Citation Nr: 1341447 Decision Date: 12/16/13 Archive Date: 12/31/13 DOCKET NO. 09-06 166 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD), for the period prior to April 20, 2012, and a disability rating in excess of 50 percent, for the period from April 20, 2012. 2. Entitlement to a disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from February 1970 to December 1971. This matter comes before the Board on appeal from a September 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, in which the RO granted service connection for PTSD and assigned a 30 percent disability rating. During the course of this appeal, the Veteran's disability rating for his service-connected PTSD was increased from 30 percent to 50 percent, effective April 20, 2012. Thus, this issue has been reflected as a staged rating and is so stated on the title page. In a September 2012 decision, the Board denied staged ratings in excess of 30 percent and 50 percent for PTSD and denied a claim for service connection for fibromyalgia. The Board also remanded for further development both a claim for service connection for a gastrointestinal disorder, to include as secondary to PTSD, and a claim for an initial disability rating in excess of 10 percent for coronary artery disease. The Veteran appealed the September 2012 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2013 Joint Motion for Partial Remand (Joint Motion), both the appellant and the VA Secretary (hereinafter "the parties") requested that the Court vacate and remand the Board's denial of higher ratings for his service-connected PTSD. The Joint Motion also indicated that the Veteran would withdraw his appeal of the Board's denial of his request for service connection for fibromyalgia and that he did not wish to disturb the Board's remand of both his service connection claim for a gastrointestinal disorder and his claim for an initial disability rating in excess of 10 percent for coronary artery disease. The Court issued an Order granting the Joint Motion later in March 2013. A TDIU claim is part of an increased disability rating claim when that claim is raised by the record. When evidence of unemployability is submitted at the same time that the Veteran is appealing the rating assigned for a disability, the claim for a TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran's attorney, in his September 2013 brief, contends that the record "hints" that a TDIU may be appropriate because the Veteran needed to retire due to his PTSD symptoms, and requested a remand to further develop a TDIU claim. Thus, the issue of entitlement to a TDIU is before the Board. The following determination is based on review of the Veteran's claims file and his electronic Virtual VA file. The issue of a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his PTSD is manifested by occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for an initial disability rating of 70 percent, but not higher, for PTSD, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 3.159, 4.1-4.14, 4.125-4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION VCAA VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 3.326(a) (2012). Proper notice from VA must inform the claimant, 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) (West 2002); 38 C.F.R. § 3.159(b) (2012); 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). The notice requirements apply to all five elements of a service connection claim, to include 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. 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. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Neither the Veteran nor his representative has alleged prejudice with respect to notice. Shinseki v. Sanders, 129 S. Ct. 1696 (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. The Veteran was notified via correspondence dated in October 2005, December 2005, and February 2008 of the criteria for establishing service connection for PTSD, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates in the February 2008 correspondence. After the correspondence dated in February 2008 was issued, the Veteran was granted service connection for PTSD and assigned an initial disability rating and effective date in the rating decision now on appeal. As this claim was more than substantiated in that it was proven, the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91. In addition, since the original higher initial rating claim for PTSD was a "downstream" issue from that of service connection, notice pursuant to the original Court decision in Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), was never required for this issue. See VAOPGCPREC 8-2003 (Dec. 22, 2003). VA also has a duty to assist a veteran in the development of a claim. In this appeal, the Board finds that the duty to assist has been fulfilled as VA and private treatment records relevant to this claim have been requested or obtained and the Veteran has been provided with a second separate VA mental examination of his higher rating claim for PTSD after service connection was granted in the rating decision now on appeal. The Board finds that the available medical evidence is sufficient for an adequate determination of this claim. There has been substantial compliance with all pertinent VA laws and regulations and to adjudicate this claim would not cause any prejudice to the Veteran. Increased Ratings - Laws and Regulations Disability ratings are determined by the application of VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The Court has held that a claim for a higher rating when placed in appellate status by disagreement with the original or initial rating award (service connection having been allowed, but not yet ultimately resolved), remains an "original claim" and is not a new claim for an increased rating. See Fenderson v. West, 12 Vet. App. 119 (1999). In such cases, separate compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the pendency of the appeal, a practice known as "staged" ratings. Id. at 126. It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2012). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204 (1994). Rating of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses are prohibited. 38 C.F.R. § 4.14 (2012). As a general matter, lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness. See Falzone v. Brown, 8 Vet. App. 398, 405 (1995). As a layperson the Veteran is only competent to report observable symptoms, but not the clinical findings which are applied to VA's Rating Schedule. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Bruce v. West, 11 Vet. App. 405, 410-11 (1998). When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating shall be assigned. 38 C.F.R. § 4.7 (2012). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2012). Service connection for PTSD was granted in the September 2009 rating decision now on appeal. An initial disability rating of 30 percent was assigned, later made effective August 24, 2005, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Under Diagnostic Code 9411 and the General Rating Formula for Mental Disorders, a 30 percent rating requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (such as 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. A 70 percent rating requires 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 work like setting); and inability to establish and maintain effective relationships. A 100 percent rating requires 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, own occupation, or own name. The symptoms recited in the criteria in the rating schedule for rating 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. In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When rating a mental disorder, the rating must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2012). Further, when rating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). Reports of psychiatric examination and treatment frequently include a Global Assessment of Functioning (GAF) score. The GAF scale includes scores ranging between zero and 100 which represent the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV). The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. Richard v. Brown, 9 Vet. App. 266 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder, which provide the primary basis for the rating assigned. 38 C.F.R. § 4.126(a) (2012). A GAF score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates 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). A GAF score of 61 to 70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Factual Background and Analysis The Veteran seeks higher ratings for his service-connected PTSD. Historically, in the appealed September 2009 rating decision, the RO granted service connection for PTSD and assigned a 30 percent rating, later made effective August 24, 2005, the date his original claim of entitlement to service connection for PTSD was received. In a September 2009 Notice of Disagreement the Veteran's attorney disagreed with the initial 30 percent rating and contended the Veteran was entitled to a higher rating. In a June 2012 rating decision, the RO increased the Veteran's rating for his service-connected PTSD to 50 percent, effective as of April 20, 2012, the date of his last VA mental examination. As noted above in the Introduction, the Board denied the Veteran's appeal for higher staged ratings for his PTSD. On appeal to the Court, the parties in their Joint Motion contended that the Board did not provide an adequate statement of reasons or bases in its September 2012 decision. The parties noted that suicidal ideation is one of the criteria for a 70 percent disability rating and at least three pieces of medical evidence provided evidence of the Veteran's suicidal ideation (see an August 2005 VA intake record, a June 2007 VA treatment record, and a February 2012 VA medical record). On remand, the Board has again reviewed the entire record and finds that a 70 percent disability rating is appropriate for the entire period of the appeal. In August 2005, the Veteran was seen at the Richmond, Virginia, VA Medical Center (VAMC) for a PTSD intake consultation with complaints of poor sleep, tearfulness, and feeling uncomfortable in crowds. He reported, however, that he had actually experienced symptoms of PTSD since returning from service in Vietnam. He said that he was employed with the North Carolina Department of Corrections (where he had been referred by a physician for enrollment in the PTSD program). On mental status evaluation, he appeared appropriately groomed, restless, and cooperative with a depressed and anxious mood. Suicidal and homicidal ideations without plan or intent were noted. The Axis I diagnosis was PTSD and a GAF score of 70 was assigned. VA treatment records dated in January 2006, February 2006, and March 2006 show treatment in PTSD group therapy. The report of a February 2006 private social worker is associated with the claims file. The licensed social worker stated that she had seen the Veteran for the past 12 months. The Veteran reported that he was on his third marriage and strongly believed that PTSD symptoms, such as difficulty trusting others, anger, and mood swings were major contributing factors to the dissolution of his previous marriages. Although the Veteran complained of trouble sleeping, the clinician attributed this to a work-related post-service event. He also reported anger and rage, avoidance of crowds, fear of venturing out at night, avoidance of intimacy, and increased arousal (especially due to low-flying planes or unrecognized sounds at night). His anger was now stirred by incompetence that endangered others. The Veteran admitted that he gave up taking risks and laughing a long time ago. He also told the social worker that nobody at work really knew him. He said that his comrades saw him as a tough fearless guy who can and will do anything he is asked to do when, in fact, there are many times when he is "shaking in his boots." The Veteran also related that his wife always made his meal choices because his unit was under attack while standing in the chow lines. He also dreaded retirement and had turned down an "early out" because retirement posed too much time on his hands without work to distract him from Vietnam flashbacks. The Axis I diagnosis was PTSD and a GAF score of 45 was assigned. The clinician said the low score was warranted based on the fact that the Veteran readily admitted that although he appeared to be a very high-functioning person on a daily basis, much of the time he lived in fear of others learning that he was not as tough as he appeared. A June 2007 VA treatment record noted that the Veteran had thought about suicide "off and on over the years." Depression remained a problem and the Veteran told the examiner he felt he had not been happy in years. It was also noted that the Veteran had been on various medications and went to PTSD group therapy for awhile, but he reported that nothing had ever made much difference. He also complained of sleep disturbance. Another June 2007 VA medical record noted diagnoses of PTSD and depression not otherwise specified with an assigned GAF score of 48. Treatment at the VA PTSD clinic was noted. The Veteran reported sleeping problems and crowd avoidance. On mental status examination, the Veteran was tearful and depressed and reported flashbacks and nightmares. According to an October 2007 VA medical record, the Veteran was seen for medication management and individual therapy and conceded he continued to have fits of rage. He also told the examiner that he heard voices, perhaps the people who were hollering at the time of medevac missions. On mental status examination, his mood was anxious and depressed and he reported nightmares and flashbacks. According to a November 2007 VA medical record, the Veteran was seen for medication management and individual therapy. He reported being irritable and mean and said that he did not want other people to get to close to him. On mental status examination, his mood was euthymic, he reported some nightmares and flashbacks, and he denied suicidal or homicidal ideation. The Veteran underwent a VA examination in March 2008. The Vietnam Veteran reported that he had been married to his current third wife for 10 years and was pleased with the relationship. He said he now had a relationship with two of his adult children, as well as a very good friend and a couple of other friends. He reported being steadily employed at the North Carolina Department of Corrections for the past 28 years, and his leisure activities included working in the yard, going out to dinner, and helping his friend by performing "odds and ends" at his home. Although he reported that the frequency and severity of his depressive symptoms ranged from mild to moderate, he said he felt that the medication and therapy was helping. He reported that he saw a private social worker once or twice a month in 2005 and 2006 before treatment at VA, where he took antidepressants and undertook individual psychotherapy and group therapy. On mental status evaluation, he was clean, neatly groomed, appropriately dressed, cooperative and attentive, and fully oriented. Speech, thought process, and content were unremarkable, although his mood was depressed and affect was constricted. There was no evidence of hallucinations or delusions, and insight and judgment were intact. The Veteran reported that he experienced chronic sleep difficulties, which had been present ever since returning home from military service. He also said he had almost nightly dreams about events related to service, as well as occasional panic attacks triggered by hospital sights and smells. He also reported rage, short-temperedness, and suicidal thoughts. Although the examiner found his memory to be normal, the Veteran reported suppressing his memories of service in Vietnam to such a degree that he had wiped out memories of his late teens and service in Vietnam. The Axis I diagnosis was depressive disorder not otherwise specified (NOS) and a GAF score of 70 was assigned. The VA examiner, a licensed clinical psychologist, found that the Veteran's symptomatology met the criteria for occupational and social impairment due to mild or transient symptoms, or the criteria for a 10 percent disability rating. According to a January 2009 VA medical record, the Veteran reported that his depression was still bothersome. Because the prescribed medication for his sleeping problems was not helping, he had stopped taking it. According to an October 2009 VA medical record, the Veteran reported that his sleep remained poor and he occasionally felt on edge. However, he said he was doing well in controlling his stress. According to a May 2011 VA medical record, the Veteran declined medication or participation in group therapy for his PTSD. He was advised to continue Clonazepam for sleep. According to a February 2012 VA treatment record the Veteran continued to think occasionally about suicide. It was noted that he had been on multiple medications and been in group therapy, but everything made him feel worse instead of better. The Veteran told the examiner that he planned to retire later in the year as he just "had enough." He complained of decreasing energy and memory. In April 2012, the Veteran underwent a VA mental examination. He reported chronic mood disturbance (depression, anxiety), chronic sleep impairment, hypervigilance, irritability, was easily angered, social withdrawal, short-term memory difficulties, weekly crying spells, recurrent distressing memories and dreams, occasional flashbacks, and passive suicidal ideation without plan or intent. He said he had been in his current marriage for 14 years and described it as good. He added that, for the past three years, he and his wife had full custody of his wife's 5-year-old granddaughter, a relationship he said he enjoyed, as he referred to the child as his "daughter." His wife had suggested he put away his loaded firearms and put them in a secure place once they obtained full custody of their granddaughter. Regarding leisure activities, he reported that he had few friends, as some of his veteran buddies were now deceased, but said he enjoyed working in the yard and taking care of his granddaughter. It was noted that the Veteran took a psychotropic medication, but no longer participated in mental health care. The Veteran told the VA examiner that he still worked for the state corrections department, where he had been employed for 32 years, but added that he had recently started working only three days per week due to increased irritability and stress. Although he denied any physical aggression on the job, he admitted to having some verbal altercations. He told the examiner that he did not work inside as a guard, but worked mainly alone and travelled. He managed supplies and vehicles. On mental status evaluation, the Veteran was noted as alert and cooperative and demonstrated good grooming and hygiene. PTSD symptoms were noted to include the following: depressed mood, anxiety, panic attacks occurring weekly or less often, chronic sleep impairment, disturbances of motivation and mood, and suicidal ideation. When he spoke about sensitive issues, such as PTSD symptoms and depression, it was noted that the Veteran became tearful. A score on one test reflected mild cognitive difficulties consistent with a PTSD diagnosis and concentration and short-term memory difficulties. The Axis I diagnosis was PTSD and a GAF score of 60 was assigned. The VA examiner noted that his occupational and social impairment reflected occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, or the criteria for a 30 percent disability rating. Resolving all reasonable doubt in favor of the Veteran, for the period of this appeal, the Board finds that the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas warranting a 70 percent disability rating. Based on the observations made in both VA examinations of record and in the other medical evidence of record, and bearing in mind the objections of the parties manifested in their recent Joint Motion before the Court, the Board finds that the lay and medical evidence is in relative equipoise as to whether the Veteran's PTSD symptoms meet the criteria for the 70 percent rating during the appeal period. Evidence from the two VA mental disorders examinations of record in 2008 and 2012 show the Veteran manifested chronic PTSD with such symptoms as sleep difficulties, depression, nightmares, panic attacks, and impaired concentration. In addition, the March 2008 VA examination noted suicidal thoughts, rage, and a short temper. The April 2012 VA examination noted suicidal ideation, irritability, social withdrawal, weekly crying spells, recurrent distressing memories, occasional flashbacks, and hypervigilance. The April 2012 VA examiner also noted that the Veteran had cut back his working hours to three days a week due to increased irritability and stress and that the Veteran had been involved in verbal altercations at work. The March 2008 VA examiner estimated the Veteran's level of occupational and social impairment as meeting the criteria for only a 30 percent disability rating, while the April 2012 VA examiner estimated the level of occupational and social impairment as meeting the criteria for a 50 percent disability rating. During the period of this appeal, the Board believes the Veteran's PTSD symptoms are more analogous to the criteria found in the Rating Schedule for occupational and social impairment with deficiencies in most areas (70 percent) rather than for occupational and social impairment with reduced reliability and productivity (50 percent) or occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (30 percent). Although the Veteran continued work in the state prison system during the period of this appeal, he preferred working alone, did not always get along with co-workers, had fits of rage and irritability, and eventually limited employment to three days a week. While the VA examiners disagreed on the severity of the Veteran's symptomatology, their findings in any event lend support to the view that the Veteran's symptomatology for his PTSD reflects such rating factors as suicidal ideation, impaired impulse control, near continuous depression, some memory and concentration impairment, and difficulty in adapting to stressful circumstances at work. Moreover, GAF scores assigned to the Veteran during the appeal period ranged from 45 to 70, which represent symptomatology ranging from mild to moderate to serious symptoms. As noted above, while GAF scores are not dispositive, in 2006 the Veteran was assigned a score of 45 by his private social worker and in 2007 was assigned a score of 48 by a VA nurse practitioner. These were the lowest assigned scores, indicating serious symptoms. The Board notes that these scores were assigned during the initial rating period on appeal, before April 20, 2012, when the Veteran had only been assigned a 30 percent disability rating. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, reasonable doubt will be resolved in favor of the claimant. By reasonable doubt is meant one that exists because of an approximate balance of positive and negative evidence which satisfactorily proves or disproves the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 C.F.R. § 3.102 (2012); 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board finds that the evidence in this appeal is, at the very least, in equipoise as to the question of whether the Veteran is entitled to a 70 percent rating for the entire period of appeal. On the one hand, several pieces of evidence point to the Veteran's suicidal ideation, irritability, and fits of rage. On the other hand, the two VA examiners of record indicated that the severity of the Veteran's symptomatology only entitled him to disability ratings actually lower than those now on appeal. However, resolving reasonable doubt in favor of the Veteran, the Board finds that under the circumstances of this case, the evidence of serious PTSD symptoms, especially continuing thoughts of suicide and of impaired impulse control, are sufficient to provide support for the award of a 70 percent disability rating for the period of this appeal. There can be no doubt that further medical inquiry could be undertaken with a view towards resolving conflicts in the evidence. However, granting the Veteran the benefit of the doubt, the Board finds that under the circumstances of this case, the evidence recited above is sufficient to provide support for the award of an initial 70 percent disability rating for the period of this appeal. The Board finds that the evidence of record does not show that the Veteran's PTSD symptoms meet the criteria for the next higher rating of 100 percent, which requires total occupational and social impairment. With the exception of a single notation in October 2007 that the Veteran said he heard voices, the Veteran's symptoms do not appear analogous to those symptoms listed under the criteria for the assignment of a 100 percent rating in the General Rating Formula. For example, there was no objective evidence of gross impairment in thought processes or communication; persistent delusions; an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. The evidence at present does not show total occupational and social impairment. The Board finds that the symptomatology described in the medical and lay evidence for the period of this appeal is more consistent with the rating criteria for the 70 percent rating. Therefore, the Board will resolve all reasonable doubt in this matter and find that a 70 percent rating for PTSD, but no higher, is warranted for the period of this appeal. The Board has considered the Veteran's assertions that his PTSD disability warrants a higher rating. The Board has considered the statements of the Veteran as to the extent of his PTSD over the entire course of this appeal. He is competent to report that his symptoms are worse than the ratings already assigned. Layno v. Brown, 6 Vet. App. 465 (1994). However, in rating a claim for an increased schedular disability rating, VA must consider the factors as enumerated in the rating criteria, which involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204 (1994). While he is competent to report that his symptoms are worse, the training and experience of medical personnel makes the medical findings found in treatment notes and examinations more probative as to the extent of the disability. Cromley v. Brown, 7 Vet. App. 376 (1995). Thus, while the Board has sympathetically considered the Veteran's appeal and increased his disability rating for the entire period on appeal, it has not awarded a 100 percent rating for total occupational and social impairment. Consideration has been given to assigning a staged rating. However, a 70 percent rating has now been assigned for the entire rating period on appeal. At no other time during the appeal period has the evidence and the Veteran's PTSD symptoms warranted the assignment of a rating higher than herein assigned. See Fenderson v. West, 12 Vet. App. 119 (1999). Finally, the Board finds that the Veteran's PTSD disability does not warrant referral for extra-schedular consideration. In exceptional cases, where schedular ratings are found to be inadequate, referral for consideration of an extra-schedular evaluation may be made. 38 C.F.R. § 3.321(b)(1) (2012). There is a three-step analysis for determining whether referral for consideration of an extra-schedular rating is appropriate. First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as governing norms, such as marked interference with employment and frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1) (2012). If so, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds that the rating criteria are not inadequate in this case. The Veteran's current symptomatology is clearly not analogous to the schedular criteria for a 100 percent rating in the time period examined in this appeal. However, the Veteran's attorney suggests there is evidence of interference with employment in this case and he has argued that the issue of a TDIU should be part of the Veteran's appeal for a higher rating for his service-connected PTSD. Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, the TDIU claim is part of the Veteran's higher rating claim for his service-connected PTSD and is discussed further in the remand section below. ORDER Entitlement to an initial disability rating of 70 percent, but not higher, for PTSD, is granted. REMAND Unfortunately, a remand is required for the Veteran's TDIU claim. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide his claim so that he is afforded every possible consideration. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. §§ 5107(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c) (2012). As noted in the Introduction, the issue of entitlement to a TDIU is raised by the Veteran's attorney as part of the Veteran's increased rating claim for PTSD. Rice v. Shinseki, 22 Vet. App. 447 (2009). Information in the record indicates that the Veteran had worked for many years for the North Carolina Department of Corrections, but has both eliminated two work days a week and delayed retirement due to his PTSD symptoms. The Board cannot currently determine, based on the medical evidence found within the claims file, whether the Veteran is unable to secure and follow substantially gainful employment by reason of his current service-connected disabilities to meet the requirements for a TDIU. The Board also notes that claims for service connection for a gastrointestinal disorder and an increased rating for coronary artery disease should be adjudicated before VA can properly determine whether the Veteran is entitled to a TDIU. Thus, further development of the claim is needed. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran and his attorney with a notice letter pertaining to his TDIU claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). 2. Obtain all VA treatment records since February 2012 from the Richmond VAMC in Virginia. All attempts to procure records should be documented in the claims file. 3. After the Veteran's claims for service connection for a gastrointestinal disorder, to include as secondary to PTSD, and for a higher rating for coronary artery disease are adjudicated, adjudicate the Veteran's claim for a TDIU. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs