Citation Nr: 1604974 Decision Date: 02/09/16 Archive Date: 02/18/16 DOCKET NO. 10-09 117 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to service connection for sleep apnea, to include as secondary to posttraumatic stress disorder (PTSD). 2. Entitlement to an initial schedular rating for PTSD in excess of 50 percent prior to October 5, 2011, and in excess of 70 percent thereafter. 3. Whether referral for extraschedular consideration of a higher rating for PTSD under 38 C.F.R. § 3.321(b) is warranted. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to October 5, 2011. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD C. Fields, Counsel INTRODUCTION The Veteran served on active duty from September 1969 to April 1971. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from several rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In December 2008, the agency of original jurisdiction (AOJ) granted service connection for PTSD with an initial rating of 10 percent, effective September 23, 2005. In March 2013, the RO increased the rating for PTSD from 10 percent to 30 percent, effective February 7, 2011; and to 70 percent, effective October 5, 2011. In the March 2013 rating decision, the AOJ also granted a TDIU effective as of August 1, 2012, based on a determination of unemployability due to PTSD, as well as meeting the percentage threshold criteria for a schedular TDIU on that date. The Veteran also met the schedular percentage threshold for a TDIU, based on a 70 percent rating for PTSD, as of October 5, 2011. It appears that the AOJ assigned August 1, 2012, as the effective date because this was the date on which the rating for prostate cancer and residuals was decreased from 100 to 40 percent. As he met the schedular criteria for a TDIU as of October 5, 2011, however, the TDIU is also warranted from that date forward. The Board will focus on the period prior to October 5, 2011. The Veteran's TDIU claim is part and parcel of his appeal of the rating for PTSD, and entitlement to a TDIU prior to October 5, 2011, remains on appeal because he asserts that he has been unemployable due to PTSD since 2002. In a July 2013 rating decision, the AOJ denied service connection for sleep apnea. The Veteran testified at a hearing before a Decision Review Officer (DRO) in February 2011, and at a Board hearing in June 2014; a transcript of each hearing is of record. The claims file is entirely in VA's electronic processing systems. In December 2014, the Board granted a 50 percent rating for PTSD prior to October 5, 2011, and denied a rating in excess of 70 percent from that date forward. The Board remanded the issues of service connection for sleep apnea and a TDIU. The Veteran appealed to the U.S. Court of Appeals for Veterans Claims (Court) from the Board's determinations regarding the ratings assigned for his PTSD. In an October 2015 Order, pursuant to a Joint Motion for Remand by the parties, the Court vacated and remanded this issue to the Board, to the extent that it denied higher ratings. The Board notified the Veteran and his representative of this determination, and the representative submitted arguments in November 2015. As the issues of service connection for sleep apnea and TDIU were not final, they were not addressed by the Court. They have now returned to the Board for further review, and the Veteran's representative submitted arguments in October 2015. The evidence is sufficient to decide the question of entitlement to higher schedular rating for PTSD, but not for a TDIU. Although extraschedular consideration under 38 C.F.R. § 3.321(b) and TDIU are not inextricably intertwined as a matter of law, both issues require a complete picture of the service-connected disabilities and their effects on employability. Brambley v. Principi, 17 Vet. App. 20, 24 (2003). If the Board denies either referral for extraschedular consideration or TDIU, the Board should take care to ensure a remand of the other aspect of a claim does not order further development pertinent to the denied issue. Id. For example, where remand of TDIU is necessary to attempt to obtain potentially favorable material evidence that may also be relevant to the issue of referral for extraschedular consideration, remand of both issues is warranted. Todd v. McDonald, 27 Vet. App. 79, 90 (2014). Accordingly, the issues of entitlement to a TDIU prior to October 5, 2011, and whether referral for an extraschedular rating for PTSD is warranted, are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The evidence is in relative equipoise as to whether the Veteran's symptoms of sleep apnea began in service, and whether it was caused or aggravated by his PTSD. 2. For the period prior to October 5, 2011, the Veteran's PTSD resulted in occupational and social impairment in multiple areas with reduced reliability and productivity, due to symptoms of a nature, frequency, and severity most nearly approximating those contemplated by a 50 percent disability rating. 3. Since October 5, 2011, the Veteran's PTSD has not resulted in total social and occupational impairment; and his symptoms have not been of a nature, frequency, and severity approximating those contemplated by a 100 percent rating. CONCLUSIONS OF LAW 1. The criteria for service connection for sleep apnea have been met. 38 U.S.C.A. §§ 1110, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2015). 2. The criteria for an initial schedular rating for PTSD in excess of 50 percent prior to October 5, 2011, and in excess of 70 percent thereafter, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The decision herein is a full grant of the benefit sought for service connection for sleep apnea; therefore, no further notice or development is needed in this regard. The appeal from the ratings assigned for PTSD is a downstream issue from the award of service connection and initial ratings, with subsequently granted higher ratings, for this disability. VA provided full notice of how to substantiate this service connection claim, including a disability rating and effective date, via letters in October 2005 and August 2006, prior to the initial adjudication of the claim. No further notice is required regarding the downstream issue of a higher initial rating, and no prejudice has been alleged. Moreover, the Veteran and his representative indicated actual knowledge of the requirements for a higher rating during the two hearings, and the DRO and the undersigned, respectively, asked questions to elicit pertinent information and try to substantiate the claim. See Bryant v. Shinseki, 23 Vet. App. 488 (2010); 38 C.F.R. § 3.103(c)(2). Indeed, new VA examinations and medical evidence were obtained in response to the hearings. All available identified, outstanding medical records were obtained. These included VA, Veterans Center, and some private psychological treatment records. The Veteran was notified in October 2007 and August 2012 of the unsuccessful efforts to obtain certain records, and allowed an opportunity to provide them. The Veteran was last afforded a VA examination for his PTSD in December 2008. He was informed in his February 2011 DRO hearing that he would be scheduled for a second VA examination. The AOJ subsequently determined, however, that a new examination was not warranted because there was sufficient evidence of record to rate the Veteran's disability. A May 2012 deferred rating decision noted that the AOJ had contacted the Veteran, and the Veteran agreed that no VA examination was needed to decide his claim. In a March 2013 rating decision, the AOJ awarded a staged increased rating for PTSD, beginning as of February 7, 2011. The claims file includes detailed VA mental health treatment records, as well as primary care records discussing the Veteran's mental health symptoms, dated through 2015, and the Veteran's testimony as to his symptoms at a Board hearing in June 2014. The mere passage of time does not require a new VA examination where an otherwise adequate examination has been conducted; rather, there must be an indication that the disability has increased in severity to warrant a new examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007). VA must provide a new medical examination where the record does not adequately reveal the current state of the claimant's disability, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the previous examination. Allday v. Brown, 7 Vet. App. 517, 526 (1995). In this case, there has been no assertion or indication that a new VA mental health examination is needed, or that the available lay and medical evidence is insufficient to determine the severity of the Veteran's PTSD. Notably, no such argument or suggestion was made in the 2015 Joint Motion, during the 2014 Board hearing, in arguments by the Veteran's representative in 2014 or in 2015 (before and after the Court remand), or by the Veteran himself. Again, the Veteran agreed in 2012, after his 2011 DRO hearing, that a new VA examination was not needed at that time, and the evidence includes medical records describing the Veteran's symptomatology. Thus, a new VA examination is not needed to adequately rate the Veteran's PTSD. There is no additional notice or assistance that would be reasonably likely to aid in substantiating the Veteran's claims that are decided herein. Any errors committed were not harmful to the essential fairness of the proceedings, and the Veteran will not be prejudiced by a decision at this time. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326; Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). II. Service Connection The Veteran filed a formal claim for service connection for sleep apnea as secondary to PTSD in May 2012. At various times, he has also asserted that his sleep apnea has existed continuously since service, although undiagnosed. Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Where a disease is first diagnosed after discharge, service connection will be granted when all of the evidence, including that pertinent to service, establishes that it was incurred in service. 38 U.S.C.A. § 1113(b); 38 C.F.R. § 3.303(d). Direct service connection generally requires evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection will be granted on a secondary basis for a disability that is proximately due to or the result of (caused) or permanently worsened beyond its natural progression (aggravated) by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc). Under certain circumstances, lay statements may be sufficient for service connection by establishing the occurrence of lay-observable events, the presence of disability, and/or symptoms of disability that are susceptible to lay observation. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim. 38 U.S.C.A. 1154(a); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. The Veteran and other lay witnesses are competent to report his observable symptoms of OSA, such as impaired sleep and breathing difficulties. Jandreau, 492 F.3d at 1376-77. These lay witnesses are not competent, however, to diagnose OSA or to provide an opinion regarding its etiology. As noted by medical professionals and in multiple medical articles submitted by the Veteran, sleep apnea is a complex disorder and may have many possible causes. Therefore, medical training or expertise is required to evaluate the available lay and medical evidence and provide a diagnosis and etiology opinion as to his current disability. Id. The Veteran underwent a sleep study at a VA facility in November 2008, which established a current disability. The impression was moderate obstructive sleep apnea (OSA) syndrome with mild desaturation in a patient with symptoms suggestive of sleep disordered breathing, obesity, hypertension, and PTSD. There is evidence of symptoms that may be due to sleep apnea prior to this diagnosis. VA treatment records documented reports of snoring that started in December 2005; the diagnosis was rule out OSA, and sleep studies were ordered in December 2005 and June 2006, but apparently did not occur until November 2008. The Veteran also reported chronic hay fever, nasal congestion, and sneezing in December 2005, as well as in subsequent treatment records. See also June 2009 treatment record (noting that the Veteran was diagnosed with OSA and started using a CPAP in November 2008, and that he had snoring history since 2005). An October 2009 record noted that the Veteran was using the CPAP machine for his OSA intermittently, and that he had a hard time remembering things and he had difficulty falling back asleep when he would wake up during the night. The provider stated that poor compliance with CPAP was partially related to insomnia problems. Subsequent records continued to note that the Veteran reported a snoring history since December 2005, that his CPAP compliance was improving, and that he also had allergic rhinitis. See, e.g., treatment records in January 2010, December 2011, December 2012, June 2013, June 2014, September 2014, and February 2015 The Veteran and other lay witnesses, however, have reported for his claim that he had symptoms that eventually resulted in a diagnosis of sleep apnea for many years. In an April 2014 statement, the Veteran indicated that he experienced loud snoring and periods of not breathing while he was sleep at times during service, prior to beginning his 20-year career as a firefighter, and prior to his cancer diagnosis (which is service-connected). The Veteran also stated that, while he was serving in Vietnam, a doctor told him that he needed his tonsils removed, but that he should wait until he returned state-side for that procedure. With regard to obesity being a risk factor for sleep apnea, the Veteran argued that his weight was not constant over the years, and he progressively gained weight, especially after his cancer diagnosis. During the June 2014 Board hearing, the Veteran testified that he did not have sleep apnea symptoms before service, and could not remember exactly when it began, but that he remembers having it when he returned from service. He indicated that he had loud snoring, restless sleep, snorting, gasping, choking, headaches, and/or dry mouth after he woke up; short temper and irritability, frequently needing to use the bathroom, heartburn, and sleeping during the day. The Veteran also testified that he could not "say with any level of certainty" that he had any of these symptoms while on active duty, but that he did not remember a lot of what happened in Vietnam, which was the majority of his military service. The Veteran indicated that, during the 1969 to 1971 time frame, he was tired all the time, and his sisters and other family members would tell him they were worried about him while he slept due to observing him choking or gasping for breath. He asserted that that very few people knew about sleep apnea at the time, and he thought it was normal. The Veteran's representative also argued that, although the July 2013 VA examiner opined that the Veteran's sleep apnea was caused by his obesity or weight gain, the examiner did not address aggravation by PTSD, and there was medical literature indicating that PTSD can aggravate PTSD. In a March 2014 statement, the Veteran's sister stated that she noticed him having trouble sleeping when he came back from service. He slept on the sofa and she noticed that he seemed to have acquired loud snoring and would sometimes stop breathing, which would sometimes wake up him and other family members. In an April 2014 statement, the Veteran's spouse indicated that she noticed that he snored, stopped breathing frequently, and was chronically tired when they were married beginning in 1987. This would have been nearly 10 years after the Veteran's service discharge, but many years before his OSA diagnosis in 2008. The Veteran's service treatment records did not show any complaints or treatment for sleep difficulties, or a diagnosis of sleep apnea or a tonsil condition. The 1971 Report of Medical Examination for his discharge from service recorded that the Veteran reported being in good condition, and no abnormalities were found upon clinical examination; however, there was no Report of Medical History with a listing of subjective symptoms for that examination. Again, the Veteran and other lay witnesses are competent to report what they remembered experiencing and observing during service and shortly thereafter. Jandreau, 492 F.3d at 1376-77. A July 2013 VA examiner opined that the Veteran's OSA was not caused by his PTSD. This examiner noted several risk factors for OSA, citing to medical literature, and stated that obesity was documented in the Veteran's case and PTSD was not a risk factor for OSA. The examiner compared the Veteran's body mass index (BMI) at service discharge based on his height and weight at that time, which was a normal weight; and his BMI at the time of the November 2008 sleep study that diagnosed OSA, which was considered obese. Thus, the VA examiner indicated that the Veteran's apnea was due to obesity, not caused by PTSD. In May 2015, a VA psychologist reviewed the claims file and gave opinions regarding a relationship between the Veteran's PTSD and sleep apnea, via reports in May 8, 2015, and May 22, 2015. In both reports, this VA examiner summarized the July 2013 examiner's report and reasoning, including that PTSD was not a risk factor for PTSD. The 2015 examiner stated, however, that there was "clear and consistent evidence" of a correlation or relationship between PTSD and sleep apnea, noting that there was a significant rate of comorbidity of the disorders. This examiner also stated that current literature and research findings were mixed regarding the direction of this relationship and the impact of the disorders on each other, and that there was "no clear or definitive evidence" to support the assertion that one disorder caused the other, i.e., that PTSD caused sleep apnea. In the May 8, 2015, report, this examiner concluded that it was not possible to determine whether the Veteran's OSA was proximately aggravated or permanently worsened beyond its natural progression by his PTSD without resort to mere speculation. This conclusion was based on the mixed findings in medical literature and lack of "clear or definitive evidence" to support the assertion that PTSD causes OSA, as well as the Veteran's multiple other medical diagnoses of Type II diabetes, hypertension, obesity, and a history of drug and alcohol dependence, that were known to be possible contributors to OSA. In the May 22, 2015, report, this examiner reiterated the information contained in his initial report, but added that some medical studies suggested that sleep apnea may predispose an individual to the development of anxiety disorders or PTSD due to increased levels of stress hormones and sympathetic nervous system impairment, which can inhibit the person's ability to adequately manage or cope with stressors and/or trauma. The examiner also stated that some evidence indicated that individuals with PTSD may be less likely to use or tolerate sleep apnea treatments, such as CPAP. The examiner concluded that, in light of the medical literature and the Veteran's other medical diagnoses that were known contributors to the development of sleep apnea, it was his opinion that the Veteran's sleep apnea was less likely as not (less than 50% probability) caused by his PTSD. This examiner further stated that in this report that it was not possible to determine whether the Veteran's sleep apnea was proximately aggravated by or permanently worsened beyond its natural progression by his PTSD without resort to mere speculation. A VA physician also reviewed the claims file and, in a May 19, 2015, report, opined that the Veteran's OSA was less likely than not aggravated by his PTSD. This examiner reasoned that PTSD is a mental health disorder, whereas OSA is a disorder of the upper airway anatomy; and that a condition that causes additional narrowing of the upper airway anatomy could aggravate OSA, but that PTSD does not cause narrowing of the upper airway. This examiner further stated that PTSD can worsen night sleep due to nightmares, but not because it worsens OSA. In addition to these VA medical opinions, the Veteran's representative submitted articles or excerpts from psychiatric and sleep disorder journals in June 2014. A medical article "can provide important support when combined with an opinion of a medical professional if it discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least 'plausible causality' based upon objective facts." Mattern v. West, 12 Vet. App. 222, 228 (1999). In brief, two articles from psychiatric sources indicated that individuals with PTSD symptoms had a more fragmented pattern of REM sleep, as well as difficulty falling asleep, waking more often, difficulty returning to sleep, and nightmares. An article from a sleep journal explained that OSA was characterized by recurrent episodes of complete or partial collapse of airways, noted that OSA can occur in nonobese individuals, and stated that REM-related OSA can progress to disordered breathing in all stages of sleep. Another article from a sleep journal indicated that OSA was a common comorbid condition in patients with PTSD, and that sleep fragmentation and insomnia due to nightmare and otherwise were common in PTSD and may significantly decrease CPAP adherence for treatment of sleep apnea. This article further stated that misperception of symptoms, overlapping symptoms of depression, and atypical presentations of OSA may limit the acceptance of a diagnosis and the need for treatment. Similarly, another article from a mental health journal stated that common sleep disorders, including OSA, may relate to PTSD symptoms in a more complex manner than sleep disturbances merely being symptoms of psychiatric stress. The articles generally note that the relationship between PTSD and OSA or other sleep breathing disorders is unclear. The multiple VA examiners do not appear to have considered the reports by the Veteran and other lay witnesses of him having symptoms that could be due to sleep apnea for many years prior to his official diagnosis of sleep apnea in 2008, to include since service. Although the VA treatment records only reflect a history of snoring since December 2005, it appears that this may have referred only to the date on which the Veteran sought treatment for snoring. Further, as summarized above, a VA examiner and medical literature noted that OSA can predispose some individuals to developing PTSD, and that symptoms of OSA and sleep difficulties due to psychiatric stress may overlap and be misdiagnosed. This could be consistent with the Veteran having had both PTSD and OSA symptoms since service, although neither conditions were diagnosed until many years later. Additionally, the medical articles noted that OSA can occur in nonobese individuals, and that sleep problems due to PTSD may negatively affect CPAP adherence for treatment of PTSD. The Veteran's treatment records confirmed that his insomnia and memory problems, which the Veteran has due to his PTSD, as discussed below, affected his CPAP adherence at times; and he was not always obese prior to 2008 when he has reported having symptoms. Moreover, the sleep study in 2008 noted the Veteran's diagnosis of PTSD in addition to other disorders that the VA examiners noted were risk factors for OSA, and the May 2015 VA examiner indicated that there was a possible causal relationship between the Veteran's PTSD and his OSA. This VA examiner stated that there was "clear and consistent evidence" of a relationship between PTSD and sleep apnea, but pointed to mixed findings in medical literature and a lack of "clear or definitive evidence" that PTSD caused OSA. This was an incorrect standard of proof, however, as VA's standard of proof only requires a 50 percent probability. In light of these factors, the evidence is in relative equipoise as to whether the Veteran's OSA had its onset in service or was caused or aggravated by PTSD. Further development in this regard would only cause unnecessary delay. Reasonable doubt is resolved in the Veteran's favor, and the criteria for service connection are met. 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. III. PTSD Schedular Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, 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. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In determining the propriety of an initial disability rating, the evidence since the effective date of the grant of service connection must be evaluated and staged rating must be considered. Fenderson v. Brown, 12 Vet. App. 110, 126-27 (1999) Evaluation of a mental disorder requires consideration of the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the capacity for adjustment during periods of remission. Evaluations will be assigned based on all evidence that bears on occupational and social impairment, rather than solely on an examiner's assessment of the level of disability at the moment of the examination. The extent of social impairment shall also be considered, but an evaluation may not be assigned based solely on the basis of social impairment. 38 C.F.R. § 4.126. Percentage ratings for service-connected mental health disabilities are based on the criteria in the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. The symptoms listed in 38 C.F.R. § 4.130 are not intended to constitute an exhaustive list but, rather, serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating for a mental disorder. In addition to the symptoms listed in the rating schedule, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The DSM-IV provides for a global assessment of functioning (GAF), a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting the DSM-IV). A veteran may only qualify for a given disability rating "by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). The Veteran's service-connected PTSD has been assigned an initial 50 percent rating prior to October 5, 2011, and a 70 percent rating thereafter. He was also awarded a schedular TDIU, effective August 1, 2012, based on his PTSD. As discussed below, the evidence does not warrant a higher rating at any point. The criteria for a 50 percent rating are as follows: 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. The criteria for a 70 percent rating are as follows: 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. Id. The criteria for a 100 percent rating are as follows: 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. Id. In this case, the Veteran has had mental health treatment at various facilities for the majority of the appeal period, and he took psychiatric medications at times, which helped his symptoms to some extent, although he does not like taking pills. For the period prior to October 5, 2011, the medical and lay evidence showed that the Veteran was distrustful and guarded; had feelings of detachment, being disconnected, alienation, numbing, and isolation; and had difficulty with relationships. He also had flattened or restricted affect, anhedonia or difficulty experiencing pleasure, and foreshortened sense of future at times. The Veteran avoided conversations and activities; was hyperalert and hypervigilant, in that he liked to be aware of everything going on around him; and had an exaggerated startle response or reaction to unexpected sounds. He also experienced frequent intrusive thoughts and intermittent panic attacks and intense psychological distress at reminders of past traumas. He had flashbacks and chronic sleep impairment with nightmares related, in part, to traumatic experiences in service. The Veteran suffered from intermittent feelings of depression, sadness, anxiety, irritability, anger, rage, racing thoughts, and difficulty concentrating. He also had intermittent feelings of helplessness, hopelessness or worthlessness, and excessive guilt and remorse about his own survival and having killed people in Vietnam. The Veteran complained of fatigue and decreased energy, decreased interest in activities such as sports, low motivation, increased appetite and weight gain at times. See, e.g., statements from Veteran in February 2006 and March 2007; VA treatment records in August 2005, June 2006, June 2007, July 2007, March 2008, and April 2008; letter from private provider in December 2006; December 2008 VA examination; Vet Center records in December 2008 and July 2009; February 2011 DRO hearing. In the prior decision that granted a 50 percent rating for this period, the Board noted that the Veteran had difficulty with short-term memory and sequencing events in an accurate time frame, as well as concerns about long-term memory loss. The 2015 Joint Motion stated that this was not an adequate discussion of memory loss, noting that during the February 2011 hearing, the Veteran reported not remembering "complete periods" of his life, including attending his grandfather's funeral, and the names of fellow soldiers or people he worked and associated with in the past. The Veteran also testified during that hearing that he could not remember the name of the doctor who operated on him in service, he had vague or partial memories of details from service, and he had difficulty remembering appointments and to take medications. The Joint Motion also noted that, in an October 5, 2011, VA evaluation, the Veteran stated that memory loss was his "main concern." This treatment record reflected that the Veteran described being unable to remember where he parked, missing appointments, and forgetting to take medications at times. The VA provider noted that the Veteran had good recall of answers for past and present upon testing, with the exception of his experiences in Vietnam. Similarly, the Veteran reported in March 2007 and March 2009 statements for his claim that he was unable to remember days, weeks, and months of his past prior to his job as a firefighter; and that he could not remember periods of his service in Vietnam, other than during nightmares or flashbacks. A March 2008 Vet Center treatment record also noted the Veteran's concern about not remembering things in his remote past, such as Vietnam experiences, although he was starting to recall others who had served with him through his writing class for combat veterans. VA treatment records in June 2006 and June 2007 noted that the Veteran's memory and recall were adequate upon testing, although he complained of memory loss. In an August 2009 letter, the Veteran's ex-wife at the time stated that they had been married from 1987 to 1997. She indicated that, when they had lived together during that period, she would find the Veteran in the middle of the night and he would not know where he was or why he was there. These episodes were well before the September 2005 effective date of service connection and, thus, have very low probative value for the degree of memory impairment during the period on appeal. The lay and medical descriptions of memory loss present during the appeal period are contemplated by the 30 percent rating criteria of mild memory loss (such as forgetting names, directions, and recent events); and by the 50 percent rating criteria of impairment of short- and long-term memory (such as retention of only highly learned material and forgetting to complete tasks). 38 C.F.R. § 4.130, DC 9411. In particular, impairment of long-term memory contemplates the Veteran's inability to remember prior events such as his grandfather's funeral and experiences in service, as well as names or details about service members, coworkers, and friends from his past. Mild memory loss of forgetting names also contemplates such symptoms. These symptoms do not rise to the level of memory loss contemplated by a 100 percent rating for PTSD, nor do they approximate the nature or severity of symptoms warranting a 70 percent rating. Id. For example, the Veteran did not indicate that he had forgotten the name of his grandfather or other close relatives, only that he had forgotten the past event of his grandfather's funeral. There was also no argument or indication that the Veteran had forgotten his own occupation or name, as opposed to the names of prior coworkers. Indeed, the Veteran has described his last occupation as a firefighter in great detail on several occasions. Again, although the Veteran has frequently complained of memory loss, the nature and severity of such symptoms is similar to the types of memory impairment contemplated by the 30 and 50 percent rating criteria. The frequency of memory loss does not approximate the level of impairment warranting a 70 percent rating. The 2015 Joint Motion further stated that the Board's previous determination that the Veteran was able to establish and maintain effective relationships prior to October 5, 2011, appeared inconsistent with certain evidence. The Joint Motion pointed to a December 2006 letter, in which a private treating provider stated that the Veteran's PTSD had resulted in a divorce and injured his relationship with his two sons because his family perceived him as not caring, disengaged, and detached. The Joint Motion further noted that, during the February 2011 hearing, the Veteran testified that he had separated from his wife in the 1990s and had not been in a meaningful romantic relationship since that time; and when asked whether he had friends, the Veteran answered, "Not really, I have some acquaintances." The Joint Motion also noted that, in an August 2009 letter, the Veteran's ex-wife at the time stated that he had few friendships or relationships and spent much of his time alone. These records establish difficulty in establishing and maintaining effective relationships, which is contemplated by the 50 percent rating that the Board previously assigned for this period. Id. Nevertheless, the totality of the evidence establishes that the Veteran maintained contact and an amicable relationship with his ex-wife and his sons, as well as with other family members, and that he had some friends and engaged in social activities despite symptoms during this period. For example, in a June 2007 VA treatment session, the Veteran reported a good relationship with his ex-wife. In March 2008, he reported that he was sharing the raising of his two sons with his ex-wife, and that he had agreed to drive his ex-wife places, noting that this interfered with his own activities, but that he found it to be useful and helpful. The fact that the Veteran's ex-wife wrote a letter on his behalf in 2009 also shows a positive relationship to some degree. Indeed, in the October 5, 2011, VA treatment record, upon which the AOJ relied in granting a 70 percent rating, the Veteran reported that he was living with his ex-wife because she wanted to save money. This indicates that she moved in with him prior to October 5, 2011. The Veteran and L.S. later remarried. See July 2013 report of general information; April 2014 statement from L.S. (identifying herself as the Veteran's wife). With regard to his children, a December 2005 VA treatment record noted that the Veteran's two sons, aged 18 and 17 at the time, lived with their mother, but that he saw them. Then, in June 2007, March 2008, and December 2008, the Veteran reported that one of his sons was living with him. In March 2008, he stated that he was close to both of his sons, and that it was difficult living with the older son, but that he tried to teach his children and was working on letting go of the stress related to his sons. Similarly, the Veteran testified in February 2011 that he had a "fairly close" relationship with his sons, stating that they would visit him at his home, but they did not live with him at that time. Consistent with his report in March 2008, the Veteran testified in 2011 that his oldest son had lived with him for a little while, but they had some difficulties due to the Veteran's PTSD symptoms. In the October 5, 2011, VA treatment record, the Veteran indicated that he still saw both of his sons regularly, and that the older son was again living with him. The Veteran also reported a good relationship with some of his siblings during this period. In a June 2006 treatment session, he reported having two sisters and a brother living in the area who were supportive of him and with whom he had a good relationship. In June 2007, he reported that he talked frequently with these siblings. With regard to friends and other social interactions, in a December 2005 VA treatment session, the Veteran reported that he had "friends he gets together with." In August 2007, he reported having good communication skills, that he talked and laughed easily, and that he had a network of support. In November 2007 and March 2008, he reported that he had reached out to people to improve his mood. Further, in March 2008, although the Veteran reported that he would isolate and avoid getting to know other veterans, he also stated that he found it difficult to socialize beyond his veteran contacts at VVSD (a veteran support center at which the Veteran had stayed for a time after being homeless in 2005) and other groups, including a writing workshop for combat veterans. The Veteran stated that he had "transient friends" and was not comfortable getting close to others, but that he feared being isolated and kept a busy volunteering schedule with commitments to serve others at VVSD, through his art class, and some Alcoholics Anonymous (AA) meetings. He was interested in going to church to find a sense of community, staying connected to VVSD, and building a network of friends, although he also reported that he had a network of support and friends. The Veteran was active in a creative writing therapy workshop at the Vet Center from 2008 to 2009, in which he was writing about themes of Vietnam, social injustice, and how people look at themselves. A December 2008 Vet Center record noted that the Veteran reported that he was doing fine, he was continuing activities with writing and painting, and he was working to stay active in spite of his isolation urges, intrusive thoughts, and depressed periods, although he wanted to wait before pursuing a romantic relationship. The December 2008 VA examination also noted that the Veteran's activities included taking walks, using the computer, and painting portraits. He denied any problems driving a car or going to the grocery store, the mall, or shopping in general. Consistent with these records, the Veteran reported in a February 2009 statement for his claim that he would structure his days to make sure that he got out of the apartment almost every day, including to volunteer at a veterans' organization, attend meetings for AA and combat veterans with PTSD, and attend a writing workshop at the Vet Center. In sum, the Veteran had difficulty socializing and establishing and maintaining effective relationships, as contemplated by a 50 percent rating, due to his PTSD. Nevertheless, he continued to have positive relationships, albeit with friction or isolation at times, with several family members, a few friends that he referenced in 2005 and 2008, and regular interaction with volunteering and group meetings. Therefore, the Veteran did not have an inability to establish or maintain effective relationships during this period, as contemplated by a 70 percent rating. Id. Further, although the Veteran had episodes of low motivation and mood, depression, anxiety, panic attacks, these symptoms were not so nearly continuous as to affect the Veteran's ability to function independently, appropriately, and effectively, so as to support a 70 percent rating for PTSD prior to October 5, 2011. Instead, as noted above, the Veteran continued to volunteer, attend group meetings, and participate in hobbies. He also addressed financial and other responsibilities. For example, a June 2006 VA treatment record noted that he was having financial problems due to back taxes, but that he was working with a VVSD lawyer to address them, and that he was also paying child support for one of his sons and paid rent for his apartment. Treatment records and the 2008 VA examination noted that the Veteran was generally pleasant, cooperative, friendly, and polite. In a June 2007 VA treatment record, the Veteran reported that he had been referred to the mental health clinic by his primary care provider because he had let his anti-hypertensive medications run out, and the provider was concerned about the Veteran's self-care behaviors and apathy about medical consequences of uncontrolled hypertension. The Veteran had also reported forgetting to take medications at times, as indicated above in the discussion of memory impairment. Nevertheless, the Veteran followed up with both primary care and mental health treatment before and after this time. Further, a private provider indicated in a 2005 letter that the Veteran had been employing positive affirmations to deal with his depression and had learned how to cope with his PTSD symptoms "extremely effectively." Similarly, in a March 2008 VA treatment record, the Veteran reported that he did a lot of maintenance projects to keep his mood up, and that he had been trying to give himself positive feedback and use humor, in addition to reaching out to others, to improve his mood. Likewise, the Veteran reported in a February 2009 statement for his claim that he would pay attention to his thoughts, words, and feelings, and would restructure his thought processes from negative to positive thoughts as needed. Thus, the notation in 2006 regarding concern for the Veteran's self-care behaviors does not establish an overall interference with functioning. During the February 2011 hearing, the Veteran reported retired early from his 20-year employment as a firefighter due to stress, in that he believed that he was no longer capable of performing routine tasks necessary for his employment due to his PTSD symptoms. Common knowledge and the Veteran's descriptions of his duties show that routine tasks as a firefighter are much different than routine tasks for daily life, and as noted above, the Veteran continued to function independently, appropriately, and effectively through many types of social and other activities. The Veteran further testified in 2011 that he was compulsive, explaining that he learned to be aware of his surroundings and what was going on around him while in the military and as a firefighter, and that he continued to be aware of what was around him, noises in other rooms, and to look at a building to assess its structural safety, for instance. The Veteran also indicated that he would get up several times a night to check the other rooms and doors because he would hear noises even though he tried to minimize background noise with fans. The December 2008 VA examiner recorded that there were no obsessive or ritualistic behaviors, and treatment records generally noted that the Veteran had appropriate behavior. The Veteran's descriptions of being compulsive, obsessive, or ritualistic are essentially descriptions of being hyperalert, hypervigilant, and suspicious. Moreover, there was no indication that these behaviors interfered with the Veteran's routine activities during this period. His sleep impairment as a result of waking up to check rooms and doors was contemplated by chronic sleep impairment under the 30 percent rating criteria. Further, the Veteran continued to engage in multiple activities outside the house and shared in child-rearing responsibilities, as noted above; and he completed household chores such as cleaning the house and personal care such as exercise. See, e.g., March 2008 Vet Center record. The Veteran repeatedly denied suicidal ideation for treatment and evaluation prior to October 5, 2011, and he has not reported suicidal thoughts as one of his concerns for mental health impairment. See, e.g., VA treatment records in June 2006, June 2007, July 2007, November 2007; VA examination in December 2008. In the June 2007 VA mental health session, the Veteran denied any current suicidal ideation; although he stated that he had passive thoughts of "what's the point," but he denied any intent or plan or a history of suicide attempts. In the October 5, 2011, VA mental health treatment evaluation, the Veteran reported feelings of worthlessness or guilt, and a depression screen showed that he reported having thoughts of being better off dead or hurting himself on several days, although he otherwise denied suicidal ideation or past suicide attempts, and there were no indications of self-harm gesture. The provider noted that the Veteran's comments about himself were not positive, but that there were no suicidal risks. This record from October 5, 2011, is relevant to the Veteran's mental health status shortly before this treatment session, as well as on that date. The Veteran's passive thoughts noted in June 2007 and occasional possible thoughts of self-harm as noted in October 2011, however, do not establish impairment of a level to warrant a 70 percent rating. Further, although the Veteran had frequent anger and irritability, there was no indication of impaired impulse control similar to the type contemplated by the 70 percent rating criteria, to include periods of violence. See 38 C.F.R. § 4.130, DC 9411. The Veteran consistently denied a history of assaultiveness or violence, as well as homicidal ideation or thoughts of hurting others. In addition, insight and judgment were repeatedly noted to be intact, good, or fair prior to October 5, 2011. See, e.g., VA treatment records in August 2005, June 2006, June 2007, July 2007, November 2007, and October 2011; VA examination in December 2008. The Veteran occasionally had soft speech, but otherwise, there was no indication of abnormal speech, communication, or thought processes prior to October 5, 2011. He had normal rate and flow of speech, and thought processes were noted to be coherent, linear, logical, or reality-based, with content within normal limits. The Veteran also consistently denied any delusions or hallucinations; and he was consistently noted to be oriented to all spheres, include space, time, and place. See, e.g., VA records in June 2006, June 2007, July 2007, and November 2007; December 2008 VA examination. A possible indication of disorientation was in the 2009 letter from the Veteran's ex-wife, which described him seeming unsure of where he was in the middle of the night at times during their prior marriage through 1997. As this was well before the appeal period, it has very low probative value and does not establish disorientation since the effective date of service connection. There was also no suggestion that the Veteran neglected his personal appearance or hygiene, or that he was unable to perform activities of daily living such as maintaining minimal hygiene at any point. He was repeatedly noted to be casually or adequately dressed, well or adequately groomed, with adequate hygiene, and he denied problems taking care of himself during the December 2008 VA examination. The Veteran has not worked since he retired early from the fire department in 2002. He has reported multiple times, including in a February 2009 statement, that he stopped working because he was afraid of encountering situations that would exacerbate his PTSD symptoms. Although this evidence is relevant to difficulty in adapting to stressful circumstances, and particularly the high-stress nature of his last working position as a firefighter, this circumstance alone does not warrant a 70 percent or higher rating since the effective date of service connection in 2005. The Veteran was assigned GAF scores from 50 to 65 prior to October 5, 2011. See, e.g., VA treatment records from June 2007 and July 2007 (60); December 2008 VA examination (65); Vet Center record in July 2009 (50). A GAF score of 61 to 70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functions pretty well with some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates moderate symptoms (e.g., flat affect, circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). A GAF score of 41 to 50 indicates that the individual has serious symptoms or a serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). The December 2008 VA examiner, who assigned a GAF score of 65, summarized that the Veteran's symptoms were transient and mild, or relatively mild-to-moderate. This examiner also stated, however, that the Veteran demonstrated "some significant psychosocial dysfunction" since service, and that his psychosocial functioning and quality of life had been "problematic." This examiner noted that the Veteran had addressed his past substance abuse that had caused more problems. Previously, the private provider who assigned a GAF score of 50 in a December 2006 letter described symptoms similar to those summarized above, but also stated that the Veteran had learned how to cope with his mental health symptoms "extremely effectively." Similarly, in a March 2008 VA treatment record, the Veteran reported that he did a lot of maintenance projects, tried to give himself positive feedback, used humor, and reached out to others in order to improve his mood. Likewise, the Veteran reported in a February 2009 statement for his claim that he would pay attention to his thoughts, words, and feelings, and would restructure his thought processes from negative to positive thoughts as needed. Neither the GAF score nor a medical summary of the level of impairment, is conclusive of the Veteran's overall impairment due to his mental health symptoms, as the Board must consider all pertinent evidence. See 38 C.F.R. §§ 4.1, 4.3. The Veteran and his representative have argued that the December 2008 VA examiner's summary of overall mild impairment and assignment of a GAF score of 65 should be rejected as not consistent with the other evidence. See March 2010 substantive appeal (VA Form 9), February 2011 hearing transcript. Consistent with these arguments, the Veteran has already been granted a higher rating of 50 percent to account for more than a mild level of impairment prior to October 5, 2011. During the June 2014 hearing, the Veteran's representative also argued that the Veteran's history of homelessness and substance abuse entitled him to a 100 percent rating from the date of service connection for PTSD, or from September 23, 2005, forward. The evidence confirms that the Veteran had periods of homelessness and a long history of past substance abuse. Since July or August 2005, however, he has had consistent shelter through either residential treatment or in a rental house or apartment, and he has been clean and sober. See, e.g., VA treatment records in August 2005, March 2008, and February 2015; hearing transcripts in February 2011 and June 2014. Similarly, although the Veteran reported private inpatient treatment in a February 2011 form and during the June 2014 hearing, he identified such treatment as occurring in 2001. The primary focus in determining the appropriate initial rating for a disability is the severity since effective date of service connection, or since September 23, 2005. Thus, these prior levels of impairment do not establish entitlement to a higher disability rating during the appeal period. The AOJ assigned a 70 percent rating for PTSD from October 5, 2011, forward, based on symptoms and GAF scores similar to those reported prior to that date. This higher rating appears to have been based on a notation in a VA treatment record on that date of "marked impairment/distress in occupational/social functioning." Nevertheless, as discussed above, prior to October 5, 2011, although the Veteran had impairment in multiple levels, his mental health symptoms did not rise to the level of severity, frequency, or duration of the types of symptoms contemplated by a 70 percent or higher rating. See 38 C.F.R. § 4.130, DC 9411. For the period beginning October 5, 2011, the evidence also does not warrant a rating higher than 70 percent at any point. Although the Veteran had occupational impairment due to PTSD, and he was awarded a TDIU on this basis effective since October 5, 2011, a 100 percent schedular rating for PTSD requires total occupational and social impairment, which has not been shown. Id. Significantly, the Veteran continued to engage in activities outside of his home for pleasure, such as art classes and painting, volunteering at VVSD, attending AA meetings, and being a freemason. He also continued to have effective relationships with several family members, albeit with friction at times. The Veteran remained close with his two sons who lived locally, and one of them continued to live with him at times in 2011, 2013, and 2015. He also continued to report a close relationship with his sister who lived in the area. As noted above, the Veteran's ex-wife was living with him as of October 5, 2011, and he reported living with his "girlfriend" in July 2013, although other evidence indicated that he had remarried this ex-wife as of July 2013. In January 2015, the Veteran reported that his wife had moved to Hawaii. The Veteran reported having friends in December 2012 and January 2014, and he was noted to have the support of family or friends, as well as strong coping or problem-solving skills, in a July 2014 VA treatment record. The Veteran also completed the VA "MOVE" program for weight loss and fitness, which addressed motivation and the relationship between emotions and eating. In September 2014, he reported engaging in 240 minutes of moderate to vigorous activity per week; this showed motivation and active participation in self-care. Further, the Veteran resumed taking psychiatric medications at times, in addition to medications for other medical conditions, despite disliking medications; they helped his mental health symptoms to some extent. See, e.g., VA treatment records in October 2011, February 2012, July 2012, December 2012, July 2013, January 2014, June 2014, July 2014, September 2014, January 2015, and February 2015. Moreover, the Veteran's symptoms were not similar in nature, frequency, or severity to those contemplated by a 100 percent rating for the period since October 5, 2011. He continued to have similar symptoms as in the prior period, including episodes of depression, sadness, feelings of worthlessness or guilt, anxiety, panic attacks, anger, irritability, sleep impairment, nightmares, decreased energy, memory loss, difficulties with attention or concentration, constricted affect, avoiding situations or people who reminded him of experiences in Vietnam, hypervigilance, exaggerated startle response. The Veteran reported in February 2012 that he was "not getting out" and that he found it "more difficult to do things." The Veteran also reported binge eating relating to emotions or boredom for the "MOVE" program in 2014. Nevertheless, the Veteran continued to deny suicidal ideation or attempts, homicidal ideation, and any history of verbal, physical, or sexual abuse. There continued to be no indication of any gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, inability to perform activities of daily living including maintaining personal hygiene, or disorientation to time or place. See id. In an October 5, 2011, treatment record, the Veteran reported having an "illusion" the previous night, in that he felt like there was "something there"' however, he denied a specific hallucination, and there was no indication of subsequent persistent hallucinations. As with the prior period, there has been no indication of memory loss for names of close relatives, the Veteran's own occupation or own name since October 5, 2011. Rather, the descriptions of his memory impairment, including during the June 2014 hearing as noted in the 2015 Joint Motion, have been similar to the types of memory loss contemplated by the 30 and 50 percent ratings. The Veteran continued to report short-term and long-term memory difficulties, such as with names, doses of medications, missing appointments, and forgetting where he parked. See, e.g., October 2011, December 2011, June 2013 VA treatment records. In January 2014, the Veteran reported being fearful when he would feel confused or forgetful, such as when he left the keys in his truck with the engine running and headlights on for several hours while at a friend's house recently. VA providers in December 2012 and June 2014 noted that there had been no progression of short-term memory loss. VA providers assigned a GAF score of 55 in February 2012, July 2012, and December 2012, which would indicate moderate impairment. A depression screen showed severe symptoms in February 2012, and this provider stated that, overall, the Veteran presented with recurrent severe depression and PTSD. A July 2013 provider assigned a GAF score of 65, which would indicate mild impairment. See Quick Reference to the DSM-IV. VA treatment records in July 2014 and January 2015 again diagnosed major depressive disorder, recurrent, severe, and PTSD, based on a similar symptoms. A February 2015 record noted that the Veteran had mild depression in addition to other mental health symptoms. The assigned 70 percent rating since October 5, 2011, accounts for severe mental health symptoms; however, there has not been total social and occupational impairment to warrant a 100 percent rating. 38 C.F.R. § 4.130, DC 9411. All potentially applicable diagnostic codes have been considered, and the Veteran is not entitled to a higher rating for any period. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Staged ratings have been assigned, based on a determination that the Veteran's PTSD was manifested by symptomatology that warranted different ratings during distinct time periods in the course of this appeal; however, no further staging is warranted. See Fenderson, 12 Vet. App. at 126-27. VA has a duty to maximize benefits when considering ratings on appeal. In this regard, the Veteran was previously assigned a 100 percent rating for his prostate cancer, effective from November 4, 2009, through July 31, 2012. He was also awarded special monthly compensation (SMC) under 38 U.S.C.A. § 1114(s), effective from October 5, 2011, through August 1, 2012, based on having 100 percent rating for prostate cancer and additional disabilities rated at 60 percent or higher. Upon implementation of the Board's grant of a 50 percent rating for PTSD prior to October 5, 2011, in the December 2014 Board decision, the AOJ also awarded SMC under subsection (s) effective from November 4, 2009, through August 1, 2012, on this basis. See February 2015 rating decision. As noted above, the AOJ reduced the prostate cancer rating to 40 percent, effective August 1, 2012; and made the TDIU award effective on this same date. Nevertheless, entitlement to a schedular TDIU arose on October 5, 2011, based on the 70 percent rating for PTSD (which met the percentage schedular threshold) and evidence of unemployability as of that date, as determined by the AOJ for the award of a TDIU. Thus, the Veteran has been awarded all possible benefits based on his PTSD rating in combination with other ratings, namely, to include separate 100 percent rating. As explained above, pertinent information may be obtained upon remand of the TDIU question; thus, the question of referral for an extraschedular rating for PTSD under § 3.321(b) is inextricably intertwined and is also being remanded. The preponderance of the evidence is against a higher schedular rating for PTSD for any period on appeal; therefore, reasonable doubt does not arise, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 C.F.R. § 4.3. ORDER Service connection for sleep apnea is granted. An initial schedular rating for PTSD in excess of 50 percent prior to October 5, 2011, and in excess of 70 percent thereafter, is denied. REMAND The Veteran contends that he has been unemployable since 2002 due to PTSD; therefore, he seeks a TDIU for the entire appeal period, prior to October 5, 2011. If there is more than one service-connected disability, to meet the schedular percentage threshold for a TDIU, there must be one disability rated at least 40 percent disabling, and additional disabilities to combine for at least a 70 percent rating. 38 C.F.R. § 4.16(a). In this case, prior to October 5, 2011, with the exception of prostate cancer and residuals rated as 100 percent disabling, effective from November 4, 2009; the Veteran's service-connected disabilities were PTSD rated as 50 percent disabling; lacerating scars rated as 10 percent disabling; and flat feet rated as 10 percent disabling. These conditions did not have a common etiology and could not otherwise be considered a single disability for TDIU purposes; instead, there were multiple disabilities and a combined rating of 60 percent. 38 C.F.R. §§ 4.16(a), 4.25. Therefore, the Veteran did not meet the schedular percentage threshold for a TDIU for this period; however, a TDIU may be granted on an extraschedular basis if warranted, after referral to VA's Director, Compensation Service, for extraschedular consideration. 38 C.F.R. § 4.16 (b). In light of the Board's grant of service connection for obstructive sleep apnea herein, the AOJ must assign an effective date for the service connection award, and readjudicate the claim for a TDIU with consideration of this additional disability. If the evidence does not warrant an effective date of service connection prior to October 5, 2011, then this award will not affect entitlement to TDIU, to include whether the Veteran meets the schedular percentage threshold, for that period. Further, the question of whether referral for extraschedular consideration of a higher rating for PTSD under 38 C.F.R. § 3.321(b) is deferred and is remanded as inextricably intertwined with the Veteran's TDIU claim, as it is possible that additional evidence or development may be pertinent to § 3.321(b). The Board obtained retrospective medical opinions regarding the Veteran's TDIU claim via reports dated May 8, 2015, and May 22, 2015, from a VA psychologist. This examiner opined that the Veteran's PTSD, alone or together with other service-connected disabilities at that point, did not render him unable to secure or follow a substantially gainful occupation at any point prior to October 5, 2011. The examiner reasoned that the October 5, 2011, VA treatment record, stated that the Veteran had three years of college education after service, followed by work as a postal clerk for four years, and then as a firefighter for 20 years before retiring in 2002. She also noted that the Veteran reported being actively involved in AA and volunteer work at VVSD, as discussed above in the section regarding the Veteran's schedular rating for PTSD. The examiner concluded that the Veteran was able to obtain and maintain gainful or viable employment prior to October 5, 2011, because he was able to hold a stable job for 20 years as a firefighter until he retired. This opinion is inadequate because it did not discuss the Veteran's symptoms and effects during the appeal period, which began several years after he retired as a firefighter, in September 2005. An addendum opinion is necessary to consider all pertinent evidence, to include the additional service-connected disability of sleep apnea, if service connection is made effective prior to October 5, 2011. If service connection is granted for sleep apnea effective prior to October 5, 2011, and the Veteran does not meet the schedular threshold criteria for a TDIU prior to that date, the case should again be referred to the Director, Compensation Service, for consideration of an extraschedular TDIU in light of the additional disability. Accordingly, the case is REMANDED for the following action: 1. Issue a rating decision implementing the grant of service connection for sleep apnea, including an initial disability rating and effective date; and provide the Veteran and his representative with due process notice. 2. Then, forward the entire claims file to the individual who issued the two retrospective TDIU opinions in May 2015, or to another qualified individual if that examiner is not available, for an addendum opinion as to the effects of the Veteran's PTSD and other service-connected disabilities, to include sleep apnea if it is made effective prior to October 5, 2011, on his employability to that date. The examiner is advised that the fact that the Veteran held long-term employment until 2002 is not, in itself, determinative as to whether he was employable during the relevant appeal period, or from September 23, 2005, through October 4, 2011. The Veteran has asserted that his PTSD symptoms had increased to the point that he could no longer work as a firefighter at the time he retired. Thus, the examiner should provide an opinion as to the effects of the Veteran's PTSD and other service-connected disabilities from September 23, 2005, through October 4, 2011, on the types of employment for which he would otherwise be qualified based on his level education, special training, and all types of prior work experience. The examiner should disregard the effects of the Veteran's age or any impairment caused by disabilities that were not service-connected prior to October 5, 2011. The examiner should provide a complete rationale, with consideration of the pertinent lay and medical evidence of record. If an opinion cannot be offered without resorting to speculation, the examiner should so state and explain why a non-speculative opinion cannot be offered. 3. Thereafter, if and only if service connection for sleep apnea is made effective prior to October 5, 2011, and the Veteran does not meet the schedular threshold criteria for a TDIU prior to that date, the entire claims file should again be forwarded to the Director, Compensation Service, for consideration of an extraschedular TDIU in light of the additional service-connected disability. 4. Then, readjudicate the claim for a TDIU prior to October 5, 2011. If the benefit sought on appeal remains denied, issue a supplemental statement of the case before returning the case to the Board, if otherwise in order. The appellant 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 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). ______________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs