Citation Nr: 1342205 Decision Date: 12/20/13 Archive Date: 12/31/13 DOCKET NO. 10-09 723 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for hypertension including as secondary to service-connected diabetes mellitus. 3. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 4. Entitlement to a total rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Kenneth L. LaVan, Attorney WITNESSES AT HEARING ON APPEAL Appellant; Appellant's spouse ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from August 1965 to July 1968. This appeal comes before the Board of Veterans' Appeals (Board) from February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office in St. Petersburg, Florida. The Veteran testified at a hearing before the Board by videoconference from the RO in January 2013. A transcript of the hearing is associated with the claims file. The Virtual VA paperless claims processing does not contain additional evidence relevant to this appeal. In the February 2009 rating decision, the RO denied service connection for hepatitis and colitis. The Veteran submitted a timely notice of disagreement the same month. The RO issued a statement of the case in February 2010, but the Veteran did not file a timely substantive appeal. The Veteran's representative listed these issues in a January 2013 pre-hearing brief but did not identify or discuss these issues at a January 2013 Board hearing one week later. The insertion of the issues in the brief was not timely as a substantive appeal and were not pursued by the representative at the hearing. Therefore, these issues are not before the Board for appellate review. 38 C.F.R. § 20.302 (2013). The issues of service connection for a back condition, bladder cancer, a prostate condition, and traumatic brain injury have been raised by the Veteran in statements in January, June, and July 2012, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction, and they are referred to the AOJ for appropriate action. The issue of service connection for hypertension is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. The competent medical opinions of record on the question of whether the Veteran's current bilateral hearing loss is etiologically related to combat noise exposure are in relative equipoise. 2. Prior to April 9, 2009, the Veteran's PTSD manifested as mild occupational and social impairment with occasional decrease in work efficiency, difficulty with anger control, and limited social engagement with symptoms such as nightmares, intrusive thoughts, hypervigilance, anxiety, and guarded attitude but without thought, communications or memory deficits. 3. From April 7, 2009 to December 8, 2011, the Veteran's PTSD manifested as moderate social and occupational impairment with reduced reliability and productivity and more restricted social isolation with symptoms such as impaired judgment in stressful situations and difficulty in establishing and maintaining effective work and social relationships. 4. Starting April 9, 2011, the Veterans PTSD is manifested as occupational and social impairment with deficiencies in most areas, such as work and family relations, and mood, due to symptoms such as: social isolation affecting the ability to function independently, appropriately and effectively; severe social isolation; impaired impulse control; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. 5. Effective December 9, 2011, the Veteran has one service-connected disability rated as 70 percent. 6. Effective December 9, 2011, the Veteran's service-connected disabilities in combination precludes all forms of substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral hearing loss are met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309, 3.385 (2013). 2. The criteria for a rating in excess of 30 percent prior to April 9, 2009 are not met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.4, 4.7, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for a rating of 50 percent from April 9, 2009 to December 8, 2011 and a rating of 70 percent thereafter for PTSD are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.4, 4.7, 4.130, Diagnostic Code 9411 (2013). 4. The criteria for a total rating based on individual unemployability effective December 9, 2011 are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA must notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). The notice requirements apply to all five elements of a service connection claim. The five elements are: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran has appealed the initially assigned rating for PTSD from the original grant of service connection. Once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006); VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). In this case, the Veteran's claim for service connection for PTSD was granted and an initial rating was assigned in the February 2009 rating decision on appeal. Therefore, no additional 38 U.S.C.A. § 5103(a) notice is required. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Regarding the claim for service connection for bilateral hearing loss, the Board is granting in full the benefit sought on appeal As the Board is granting the claims for service connection, the claim is substantiated, and there is no need for further notice and assistance. Wensch v. Principi, 15 Vet App 362, 367-68 (2001). Regarding the claim for a TDIU, the RO provided a notice in August 2011 that met the requirements. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment, post-service VA treatment, Social Security Administration, and identified private treatment records have been obtained and associated with the claims file. The duty to assist also includes providing a medical examination or obtaining a medical opinion when it is necessary to make a decision on a claim. The Veteran was provided VA examinations for hearing loss in May 2008, December 2008, and August 2011, and for PTSD in December 2008, July 2010, and August 2011. The results have been included in the claims file. The examinations and opinions involved summary of the history from a review of the record and from reports by the Veteran, lay statements by friends and relatives, and a thorough clinical examination in compliance with regulations and protocols. In June 2013, the Board received additional evidence including a multi-disorder evaluation by a private physician and several lay statements with a waiver of consideration by the RO. A Veterans Law Judge who chairs a hearing must fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. 38 C.F.R. § 3.103(c)(2) (2013); Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the January 2013 Board hearing, the VLJ advised the Veteran of the basis for the prior determinations and the elements of the claims that were lacking. In addition, the VLJ sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim including records of private treatment reported by the Veteran. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor has identified any prejudice in the conduct of the RO/Board hearing. The Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits and his representative submitted additional evidence to support the claims. Consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2). As VA has satisfied its duties to notify and assist the Veteran, the Board will proceed to review and decide the claim based on the evidence that is of record. The Veteran served as a U.S. Army infantryman with combat duty in the Republic of Vietnam and was awarded the Combat Infantryman's Badge. He contended in a March 2008 claim and in a January 2013 Board hearing that his current bilateral hearing loss was caused by high levels of noise during combat service. He contended in a February 2009 notice of disagreement, a July 2011 claim, and in a January 2013 brief, written statements, and Board hearing testimony that his service connected PTSD is more severe than is contemplated by the current rating and in combination with other service-connected disabilities makes him unemployable. Service Connection for Bilateral Hearing Loss Service connection is granted if it is shown the Veteran suffers from disability resulting from an injury sustained or a disease contracted in the line of duty during active military service, or for aggravation during service of a pre-existing condition beyond its natural progression. 38 U.S.C.A. §§ 1110; 38 C.F.R. §§ 3.303(a), 3.306. To establish entitlement to direct service connection, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a nexus or link between the in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including organic diseases of the nervous system, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In an October 4, 1995, opinion, VA's Under Secretary for Health determined that it was appropriate to consider high frequency sensorineural hearing loss an organic disease of the nervous system and therefore a presumptive disability. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The United States Court of Appeals for Veterans Claims (Court) has held that service connection can be granted for a hearing loss where the Veteran can establish a nexus between his current hearing loss and a disability or injury he suffered while he was in military service. Godfrey v. Derwinski, 2 Vet. App. 352, 356 (1992). The Court has also held that VA regulations do not preclude service connection for a hearing loss which first met VA's definition of disability after service. Hensley, supra, at 159. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service personnel records show that the Veteran was in combat. Therefore, the Veteran was exposed to high noise levels from explosives, artillery, and small arms fire. An audiometric test of hearing acuity obtained in August 1965 at the time of entry on active duty was normal except in the left ear at 4000 Hz. The Veteran did not report subjective hearing difficulty. Inconsistently, a May 1968 audiometric test was entirely normal, and the associated physical examination was silent for any reports by the Veteran or observations by the examiner of any hearing acuity abnormalities. Records of private primary and cardiovascular care from 2002 to 2006 are silent for any symptoms of hearing loss. In October 2006, a physician noted that the Veteran denied any symptoms of hearing loss or tinnitus. However, in December 2005, the Veteran underwent a hearing examination for his employment as a truck driver. He acknowledged exposure to high noise levels in service but denied any previous or current hearing difficulty. An audiometric test showed puretone thresholds at 55 and 60 decibels in the right and left ears respectively. Speech recognition testing was not performed. In May 2008, the Veteran was examined in a VA audiology clinic with symptoms of tinnitus and difficulty understanding conversations. The examiner noted the Veteran's military noise exposure and post-service exposure from recreational motorcycle riding but not from his occupation as a truck driver. Audiometric test results in decibels were as follows: Hertz 500 1000 2000 3000 4000 Right 20 20 25 35 55 Left 20 20 40 75 100 Speech recognition testing was performed but the results were not recorded. The audiologist diagnosed bilateral sensorineural hearing loss at the higher frequencies and noted that military noise exposure was more likely than not a contributing factor to his hearing impairment. She explained that the impairment was consistent with both aging and noise induced cochlear pathology as indicated by the asymmetry. In December 2008, the Veteran underwent a hearing examination by another VA audiologist who noted a review of the claims file and the same symptoms and noise exposure history. The Veteran reported that he sensed tinnitus a few times per day starting on the left and then on the right. Audiometric test results in decibels were as follows: Hertz 500 1000 2000 3000 4000 Right 20 10 25 45 50 Left 20 10 40 75 95 Speech recognition was 100 and 96 percent on the right and left respectively. The audiologist noted that the tinnitus was likely associated with hearing loss and that tinnitus was likely caused by military noise exposure because the Veteran reported the onset following his service in a combat environment. The audiologist noted that the bilateral sensorineural hearing loss was not caused by military noise exposure because the discharge examination was normal. The audiologist did not address the possibility of a delayed onset or a contribution of the military noise to other factors such as aging or post-service motorcycle riding. In February 2009, the RO granted service connection for tinnitus but denied service connection for bilateral hearing loss. In a May 2010 letter, the Veteran's spouse noted that the Veteran had difficulty hearing conversation when not looking at a speaker and difficulty hearing a television or an automobile turn signal. In August 2011, another VA audiologist noted a review of the claims file and the same symptoms and noise exposure history. Additional audiometric test performance was substantially the same as previous tests. The audiologist noted only that the Veteran's hearing disability would not alone preclude employment in a quiet environment and did not offer an opinion on the etiology of the hearing loss. At a January 2013 Board hearing, the Veteran testified that he experienced hearing loss since his return from Vietnam. He stated that he was first informed that his hearing was "horrible" in the early 1970s when he was tested in conjunction with an application for a job driving a truck. The Board finds that there is a relative equal balance of evidence both for and against the claim, and therefore, resolving all doubt in favor of the Veteran, service connection for bilateral hearing loss is warranted. There is credible and probative evidence that the Veteran has current bilateral hearing loss that meets the VA criteria for disability because several tests reveal puretone thresholds at 40 decibels or greater in both ears. There is credible and probative evidence of substantial noise exposure in combat as well as reports by the Veteran of truck and motorcycle driving after service. Regarding service connection based on a continuity of symptoms since service, the Veteran is competent to report his sensed hearing difficulty since returning from Vietnam and that he was told that it was "horrible" in the early 1970s. The Board finds that this report is not credible. The Veteran's hearing was measured as normal in 1968 upon return from Vietnam, and the Veteran was allowed to operate a truck for several decades. He denied any hearing difficulty in 2006 although a test in 2005 did show high frequency loss. The Board turns to the opinions of VA audiologists in 2005. The audiologist in May 2005 acknowledged the Veteran's noise exposure history but did not mention the normal testing in 1968. Nevertheless, this audiologist concluded that the Veteran's military noise exposure was at least a contributor to his current disability. The audiologist in December 2008 concluded that the Veteran's tinnitus was caused by noise exposure because he reported symptoms at the time of the exposure or shortly thereafter. However the audiologist found that current hearing loss was not caused by service because of the normal test in 1968. This audiologist acknowledged the onset of tinnitus caused by acoustic trauma but did not address the possibility of late onset of hearing loss caused by the same acoustic trauma. The Board concludes that both audiologists noted awareness of the nature and timing of the Veteran's acoustic trauma during and after service and the nature and level of severity of his current hearing acuity. Although both opinions contain little explanation, both are of relatively equal probative weight and represent a difference of professional opinion on whether hearing loss must be evident immediately after the exposure or may contribute along with other factors such as aging to reach a sensed and disabling level at some time after service. As the credible and probative evidence is in relative equipoise, the Board resolves all doubt in favor of the Veteran and grants service connection for bilateral hearing loss. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating for PTSD Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where the question for consideration is entitlement to a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. The criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Pursuant to the General Rating Formula, a 30 percent rating is assigned for a mental disorder (including PTSD) 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 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is 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. A 70 percent rating is assigned when the psychiatric condition produces occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is total occupational or social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation 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. Further, when evaluating the level of disability from a mental disorder, the rating agency shall consider the extent of social impairment, but shall not assign an evaluation based solely on the basis of social impairment. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only insofar as it affects earning capacity. 38 C.F.R. §§ 4.126, 4.130. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th Ed.) (DSM-IV) (1996), GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. There is no question that the GAF score and interpretations of the score are important considerations in evaluating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (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 evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). According to the DSM-IV, GAF scores from 61 to 70 reflect 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 indicate that the individual is functioning pretty well, and has some meaningful interpersonal relationships. Scores from 51 to 60 are indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Scores from 31 to 40 indicate impairment in reality testing or communication (e.g., speech 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., depressed man avoids friends, neglects family, and is unable to work). Service connection for PTSD was granted effective in March 2008, the date of receipt of the claim for service connection. Prior to this date, the Veteran was once hospitalized for psychiatric care for uncontrollable temper at a VA facility in 1972. The diagnosis was severe sociopathic personality and adjustment reaction. Records of private primary care from 2002 to 2007 are silent for any mental health symptoms or diagnoses. An initial examination for the start of VA primary care in July 2007 is silent for any mental health symptoms and a screening for PTSD was negative. The Veteran denied any nightmares, avoidance behavior, hypervigilance, or social isolation. The Veteran sought initial VA mental health care in February 2008 for symptoms of nightmares, transient irritability, and interrupted sleep. The Veteran reported working full time as a tractor-trailer driver for a large shipping firm for the past twelve years although he reported numerous previous jobs from which he was fired for arguments or inability to adapt to the situation. He reported that he was an active member of a church, exercised at a gym, and associated with fellow veterans in a motorcycle riding group. A social worker diagnosed possible PTSD and assigned a GAF score of 60. The Veteran subsequently received periodic VA outpatient mental health care. In June 2008, a clinician noted that the Veteran worked as a truck driver to avoid social contact but occasionally engaged in episodes of "road rage." He did spend time with friends riding motorcycles and was active in his church. In December 2008, a VA psychiatrist noted a review of the claims file and the Veteran's reports of daily symptoms of intrusive thoughts, nightmares, hypervigilance, sleep disturbances, and detachment from others associated with combat events. The Veteran reported that he was previously divorced but now had a good relationship with his current spouse. The Veteran continued to work full time as a truck driver. On examination, the psychiatrist noted a anxious mood, constricted affect, and guarded attitude. However, there were no hallucinations, delusions, suicide ideations, thought process or communications deficits, or shortcomings in judgment or insight. There were no reports of panic attacks, obsessive behavior, or recent episodes of inappropriate behaviors. The psychiatrist noted that the symptoms were moderate with decreased efficiency at work, difficulty with social interactions, and a decreased quality of life. The psychiatrist assigned a GAF score of 65. The Veteran continued VA outpatient care through June 2010. Clinicians noted continued symptoms of irritability and lack of anger control. He reportedly coped with his anger in part through social isolation although he continued good marital and church group relationships. The Veteran reported that he quit his job in April 2009 because of stress and increased PTSD symptoms. A clinician in May 2009 assigned a GAF score of 53. In June 2009, the Veteran reportedly punched another man after being provoked. Treatment focused on anger control strategies; there continued to be no thought or communications deficits. The claims file contains records of group and individual counseling at a Vet Center from February 2010 to March 2013. Counselors noted increasing severity of symptoms of anxiety, pressured speech, irritability, and social isolation. Treatment focused on anger control and coping skills. There were no reports of additional violent acts. In a May 2010 letter, the Veteran's spouse noted her observations of the Veteran's irritability, depression, aggressiveness, sleep interruptions, recurrent recollections of combat, and emotional withdrawal over their entire marriage and its effect on his children. In July 2010, another VA psychiatrist noted a review of the claims file and the Veteran's reports of increased problems with social interactions because of angry confrontations and sleep impairment. He reportedly left his job and had a strained marriage because of the irritability and lack of anger control. He did continue to associate with his motorcycle group. He continued to have distressing recollections of combat events and reactions to cues that remind him of the events. On examination, the psychiatrist noted a normal affect but agitated mood. There were no speech, thought, judgment, insight, memory, or cognitive deficits. There were no panic attacks, hallucinations, or suicidal ideations. The psychiatrist noted that the daily symptoms were moderate to severe but assigned a GAF score of 58 indicating only moderate symptoms. In August 2011, another VA physician noted a review of the claims file, examined the Veteran, and noted the same symptoms as were reported or observed in previous treatment encounters and examinations. The Veteran reported increased marital stress and that he could only comfortably associate with other combat veterans. The physician found that the occupational and social impairment was mild or transient which decreased work efficiency during periods of stress and assigned a GAF score of 52. In August 2011, the Veteran's most recent employer reported that he was employed through April 6, 2009 and had three periods of short term disability leave prior to September 2005. In a concurrent statement, the Veteran reported that the disability time off was for symptoms or medical appointments for diabetes, heart disease, hypertension, PTSD, and other illnesses. He further noted that conflict with other employees was a factor in his job termination. He reported that he was receiving SSA disability benefits for these illnesses including PTSD. SSA records were obtained but consist of the VA and private records discussed above as well as records of medical treatment for musculoskeletal and cardiovascular disorders. The file does not indicate the specific disabilities for which compensation was granted or the effective date, although the file was created in April and May 2009, and the Veteran was employed until April 2009. In a December 2011 letter, the Veteran's VA primary care physician briefly noted that the Veteran was under her care for several disorders including PTSD that required multiple treatment visits and multiple medications. The physician concluded that the Veteran was unemployable without further details. In a January 2013 letter, a private physician noted that he was treating the Veteran for multiple medical condition including diabetes, coronary artery disease, hyperlipidemia, major depression, and PTSD and concluded that the Veteran was not employable In a January 2013 Board hearing, the Veteran described his daily symptoms including the desire to remain alone for days at a time and experiencing "breakdowns" that prevent him from completing projects. He described panic attacks once or twice per week when he was unable to control his behavior and engaged in angry confrontations with others. He reported no tolerance or patience and that medication was not effective. He reported that he did not trust anyone other than Vietnam combat veterans especially those he met during therapy. The Veteran's spouse reported that she observed the Veteran's intense nightmares and sleeplessness. In February 2013, the Veteran submitted a report from a private physician specializing in internal medicine and disability assessment. He noted that he was not treating the Veteran but was asked to provide a disability evaluation by the Veteran's representative. He noted a review of the claims file and accurately summarized the Veteran's military history and diagnosis of PTSD. In brief examination report, the physician noted a calm demeanor, no speech or memory deficits and a fair affect. The physician noted the Veteran's reports of the same daily symptoms as were noted by previous examiners except that the Veteran denied any recent panic attacks. The Veteran did report frequent crying spells and worries about his own health. The physician assigned a GAF score of 57 but also noted that the Veteran had significant occupational and social impairment because of deficiencies in thinking, mood, depression, and impaired impulse control. He concluded that the Veteran would have problems dealing with stress in a work environment and his antisocial behavior would create difficulty in maintaining effective relationships. He concluded that the Veteran was unemployable because of all medical conditions and PTSD. As a preliminary matter, the Board finds that the lay statements and reports of symptoms to clinicians, examiners, and the Board by the Veteran and his spouse are competent and credible as they address observable symptoms and have been accepted by clinicians and counselors without challenge. The Board also finds that the VA and private medical evidence is adequate to decide the claim as it is substantially consistent and represents detailed assessments of the Veteran's symptoms and their level of occupational and social impairment, largely based on the Veteran's own credible reports. The Board places somewhat less probative weight on the February 2013 disability evaluation because the physician's qualification as an internal medicine specialist does not appear to extend to the same level of expertise in mental health as those clinicians and examiners who do. Nevertheless, all medical reports warrant some probative weight because they are based on interviews and therapy sessions with the Veteran and an accurate understanding of the Veteran's history of military experiences and previous treatment. The Board acknowledges that throughout the period of this appeal, the Veteran experienced nightmares, intrusive thoughts, sleep disturbance, hypervigilance, irritability, anxiety, depressed mood, and lack of behavioral control. The Board also acknowledges that there were no reports or observations of thought, communications, memory, or judgment deficiencies. There were no suicidal or homicidal ideations, delusions or hallucinations. Behavioral deficits extended only to lack of anger control, "road rage," one occasion of a provoked fight, and a desire to associate only with other Vietnam combat veterans. Therefore, the Board will focus on the severity of the symptoms and their impact on his social and occupational functioning. The Board concludes that an initial or staged rating in excess of 30 percent for PTSD is not warranted through to April 6, 2009, the date that the Veteran was last employed. Prior to this date, the Veteran worked full time, maintained a good marital relationship, and associated with others at church and in a motorcycle group. Although the Veteran received periodic VA mental health care, he did not participate in group or individual therapy. The examiner in December 2008 assigned a GAF score of 65 indicating mild symptoms with some social and occupational difficulties but generally functioning satisfactorily. The Board concludes that starting on April 7, 2009 when the Veteran ceased employment, his symptoms began a gradually worsening trajectory as shown in outpatient treatment and counseling reports. Establishing specific effective dates for increased ratings is difficult because the records do not indicate dramatic changes but rather a gradual increase in symptom severity and impairment. The most significant factor was the Veteran's increasing lack of anger control leading to a violent confrontation, additional social isolation from friends, and increased marital tension. The Board concludes that a rating of 50 percent but not higher for PTSD is warranted effective from April 7, 2009 to December 8, 2011; and that a rating of 70 percent for PTSD is warranted effective December 9, 2011. Between April 2009 and December 2011, the Vet Center counselors and the Veteran spouse reported the Veteran's increased irritability and lack of anger control and social isolation. The Veteran chose to associate only with other combat Veterans and was emotionally withdrawn in his marriage. The single incident of violence in June 2009 was provoked and did not recur although the Veteran used social isolation as a coping technique. GAF scores during this period of the appeal were in the 50s, indicating moderate symptoms with some difficulty in social and occupational functioning. Although SSA awarded disability benefits and the Veteran did not return to work, the records and statements from the Veteran indicated that his occupational limitations were also imposed by other medical disorders including diabetes, the residuals of a heart attack, and back pain. The Veteran continued to associate with other combat veterans. At no time did examiners note deficiencies in thinking, communicating, or other cognitive functioning. Starting on December 9, 2011, the date of the letter from the Veteran's VA primary care physician, a 70 percent rating but not higher is warranted. On this date and in several subsequent evaluations, treating physicians and examiners concluded, albeit without much explanation, that the Veteran was unemployable at least in part because of PTSD. The Veteran and his spouse credibly reported that social isolation extended to episodes of confinement at home for days at a time. The February 2013 consulting physician assigned a GAF score in high 50s but subjectively noted that the level of impairment was severe primarily because of the Veteran's antisocial behavior and inability to deal with stress. Contrary to his hearing testimony, the Veteran denied any panic attacks but did describe crying spells and "road rage" that would impair occupational and social activities outside the home. The Veteran displayed some but not all symptoms listed as examples under the 70 percent criteria. Resolving all doubt in favor of the Veteran, the Board finds that the overall level of impairment during this staged period is serious with deficiencies in most areas, such as work and family relations, isolation that interfere with routine activities; impaired impulse control, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. A 100 percent rating is not warranted because the Veteran does not have total impairment. He is able to think, communicate, and manage his own affairs. He does not display a level of impairment associated with symptoms such as such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. His inappropriate behavior involves a lack of anger control but not actual violence or bizarre activities. The Board considered whether an extra-schedular rating is warranted at any time during the period of the appeal. The determination of whether a claimant is entitled to an extra-schedular rating is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The first step is to determine whether the "evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. If it is determined that this is so, the second step of the inquiry requires a determination of "whether the claimant's exceptional disability picture exhibits other related factors," such as marked interference with employment or frequent periods of hospitalization. Id. at 116. Finally, if the first two steps of the inquiry have been satisfied, the third step requires referral of the claim to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether an extra-schedular rating is warranted. Id. The Board finds that neither the first nor second Thun element is satisfied here. The Veteran's service-connected PTSD is manifested by signs and symptoms that address the level of social and occupational impairment and include some of the typical symptoms contemplated by the rating schedule. Higher ratings including a 100 percent rating are available for more severe levels of impairment. The Board finds that the schedular rating criteria reasonably describe the Veteran's disability picture, which is manifested primarily by lack of anger control and ability to associate with others in the home and on the job. In short, there is nothing exceptional or unusual about the Veteran's PTSD disability because the rating criteria reasonably describe his disability level and symptomatology. Thun, 22 Vet.App. at 115. With respect to the second Thun element, the evidence does not suggest that any of the "related factors" are present. In particular, the Veteran does not contend, and the evidence of record does not suggest, that his PTSD has resulted in any hospitalizations or other forms of intensive treatment. Thus, even if his disability picture was exceptional or unusual, referral would not be warranted. The record does raise the issue that the Veteran's PTSD interferes with employment in combination with other service-connected disabilities. To this extent, entitlement to a total rating based on individual unemployability is addressed below. Total Rating Based on Individual Unemployability In order to establish entitlement to TDIU due to service- connected disabilities, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2006); Van Hoose v. Brown, 4 Vet. App. 361 (1993). The regulatory scheme for a TDIU provides both objective and subjective criteria. Hatlestad, supra; VAOPGCPREC 75-91 (Dec. 27, 1991), 57 Fed. Reg. 2317 (1992). The objective criteria, set forth at 38 C.F.R. § 3.340(a)(2), provide for a total rating when there is a single disability or a combination of disabilities that results in a 100 percent schedular evaluation. Subjective criteria, set forth at 38 C.F.R. § 4.16(a), provide for a TDIU when, due to service-connected disability, a veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). Prior to December 9, 2011, the Veteran did not have a service-connected disability rated as 60 percent or more or at least one rated as 40 percent or more. In part as a result of the decision above, effective December 9, 2011, the Veteran had the following service-connected disabilities; PTSD, rated as 70 percent disabling; coronary artery disease, rated as 30 percent disabling; diabetes mellitus, rated as 20 percent disabling; tinnitus and polyneuropathy of the left upper extremity, each rated as 10 percent disabling; and residuals of malaria, rated as noncompensable. Therefore, effective December 9, 2011, the Veteran meets the statutory criteria for a TDIU. The Board refers to the evidence discussed above in the section for rating PTSD and notes that a VA physician in December 2011, a private physician in January 2013, and the private consulting physician in February 2013 all either provided on-going care or reviewed the entire claims file and all concluded that the Veteran was not employable as a consequence of service-connected PTSD, diabetes, and coronary artery disease. Therefore, the weight of competent and probative lay and medical evidence warrants a TDIU, effective December 9, 2011. A total rating prior to December 9, 2011 is not warranted. Even though the Veteran ceased working at his occupation as a truck driver in April 2009, his combined service-connected disabilities did not meet the statutory criteria, and there were no competent opinions that he was precluded from all forms of substantially gainful employment prior to that date. The Veteran's activities in and outside the home were not precluded by symptoms or medications for coronary artery disease or diabetes as the symptoms and level of disability were present while he was working prior to April 2009. ORDER Service connection for bilateral hearing loss is granted. An initial rating in excess of 30 percent for PTSD prior to April 7, 2009 is denied. A staged rating of 50 percent effective from April 7, 2009 to December 6, 2011, and a rating of 70 percent thereafter for PTSD is granted. A total rating based on individual unemployability effective December 9, 2011 is granted. REMAND Upon review of the record, the Board finds that the medical evidence relevant to the claim for service connection for hypertension including as secondary to diabetes mellitus requires additional development including a VA examination and opinion. VA must provide a medical examination or obtain an opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C.A. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. Sufficient lay and medical evidence is of record to address the Veteran's claim for service connection for hypertension on a direct basis and as secondary to diabetes. However, during the January 2013 Board hearing, the Veteran raised the issue of causation or aggravation of hypertension by his service-connected PTSD. Separate theories in support of a claim for a particular disability are to be adjudicated under one claim. See Robinson v. Peake, 21 Vet. App. 545, 550-51 (2008). Here, the Veteran has been diagnosed with hypertension and has been awarded service-connection for PTSD. The Veteran stated that his hypertension was diagnosed at about the same time as his PTSD symptoms increased in severity and that he measured increased blood pressure during time of increased anxiety. The Board finds that the Veteran's reports are credible and notes that competent evidence is not required to "indicate' that his symptoms may be associated with his service-connected PTSD. Therefore, a review of the history, an examination, and opinion is necessary to decide the claim. Further, VA is required to make reasonable efforts to help a claimant obtain records relevant to his/her claim, whether or not the records are in Federal custody. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). VA has constructive notice of VA generated documents that could reasonably be expected to be part of the record, and that such documents are thus constructively part of the record before the Secretary and the Board, even where they are not actually before the adjudicating body. Accordingly, the RO should request VA medical records pertaining to the Veteran that are dated from March 2013 to the present. Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. Request all records of VA outpatient treatment since March 2013 and associate any records received with the paper or electronic claims files. 2. Send the Veteran a notice that offers the opportunity to provide or identify any evidence relevant to the claim for service connection for hypertension including as secondary to diabetes or PTSD in accordance with 38 C.F.R. § 3.159(b)(1). Obtain any identified and authorized evidence and associate any evidence received with the electronic or paper claims files. 3. Then, schedule the Veteran for a VA examination for hypertension with an appropriately qualified physician. Provide the claims file or access to the Virtual VA electronic record to the physician. Request that the physician review the claims file and note the review in an examination report. Request that the physician provide an opinion on the timing of onset of the Veteran's hypertension (as may be different from isolated episodes of high blood pressure) and whether it is at least as likely as not (50 percent probability or greater) that the disorder was caused or aggravated by the Veteran's service-connected diabetes, coronary artery disease, PTSD, or any other aspect of active military service. A rationale for the opinion is required. If an opinion cannot be provided, the physician must explain the reason such as insufficient evidence, inadequate state of medical knowledge, or lack of knowledge or experience of the physician in the appropriate medical field. 4. After completing the above action and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim for service connection for hypertension should be readjudicated. If the claim remains denied, a supplemental statement of the case should be provided to the Veteran and his representative. After an adequate opportunity to respond, the appeal should be returned to the Board for appellate review. 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). ______________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs