RO, is required by the Board. Manlincon v. West, 12 Vet. App. 238 (1999). Consequently, the Board must remand the issue of a TDIU for further procedural action. Accordingly, the issue of TDIU and service connection for hypertension is REMANDED for the following action: 1. The AOJ should issue a statement of the case that addresses the issue of entitlement to a TDIU. The Veteran should be informed that, in order to perfect an appeal of this issue to the Board, he must file a timely and adequate Substantive Appeal following the issuance of the statement of the case. 2. Schedule the Veteran for the appropriate VA examination(s) regarding the claimed hypertension with a different examiner(s) then the one who conducted the October 2011 VA examination. The examiner(s) should be a physician. The examiner(s) must be provided with the Veteran's claims file for review, and any indicated studies should be completed. Following examination of the Veteran and review of the claims file, the examiner(s) should provide an opinion as to whether it is at least as likely as not that the Veteran's diagnosed hypertension is proximately due to, or aggravated by, service-connected PTSD or is otherwise related to service. The rationale for any opinion expressed should be set forth. 3. Thereafter, the remaining issues on appeal should be readjudicated. If the benefits sought on appeal are not granted, the Veteran and his representative should be provided with a supplemental statement of the case (SSOC) and afforded the appropriate time period within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the 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. 2013). ______________________________________________ K.J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs