Citation Nr: 1601339 Decision Date: 01/13/16 Archive Date: 01/21/16 DOCKET NO. 12-08 316A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with depression, to include entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G.R. Waddington, Associate Counsel INTRODUCTION The Veteran had active service in the U.S. Army from October 1969 to April 1972, and served in the Republic of Vietnam from April 1970 to March 1971. This matter is on appeal from a September 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In that decision, the RO implemented an August 2009 Board decision awarding service connection for PTSD. The RO assigned an initial disability rating of 10 percent for the service-connected PTSD, effective October 18, 2004. In December 2009, the RO granted a higher rating of 30 percent for PTSD, effective October 18, 2004. This appeal was processed using the Virtual VA paperless claims processing system. Any future consideration of this case should account for the electronic record. The issue of entitlement to an initial disability rating in excess of 50 percent for PTSD, to include entitlement to a TDIU, is addressed in the REMAND section of this decision and are REMANDED to the Agency of Original Jurisdiction (AOJ). The issue of entitlement to service connection for dizziness as secondary to service-connected PTSD (i.e., medication taken to treat PTSD) has been raised by the record, but has not been adjudicated by the AOJ. See June 2013 Notice of Disagreement (NOD). The Board does not have jurisdiction over this issue and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). FINDING OF FACT The Veteran's PTSD with depression is characterized by depressed mood, anxiety (especially in crowds), panic attacks, chronic sleep disturbance, lack of motivation/interest, increasing social isolation, irritability/angry outbursts, and difficulty maintaining effective work and social relationships. CONCLUSION OF LAW The criteria for an initial disability rating of 50 percent for PTSD with depression are satisfied. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3, 4.130, Diagnostic Code (DC) 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION VA has adopted a Schedule for Rating Disabilities (Schedule) to evaluate service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R., Part IV. Disability evaluations assess the ability of the body as a whole, the psyche, or a body system or organ to function under the ordinary conditions of daily life, to include employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Id. The Schedule assigns DCs to individual disabilities. DCs provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the claimant. 38 C.F.R. § 4.3. The Schedule recognizes that a single disability may result from more than one distinct injury or disease; however, rating the same disability or its manifestation(s) under different DCs-a practice known as pyramiding-is prohibited. Id; see 38 C.F.R. § 4.14. In initial disability rating cases, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). The Veteran's service-connected PTSD with depression has been evaluated under the General Rating Formula for Mental Disorders, which assigns ratings based on particular symptoms and the resulting functional impairment(s). See 38 C.F.R. § 4.130, DC 9411. The General Rating Formula is as follows: A 100 percent rating is assigned for 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. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events) The symptoms associated with each rating in 38 C.F.R. § 4.130 do not constitute an exhaustive list; rather, they serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the DCs. See id. VA must consider all the symptoms of a claimant's service-connected disability that result in occupational and/or social impairment, including those symptoms identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (1st through 4th eds.) (DSM). See id. at 443. If the evidence shows that a claimant has symptoms that cause occupational or social impairment equivalent to the occupational or social impairment that would be caused by the symptoms listed in the DC, the appropriate, equivalent rating will be assigned. Id. VA considers the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126; Vazquez Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (noting that the "frequency, severity, and duration" of a veteran's symptoms "play an important role" in determining the disability level). Although VA considers the level of social impairment that results from a service-connected disability, it will not assign an evaluation based solely on social impairment. Id. VA must first find that the veteran has one or more symptoms of similar severity, frequency, and duration to the symptoms listed in the General Rating Formula for a given rating. If VA makes such a finding, it then determines whether one or more of the pertinent symptoms produce the level of occupational and social impairment contemplated by that rating. See id. at 116-118. In evaluating psychiatric disorders, VA considers a claimant's Global Assessment Functioning (GAF) scores, which are based on a scale set forth in the DSM reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). According to DSM (4th ed.), a score of 61-70 indicates "[s]ome mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships." A score of 51-60 indicates "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." Id. A score of 41-50 indicates "[s]erious 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)." Id. A score of 31-40 indicates "[s]ome impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work)." Id. The Court has found that certain scores may demonstrate a specific level of impairment. See Richard, 9 Vet. App. at 267; Bowling v. Principi, 15 Vet. App. 1, 14-15 (2001) (observing that a GAF score of 50 indicates serious impairment). The Veteran began treatment for PTSD in 2004. In August 2004, a VA psychiatrist assigned a GAF score of 55, which is indicative of moderate symptoms and/or difficulty in social and occupational functioning. The psychiatrist noted the Veteran's inadequate hygiene, poor sleep and appetite, and depressed mood. He also noted that the Veteran was generally coherent during the consult, did not report hallucinations or suicidal ideation, exhibited an euthymic mood and bright affect, and stated he had a good marriage and good relationships with his twin sons. In the same month (August 2004), a VA social worker observed that the Veteran had anxiety and depression and may be minimizing his PTSD symptoms. In September 2004, the Veteran reported that he directs his anger and frustration at his spouse in the form of verbal attacks and that he fears his marriage may fall part. He also reported difficulty concentrating at work, becoming irritable for no apparent reason, and experiencing anger outbursts as well as some suicidal ideation. September 2004 VAMRs. The following month (October 2004), the Veteran reported having panic attacks that last about five minutes. Throughout his early treatment for PTSD, the Veteran reported that his mental health symptoms affected his work and limited his social activities. In November 2004, he expressed concern about losing his temper at his job, but stated that he was "coping well" with his job duties due to the fact that he has a "private office where he can retreat" when his symptoms manifest. In May 2005, he reported hypervigilance and hyper startle response at home and at work. In June 2005, the Veteran stated that he struggled "to put on a facade and go do his job when he is feeling depressed," that he is easily angered and irritable, and that he recently threatened wife with divorce. He also reported that his medications reduced his irritability. The following month (July 2005), the Veteran stated that he no longer plays golf because he "feels more at ease just staying at home"; he appeared neatly dressed and groomed and cooperative during the July 2005 therapy session. In August 2005, the Veteran reported an increase in the severity of his symptoms. See also December 2008 Wife's Statement (reporting that the Veteran's attitude and behavior changed around 2005: he isolated himself from his family, was violent in his sleep, and became short tempered). He reported feeling "jumpy" and having paranoid thoughts and mood swings. In September 2005, he reported an increase in panic attacks and irritability and in late 2005 he was assigned a GAF score of 50, which is indicative of serious mental health symptoms and/or impairment in social and occupational functioning. November 2005 and December 2005 VAMRs; see also January 2006 VAMRs (assigning a GAF score of 52). In June 2007, the Veteran reported that he felt like he has "been on a roller coaster Lately . . . Some weeks he does well and other weeks his irritability and lack of patience is overwhelming." He expressed concern regarding his feelings of anger at work. The following month (July 2007), the Veteran announced his intent to stop working. He explained that he "had planned on retiring in a couple of years, but due to his ongoing struggles with PTSD symptomology, he feels it is best to go ahead and leave." The Veteran expressed a desire to move to Oklahoma to be close to his son and grandson. At the July 2007 travel Board hearing, the Veteran testified that his PTSD made him feel "lost," radically reduced his ambition, and resulted in significant social isolation. He explained that he hardly left the house over the weekends and that he decided to stop working due to his PTSD symptoms. July 2007 Hearing Transcript ("That's one reason that I decided to leave work when I did. It wasn't because I wanted to, but I couldn't even go to the classes anymore that I had to go to."); see also July 2007 VAMRs (reporting more frequent nightmares and increased irritability, especially at work). The Veteran stated that his PTSD has also taken a major toll on his marriage and that he remains married to his wife only because "she just doesn't believe in divorce." A July 2007 statement from the Veteran's treating psychologist and counselor confirmed that the Veteran has ongoing problems with intrusive memories, sleep disturbance, feelings of estrangement/detachment, irritability, and hypervigilance and that he experiences poor concentration and isolation tendencies. VA treatment records from the same month note that the Veteran "has recognized the need to leave his job" of thirty years due to persistent high levels of anxiety due to his combat-related PTSD. The Veteran reported ongoing problems with irritability and decreased concentration and that his symptoms were exacerbated by working at the VA (i.e., having war-related conversations). He was assigned a GAF score of 48, which is indicative of serious mental health symptoms and impairment. See also November 2009 VAMRs (documenting that the Veteran had worked as a supervisor in housekeeping at VAMC Mountain Home for 31 years and that he "retired earlier than anticipated with getting angry at employees etc."). The Veteran's GAF scores increased after he retired from VA. In November 2008, he was assigned a GAF score of 60 and in December 2008 he was assigned a GAF score of 65. See also September 2008 and March 2009 VAMRs (assigned GAF scores of 65). VA medical records from this time period indicate good cognitive and social skills. However, in a December 2008 statement the Veteran's wife reported that the Veteran's symptoms had strained their marriage to the point where she was considering divorce. The Veteran continued to report significant mental health symptoms that had a particularly marked effect on his social functioning through 2010. In November 2009, he reported being more depressed, sensitive to stimuli, and easily angered, and was assigned a GAF score of 55. However, in May and July 2010 he was assigned GAF scores of 50, which, again, are indicative of serious mental health symptoms and limitations. The Veteran reported becoming angry three to four times a week, recurrent frustration and hypervigilance, suspiciousness, sleep disturbance with nightmares, and vague auditory illusions. He denied suicidal or homicidal ideation, overt delusions, and/or hallucinations. He exhibited fair cognitive functioning, acceptable calculative skills, good insight, and adequate judgment, but poor concentration and diminished memory on assessment. May 2010 VAMRs. In a September 2010 statement, the Veteran's wife noted that the Veteran's symptoms had worsened over the last few years and that he was in "pretty bad shape." She observed that the Veteran is hypervigilant, socially isolated and removed from his family, depressed, suspicious, and constantly on guard. She also observed that the Veteran does not shave, shower, or change his clothes for extended periods. The Veteran's wife opined that the Veteran's PTSD symptoms prevent him from working and confirmed that she remained married to the Veteran only because she does not believe in divorce. In November 2010, the Veteran was assigned a GAF score of 50. Medical treatment records from 2011 show continued social impairment due to PTSD limitations with normal cognitive skills. In March 2011, the Veteran appeared alert and oriented during a psychological assessment. He was appropriately groomed and dressed, maintained appropriate eye contact and speech, and demonstrated logical, linear, and goal directed thought processes. March 2011 VAMRs. He denied suicidal/homicidal ideation, auditory/visual hallucinations, delusions, and paranoia. His cognition, judgment, and insight appeared intact and his fund of knowledge was good. However, he was assigned a GAF score of 40, which is indicative of major impairment in several areas, such as work, family relations, judgment, thinking, or mood. In June 2011, the Veteran explained that he keeps to himself: he avoids crowds, drives his wife to Walmart but waits in the car when he becomes anxious, is hypervigilant to the extent that he sits with his back to wall when he is in a restaurant to avoid being startled, and retreats to his home computer room when his symptoms become exacerbated. In November 2011, a VA examiner found that the following symptoms resulted in clinically significant distress or impairment: distress triggered by recollections of the traumatic in-service event; avoidance; markedly diminished interest in significant activities; irritability; and outbursts of anger. She noted that the Veteran gets along better with his grandchildren when he stays at a distance, does not speak to one of his adult sons, and that his PTSD symptoms first manifested 15 years ago in connection with the death of his father. The examiner also noted that the Veteran was recalcitrant during the examination and observed inconsistencies in connection with his symptoms. She stated that the "Veteran's reported symptoms appear to be more severe than his stressors would suggest" and indicated that the Veteran was malingering in order to protect his benefits. The examiner concluded that the Veteran's PTSD symptoms resulted in "occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks" and that the Veteran could "generally function[] satisfactorily, with normal routine behavior, self-care and conversation." VA treatment records from November 2011 indicate more severe social impairment than is documented in the November 2011 VA examination report. The November 2011 records show that the Veteran experiences severe PTSD symptoms, to include daily depression, significant hypervigilance and concentration difficulties, hyperarousal, and rage with minimal provocation. A VA psychiatrist noted emotional numbing, constant fatigue, nightmares and intrusive thoughts, and failure to shower or perform household chores on a regular, routine basis. The Veteran reported thinking about death and dying, but denied suicidal ideation. He also reported that his wife is tired of his behavior that she recently hit him. The VA psychiatrist assigned a GAF score of 45. The following month (December 2011), the Veteran demonstrated good judgment and insight and remained alert and oriented during a VA mental health assessment. His thought processes were coherent and logical with no evidence of formal thought disorder and he denied experiencing hallucinations or delusions. The Veteran reported problems with his grandson and complained that the November 2011 VA examiner minimized the severity of his PTSD symptoms. In February 2012, he complained that his wife was driving him crazy. The Veteran's GAF score remained at 45 through March 2012. March 2012 VAMRs. The Veteran's PTSD has continued to result in social and occupational limitations through to the present. In March 2012, the Veteran reported that he struggled with the fact that his grandson was living with him. In April 2012, the Veteran's wife reported that the Veteran "is in bad shape mentally" and "could never work a job again." She noted that the Veteran is consistently argumentative, verbally abusive, and subject to panic attacks whenever he is in public. She also noted that she and her husband no longer have a sexual relationship and that "[i]f it was not for my religious beliefs I would have divorced him long ago." In June 2012, the Veteran was assigned a GAF score of 47. Moreover, recent VA medical records indicate that the Veteran's PTSD symptoms have worsened and have a significant impact on his personal relationships. In June 2013, the Veteran's prescription medications were increased to better manage his PTSD symptoms. In July of the following year (2014), the Veteran reported that his depression was worse and he was referred to a VA psychologist to review his prescription medications. He reported that "his marriage is not doing well . . . in great part . . . [due to] his PTSD" and that he is on the verge of marital separation. A VA therapist recommended that the Veteran and his wife attend couple's therapy. He also reported that he continues to become irritated quickly and that "his memory is terrible and wife has to constantly remind him to do things such as taking his medications." In August and September 2014, the Veteran appeared alert and oriented during his psychological assessment. He was cooperative, exhibited an appropriate and stable affect and attitude, demonstrated intact intellectual functioning, memory, and concentration, and moderate to good insight and judgment. However, he observed that "his marriage is still not good, but he doesn't see that either of them will file for divorce" and expressed general "hopelessness about his life." The August 2014 VA examiner found that the Veteran's PTSD symptoms had remained largely constant for the past several years and that they did not result in major social and/or occupational limitations. She noted that the Veteran suffered from intrusion symptoms (e.g., recurrent and distressing memories and dreams and psychological distress when exposed to cues that trigger recollections of a traumatic event), persistent avoidance of stimuli associated with the traumatic event, lack of interest and motivation, irritability, hypervigilance, exaggerated startle response, and problems with concentration. She also noted that the Veteran's symptoms resulted in "clinically and significant distress or impairment in social, occupation, or other important areas of functioning." On examination, the Veteran initially appeared anxious but was generally pleasant and cooperative. He was well groomed, made normal eye contact, exhibited normal memory and good concentration throughout the examination (to include during cognitive testing), and exhibited a "down" mood. He denied suicidal ideation. The examiner found that the Veteran's answers to test questions "overemphasize[d] impairment" and, therefore, that test results did not always accurately reflect his cognitive abilities The August 2014 VA examiner found that the Veteran's PTSD symptoms resulted in "occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks" and that the Veteran could "generally function[] satisfactorily, with normal routine behavior, self-care and conversation." The examiner noted "no history of serious problems or write-ups" and that the Veteran "retired for age reasons." The examiner also found that the Veteran has good family relations, assists his wife (who is legally blind) with daily tasks such as reading, cooking, and driving, and engages in some social activities. The Veteran sees his brother-in-law once a week, attends church three times a week (an activity that he enjoys), and very occasionally fishes and/or plays golf. The examiner also noted that the Veteran's activities and excursions outside of the home are limited: he and his wife visit large stores, such as Walmart, twice a year and he leaves the store if it is crowded; he "cooks little"; and he and his wife eat out once a month. The Veteran constantly argues with his wife and his wife reportedly requested a divorce within a year prior to the August 2014 examination. In July 2015, the Veteran's treating psychotherapist and a specialist in PTSD treatment, noted that the "Veteran's progress has been inconsistent over the past ten years" and "minimal for the most part." The psychotherapist also noted that the Veteran's "path to recovery has been an ongoing struggle" and that he experiences chronic nightmares, intrusive thoughts, and irritability. Statements submitted by the Veteran's spouse and other family members further suggest that the Veteran's mental health has deteriorated over the last several years. In a July 2015 statement, the Veteran's wife observed that "[n]ow he is so depressed he shakes his knees, his hands shake and he does not participate in family functions like he used to." The Veteran's wife also observed that the Veteran is increasingly hypervigilant, easily frustrated and irritable, and verbally abusive, and that he experiences suicidal ideation. In addition, she confirmed that she and the Veteran have not been happily married for many years. July 2015 Statement ("We have been married for 45 years, not because I have wanted to stay the last 10 years of our marriage."); see also August 2015 Statement ("I really think he would kill his self if he didn't have the Lord in his life."). In the same month (July 2015), the Veteran's sister testified that "over the past few years I have noticed a . . change in" the Veteran and that the Veteran remains socially isolated to the extent that "he doesn't like to participate in any family activities." In a July 2015 statement, the Veteran's son noted a worsening of the Veteran's symptoms within the last three to four years, to include poor personal hygiene. The evidence of record to does not provide a straightforward disability with respect to the severity of the Veteran's PTSD symptoms. The medical evidence documents significant fluctuations in the severity of the Veteran's PTSD symptoms. His GAF scores range from 40 to 65, to suggest that at times the Veteran's mental health symptoms have resulted in major impairments and that at other times the Veteran's symptoms have resulted in mild impairment. The differences in the Veteran's GAF scores may be due to changes in the Veteran's medical providers over the last decade. April 2011 VAMRs (expressing concern that the Veteran's GAF scores fluctuate depending on who is assessing the severity of his PTSD symptoms). The differences may also be due the Veteran's reluctance to fully disclose the affects and limitations associated with his PTSD. See August 2004 VAMRs (suggesting that the Veteran may be minimizing his PTSD symptoms). The "rollercoaster" trajectory of the Veteran's symptoms may also be explained by changes in his lifestyle (e.g., the Veteran's GAF scores temporarily increased after he stopped working) and changes in the dosage of his prescription PTSD medications. See June 2007 VAMRs; September 2008 and March 2009 VAMRs; June 2013 VAMRs The Veteran's contradictory statements regarding the impact of his PTSD on his social and occupation functioning are more difficult to reconcile. The Veteran has reported that his PTSD symptoms interfered with his ability to complete his job duties and that he eventually stopped working due, in large part, to his mental health symptoms. See June & July 2007 VAMRs; July 2007 Hearing Transcript. He has also reported that he had good working relationships and that he retired for age-related reasons. August 2014 VA Examination Report. Similarly, the Veteran has stated that he rarely leaves his home and is socially isolated from friends and family; however, he has also stated he sees his brother-in-law on a weekly basis, lives with his grandson, and attends church-a social activity, which he reportedly enjoys-three times a week. Id. Despite some inconsistencies in the Veteran's statements-statements that were made over a period of over ten years-, the lay and medical evidence as a whole establishes that the Veteran has significant difficulty maintaining loving and stable familial relationships. After the Veteran retired from VA, he and his wife moved to Oklahoma to be close to his adult sons and grandchildren. However, in November 2011 the Veteran reported that he "gets along better with his grandchildren from a distance." See also August 2014 VA Examination Report (stating that the Veteran "get[s] along with" his grandson, who was living with the Veteran and his wife). In August 2004, the Veteran reported good relationships with his twin, adult sons; however, in November 2011 he reported that he was no longer speaking to one of his sons. Moreover, the evidence of records establishes that the Veteran's PTSD symptoms have had a major and damaging impact on his marriage. The Veteran and his wife both report that they remain married only for religious reasons. September 2004 VAMRs; April 2012 & July 2015 Wife's Statements. In 2013, the Veteran's wife requested a divorce but ultimately did not divorce the Veteran. Although the Veteran and his wife remain married, the lay evidence makes clear that the Veteran's PTSD symptoms have strained his marriage to the point where he and his wife are no longer happily married. In so far as the November 2011 and August 2014 VA examination reports suggest that the Veteran's PTSD does not significantly impact his ability to establish and maintain effective social relationships, the reports lack significant probative value. The November 2011 VA examiner opined that the Veteran's PTSD was due to his relationship with his father-a position the Board rejected in its August 2009 decision, which granted service connection for the Veteran's PTSD. In addition, her findings are inconsistent with contemporary VA medical records, which indicate severe mental health problems, and with the Veteran's reports of significant marital, cognitive, and social problems. See November 2011 VAMRs. Moreover, the Veteran alleges that the November 2011 examination report does not accurately assess the severity of his symptoms. June 2013 NOD (challenging the VA examiner's finding that his PTSD resulted from the death of his father and that his responses were intended to "protect my benefits."). The August 2014 VA examiner failed to provide an adequate rationale in support of her opinion that the Veteran can "generally function[] satisfactorily." Specifically, she found that the Veteran had a successful career and good familial and social relationships without addressing the lay evidence that clearly indicates that the Veteran's PTSD forced him to take early retirement and undermined his marriage. See e.g., July 2015 Wife's Statement. Thus, the VA examiners' findings are outweighed by the lay evidence that documents the Veteran's inability to maintain stable and strong familial relationships to the extent that he has a volatile, often (verbally) abusive relationship with his wife. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that lay statements regarding symptoms that are experienced on a first-hand basis constitute competent evidence); Jandreau v. Nicholson, 492 F. 3d 1372, 1377 & n4 (Fed. Cir. 2007). The matters of entitlement to an extraschedular rating for the Veteran's PTSD symptoms and to TDIU are inextricably intertwined with the issue of entitlement to a disability rating in excess of 50 percent, which is remanded for further development. Accordingly, the matter of entitlement to an extraschedular rating in connection with service-connected PTSD is deferred pending adjudication of the remanded claim. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). In summary, the evidence is at least in equipoise. The benefit-of-the-doubt rule applies and a disability rating of 50 percent effective October 18, 2004 is granted for the Veteran's service-connected PTSD with depression. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER An initial disability rating of 50 percent for PTSD with depression is granted. REMAND The Veteran's claim of entitlement to an initial disability rating in excess of 50 percent for service-connected PTSD with depression, to include entitlement to a TDIU, is remanded for further development, to include a new VA examination to determine the present severity of the Veteran's disability. As an initial matter, the claims file contains evidence that has not been reviewed by the RO. VA received several lay statements from family members regarding the severity of the Veteran's PTSD symptoms after the issuance of the October 2014 supplemental statement of the case (SSOC). The RO did not review these statements and the Veteran has not waived his right to review by the agency of original jurisdiction. See 38 C.F.R. § 20.1304 (2014). Moreover, the new lay evidence suggests that the Veteran's symptoms may have worsened since his last VA examination in August 2014. See June 2015 Statement of Accredited Representative in Appealed Case; see also Washington, 19 Vet. App. at 368; Jandreau, 492 F. 3d at 1377 & n4. A July 2015 letter by the Veteran's wife states that the Veteran is "so depressed he shakes his knees, his hands shake and he does not participate in family functions like he used to." The Veteran's wife also observed that the Veteran is increasingly hypervigilant and that he "would kill his self if he didn't have the Lord in his life." August 2015 Statement. The Veteran's sister submitted a statement that the Veteran no longer participates in family activities and his son submitted a statement indicating that the Veteran no longer takes care of his personal hygiene. The statements by the Veteran and his family members are sufficient to warrant a new VA examination. See 38 C.F.R. § 3.327(a) (2015) (providing that reexaminations will be requested whenever VA needs to determine the current severity of a disability); VAOPGCPREC 11-95; Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007), citing Caluza v. Brown, 7 Vet. App. 498, 505-06 (1998) ("Where the record does not adequately reveal the current state of the claimant's disability . . . the fulfillment of the statutory duty to assist requires a thorough and contemporaneous medical examination."). The RO should schedule the Veteran for a mental health examination before issuing an SSOC that adjudicates the claims on appeal based on a review of all the evidence of record. In addition, remand is necessary to establish the exact date when the Veteran stopped working. See March 2006 VA Medical Records, November 2011 VA Examination Report, April 2012 Veteran's Application for Increased Compensation Based on Unemployability (indicating that the Veteran stopped working sometime between 2006 and 2008). The case is REMANDED for the following actions: 1. Obtain any outstanding VA medical records from September 2014 onward and associate them with the claims file. 2. Ask the Veteran to provide a detailed history of his employment since October 2004. See March 2006 VA Medical Records (reporting that the Veteran stopped working in 2006); November 2011 VA Examination Report (reporting that the Veteran stopped working in 2008); April 2012 Veteran's Application for Increased Compensation Based on Unemployability (reporting that the Veteran stopped working in August 2007). He should also be asked to provide documentation, such as copies of tax returns, showing his income since 2004. 3. Then, schedule the Veteran for a VA psychiatric examination to assess the severity of his service-connected PTSD with depression. The entire claims file, to include a copy of this REMAND, must be provided to the VA examiner, who must note its review. The examiner should use the appropriate Disability Benefits Questionnaire(s) (DBQs) to assess the severity of the Veteran's service-connected PTSD with depression. The examiner should elicit from the Veteran his complete educational, vocational, and employment history and should note his complaints regarding the impact of his service-connected PTSD with depression on his employment. The examiner should identify all limitations imposed on the Veteran as a consequence of his service-connected PTSD with depression and opine as to the impact of that disability on his ability to secure and follow a substantially gainful occupation, for the time period from October 2004 to the present. The examiner should also identify any change(s) in the severity of the Veteran's PTSD symptoms since October 2004. If the VA examiner identifies any such change(s), he or she must note the approximate date(s) of the identified change(s) and assess the severity of the Veteran's PTSD with depression at each date. The examination report must include a complete rationale for all opinions and conclusions reached. 4. After the VA examination has been completed, review the medical examination report to ensure that it adequately responds to the above instructions. If the report is deficient in this regard, return the case to the VA examiner for further review and discussion. 5. Finally, after the above development and any other development that may be warranted based on additional information or evidence received is completed, readjudicate the claim on appeal. If the benefit sought is not granted, the Veteran and his representative should be furnished with a Supplemental Statement of the Case (SSOC) and afforded a reasonable opportunity to respond to the SSOC before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs