Citation Nr: 1343393 Decision Date: 12/31/13 Archive Date: 01/07/14 DOCKET NO. 10-13 728 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an increased initial disability rating for posttraumatic stress disorder (PTSD), rated as 50 percent disabling prior to January 28, 2013, and rated at 70 percent disabling from January 28, 2013, forward. 2. Entitlement to service connection for a liver disorder. 3. Entitlement to a total disability rating based upon individual unemployability due to a service-connected disability (TDIU). REPRESENTATION Veteran represented by: Daniel G. Krasnegor, Esq. ATTORNEY FOR THE BOARD L. Pelican, Associate Counsel INTRODUCTION The Veteran served honorably in the United States Navy from April 1966 to January 1970. The Veteran had service in the Republic of Vietnam, for which he received the Vietnam Service Medal and the Vietnam Campaign Medal. These matters comes before the Board of Veterans' Appeals (Board) on appeal from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia, which granted service connection for PTSD evaluated as 30 percent disabling. The Veteran appealed the decision. An October 2012 rating decision granted service connection for the Veteran's diagnoses of major depressive disorder and anxiety disorder. That rating decision incorporated these diagnoses into his rating for PTSD, and increased the PTSD rating to 50 percent disabling, effective from October 17, 2008, the date of the grant of service connection. A subsequent decision in October 2013 increased the Veteran's PTSD rating to 70 percent disabling, effective January 28, 2013. Regardless of the RO's actions, the issue remains before the Board because the increased rating was not a complete grant of the maximum benefits available. See AB v. Brown, 6 Vet. App. 35 (1993). Pursuant to the Veteran's request, he was listed for a video conference hearing at a future date. However, in a January 2013 statement, the Veteran's representative stated that the Veteran wanted to cancel his hearing request. Under these circumstances, the regulations consider the hearing request to have been withdrawn. 38 C.F.R. § 20.704 (e) (2013). The Board has not only reviewed the Veteran's physical claims file, but also his Virtual VA electronic claims file to ensure a total review of the evidence. The issues of entitlement to TDIU and entitlement to service connection for a liver disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO. FINDING OF FACT For the entire period on appeal, the Veteran's PTSD was manifested by symptoms such as frequent depression, anxiety, suspiciousness, panic attacks that occur weekly or less, chronic sleep impairment, disturbances of motivation and mood, suicidal ideation, and a difficulty and an inability to establish and maintain effective work and social relationships. CONCLUSION OF LAW For the entire period on appeal, the criteria for a disability rating of 70 percent, but no higher, for PTSD have been met or approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has reviewed the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (explaining that the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Duties to Notify and Assist In correspondence dated December 2008, VA satisfied its duty to notify the Veteran pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), 4.2 (2013). The VCAA requires VA to assist a claimant at the time he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of the evidence that is necessary, or would be of assistance, in substantiating their claims, and provide notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2013); 38 C.F.R. § 3.159(b)(1) (2013); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006). The appeal for a higher initial disability rating for the service-connected PTSD arises from a disagreement with the initial evaluation following the grant of service connection. The Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. VA's duty to assist under the VCAA includes helping the Veteran obtain service treatment records and other pertinent records, as well as performing an examination or obtaining a medical opinion when one is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002 & Supp. 2013); 38 C.F.R. § 3.159(c) (2013). Here, the Veteran's service treatment records, VA medical records, and private treatment records identified by him are in the claims file. He has not identified any other records or evidence that remains outstanding. Thus, the duty to obtain relevant records on the Veteran's behalf is satisfied. See 38 C.F.R. § 3.159(c) (2013). With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). Additionally, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2013). The RO provided the Veteran VA examinations in October 2009 and September 2013. The examination reports are thorough and supported by the other evidence of record. The examination reports discussed the clinical findings and the Veteran's reported history as necessary to rate the disability under the applicable rating criteria. The examination reports also discussed the impact of the Veteran's PTSD on his daily living. Based on the examinations, the absence of evidence of worsening symptomatology since the latest examination, and the fact there is no rule as to how current an examination must be, the Board concludes the examination reports in this case are adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (noting that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2013). The Veteran declined the opportunity to present testimony before a Veterans Law Judge. The Veteran has been accorded the opportunity to present evidence and argument in support of his claim. Thus, the Board finds that VA has satisfied its duties to inform and assist the Veteran at every stage of this case, and may proceed to the merits of the Veteran's claim. Analysis Disability ratings are assigned, under a schedule for rating disabilities, based on a comparison of the symptoms found to the criteria in the rating schedule. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). 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 upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (2013). If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). The degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) As discussed above, the Veteran's disability rating for his service-connected PTSD was evaluated as 50 percent disabling prior to January 28, 2013, and 70 percent disabling thereafter. The Veteran claims the ratings do not accurately depict the severity of his condition. The General Rating Formula for Mental Disorders provides, in pertinent part: 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 .........50 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.........70 Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or name.........100 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the AMERICAN PSYCHIATRIC ASSOCIATION: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed. 1994) (hereinafter DSM-IV). Id. Additionally, a Global Assessment of Functioning (GAF) score is often used by treating examiners to reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996). According to a private treatment record from April 2008, the Veteran reported no nightmares, though he said that every night for the past 30 years he has woken up at 2:22 AM. He said he had a superficial support network, but did not allow anyone, including family or friends, to get close to him, adding that while he liked his friends as buddies, he did not have close relationships with anyone. He also reported having a limited intimate relationship with his wife. He said he felt he hid behind work most of his adult life and did not relate well with much of anything. The Veteran also said that he was experiencing no active flashbacks, but had experienced them in the past. The psychologist reported that the Veteran was on time for the appointment, and appeared very neatly dressed and groomed with a very pleasant demeanor. The psychologist said that the Veteran appeared alert and oriented in all spheres, and his thought content focused on competitiveness and secrecy. The psychologist added that the Veteran displayed no evidence of formal thought disorder or frank psychosis, and noted that the Veteran's memory, concentration, and general executive functioning were all within normal limits. The psychologist diagnosed the Veteran with PTSD, explaining that the Veteran was struggling with long term residual effects of emotional numbing, escape, and avoidance behaviors, and displayed some hypervigilance and caution. A private treatment record from May 2008 indicated that the Veteran said he had walls around his emotions, kept people at a distance, and enjoyed solitary or emotionally disconnected activities. A June 2008 private treatment record documented the Veteran's feeling that everyone would ultimately betray him, and that he kept emotionally distant from everyone except possibly his children. A private treatment record dated September 2008 noted his treating psychologist's opinion that the Veteran's PTSD symptoms were not severe, although they at times interfered with the Veteran's daily functioning. In a January 2009 private treatment note, the treating psychologist indicated that the Veteran was reluctant to take physical or emotional risks, and maintained a secret life away from his wife as a means of avoiding her disapproval. Another record from that same month noted that the Veteran tended to keep people at bay with pleasantries and humor and never let anyone know who he really was. According to a VA examination report dated October 2009, the Veteran reported often feeling depressed and suicidal, but that he hid that from others. The Veteran added that he had been battling those feelings for about 20 years. He said that he became very fearful of any type of confrontation after leaving Vietnam, and allowed others to take advantage of him over the years, as a mechanism to help deal with his significant hypervigilance. The Veteran reported experiencing intrusive thoughts related to Vietnam on a daily basis and recurrent nightmares two to three times per week. He reported difficulty sleeping at night, but said he was able to sleep five to six hours per night. The Veteran denied experiencing hallucinations or delusions. He also reported experiencing a persistent state of foreshortened future, as well as marked difficulty with social emotional detachment since leaving Vietnam. As an example of this, the Veteran explained that while he was quite close to his parents, he did not cry or show any outward emotion when they passed away. He said he had a difficult time expressing either negative or positive emotions of a genuine nature. He also reported experiencing intimacy with his wife maybe once per year and that he did not feel any desire to be close to her or anyone else. With respect to mental health care, the Veteran admitted he found it very difficult to open up about his experiences. The examiner reported the Veteran appeared clean, well groomed, and neatly dressed, and that he interacted in a friendly and cooperative manner, though the examiner observed that the Veteran was clearly using the outward friendliness at times to mask a significant amount of internal emotional trouble. The examiner noted that when the conversation turned to Vietnam, the Veteran became agitated and clearly anxious. The examiner observed that the Veteran's motivation was fair, and that his speech was clear, goal-directed, spontaneous, and of normal pace and volume. The examiner further noted that the Veteran's insight was weak, but that his judgment was fair and adequate for current safety. The examiner found that the Veteran was capable of managing all activities of daily living on his own, and stated that the Veteran's current level of distress would not preclude him from working on a full-time and consistent basis. Moreover, the examiner noted that Veteran was able to interact appropriately with others in a work environment, and that he could tolerate routine work stressors. However, the examiner also noted that the Veteran masked much of what he felt with a superficial display of pleasantness that has lead others to believe the Veteran functioned at a higher level at times than he appeared; the examiner explained that underneath there was certainly a high level of emotional distress. The examiner found that the symptoms described by the Veteran ranged in intensity and met the diagnostic criteria for PTSD; the examiner also assessed a GAF score of 55. A January 2010 VA psychological report indicated that the Veteran reported longstanding middle insomnia and dreams of Vietnam once or twice per week, as well as emotional numbing and a general lack of connection with others. The examiner noted that the Veteran appeared well groomed and maintained good eye contact, adding that the Veteran's attitude was cooperative and his speech was fluent, relevant, and coherent. The examiner described the Veteran's mood as euthymic, and his affect as appropriate to overt mood, explaining that the Veteran exhibited no emotional reaction to references to Vietnam. The Veteran's perception and thought content were normal, and his thought flow was spontaneous, linear, logical, and goal oriented. The Veteran denied suicidal and homicidal ideation. The Veteran's capacity for judgment was deemed good by history and his insight and reliably were found to be fair. The Veteran was oriented to all spheres and exhibited good concentration. The examiner continued the Veteran's diagnosis of PTSD and assessed a GAF score of 60. According to a private treatment record dated June 2010, the Veteran reported experiencing persistently intrusive and distressing memories and dreams of the trauma he experienced in Vietnam. The Veteran said that when he was exposed to cues reminding him of Vietnam, he isolated himself by getting in his car and leaving. He reported having a diminished interest or participation in significant activities, feeling detached and emotionally distant from others, and experiencing restricted emotions. He said that his emotional detachment had continued, as exemplified by his unwillingness to attend his aunt's funeral because he "didn't feel it." He indicated experiencing persistent symptoms of increased arousal including difficulty falling and staying asleep, irritability, difficulty concentrating, hypervigilance, and an exaggerated startle response. He said he continued to wake up at around 2:00 AM each night. He reported that his wife called him "the most dysfunctional person she has ever met." He said that he occasionally had thoughts of becoming violent, but that he did not act on those thoughts; similarly, he reported suicidal ideation but said he would never act on it. The Veteran reported experiencing panic attacks out of the blue, with symptoms such as a racing heart, perspiration, and hot flashes or chills; he added that he experienced panic attacks in the presence of authority figures. He also reported experiencing anxiety prior to social interactions. He reported not having any social support aside from running buddies and two friends with whom the Veteran served in Vietnam, but noted that he never shared personal thoughts with anyone, including family. He reported enjoying his jobs as a marriage celebrant and part-time pharmacy technician. The Veteran's wife reported that he was disorganized all the time, was unable to express sadness, and acted as though everything was okay even when it was not. She added that he had no close male friends, that he did not socialize, and only saw his running buddies on a regular basis. The examiner reported that the Veteran was early for each assessment session, was consistently well groomed, congenial, extremely talkative and personable during the sessions. The Veteran answered questions willingly, often adding anecdotes or metaphors to illustrate a point, and coherently spoke at a normal rate. The examiner noted that the Veteran's concentration and attention appeared within normal limits, and that his thought process and content were logical and goal-directed, though the examiner noted the Veteran tended to jump from subject to subject quickly. The examiner said that the Veteran endorsed symptoms including anxiety and autonomic hyperarousal; depression, thoughts and general feelings of sadness, as well as thoughts about death and dying and periods of self-isolation; angry mood and irritable affect; intrusive experiences like flashbacks, nightmares, or upsetting memories; emotional avoidance; cognitive disengagement, depersonalization, derealization and emotional numbing; sexual distress and dysfunction; and an inadequate sense of self and personal identity. The examiner assessed the Veteran with PTSD, Major Depressive Disorder, recurrent, and anxiety. Further, the examiner observed that the Veteran experienced severe impairment from his PTSD and depression that kept him from attaining career goals and significantly inhibited his relations with friends and family. A buddy statement from T.W., received in December 2010, indicated that the Veteran discussed with T.W. finding a cave in the mountains and lying down and starving himself to death. T.W. also wrote that the Veteran said he spent more and more time alone, and often felt hopeless. T.W.'s statement included a poem written by the Veteran, which T.W. said disturbed him and could be interpreted as a suicide note. A private medical record received in December 2010 indicated that the Veteran's interpersonal, social, and emotional life had been severely impaired by his PTSD. The examiner recounted the Veteran's wife's statement that the Veteran is pleasant to talk to but that one would not get a "heartfelt conversation" from him, adding that he always stayed on the surface. According to a January 2013 VA mental health consultation report, the Veteran reported often feeling irritable and that he felt completely detached from most people in his life, including his wife of 35 years and his children, but that he did not let that feeling show. He said he only found pleasure in his morning oatmeal on the porch and his daily running, and little pleasure from anything else. He stated that his sleep was very poor and erratic, and that he was never able to sleep through the night, only getting about two to three hours of rest during the night. He reported racing thoughts but no rapid speech. He said that his wife often told him that he was "f&*^%ed up," and that people in his church often told him the same thing. He denied experiencing paranoia, hallucinations, and ideas of reference, thought insertion, deletion, or blocking. He denied suicidal and homicidal ideation, but also said that he had thoughts of "letting himself die." He also said that he bit his hand whenever he felt irritated or stressed. The examiner observed that the Veteran appeared unkempt, noting that his shirt was halfway unbuttoned and his pants were dirty and stained. The examiner described his activity as restless, explaining that the Veteran got up several times during the interview to demonstrate things. The Veteran's attitude was cooperative, frank, ingratiating, and his speech was fluent, relevant, and coherent. The examiner noted that while the Veteran described his mood as depressed and "silent anger," the Veteran's affect was incongruent with that mood and instead was pleasant and placid in an almost forced manner. The examiner noted that the Veteran's thought content, specifically regarding people telling him that he was "f&*^%ed up," could have been a perceptual alteration or in the Veteran's mind. The examiner also noted that the Veteran's judgment was fair and his insight poor. The examiner assessed a GAF score of 50. According to a VA examination report dated September 2013, the Veteran reported experiencing symptoms including depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss, flattened affect, disturbances of motivation and mood, and difficulty in and an inability to establish and maintain effective work and social relationships. The Veteran denied any current suicidal or homicidal ideation, intent, or plan, as well as any hallucinations or delusions. The Veteran reported independent management of his activities of daily living. He said he had no real relationship with his wife and family, and noted that he exhibited isolating behavior and fear of embarrassing and hurting others. The Veteran indicated that he remained non-social, and drove to church alone rather than with his wife, adding that he and his wife slept in different bedrooms and had not been intimate in several years. He also complained that his symptoms had worsened in severity and intensity in the last few years. The examiner noted that the Veteran appeared alert, oriented, cooperative, and demonstrated good grooming and hygiene. The Veteran's mood was extremely anxious with congruent affect, and his speech was of a normal rate, rhythm, and volume. The Veteran also exhibited dismissive and emotionally distant behavior when discussing the traumatic events he experienced in Vietnam. The examiner confirmed the diagnosis of PTSD and assessed a GAF score of 55. The Board concludes that the objective medical evidence and the Veteran's statements regarding his symptomatology show a disability that more nearly approximates the assignment of a 70 percent disability rating prior to January 28, 2013. See 38 C.F.R. § 4.7 (2013). In reaching this conclusion, the Board notes the statement of the Veteran's representative indicating the Veteran experienced suicidal ideation prior to January 2013, and that a private medical report indicated the Veteran's impairment due to PTSD was severe. The Veteran reported little social interaction with others and anxiety prior to social engagement; the record indicates that socializing that did occur was largely limited to superficial interactions. For the entire period on appeal, the Veteran reported a limited, and at times strained, relationship with his wife; he said that he did not feel any desire to be close to her or anyone else. The Veteran also reported feeling detached from his children. The Veteran's wife said that his inability to express sadness made a marriage difficult, and that the Veteran acted as though everything was okay even when it was not. He reported often feeling depressed and suicidal, and described severe emotional detachment to the degree that he felt no emotions from his parents' passing, despite being quite close to them. This depression was corroborated by the Veteran's friend T.W., who wrote that the Veteran isolated himself and often felt hopeless. The Veteran also reported experiencing intrusive thoughts related to Vietnam on a daily basis, and nightmares and distressing dreams about his experiences there as well. The October 2009 VA examiner noted that the Veteran's pleasant exterior served as a mechanism to mask significant internal emotional trouble. The examiner added that this exterior likely led others to believe that the Veteran functioned at a higher level than he appeared. The Board finds this notation significant. In summary, the Board finds that the above symptoms, which have persisted throughout the appeal period, more closely approximate those contemplated by the higher 70 percent rating. 38 U.S.C.A. § 5107 (West 2002). The Board acknowledges that the results of the VA examinations and the symptoms described in the VA and private treatment records do not indicate that the Veteran experienced all of the symptoms associated with a 70 percent disability rating for PTSD. However, the United States Court of Appeals for Veterans Claims (the Court) has held that the symptoms enumerated under the schedule for rating mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular disability rating. See Mauerhan, 16 Vet. App. 436. Thus, a finding that there is occupational and social impairment resulting in deficiencies in most areas is sufficient to warrant a 70 percent disability rating for the entire period on appeal, even though all the specific symptoms listed for a 70 percent rating are not manifested. The evidence does not reflect that the Veteran's PTSD symptoms are of such severity as to warrant a disability rating in excess of 70 percent at any time. Significantly, the Veteran has not been found to have symptoms such as gross impairment in thought processes, grossly inappropriate behavior, persistent delusions or hallucinations, persistent danger of hurting self or others, or disorientation to time or place-all symptoms which would warrant a 100 percent disability rating. Nor has he experienced other symptoms on a par with the level of severity exemplified in these manifestations. Accordingly, entitlement to a rating in excess of 70 percent for any period of time on appeal is not warranted. Extraschedular Consideration The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the Rating Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the Rating Schedule is inadequate to evaluate the Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the Veteran reported multiple psychiatric symptoms, including frequent depression, anxiety, suspiciousness, panic attacks that occur weekly or less, chronic sleep impairment, disturbances of motivation and mood, suicidal ideation, and a difficulty and an inability to establish and maintain effective work and social relationships. The current 70 percent rating contemplates these and other psychiatric symptoms. In short, the rating criteria reasonably describe the Veteran's disability levels and symptomatology. 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 caused him to miss work or has resulted in any hospitalizations. Therefore, the Veteran's service-connected PTSD does not result in marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1). Thus, even if his disability picture was exceptional or unusual, referral would not be warranted. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. (CONTINUED ON NEXT PAGE) ORDER An initial disability rating of 70 percent is granted for the service-connected PTSD for the entire period on appeal, subject to the laws and regulations governing the payment of monetary benefits. REMAND The December 2009 rating decision denied the Veteran's claim of entitlement to service connection for a liver disorder on the basis that no liver disorder was shown to have occurred in service, nor did the record contain a nexus opinion linking the Veteran's liver disorder to his military service. However, a statement submitted by the Veteran in August 2013 indicates the existence of in-service events that may be linked to the Veteran's current liver disorder. Specifically, the Veteran described exposure to blood on multiple occasions while working as an Operating Room Technician during his period of service in Vietnam. VA regulation provides in pertinent part that a VA examination is necessary where the record does not contain sufficient competent medical evidence to decide the claim, but there is evidence of an in-service event, injury, or disease. 38 C.F.R. § 3.159(c)(4)(i) (2013). Given the aforementioned evidence, the Veteran should be afforded a VA examination to evaluate the current nature and etiology of his liver disorder. Additionally, as the claim for entitlement to TDIU is now on appeal before the Board, a medical opinion should be obtained as to whether the Veteran is precluded by reason of any of his service-connected disabilities from obtaining and maintaining any form of substantial gainful employment consistent with his education and occupational experience. While on remand, all outstanding VA and private treatment records relating to the Veteran's liver disorder should be obtained and made part of the record. Next, the Veteran should be scheduled for a VA examination for his liver disorder. Then, a VA medical opinion should be obtained for his TDIU claim. Any accompanying opinion should be supported by a rationale. Accordingly, the case is REMANDED for the following actions: 1. Obtain all outstanding VA treatment and evaluation records dated for the entire period on appeal to present. In particular, all records and reports relating to the Veteran's liver disorder should be obtained. All records received should be associated with the claims file. 2. Request the Veteran furnish all dates and places of treatment for his liver disorder. After obtaining authorization from the Veteran, request copies of any outstanding treatment records from any treatment provider identified by the Veteran. If VA is unable to obtain such records, the Veteran should be accorded the opportunity to furnish such records directly to VA. All records received should be associated with the claims file. 3. When the above actions have been accomplished, to the extent possible, afford the Veteran an examination by an appropriate examiner, to determine the current nature and etiology of his liver disorder. The examiner should review the Veteran's claims file in conjunction with the examination. Any indicated studies or diagnostic tests should be performed. Based on the review and the exam, the examiner is asked to opine whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran's current liver disorder had its onset in service or is otherwise related to service. Review of the entire file is required; however attention is invited to the August 2013 statement describing his duties as an Operating Room Technician while in Vietnam. A rationale for any opinion offered is requested. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. 4. After completion of the above development, and if necessary, schedule the Veteran for an appropriate VA examination for his claim of entitlement to TDIU. The claims file should be provided to the appropriate examiner for review, and the examiner should note that it has been reviewed. The examiner should elicit a history from the Veteran regarding his recent employment and examine the Veteran thoroughly. After reviewing the file, noting the Veteran's reported history, and examining the Veteran, the examiner should render an opinion as to whether the Veteran is precluded solely by reason of his service-connected disabilities from obtaining and maintaining any form of substantial gainful employment consistent with his education and occupational experience. The examiner is advised that only symptoms related to the Veteran's service-connected disabilities should be considered in determining whether the Veteran is precluded from obtaining and maintaining employment. Symptoms related to non-service-connected disabilities should not be considered in this determination. A rationale for any opinion offered is requested. 5. Ensure completion of the foregoing and any other development deemed necessary, then readjudicate the Veteran's claims. If the claims remain denied, the Veteran should be provided with a Supplemental Statement of the Case and an opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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). ______________________________________________ Bethany L. Buck Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs