Citation Nr: 1415621 Decision Date: 04/09/14 Archive Date: 04/15/14 DOCKET NO. 12-08 101 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an initial rating higher than 30 percent for posttraumatic stress disorder before June 27, 2012. 2. Entitlement to an initial rating higher than 40 percent for impairment of the right upper extremity due to Parkinson's disease. 3. Entitlement to an initial rating higher than 30 percent for impairment of the left upper extremity due to Parkinson's disease. 4. Entitlement to an initial rating higher than 20 percent for impairment of the right lower extremity due to Parkinson's disease. 5. Entitlement to an initial rating higher than 20 percent for impairment of the left lower extremity due to Parkinson's disease. 6. Entitlement to an initial rating higher than 10 percent for impairment of the facial muscles due to Parkinson's disease. 7. Entitlement to a total disability rating for compensation based on individual unemployability. WITNESSES AT HEARING ON APPEAL The Veteran and M.M. ATTORNEY FOR THE BOARD Joshua Castillo, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1970 to April 1972. This matter is before the Board of Veterans' Appeals (Board) on appeal of rating decisions in May 2010 and in January 2011 of a Department of Veterans Affairs (VA) Regional Office (RO). In March 2013, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is in the record. In February 2011, the Veteran raised the claim for a total disability based on individual unemployability, which is REMANDED to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. Before June 27, 2012, PTSD was manifested by symptoms resulting in no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. Parkinson's disease is manifested by moderate impairment of the right (major) upper extremity. 3. Parkinson's disease is manifested by moderate impairment of the left (minor) upper extremity. 4. Parkinson's disease is manifested by moderate impairment of the right lower extremity. 5 Parkinson's disease is manifested by moderate impairment of the left lower extremity. 6 Parkinson's disease is manifested by moderate impairment of the facial muscles. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 30 percent for PTSD before June 27, 2012. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, DC 9411 (2013). 2. The criteria for an initial rating higher than 40 percent for impairment of the right upper extremity due to Parkinson's disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, Diagnostic Codes (DC) 8004-8513 (2013). 3. The criteria for an initial rating higher than 30 percent for impairment of the left upper extremity due to Parkinson's disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, DC 8004-8513 (2013). 4. The criteria for an initial rating higher than 20 percent for impairment of the right lower extremity due to Parkinson's disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, DC 8004-8520 (2013). 5. The criteria for an initial rating higher than 20 percent for impairment of the left lower extremity due to Parkinson's disease have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.124a, DC 8004-8520 (2013). 6. The criteria for an initial rating higher than 10 percent for impairment of the facial muscles due to Parkinson's disease have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1-4.10, 4.68, 4.124a, DC 8004-8207 (2013). The Veterans Claims Assistance Act of 2000 (VCAA) Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of (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. Duty to Notify Where, as here, service connection has been granted and the initial ratings have been assigned, the claims of service connection has been more than substantiated, the claims have been proven, thereby rendering 38 U.S.C.A. §5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once the claims of service connection have been substantiated, the filing of a notice of disagreement with the RO's decision, rating the disabilities does not trigger additional 38 U.S.C.A. § 5103(a) notice. Goodwin v. Peake, 22 Vet. App. 128, 136 (2008). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The RO has obtained service treatment records, VA records, and private medical records. On the claim for increase for PTSD, the Veteran was afforded a VA psychiatric examination in March 2010 and an addendum opinion was obtained in April 2010. The Veteran asserts that the examination was inadequate for rating PTSD, because the examination was only 20 minutes and did not reflect the severity of PTSD. A second VA examination was conducted in March 2011. The Veteran does not argue that the second examination was inadequate. As the reports of the VA examinations were based on the Veteran's medical history and described PTSD in sufficient detail so that the Board's decision is a fully informed one, the examinations were adequate. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). On the claim for increase for Parkinson's disease, the Veteran was afforded VA examinations in December 2010, in July 2011, and in July 2012. The Veteran asserts that the VA examination in July 2012 was inadequate for rating Parkinson's disease, involving the upper and lower extremities and facial muscles. As the reports of the VA examinations were based on the Veteran's medical history and described Parkinson's disease in sufficient detail so that the Board's decision is a fully informed one, the examinations were adequate. Stefl, at 123. As there is no indication of the existence of additional evidence to substantiate the claims, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Legal Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate Diagnostic Codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If there is a question as to which of two evaluations shall be applied, 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. 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). PTSD Rating Criteria PTSD was rated 30 percent before June 28, 2012, and is currently rated 100 percent, the maximum rating, from June 28, 2012, under 38 C.F.R. § 4.130, the General Rating Formula for Mental Disorders, Diagnostic Code 9411. Under the General Rating Formula for Mental Disorders, Diagnostic Code 9411, the criteria for a 50 percent, the next higher rating above 30 percent, are 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. Under the General Rating Formula for Mental Disorders, Diagnostic Code 9411, the criteria for a 70 percent rating are 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. Under the General Rating Formula for Mental Disorders, Diagnostic Code 9411, the criteria for a 100 percent rating are 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 of 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. Ratings are assigned according to the manifestation of particular symptoms, but the use of the term "such as" in the General Rating Formula demonstrates that the symptoms after the 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. Accordingly, the evidence considered in determining the level of impairment from posttraumatic stress disorder under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411. Rather VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, symptoms identified with the diagnosis of posttraumatic stress disorder in DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health- illness." DSM-IV at 32. A GAF score of 51 to 60 indicates that the examinee has 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 co-workers). A GAF score of 41 to 50 indicates that the examinee has serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job). While the GAF score is relevant evidence, the GAF score alone is neither statutorily nor regulatory controlling in rating a psychiatric disorder, rather the rating is determined by the application of the Rating Schedule, 38 C.F.R. Part 4. Evidence On VA psychiatric examination in March 2010, the Veteran complained of difficulty sleeping; intrusive thoughts about Vietnam; hypervigilance; exaggerated startle response to loud noises; difficulty in crowds; and decreased focus and memory. He denied symptom of hopeless, flashbacks, anger, irritability, and suicidal or homicidal ideation. He described himself as a "good natured person". The Veteran stated that he had good relationships his wife of 32 years, children, and several close friends outside the family. The Veteran stated he was currently self-employed as a financial consultant and he had 30 years of experience in the banking industry. He indicated that his analytical work-related skills were sharp. The VA examiner reported that the Veteran was alert and well-oriented. The Veteran's thought processes were linear. His affect was mildly anxious. There was mild difficulty with attention and memory. There were no symptoms of psychosis. The VA examiner found that the Veteran was competent to manage his funds. The VA examiner expressed the opinion that PTSD was mild. The VA examiner concluded that PTSD was manifested by mild impairment of social and occupational functioning. The GAF score was 60. On VA examination in March 2011, the Veteran complained that he was worried that he was not going to be able to perform his job because of his Parkinson's disease. He described symptoms of a depressed mood, loss of interest, decreased energy, irritability, a decrease in concentration since his last VA examination. The VA examiner noted that the Veteran was in counseling with VA, but he was not on medication. The VA examiner described the Veteran was neatly dressed and groomed. The Veteran's affect was flat. His mood was dysphoric. He was oriented. Attention and concentration were fair. Insight and judgment were adequate. The VA examiner found that the Veteran was competent to manage his funds. The diagnoses were PTSD and depressive disorder due to Parkinson's disease. The GAF score was 50. In March 2013, the Veteran asserted that the 100 percent rating should be effective from the original date of claim in November 2009, because the VA examination in April 2010, which essentially consisted of a questionnaire and lasted about 20 minutes, which was the basis for 30 percent rating, was inadequate. Analysis The Board has already addressed the Veteran's assertion about the inadequacy of the VA examination in April 2010. And the Board has restated the issue as an initial rating higher than 30 percent before June 2012, which is another way of stating that the claim is one for a 100 percent rating before June 2012 and the restatement does not affect the facts or the application of the law or the analysis. Reconciling the various reports into a consistent disability picture, two elements of the PTSD before June 2012 emerge. First, the Veteran has symptomatology that is associated with the rating criteria under the General Rating Formula and symptomatology not covered in the rating criteria, but are associated with the diagnosis of posttraumatic stress disorder under the DSM-IV, which is referred to in 38 C.F.R. Part 4, § 4 .130 (rating mental disorders). And two, while there has been some fluctuation in the symptoms of PTSD, a material increase in the overall severity of PTSD was not shown before June 2012. As the disability picture has remained essential constant in symptomatology, in the clinical findings, and in the impact on occupational and social function before June 2012, there is no factual basis for a staged rating before June 2012. As for the Veteran's symptomatology covered under the General Rating Formula, the Veteran complained of difficulty with attention and memory, a depressed mood, loss of interest, decreased energy, anxiety, and a flat affect. As for the Veteran's symptomatology associated with the diagnosis of posttraumatic stress disorder under the DSM-IV, the Veteran complained of difficulty sleeping, intrusive thoughts about Vietnam, hypervigilance, exaggerated startle response to loud noises, difficulty in crowds, and decreased concentration. As for meeting the criteria for the next higher rating before June 27, 2012, on the VA examinations the Veteran's affect was mildly anxious or flat. While there was evidence of some difficulty with attention and concentration, the symptoms were described as mild or fair. The Veterans' mood was dysphoric. Although the Veteran had some of the symptoms for the higher rating, such as flattened affect and depressed mood, and symptoms associated with PTSD, neither the number of symptoms, nor the type of symptoms, nor the GAF score controls in determining whether the criteria for the next higher rating have been met. It is the effect of the symptoms, rather than the presence of symptoms, pertaining to the criteria for the next higher rating, that is determinative. The record shows that there was no circumstantial, circumlocutory, or stereotyped speech, and no panic attacks. There was no evidence of difficulty in understanding complex commands, or of impairment of short- and long-term memory, for example, forgetting to complete tasks. Insight and judgment were adequate. There was no evidence of impaired abstract thinking. And there was no evidence of difficulty in establishing and maintaining effective work or social relationships. One VA examiner found that the symptoms of PTSD did not result in more than mild difficulty in social and occupational functioning, consistent with a GAF score of 60, indicative of no more than moderate symptoms. The other VA examiner assigned a GAF score of 50 indicative of serious symptoms, for example, suicidal ideation, severe obsessional rituals, no friends, and inability to keep a job, none of which was evident by history, by the Veteran's complaints, by the clinical findings, or by the VA examiner's conclusions. The effect of the symptomatology does not more nearly approximate or equate to occupational and social impairment with reduced reliability and productivity. And before June 27, 2012, the criteria for a 100 percent rating, namely, 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 of others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name was not shown. The overall combined symptoms of PTSD under the General Rating Formula for Mental Disorders and under DSM-IV do not more nearly approximate or equate to the criteria for an initial rating higher rating than 30 percent under Diagnostic Code 9411, before June 27, 2012, and the criteria for a 100 percent rating were not met before June 27, 2012. As the preponderance of the evidence is against the claim for increase, the benefit-of-the-doubt standard of proof does not apply. Parkinson's Disease Rating Criteria Parkinson's disease is rated under Diagnsotic Code 8004. Under Diagnostic Code 8004, the minimum rating is 30 percent when there are ascertainable residuals of the disability. For a rating higher than the minimum rating, the residuals of the disability may be rated separately under the appropriate Diagnostic Code. The ascertainable residuals of Parkinson's disease are rated separately as impairment of the upper extremities, 40 percent for the right upper extremity and 30 percent for the upper left extremity; impairment of the lower extremities, 20 percent for the right lower extremity and 20 percent for the lower left extremity, and for impairment of the facial muscles, 10 percent. The combined rating exceeds 30 percent, the minimum rating for the disability under Diagnostic Code 8004. Impairment of the right (major) upper extremity is rated 40 percent rating under Diagnostic Code 8513. Under Diagnostic Code 8513, the criterion for the next higher rating, 70 percent, is severe, incomplete paralysis of a major radicular group. Impairment of the left (minor) upper extremity is rated 30 percent rating under Diagnostic Code 8513. Under Diagnostic Code 8513, the criterion for the next higher rating, 60 percent, is severe, incomplete paralysis of a major radicular group. Impairment of the right lower extremity and impairment of the left right lower is each rated 20 percent under Diagnostic Code 8520. Under Diagnostic Code 8520, the criterion the next higher rating, 40 percent, is moderately severe, incomplete paralysis of the sciatic nerve. Impairment of the facial muscles is rated 10 percent under Diagnostic Code 8207. Under Diagnostic Code 8207, the criterion for the next higher rating, 20 percent, is for severe, incomplete paralysis of the cranial nerves. The term "incomplete paralysis," as it pertains to the peripheral nerves indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve. Evidence VA records show that in February 2010 the Veteran stated that since Parkinson's disease was diagnosed the disease had progressed, but the disease was still fairly well controlled with an increase in medication. The pertinent finding was a tremor at rest in the left upper. The cranial nerves II through XII were grossly intact. Motor function was 5 of 5. Sensory function was intact to light touch. The deep tendon reflexes were 2+. In March 2010, the Veteran was seen in follow-up for ongoing VA primary care. On evaluation, the oropharynx was normal. Gait and station were normal. Muscle strength and tone of the upper extremity was normal and sensation to touch of the upper extremities was normal. The knee and elbow areas had no pathological reflexes. The findings were similar on follow-up on February 2011. On VA examination in December 2010, the Veteran described tremors on the entire left side of his body; impaired use of his hands, unable to button or unbutton his clothes, difficulty with balance and with getting in and out of chairs, and decreased blinking. He complained of drooling. The pertinent findings were a mild shuffling gait, increased muscle tone in all four extremities, more so on the left than the right, obvious resting tremors, more so on the left, decreased number of blinks per minute, and poverty of facial expression. The VA examiner characterized Parkinson's disease as moderate. In July 2011, the Veteran described numbness and shaking in all four extremities. He stated that his upper left extremity is in a claw shape, and that he has to rely on his right upper extremity for physical tasks. He also described slow walking and stumbling. On VA examination of the left hand in July 2011, there was no opposition thumb defect. There was normal strength and dexterity. On VA neurological examination in July 2011, the Veteran stated that his left hand was useless and it took 1.5 hours to type an email. He stated that he needed assistance to tie his shoes, cut his food, and rake the yard. The Veteran indicated that there was a slow response from the time he thought of moving an extremity until there was actual movement in the extremity. He stated that he continued with fulltime self-employment as a banking consultant. The VA examiner reported increased muscle tone in all four extremities, tremors in the upper extremities, moderate weakness in all four extremities, present and symmetrical deep tendon reflexes, and decreased facial expressions or mask-like face. The VA examiner characterized Parkinson's disease as moderate. In a Parkinson's disease Disability Benefits Questionnaire, dated in June 2012, the Veteran described the following impairments as either severe or moderate: stooped posture, balance impairment, bradykinesia or slowed motion, loss of automatic movements, speech changes, tremor, muscle rigidity, depression, cognitive impairment, partial loss of smell, sleep disturbance, difficulty swallowing, urinary problems, constipation, and sexual dysfunction. On VA examination in July 2012, the Veteran denied facial symptoms, such as electric shock pain, twitching or spasm, and weakness or paralysis of facial muscles. The Veteran did describe drooling and difficulty speaking, which the VA examiner characterized as mild. Sensory examination of cranial nerve V (trigeminal nerve) was normal. Motor examination as to masticatory function was symmetrical. Examination of cranial nerve XI (spinal accessory nerve) showed that the right and left trapezius muscles and the right and left sternocleidomastoid muscles were normal. There was no evidence of atrophy or asymmetry. On examination of cranial VII (facial nerve), eyebrow lifting was absent, and forehead wrinkling, closing the eyes, and frowning were weak on the right and left sides. Symmetry, smiling, showing of teeth, puffing of cheeks, and tearing were normal on the right and left sides. There was no loss of taste on the anterior 2/3 part of the tongue. On examination of cranial nerve XII (hypoglossal nerve), there was no atrophy and speech was normal. On examination of cranial nerve IX (glossopharyngeal) and cranial nerve X (vagus nerve), the ability to swallow was normal. Dysarthria was mild. There was no loss of taste on the posterior 1/3 part of the tongue. The VA examiner stated that the facial expression and facial nerve abnormalities and hypophonia were due to Parkinson's disease, and not to any dysfunction of the facial nerve. The summary was facial expressions slow and incomplete. As for the upper and lower extremities, there was no evidence of pain. Muscle testing at the elbow, wrist, grip, knee, and ankle were 5 of 5. There was no evidence of atrophy. The deep tendon reflexes were normal in the upper and lower extremities. Sensation to light touch was normal in the upper and lower extremities. Gait was stooped and with little steps. There was no evidence of paralysis in the peripheral nerves of the upper and lower extremities. The VA examiner stated that the Veteran had moderate symptoms of Parkinson's disease, resulting in poor social interactions, decreased mobility, decreased manual dexterity, problems lifting and carrying, speech difficulty, and weakness. Analysis The Veteran does not assert and the clinical findings do not show complete paralysis of any upper or lower extremity peripheral nerve or facial nerve. The remaining questions are whether there is severe incomplete paralysis, the criterion for the next higher rating for the affected peripheral nerve of the upper extremities under Diagnostic Codes 8513, or whether there is moderately severe impairment, the criterion for the next higher rating, of the peripheral nerve of the lower extremities under Diagnostic Code 8520, or whether there is severe incomplete paralysis of the affected facial nerve under Diagnostic Code 8207. Severe incomplete paralysis of a peripheral or cranial nerve is characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain. 38 C.F.R. § 4.123. The record shows that since Parkinson's disease was diagnosed the disease had progressed, but the disease was still fairly well controlled with an increase in medication. And during the pendency of the appeal, Parkinson's disease has been characterized as moderate on three separate VA examinations. The pertinent findings for the upper extremities are: tremors, motor function of 5 of 5, intact sensation to light touch, 2+, normal, deep tendon reflexes, increased muscle tone, moderate weakness, no evidence of pain, and no evidence of atrophy. In the absence of evidence of the loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, the findings do not more nearly approximate or equate to severe incomplete paralysis of the peripheral nerve of the upper extremities under Diagnostic Code 8513. The pertinent findings for the lower extremities are: a stooped and mild shuffling gait, no pathological reflexes, increased muscle tone, moderate weakness, normal sensation to light touch, no evidence of pain, and no evidence of atrophy. In the absence of evidence of the loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, the findings do not more nearly approximate or equate to either severe or moderately severe incomplete paralysis of the peripheral nerve of the lower extremities under Diagnostic Code 8520. The pertinent findings for the affected cranial nerve are: grossly normal intact cranial nerves II through XII, decreased number of blinks per minute, poverty of facial expression, drooling and difficulty speaking, which the VA examiner characterized as mild. In the absence of evidence of the loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, the findings do not more nearly approximate or equate to severe incomplete paralysis of the affected facial nerve under Diagnostic Code 8207. As the preponderance of the evidence is against the claims for initial higher ratings for the impairment of the upper extremities, of the lower extremities, and of a facial nerve, due to Parkinson's Disease, the benefit-of-the-doubt does not apply. Extraschedular Consideration Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for a service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of a service-connected disability with the established criteria. If the criteria reasonably describe the disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned rating is adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Rating PTSD before June 27, 2012, comparing the disability level and symptomatology to the Rating Schedule, the degree of disability is encompassed by the Rating Schedule and the assigned schedule rating was adequate. In other words, the rating criteria reasonably describe the Veteran's disability and symptomatology, and the Veteran does not have any symptomatology not already encompassed under the General Rating Formula for Mental Disorders and under DSM-IV. Parkinson's disease, which is rated as impairment of the upper and lower extremities and facial muscles, is manifested by signs and symptoms such as stooped posture, balance impairment, bradykinesia or slowed motion, loss of automatic movements, depression, sleep disturbance, constipation, partial loss of smell and moderate speech changes, cognitive impairment or dementia, difficulty swallowing, and sexual dysfunction. The level of impairment is encompassed in the rating schedule under Diagnostic Codes 8004, 8513, 8520, and 8207 on the basis of the ascertainable residuals of Parkinson's disease, including impairment of the upper and lower extremities and facial muscles. Accordingly, the Board concludes that the schedular rating criteria reasonably describe the Veteran's disability picture. For these reasons, referral of either Parkinson's disease or PTSD for an extraschedular rating is not warranted under 38 C.F.R. § 3.321(b)(1). ORDER An initial rating higher than 30 percent for posttraumatic stress disorder before June 27, 2012, is denied. An initial rating higher than 40 percent for impairment of the right upper extremity due to Parkinson's disease is denied. An initial rating higher than 30 percent for impairment of the left upper extremity due to Parkinson's disease is denied. An initial rating higher than 20 percent for impairment of the right lower extremity due to Parkinson's disease is denied. An initial rating higher than 20 percent for impairment of the left lower extremity due to Parkinson's disease is denied. An initial rating higher than 10 percent for impairment of the facial muscles due to Parkinson's disease is denied. REMAND In February 2011, during the pendency of the appeal, the Veteran raised the claim for a total disability rating for compensation based on individual unemployability (TDIU), which is not a separate claim, but a part of the claim for increase. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (in a claim for increase, where the Veteran expressly raises a claim for a total disability rating on the basis of individual unemployability or the claim is reasonably raised by the record, the claim is not a separate claim, but a part of a claim for increase). Accordingly, the case is REMANDED for the following action: 1. Ensure VCAA compliance with the duty to notify and the duty to assist on the TDIU claim. 2. After the above development, adjudicate the TDIU claim. If the benefit sought is denied, furnish the Veteran and his representative a supplemental statement of the case and return the case to the Board The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The 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 (Court) for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs