Citation Nr: 1343151 Decision Date: 12/27/13 Archive Date: 01/07/14 DOCKET NO. 08-10 515 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for a skin disability, claimed as due to herbicide exposure. 2. Entitlement to an initial disability rating in excess of 20 percent for type II diabetes mellitus. 3. Entitlement to an initial disability rating greater than 30 percent prior to April 28, 2010, for posttraumatic stress disorder (PTSD). 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Evan M. Deichert, Counsel INTRODUCTION The Veteran served on active duty from June 1970 to January 1972. Thereafter, the Veteran served for an unconfirmed amount of time in the Army Reserves between May 1976 and May 1977. Though VA attempted to ascertain the nature of this second period of service, the NPRC was unable to locate any further documentation. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions of July 2007, March 2008, and August 2008 of the Detroit, Michigan, Department of Veterans Affairs (VA) Regional Office (RO). In the July 2007 rating decision, the RO denied service connection for a skin disability and for PTSD. In March 2008, the RO granted service connection for diabetes and assigned a 20 percent disability rating. In August 2008, the RO granted service connection for PTSD and assigned a 30 percent disability rating; the RO also denied the claim for a TDIU. Subsequent rating decisions increased the Veteran's PTSD rating to 50 percent and then 100 percent, both effective April 28, 2010; the period before that time remains at 30 percent. In the June 2011 rating decision that increased the Veteran's rating for PTSD to 100 percent, the RO determined that the issue of entitlement to a TDIU had become moot. However, in cases where a claimant has perfected his appeal, a subsequent rating decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal. AB v. Brown, 6 Vet. App. 35 (1993). Thus, both the issues of entitlement to a TDIU and entitlement to an increased initial rating for PTSD prior to April 28, 2010 remain on appeal. The Veteran appeared at a hearing before a decision review officer at the RO in February 2010; a transcript of the hearing is in the Veteran's file. In July 2012, the Board remanded the case for further development. Following this remand, the Veteran's claim for service connection for bilateral hearing loss was granted; this claim is no longer before the Board. The development ordered for the issues being decided has been completed. Stegall v. West, 11 Vet. App. 268, 271 (1998). The issue of entitlement to a TDIU prior to April 28, 2010 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 Veteran did not suffer from a skin disability during his active service or for many years thereafter. 2. The Veteran's skin disability is not included among those considered presumptively related to herbicide exposure, and there is no competent evidence that the Veteran's skin disability is directly related to in-service herbicide exposure. 3. The Veteran's treatment for diabetes requires the use of oral hypoglycemic agents and a restricted diet, but does not require insulin or regulation of activities. 4. Prior to April 28, 2010, the Veteran's PTSD symptomatology resulted in occupational and social impairment with reduced reliability and productivity CONCLUSIONS OF LAW 1. The criteria for service connection for a skin disability, claimed as due to herbicide exposure, have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1154, 5103, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 2. The criteria for an initial disability rating in excess of 20 percent for type II diabetes have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.41, 4.119, Diagnostic Code (DC) 7913 (2013). 3. Prior to April 28, 2010, the criteria for a 50 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.125 Diagnostic Code (DC) 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and to Assist Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. With regard to the Veteran's claims for increased initial ratings, these appeals arise from the Veteran's disagreement with the initial evaluations following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial and will not be discussed. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). With regard to the claim for service connection for a skin disability, a March 2007 letter satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); 38 C.F.R. § 3.159(b)(1). This letter also notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The claim was subsequently readjudicated, most recently in an August 2013 supplemental statement of the case. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices. See Shinseki v. Sanders, 556 U.S. 396 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); see also Mayfield, 444 F.3d at 1333-34. The Veteran's service treatment records, VA medical treatment records, and private treatment records have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran has not indicated, and the record does not contain evidence, that he is in receipt of disability benefits from the Social Security Administration. 38 C.F.R. § 3.159(c)(2). VA examinations for the Veteran's claims were conducted in February 2008, April 2010, April 2011, and August 2013; the Veteran has not argued, and the record does not reflect, these examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). These examinations contain sufficient information to determine whether service connection is warranted or to rate the Veteran under the applicable Diagnostic Codes. There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claim file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 556 U.S. 129 (2009). II. Service Connection for a Skin Disability Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) ; see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Service connection may also be granted for specific diseases associated with exposure to herbicide agents, including chloracne or other acneform diseases consistent with chloracne. 38 C.F.R. § 3.309(e). These diseases will be considered to have been incurred in or aggravated by service despite any lack of evidence of such disease during service. 38 C.F.R. § 3.307(a). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(6). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises and statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau, 492 F.3d at 1377. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, 492 F.3d at 1376-77. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. Facts The Veteran's service treatment records do not show complaints of or treatment for a skin disability during his active service. The Veteran's January 1972 report of medical examination at separation was silent as to any current skin disability. On a January 1977 report of medical examination during the Veteran's second, unconfirmed period of service, no skin disability was noted. On a January 1977 report of medical history from this same period, the Veteran denied currently or ever suffering from any skin diseases. An October 2006 VA dermatology consult reflects that the Veteran stated he had suffered from sores across his body (including his scalp, back, arms, abdomen, and groin) for the past 20 years. The Veteran was diagnosed as suffering from an epidermal cyst. In his August 2007 notice of disagreement, the Veteran stated that he suffers from skin cysts all over his body, and that they occurred after his return from Vietnam. The Veteran contended that they were connected to his in-service herbicide exposure. In his September 2008 substantive appeal, the Veteran stated that he had suffered from skin issues for 35 years. At his February 2010 hearing, the Veteran stated that he began suffering from skin problems within 6 months of his separation from active service. The Veteran underwent a VA examination in August 2013. The examiner diagnosed the Veteran as suffering from epidermal inclusion cysts. She stated that there were no skin lesions suggestive of acne or chloracne. She also concluded that, per her review of medical literature, the Veteran's skin disability is not caused or aggravated by his exposure to Agent Orange during his active service. Analysis The Veteran has been diagnosed as suffering from epidermal inclusion cysts. The current disability criterion is met. There is no evidence that the Veteran suffered from a skin disability during his active service. His service treatment records are silent as to any complaints of or treatment for a skin disability, and the Veteran has never contended that he began suffering from his disability during his active service. The Veteran, however, contends that his skin disability is related to his exposure to herbicides during his active service. The Veteran served in the Republic of Vietnam during his active service, so he is presumed to have been exposed to herbicides. The Veteran's particular skin disability (epidermal inclusion cysts) is not included among the disabilities found to be related to herbicide exposure. 38 C.F.R. § 3.309(e). Though chloracne and other acneform diseases are listed, the examiner from the August 2013 examination stated that the Veteran had no skin lesions suggestive of acne or chloracne. There is also no evidence of the Veteran being diagnosed as suffering from chloracne at any point during the appeal period. Service connection is thus not warranted on a presumptive basis. Service connection may still be warranted on a direct basis if it is shown that the Veteran's disability is directly related to herbicide exposure. Combee, 34 F.3d at 1042. The evidence does not establish that the Veteran's skin disability is directly related to herbicide exposure. The examiner from the August 2013 examination stated that, per her review of medical literature, the Veteran's skin disability is not caused or aggravated by his exposure to Agent Orange during his active service There is no other competent evidence in the claims file linking the Veteran's skin disability to his active service and his in-service herbicide exposure. Though the Veteran contends that such a link exists, determining the etiology of his skin disability requires medical knowledge or training and is not susceptible to lay opinion. Jandreau, 492 F.3d at 1376-77. Finally, to the extent that the Veteran contends that he began suffering from his skin disability immediately after his return from Vietnam, the Board does not find these statements to be credible. The Veteran has offered varying timelines for his development of his skin disability. In October 2006, he placed the onset in the 1980s, a decade after his return from Vietnam. He later contended that he began suffering from his skin disability within 6 months of his active service. Further, the 1977 report of medical history and medical examination showed that the Veteran himself did not contend that he was suffering from any skin disability at that time. The Veteran's observations in 1977 carry a much greater probative value than his recollections made more than 30 years after the fact. The preponderance of the evidence is against the claim for service connection for a skin disability; there is no doubt to be resolved; and service connection for a skin disability is not warranted. III. Increased Initial Ratings Claims Disability ratings are determined by applying a schedule of ratings based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Further, examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. While the Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Type II Diabetes Mellitus The Veteran's type II diabetes mellitus has been evaluated as 20 percent disabling under 38 C.F.R. § 4.119, Diagnostic Code 7913. The 20 percent rating assigned contemplates diabetes mellitus requiring insulin and a restricted diet, or requiring the use of an oral hypoglycemic agent and restricted diet. A higher 40 percent rating is warranted for diabetes requiring insulin, restricted diet, and regulation of activities. Id. Still higher ratings are authorized for manifestations not demonstrated by the evidence of record, all of which require the use of insulin and regulation of activities. The term "regulation of activities" is defined as an "avoidance of strenuous occupational and recreational activities." Camacho v. Nicholson, 21 Vet. App. 360, 363 (2007). In order for a claimant's diabetes to warrant a rating in excess of 20 percent, "it must be shown that a regulation of these activities is medically necessary." Id. Facts At a February 2008 VA diabetes examination, the Veteran stated that he was diagnosed as suffering from diabetes at the age of 57. He denied suffering from ketoacidosis, but stated that he does have hypoglycemic symptoms once or twice per week. He denied any hospitalizations for his hypoglycemia. The Veteran stated that he restricts his activities because of negative reactions that occur with strenuous activity. The Veteran stated that he treats his diabetes with Metformin and Byetta, both of which are oral hypoglycemic agents. The examiner diagnosed the Veteran as suffering from type II diabetes, but he did not state that the Veteran was on insulin. He also did not address whether the Veteran's diabetes required the use of insulin. In his May 2008 notice of disagreement, the Veteran stated that he gets the shakes and becomes dizzy when his blood sugar changes. He stated that because of the side effects of his diabetes, he was no longer able to safely do his job. In his February 2010 hearing, the Veteran stated that he has difficulty with physical exertion, but he denied using insulin to treat his diabetes. At an April 2011 VA diabetes examination, the Veteran stated that he was first diagnosed in 2006. He reported using oral medication (Metformin) to treat his disability. He denied suffering from hypoglycemic reactions or ketoacidosis. He stated that he is instructed to follow a restricted diet, but denied being restricted in his ability to perform strenuous activity. The examiner diagnosed the Veteran as suffering from diabetes, but did not provide any information contrary to the Veteran's medical history. Most recently, the Veteran underwent a VA examination in August 2013. The Veteran stated that he used an oral hypoglycemic agent to control his diabetes. He denied requiring regulation of activities as part of his diabetes management. He also denied suffering from ketoacidosis or hypoglycemic reactions requiring hospitalization. Once again, the examiner diagnosed the Veteran as suffering from diabetes, but did not provide any information contrary to the Veteran's medical history. Analysis This evidence shows that the 20 percent rating assigned is appropriate. Such a rating is assigned for diabetes requiring the use of an oral hypoglycemic agent and a restricted diet. The medical and lay evidence both show that the Veteran controls his diabetes via these methods. A 40 percent rating or higher would only be warranted with evidence that the Veteran's diabetes required the use of insulin and regulation of activities. The Veteran's diabetes management has never required the use of insulin. VA records consistently show that the Veteran manages his diabetes through the use of oral hypoglycemic agents alone, and in his February 2010 hearing, the Veteran denied using insulin. There is also no evidence that the Veteran is required to regulate his activities. In both his April 2011 and August 2013 examinations, the Veteran denied having to regulate his activities. Though the Veteran reported at his February 2008 examination that regulation of activities was required, the Veteran does not have the requisite medical training or experience necessary to determine that his diabetes requires regulation of her activities, so his statement is not considered competent. Jandreau, 492 F.3d at 1377. An extraschedular rating is also not warranted. The evidence shows that the Veteran's service-connected diabetes requires the use of oral hypoglycemic agents and a restricted diet; the rating criteria considered in this case reasonably describe the Veteran's disability level and these symptoms. Further, the Veteran is service-connected for his complications of diabetes, including bilateral peripheral neuropathy of the lower extremities and erectile dysfunction. The Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation for diabetes is adequate, and referral for extraschedular consideration is not required. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321(b)(1). The preponderance of the evidence is against the claim for an initial rating for rating in excess of 20 percent for type II diabetes mellitus; there is no doubt to be resolved; and an initial rating in excess of 20 percent is not warranted. PTSD Prior to April 28, 2010 The Veteran's PTSD has been evaluated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, DC 9411. A 30 percent rating is warranted 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). Id. A 50 percent rating is warranted 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. Id. The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition, in Mittleider v. West, 11 Vet. App. 181 (1998), the Court held that VA regulations require that when the symptoms and/or degree of impairment due to a veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to DSM-IV. See 38 C.F.R. § 4,125(a). Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). 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). Facts In his August 2007 notice of disagreement, the Veteran stated that he lives with symptoms of guilt, fear and abandonment. He stated that he suffers from panic attacks and nightmares, and that his PTSD symptoms had destroyed his family. In a second letter, the Veteran stated that he suffers from severe nightmares and panic attacks, and that he is depressed. He stated that his symptoms led him to neglect his family. The Veteran's family wrote letters in support of his claim in August 2007. The Veteran's son wrote that the Veteran was very strict and protective. He suffered from bad moods and frequent recollections of his service in Vietnam. The Veteran's sister stated that he was no longer comfortable in crowds after his return. She described him as bitter and angry. The Veteran's wife stated that he frequently went into rages, and would then be withdrawn. She stated that he was not good at holding his temper. She described him as depressed and suicidal at times, and stated that he suffered from nightmares and flashbacks. In a November 2007 VA PTSD consult, the Veteran related symptoms of suicidal ideation and anxiety. The Veteran also described suffering from depressive symptoms that made it difficult to work, take care of things at home, and to get along with others. A December 2007 psychiatric note reflects that the Veteran suffered from suicidal thoughts, sleep problems, and intrusive thoughts of Vietnam. The psychologist noted that the Veteran had a blunted, restricted, and constricted affect, and that his insight was limited. A February 2008 treatment note reflects that the Veteran had a disheveled appearance. It described the Veteran as depressed with limited eye contact. At a February 2008 VA examination, the Veteran stated that he was in the process of retiring as a truck driver, an occupation he held most of his life. He stated that he could no longer perform his job because of his psychotropic medication and his diabetes. Upon examination, the Veteran was casually dressed but marginally groomed. He was described as alert, fully oriented, and cooperative. The Veteran made limited eye contact, and he was not spontaneously conversational. His thought process was logical, and he had no thought disorder. He had no hallucinations or delusions. His judgment was intact, but his insight was minimal. His mood was anxious and his range constricted; the Veteran was reported to become tearful. The Veteran reported suicidal thoughts without plan or intent. He endorsed chronic irritability, but denied domestic violence or assaultive behavior. The Veteran spoke of recurrent intrusive memories of Vietnam resulting in sleep disorders and nightmares. He reported being uncomfortable in crowds. The examiner diagnosed the Veteran as suffering from PTSD, and he assigned a GAF score of 52. He stated that the Veteran suffered from moderate PTSD symptoms and moderate impairment in social and occupational functioning. In his September 2008 substantive appeal, the Veteran again stated that he suffered from flashbacks and nightmares. He reported having trouble with his memory. At his February 2010 hearing, the Veteran reported suffering from nightmares and stated that he avoids crowds. He stated that he has memory problems and difficulty completing projects he starts. He reported a confrontation with a police officer, and stated that he had thoughts of harming others while driving. Analysis The Veteran's symptoms more closely match those described by the 50 percent rating. Both lay and medical evidence show that the Veteran has a flattened affect, panic attacks, a difficulty in understanding complex commands, memory impairment, and disturbances of motivation and mood. These symptoms are all described by the 50 percent rating. These symptoms have resulted in the occupational and social impairment with reduced reliability and productivity required for a 50 percent rating. Further, the Veteran's GAF score of 52 is consistent with this increased rating. The Veteran's symptoms do not rise to the level described by the 70 percent rating. Though the Veteran has reported intermittent suicidal ideation, he has never been found to have a plan or intent. His speech is not illogical, obscure, or irrelevant. Though he suffers from panic attacks and depression, they do not affect his ability to function independently, appropriately and effectively. The Veteran denied any history of domestic violence or assaultive behavior. There is no evidence of spatial disorientation. Though the Veteran was once described as disheveled and once described as marginally groomed, he was consistently found to be attired appropriately, and had many more instance where his grooming was appropriate. Of the other symptoms reported during this period, none approximate those described by the 70 percent rating. An extraschedular rating is also not warranted. The evidence shows that the Veteran's service-connected PTSD results in panic attacks, impaired memory, impaired abstract thinking, and a difficulty in establishing relationships; the rating criteria considered in this case reasonably describe the Veteran's disability level and these symptoms. The Veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation for PTSD is adequate, and referral is not required. Thun v. Peake, 22 Vet. App. 111 (2008); 38 C.F.R. § 3.321(b)(1). ORDER Entitlement to service connection for a skin disability, claimed as due to herbicide exposure is denied. Entitlement to an initial disability rating in excess of 20 percent for type II diabetes mellitus is denied. Entitlement to an initial disability rating of 50 percent prior to April 28, 2010, for posttraumatic stress disorder is granted. REMAND Since April 28, 2010, the Veteran has been in receipt of a 100 percent rating for his PTSD. This rating precludes awarding a TDIU from this date forward. Evidence also indicates that the Veteran was working full time as a truck driver until February 25, 2008. As the Veteran was steadily employed prior to this date, a TDIU is not warranted before February 2008. The question of whether a TDIU is warranted between February 2008 and April 2010 is unresolved. The Veteran contends that both his PTSD and his diabetes made it impossible for him to continue working as a truck driver, the only occupation he had held for many decades prior. As no opinion regarding the Veteran's employability from this period have been obtained, a remand is required. Accordingly, the case is REMANDED for the following actions: 1. Obtain an opinion regarding the Veteran's employability from an appropriate medical professional. The entire claim file (i.e., the paper claim file and any medical records contained in Virtual VA, VBMS, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to the virtual file, any relevant treatment records contained in the virtual file that are not available on CAPRI or AMIE must be printed and associated with the paper claim file so they can be available to the examiner for review. If the examiner determines that it is impossible to offer an opinion regarding the Veteran's employability without scheduling him for an examination, then such an examination must be scheduled. After reviewing the claim file, the examiner must identify each impairment or symptom found as a result of his service-connected disabilities from the period between February 2008 and April 2010, including PTSD, diabetes, tinnitus, bilateral peripheral neuropathy of the lower extremities, bilateral hearing loss, and erectile dysfunction. The examiner must state the occupational impact that each impairment or symptom has on the Veteran's ability to secure or follow substantially gainful employment. The examiner must state the functions which would be difficult or impossible to do as a result of the associated service-connected symptom or impairment. Further, the examiner must state the impact that the Veteran's service-connected impairments and symptoms both individually and as a whole have on his ability to accomplish sedentary and manual employment. In offering this opinion, the examiner must also take into consideration the Veteran's level of education, special training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities. 2. Then, readjudicate the appeal. If the benefit sought remains denied, issue a Supplemental Statement of the Case and return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs