Citation Nr: 1422650 Decision Date: 05/19/14 Archive Date: 05/29/14 DOCKET NO. 07-16 049 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUES 1. Entitlement to an effective date earlier than June 2, 1997, for the grant of service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial rating in excess of 30 percent for PTSD. 3. Entitlement to a rating in excess of 40 percent for diabetes mellitus. 4. Entitlement to an initial rating in excess of 10 percent for right upper extremity peripheral neuropathy. 5. Entitlement to an initial rating in excess of 10 percent for left upper extremity peripheral neuropathy. 6. Entitlement to an initial rating in excess of 10 percent for right lower extremity peripheral neuropathy. 7. Entitlement to an initial rating in excess of 10 percent for left lower extremity peripheral neuropathy. 8. Entitlement to a disability rating in excess of 10 percent for arteriosclerosis and hypertension. 9. Entitlement to a total disability rating based on individual unemployability (TDIU). 10. Entitlement to additional compensation benefits for D.C. as an allowable dependent. 11. Entitlement to additional compensation benefits for P.C. as an allowable dependent. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Devon Rembert-Carroll, Associate Counsel INTRODUCTION The Veteran had active duty service from January 1970 to November 1971 and from December 1972 to December 1973. This mater was originally before the Board of Veterans' Appeals (Board) on appeal from July 2005 and December 2007 rating decisions. In December 2011, the Veteran appeared at a hearing before a Veterans Law Judge (VLJ). In April 2012, the Board issued a decision that, in part, dismissed a claim of entitlement to a rating in excess of 40 percent for diabetes mellitus; and denied the claims of entitlement to an effective date earlier than June 2, 1997, for the grant of service connection for PTSD, entitlement to an initial rating in excess of 30 percent for PTSD, entitlement to an initial rating in excess of 10 percent for right upper extremity peripheral neuropathy, and entitlement to an initial rating in excess of 10 percent for left upper extremity peripheral neuropathy. The decision also granted the claims of entitlement to an initial rating in excess of 10 percent for right lower extremity peripheral neuropathy and entitlement to an initial rating in excess of 10 percent for left lower extremity peripheral neuropathy. Pursuant to a settlement agreement in the case of National Org. of Veterans' Advocates, Inc. v. Secretary of Veterans Affairs, 725 F.3d 1312 (Fed. Cir. 2013), the Board's April 2012 decision was identified as having been potentially affected by an invalidated rule relating to the duties of the VLJ that conducted the December 2011 hearing. In order to remedy any such potential error, the Board sent the Veteran a letter notifying him of an opportunity to receive a new decision from the Board that would correct any potential due process error relating to the duties of the VLJ that conducted the December 2011 hearing. See Bryant v. Shinseki, 23 Vet. App. 488 (2010) (holding that the requirements of 38 C.F.R. § 3.103(c)(2) apply to a hearing before the Board and that a VLJ has a duty to explain fully the issues and to suggest the submission of evidence that may have been overlooked). In October 2013, the Veteran responded that he wished to have the prior decision vacated and a new one issued in its place. This decision satisfies that request. The Board notes that an April 2012 rating decision implemented the Board's grant of the claims of entitlement to an initial rating in excess of 10 percent for right lower extremity peripheral neuropathy and entitlement to an initial rating in excess of 10 percent for left lower extremity peripheral neuropathy. This decision will not disturb that favorable rating decision. The Board also notes that a review of the Virtual VA paperless claims processing system and Veteran's benefit Management System (VBMS) does not reveal any additional documents not already associated with the claims file. The issues of entitlement to a disability rating in excess of 10 percent for arteriosclerosis and hypertension, entitlement to TDIU, and entitlement to additional compensation benefits for P. C. and D. C. are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The earliest document that may be accepted as a claim for service connection for PTSD is an informal claim filed by the Veteran and received by the VA on June 2, 1997. 2. The Veteran's PTSD manifested by nightmares, sleep difficulties, intermittent depression, a single subjective report of suicidal and a single reported instance of panic attacks; there was no evidence of occupational impairment, a flattened effect, circumstantial, circumlocutory or stereotyped speech, difficulty understanding complex commands, impairment in short and long term memory, impaired judgment, impaired abstract thinking, impaired impulse control, neglect of personal appearance, difficulty in establishing and maintaining work or social relationships or clinical evidence of suicidal or homicidal ideations with intent or plan. 3. The Veteran withdrew his claim for an increased rating for diabetes mellitus at his December 2011 hearing. 4. The Veteran is right-handed. 5. The Veteran's bilateral upper extremity peripheral neuropathy manifested as subjective complaints of hand numbness, pain, tingling and reduced hand strength with objective evidence of nerve root irritation; there was no evidence of the loss of reflexes, reduced muscle tone, reduced grip strength or pain on palpation. 6. The Veteran's bilateral lower extremity peripheral neuropathy manifested as subjective complaints of pain, tingling, numbness and weakness with objective evidence of diminished deep tendon reflexes, fair-to-good muscle strength and decreased vibration sense; there was no evidence of a loss of reflexes, reduced muscle tone, muscle atrophy or abnormal motor function. CONCLUSIONS OF LAW 1. The criteria for an effective date prior to June 2, 1997 for the grant of service connection for PTSD have not been met. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. §§ 3.155, 3.157, 3.400 (2013). 2. The criteria for an initial rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.126, 4.130, 9411 (2013). 3. The criteria for withdrawal of an appeal with regard to a claim for an increased rating for diabetes mellitus have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2013). 4. The criteria for an initial rating in excess of 10 percent right upper extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.20, 4.27, 4.120, 4.123, 4.124a, 8515 (2013). 5. The criteria for an initial rating in excess of 10 percent left upper extremity peripheral neuropathy have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.20, 4.27, 4.120, 4.123, 4.124a, 8515 (2013). 6. The criteria for a rating of 20 percent for right lower extremity peripheral neuropathy have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.21, 4.120, 4.123, 4.124a, 8520 (2013). 7. The criteria for a rating of 20 percent for left lower extremity peripheral neuropathy have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.10, 4.21, 4.120, 4.123, 4.124a, 8520 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2013). The appeal with regard to the instant claims for an earlier effective for PTSD as well as claims for an increased rating for PTSD, bilateral upper extremity peripheral neuropathy and bilateral lower extremity peripheral neuropathy arise from disagreement with the initial rating following the grant of service connection. The courts have held that once service connection is granted the claim is substantiated, additional VCAA 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). The Court of Appeals for Veterans Claims (CVAC) has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements are appropriately addressed under the notice provisions of 38 U.S.C. §§ 5104 and 7105. Hartman, supra. Where a claim has been substantiated after the enactment of the VCAA, a veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). There has been no allegation of prejudice in this case with regard to the instant claims. The VCAA requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. §5103A; 38 C.F.R. §3.159(c)(d). VA will help a claimant obtain records relevant to his claim(s), whether or not the records are in Federal custody, and that VA will provide a medical examination and/or opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has met the duty to assist the Veteran in the development of the instant claims. The evidence of record includes the service treatment records, various private treatment records, Social Security Administration (SSA) records, VA treatment records, and the VA examination reports. The Veteran has not alleged that his PTSD, bilateral upper extremity or bilateral lower extremity peripheral neuropathy have worsened since his last VA examination. Moreover, the VA examination report and the VA medical records may be accepted as adequate reports of examination of the Veteran, without further VA examination. 38 C.F.R. § 3.326. These medical reports provide evidentiary information that speaks directly to the Veteran's subjective complaints as well as to the objective findings found on evaluation, and they represent the actual evaluation results of the Veteran's participation in those clinical studies. Barr v. Nicholson, 21 Vet. App. 303 (2007). As previously noted, the Veteran was provided an opportunity to set forth his contentions during a hearing before the undersigned in December 2011. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that a "hearing officer" who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, it is clear from the record that the Veteran has either actual knowledge of the evidence necessary to substantiate his claims, or that a reasonable person could be expected to understand from the notice what was needed. First, the VLJ clarified all issues that were on appeal. The Veteran also provided arguments in support of his claims and testified to the current severity of his service-connected disabilities. As such, the Board finds that the Veteran was not prejudiced by any deficiencies in the hearing. Thus, there is no indication that there is any additional relevant evidence to be obtained by either VA or the Veteran. Therefore, the Board determines that VA has made reasonable efforts to the assist the Veteran in obtaining the evidence necessary to substantiate his claims. Earlier Effective Date Claim The Veteran contends that the appropriate effective date for the grant of service connection for PTSD is January 1, 1989, the date of a private psychiatric evaluation. The effective date for the grant of service connection for disability compensation is the "day following separation from active service or date entitlement arose if the claim is received within 1 year after separation from service; otherwise, date of receipt of claim, or date entitlement arose, whichever is later." 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i) (Emphasis Added). The effective date of an award of compensation based on direct service connection is the date following separation from service, if the claim is received within one year of that date. Otherwise, the effective date is the date VA receives the claim, or the date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(a), (b)(1); 38 C.F.R. § 3.400(b)(2). The date of receipt of a claim is the date on which a claim, information, or evidence is received by VA. 38 C.F.R. § 3.1(r). A "claim" is defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit. See 38 C.F.R. § 3.1(p); see also Brannon v. West, 12 Vet. App. 32, 34-5 (1998); Servello v. Derwinski, 3 Vet. App. 196, 199 (1992). Any communication or action indicating intent to apply for one or more benefits under the laws administered by VA, from a Veteran or his representative, may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. If received within one year from the date it was sent to the Veteran, it will be considered filed as of the date of receipt of the informal claim. A report of examination or hospitalization which meets the requirements of this section will be accepted as an informal claim for benefits if the report relates to a disability which may establish entitlement. Once a formal claim for pension or compensation has been allowed or a formal claim for compensation has been disallowed for the reason that the service-connected disability is not compensable in degree, receipt of a report of examination or hospitalization by VA or the uniformed services will be accepted as an informal claim for benefits. The date of outpatient or hospital examination or date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of a claim. The provisions of this paragraph apply only when such reports relate to examination or treatment of a disability for which service-connection has previously been established or when a claim specifying the benefit sought is received within one year from the date of such examination, treatment or hospital admission. 38 C.F.R. § 3.157. Evidence from a private physician or layman will also be accepted as an informal claim for increased benefits, effective from the date received by VA. 38 C.F.R. § 3.157(b)(2). Medical records cannot constitute an initial claim for service connection; rather there must be some intent by the claimant to apply for the benefit. Criswell v. Nicholson, 20 Vet App 501 (2006); Brannon v. West, 12 Vet. App. 32, 35 (1998). A July 2005 rating decision granted service connection for PTSD, effective June 2, 1997. The RO had determined that the earliest document which can be construed as a claim for service connection for this disability was a June 2, 1997 informal claim filed by the Veteran. The private psychiatric evaluation referenced by the Veteran, which was dated in January 1989, was first received by VA on August 20, 1997. While evidence from a private physician may be accepted as an informal claim in some instances, the appropriate effective date is the date such evidence is received by VA, not the actual date of the treatment report. 38 C.F.R. § 3.157(b)(2). A thorough review of the claims file reveals that the Veteran first filed an informal claim for service connection for PTSD on June 2, 1997. Although the Veteran has alleged filing such a claim for service connection in the 1980s and having this claim denied, the claims file contains no such filing or denial. The earliest effective date that can be granted for the service connection for PTSD is the date of receipt of informal claim, June 2, 1997. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(b)(2). The law is controlling and not the facts. The appeal for an earlier effective date than June 2, 1997, for the grant of service connection for PTSD must be denied as a matter of law. Sabonis v. Brown, 6 Vet. App. 426 (1994). Increased Rating Criteria Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In instances in which a veteran disagrees with the initial rating, the entire evidentiary record from the time of a veteran's claim for service connection to the present is of importance in determining the proper evaluation of disability, and staged ratings are to be considered in order to reflect the changing level of severity of a disability during this period. Fenderson v. West, 12 Vet. App. 119, 126 (1999). 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. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by a veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If there is a question as to which of two evaluations should apply, the higher rating is 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. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. PTSD The Veteran contends that the severity of his PTSD warrants a 100 percent rating. PTSD is evaluated under VA's General Rating Formula for Mental Disorders. Under the formula, a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9411. 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 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. Id. A 70 percent rating is warranted where 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; 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. Id. A 100 percent rating is warranted when there is 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 own name. 38 C.F.R. § 4.130, DC 9411. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Ultimately in Mauerhan, the Court upheld the Board's decision noting that the Board had considered all of the Veteran's psychiatric symptoms, whether listed in the rating criteria or not, and had assigned a rating based on the level of occupational and social impairment. Mauerhan, supra at 444. GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). A GAF of 61 to 70 reflects some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. A GAF of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. A GAF of 41 to 50 signifies serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 31 to 40 signifies some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., where a depressed man avoids friends, neglects family, and is not able to work). DSM-IV; 38 C.F.R. §§ 4.125, 4.130. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). Although GAF are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). A July 1997 VA psychological examination reflected the Veteran's reports of problems with his temper, depression, occasional nightmares, sleep disturbances, irritability, intrusive thoughts, avoidance symptoms, occasional flashbacks, hypervigilance, a restricted effect and concentration problems. He reported being married to his wife since 1972, that they were separated but trying to reconcile, that he was active in his church and that he had regularly attended church over the last few years. He indicated that he was not very social except with others at church as did not really like being around other people and spent most of his time watching television and occasionally working on cars. Current psychiatric treatment, suicidal ideations or attempts and hallucinations were denied. Mental status examination conducted by the July 1997 VA psychological examiner found the Veteran to be cooperative during the interview and oriented to person, place and time. His responses were logical and goal directed without evidence of a thought disorder. Concentration and memory appeared to be good, recall was fairly good and abstract reasoning was fairly good. Mood appeared to be moderately depressed and affect was appropriate to mood. Insight, judgment and impulse control were fairly good. Following this examination and a review of the Veteran's claims file, a diagnosis of chronic PTSD was made and a GAF of 60 was assigned. During a July 2002 Board hearing on the issue of service connection for PTSD, the Veteran testified that he had been prescribed medication to treat his psychiatric symptoms including temper, mood swings, nervousness and restless. He was in control of himself and felt he should not be labeled as a violent person due to his answering questions honestly. A May 2004 VA treatment note reflected the Veteran's reports of nightmares and frustration with his disability claims. He also experienced recurrent intrusive recollections, an exaggerated startle response and the avoidance of situations which reminded him of trauma. Mental status examination found him to be oriented without active psychosis. Judgment and insight were fair. A February 2005 VA treatment note reflected the Veteran's reports nightmares. He denied feeling numb or detached from others, activities or surroundings and feeling constantly on guard, watchful or easily startled. A May 2005 VA psychological examination reflected the Veteran's reports of becoming a pastor of a small church in October of last year and that he received pleasure from his church activities. He spent most of his time at home or in church and enjoyed watching boxing and practicing martial arts. He had reconciled with his wife since that last VA examination and they had resided together since that time. Current symptoms included a bad temper, restlessness and social isolation except for church, significant sleep difficulties secondary to sleep apnea and his level of arousal. He has received psychiatric treatment since 2002 and had been using medications treating his symptoms with some success. Psychiatric hospitalizations were denied. Mental status examination found him well oriented with no apparent cognitive impairment, his affect broad and his mood mildly depressed. Speech was of normal rate, rhythm and volume and verbalizations were coherent, relevant and goal-directed. There were no panic attacks, obsessive or ritualistic behavior, inappropriate behavior, delusional beliefs, hallucinations, suicidal ideations or homicidal ideations. Impulse control appeared adequate. No psychological testing was deemed necessary. Following this examination and a review of the Veteran's claims file, a GAF of 62 was assigned. The examiner opined that the Veteran functioned rather well psychologically and reported symptoms which were minimally intrusive upon his life. A November 2006 VA treatment note reflected the Veteran's reports of anxiety and sleep disturbances. He denied depression, suicidal ideations, homicidal ideations and auditory or visual hallucinations. Mental status examination found his mood to be somewhat irritable and anxious with a congruent effect. Thoughts were organized with no evidence of delusional thinking. Impulse control, insight and judgment were fair. A GAF of 60 was assigned. An August 2007 VA psychological examination reflected the Veteran's reports of working nearly every day on church functions and that he devoted most of his energies to being a pastor but had retired from his employment due to medical problems in 1994. Current symptoms included anger, depression and sleep disturbances. He had been married to his wife for 36 years and they got along "fairly well" but slept in separate bedrooms due to his sleep apnea machine. He reported being a "dedicated and effective" father to his adult children and had "taken over" the parenting of a 12 year old. Current treatment included medication. Mental status examination found his affect to be broad, stable and congruent with the topic of discussion. He was alert and well-oriented with overall intellectual and memory functioning intact. There was no impairment of thought process or communication, delusions or hallucinations. He was not dangerous to himself or others. There was occasional decrease in productivity and sociability due to the effect of his war memories but his functioning was generally satisfactory. Following this examination and a review of the Veteran's claims file and psychiatric records, a GAF of 65 was assigned. In a March 2008 notice of disagreement, the Veteran wrote that it was "hard" not to "lose it with people" and that he sometimes wanted to hurt people. A February 2010 VA treatment note reflected the Veteran's reports of decreased motivation and energy. His temper remained a "problem" but he was able to control himself. A worsening of his depression symptoms or other psychiatric difficulties was denied. He used to go to church every Sunday to give the sermon as preacher and reported receiving good support from his wife. Mental status examination found him to be casually dressed with good eye contact and a logical thought process. Judgment and insight were good. Suicidal or homicidal ideations were denied. A GAF of 65 was assigned. In a January 2011 VA treatment note, the Veteran denied suicidal ideations. A March 2011 VA treatment note indicated that the Veteran's nightmares occurred once or twice per week and that his flashbacks occurred two to three times per month. He reported going to church every Sunday for sermon but otherwise stayed home and watched movies most of the time. No other psychiatric difficulties or problems were reported. A worsening of symptoms or suicidal ideations was denied. A GAF of 70 was assigned. An August 2011 VA treatment note reflected the Veteran's reports of continued nightmares and flashbacks a few times per week. A worsening of these symptoms, depression or emotional problems was denied. Suicidal ideations were denied. He reported "good support" from his wife and that he planned to resume sermons at his church the next weekend. A GAF of 70 was assigned. During a December 2011 hearing, the Veteran testified that he used two prescription medications to treat his psychiatric symptoms. He experienced panic attacks three to four times per month and was antisocial. While he "got along" with his spouse and family and would greet them during family functions, he basically stayed to himself. He slept in a separate bedroom from his wife due to nightmares and a history of violently striking out while sleeping. He has had suicidal ideations or homicidal ideations every month for the past 12 months; he experienced these thoughts after "someone press[ed] him too much or [said] the wrong thing or cross[ed] [him] in any way." He had previously lost a lot of time at work due to his temper, which "helped" him lose his job. He was so depressed at times that he did not want to get out of bed. In addition, he had difficulty concentrating and forgot names and places. The Board finds that the Veteran's symptoms of PTSD most nearly approximated, at worst, the criteria associated with the current 30 percent rating. The Veteran did not manifest symptoms associated with a 50 percent rating under the general formula for rating mental disorders to warrant a higher rating. The clinical evidence was negative for, and the Veteran has not alleged, auditory and visual hallucinations suggesting no deficiency in the area of abstract thinking. Thought processes were consistently noted to be logical while judgment was consistently found to be good on examination. Although the Veteran subjectively reported difficulties controlling his temper, impulse control was found to be adequate on examination and he reported no violent incidents during the course of the appeal. There is no indication that the Veteran had difficulty understanding complex commands as he intermittently reported preparing weekly sermons as his church and performing other church-related work. His speech was consistently noted to be of a normal rate, flow and volume. While the Veteran testified during the December 2011 hearing that he generally forgot names and places, memory functioning had been found to be intact on objective examination. In addition, the Veteran's December 2011 testimony that he had experienced suicidal ideations "every month" in the past year is contradicted by the clinical evidence from this same period in which he denied such ideations. Such ideations had previously been consistently denied. Disturbances of mood were shown as the Veteran reported intermittent depression and decreased motivation in February 2010. The Veteran maintained his long-term marriage, reported a good relationship with his adult children and explained that he and his wife were taking care of another child. He was able to socialize with people from his church and his family, although he did report limiting these interactions. While the Veteran suggested during his December 2011 hearing that he was no longer sleeping in the same bed as his wife due to nightmares, he had previously reported that this arrangement was due to his sleep apnea machine in an August 2007 VA examination. No occupational impairments were shown as he did not maintain paid employment during the course of this appeal. In addition, a May 2005 VA examination noted that he had become the pastor of his church and he reported engaging in church-related activities throughout the remainder of the appellate period. While the Veteran suggested during his December 2011 hearing that he had lost his last employment position due to absentee associated with his PTSD, he reported retiring from his position due to unrelated medical problems in an August 2007 VA examination. Although the Veteran has displayed such symptoms as disturbances of mood, a single instance of reduced motivation and a single reported instance of panic attacks, his impairments overall most closely approximately a 30 percent rating. The Veteran's assigned GAFs have ranged from 60 to 70 throughout the course of the appeal, suggesting no more than mild impairment. The totality of the clinical evidence further suggests no more than moderate impairment. Carpenter, supra. Accordingly, an increased rating is not warranted. 38 C.F.R. §§ 4.125, 4.130, 9411. Diabetes During his December 2011 hearing, the Veteran testified that he wished to withdraw his appeal with regard to the claim of entitlement to an increased rating for diabetes mellitus. Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal that fails to allege specific error of fact or law in the determination being appealed. An appeal may be withdrawn in writing at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the veteran or by his authorized representative. Id. The Veteran has withdrawn his appeal as to this claim and there remain no allegations of errors of fact or law for appellate consideration. As such, the Board does not have jurisdiction to review his claim of entitlement to an increased rating for diabetes mellitus and the claim is dismissed. Bilateral Upper and Bilateral Lower Extremities Peripheral Neuropathy The Veteran's bilateral upper extremity peripheral neuropathy is rated under the diagnostic code for paralysis of the median nerve. Mild incomplete paralysis of the median nerve warrants a 10 percent for either extremity. Moderate incomplete paralysis warrants a 30 percent rating in the major extremity and a 20 percent rating in the minor extremity. Severe incomplete paralysis warrants a 50 percent rating in the major extremity and a 40 percent rating in the minor extremity. 38 C.F.R. § 4.124a, 8515. Complete paralysis of the medial nerve warrants a 70 percent rating for the major extremity and a 60 percent rating in the minor extremity. Complete paralysis occurs where the hand was inclined to the ulnar side, the index and the middle fingers were more extended that normally, there was considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand), pronation was incomplete and defective, there was the absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, the index and middle fingers remained extended, cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm and flexion of wrist was weakened and there was pain with trophic disturbances. Id. The Veteran's bilateral lower extremity peripheral neuropathy is rated under the diagnostic code for paralysis of the sciatic nerve. Ratings of 10 percent, 20 percent and 40 percent are assignable for incomplete paralysis which is mild, moderate or moderately severe in degree, respectively. A 60 percent rating is warranted for severe incomplete paralysis with marked muscle atrophy. Complete paralysis of the sciatic nerve, which is rated as 80 percent disabling, contemplates foot dangling and dropping, no active movement possible of muscles below the knee, and flexion of the knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, 8520. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. In a November 1969 Report of Medical History (RMH), the Veteran indicated that he was right handed. A May 2005 private pain management treatment note reflected the Veteran's reports of bilateral arm pain with numbness and paresthesias and that he felt as if his hands were "asleep." He reported having difficulty with his handgrip in terms of weakness. There was also pain that radiated into this bilateral lower extremities, with the left worse than the right, along the posterolateral thigh going down the lateral part of the lower leg in the L5-S1 distribution. This pain was rated as "6-8/10" depending on his activity level. Physical examination found fair-to-good muscle strength in all muscle groups tested. Sensation was grossly intact and deep tendon reflexes were 1+ and equal. Electrodiagnostic evaluation of the bilateral upper extremities revealed bilateral early carpal tunnel syndrome and C6-7 root irritation. Subsequent electromyography (EMG) testing revealed L4-5 and L5-S1 root irritation as well as "severe" peripheral neuropathy. A September 2007 VA diabetes mellitus examination reflected the Veteran's reports of a loss of strength in his right hand as well as numbness and tingling in his hands and feet. He experienced these symptoms daily and they lasted a few minutes to half an hour. His pain was described as "6/10." Aggravating factors included the way he was laying on his arm or leg or sitting while alleviating factors included the elevation of his legs or laying down. Loss of function and loss of sensation were denied. Physical examination found diminished tendon reflexes which were probably secondary to obesity and deep tendon reflexes were not able to be elicited. Upper extremity and lower extremity sensation was intact to monofilament, pinprick, vibration, temperature and proprioception. There was no erythema, edema or pain with palpation in the upper extremities. Lower extremity examination was negative for erythema, edema or open ulcers. In a March 2008 notice of disagreement, the Veteran wrote that he did not walk too much as he had fallen before and hurt himself. There was a loss of sensation in his left leg and thigh that burned and was painful. His legs and feet also swelled. His hands were painful and he often dropped things. A June 2010 VA treatment note reflected the Veteran's reports of generalized aches and pains. Monofilament examination found abnormal sensation on the tips of the toes bilaterally and vibration testing found "decreased." A January 2011 VA treatment note indicated that the Veteran's peripheral pulses were palpable and that his legs were swollen, with his left leg worse than his right leg. During his December 2011 hearing, the Veteran testified that his legs swelled and would not support him while climbing or walking for an extended period of time. His arms became fatigued and painful with activity such as mowing the yard. He experienced pain in all of his extremities as well as intermittent numbness and tingling. He had difficulties grasping items and was afraid that he would drop these items. These symptoms were present daily and may last for hours. The Veteran's bilateral upper extremity peripheral neuropathy manifested as subjective complaints of hand numbness, tingling, pain and weakness. The May 2005 private pain management treatment note but found no difficulty with handgrip in terms of weakness and found sensation to be grossly intact. Electrodiagnostic testing did reveal C6-7 root irritation. A September 2007 VA examination also found sensation to be intact and found no erythema, edema or pain on palpation. As the evidence suggests hand numbness and pain without the loss of reflexes or objective evidence of reduced handgrip or weakness, the Veteran's bilateral upper extremity most closely approximates mild incomplete paralysis and a higher rating is not warranted. 38 C.F.R. § 4.124a, 8515. Similarly, the Veteran's bilateral lower extremity peripheral neuropathy manifested as subjective complaints of numbness, tingling, pain and weakness. The May 2005 private pain management treatment note found muscle strength to be fair-to-good, sensation to be grossly intact and deep tendon reflexes to be 1+. A September 2007 VA examination found diminished deep tendon reflexes and intact sensation with no edema. Vibration was found to be decreased in June 2010 and his legs were found to be swollen in January 2011. In light of the Veteran's subjective complaints of constant pain and the objective evidence of diminished reflexes and decreased sensation, a rating of 20 percent for moderate in complete paralysis is warranted. A rating in excess of 20 percent is not warranted as muscle atrophy was not found or alleged by the Veteran. In addition, sensation and reflexes were found to be diminished on examination but were present. 38 C.F.R. § 4.124a, 8520. Extra-schedular Consideration Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extra-schedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(1)(b). The question of an extra-schedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extra-schedular rating in the first instance, it must specifically adjudicate whether to refer a case for extra-schedular consideration when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extra-schedular rating, the threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the Rating Schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step--a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Id. As detailed above, the Veteran's PTSD manifested by nightmares, sleep difficulties, intermittent depression, a single subjective report of suicidal ideations and a single reported instance of panic attacks. His bilateral upper extremity peripheral neuropathy manifested by subjective complaints of hand numbness, pain, tingling and reduced hand strength with objective evidence of nerve root irritation. In addition, his bilateral lower extremity peripheral neuropathy is manifested by subjective complaints of pain, tingling, numbness and weakness with objective evidence of diminished deep tendon reflexes, fair-to-good muscle strength and decreased vibration sense. These factors are contemplated by the rating criteria. There have been no reported factors outside the rating schedule. Marked interference with employment was not shown as the Veteran was not employed during the course of the appeal. Consideration of an extra-schedular rating is therefore not warranted. ORDER Entitlement to an effective date earlier than June 2, 1997, for the grant of service connection for PTSD is denied. Entitlement to an initial rating in excess of 30 percent for PTSD is denied. Entitlement to a rating in excess of 40 percent for diabetes mellitus is dismissed. Entitlement to an initial rating in excess of 10 percent for right upper extremity peripheral neuropathy is denied. Entitlement to an initial rating in excess of 10 percent for left upper extremity peripheral neuropathy is denied. Entitlement to an initial rating of 20 percent for right lower extremity peripheral neuropathy is granted. Entitlement to an initial rating of 20 percent for left lower extremity peripheral neuropathy is granted. REMAND The April 2012 Board decision also remanded the issues concerning entitlement to an increased rating for arteriosclerosis and hypertension, entitlement to TDIU, and entitlement to additional compensation benefits for P. C. and D. C. A review of the record shows that the development has not yet been initiated by the AOJ. As such, the April 2012 Remand and its directives are incorporated by reference herein; and, therefore, the issues are REMANDED to the AOJ for further development and adjudication consistent with the April 2012 Remand. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs