Citation Nr: 1616743 Decision Date: 04/27/16 Archive Date: 05/04/16 DOCKET NO. 13-04 297 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to service connection for a left knee disorder. 2. Entitlement to service connection for peripheral artery disease, to include as due to Agent Orange exposure and as secondary to service-connected coronary artery disease. 3. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as due to Agent Orange exposure and as secondary to service-connected coronary artery disease. 4. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as due to Agent Orange exposure and as secondary to service-connected coronary artery disease. 5. Entitlement to service connection for peripheral neuropathy of the left lower extremity, to include as due to Agent Orange exposure and as secondary to service-connected coronary artery disease. 6. Entitlement to an initial rating in excess of 10 percent for service-connected peripheral neuropathy of the right lower extremity. 7. Entitlement to a rating in excess of 10 percent prior to March 25, 2013, and 50 percent effective from March 25, 2013, for service-connected posttraumatic stress disorder (PTSD). 8. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Veteran represented by: AMVETS WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD D.M. Casula, Counsel INTRODUCTION The Veteran served on active duty from February 1969 to January 1971, with service in Vietnam from March 1970 to January 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision issued by the above Regional Office (RO) of the Department of Veterans Affairs (VA) which, in pertinent part, denied service connection for a left knee disorder and for peripheral artery disease, and granted service connection for PTSD, assigning an initial 10 percent rating, effective from March 14, 2012. This matter further comes before the Board from a May 2013 rating decision in which the RO granted service connection for superficial peripheral sensory neuropathy of the right lower extremity, assigning a 10 percent rating, effective December 26, 2012; and granted a 30 percent rating for PTSD, effective March 25, 2013. This matter also comes before the Board from an October 2013 rating decision in which the RO denied service connection for right upper peripheral neuropathy, left upper peripheral neuropathy, and left lower peripheral neuropathy. In an April 2014 decision, the RO granted a 50 percent rating for PTSD, effective from March 25, 2013; the Veteran continued his appeal for a higher rating for PTSD. In November 2015, the Veteran testified at a videoconference hearing at the RO, before the undersigned Veterans Law Judge. The Board finds that through the Veteran's testimony provided in November 2015, as well as private medical evidence he submitted, a claim of entitlement to a TDIU rating has been reasonably raised as part of his claim of entitlement to a higher rating for peripheral neuropathy of the right lower extremity. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, the title page of this decision has been modified to reflect this issue on appeal. The claims for service connection for a left knee disorder, peripheral artery disease, and for peripheral neuropathy of the right upper extremity, left upper extremity, and left lower extremity, a higher rating for peripheral sensory neuropathy of the right lower extremity, and entitlement to TDIU, are addressed in the REMAND below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT Throughout the period on appeal, the Veteran's PTSD is manifested by no more than reduced reliability and productivity due to such symptoms as impairment of short-term memory, impulse control, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships, and other symptoms not explicitly listed in the applicable rating diagnostic code including, but not limited to, sleep problems, nightmares, flashbacks, intrusive thoughts, irritability and anger, depression, isolating behaviors, and avoidance behaviors. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 50 percent, but no more, prior to March 25, 2013, for PTSD, have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, DC 9411 (2015). 2. Throughout the appeal period, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, DC 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSIONS I. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C.A. §§ 5103, 5103A (West 2014) and 38 C.F.R. § 3.159 (2015). For the issues decided in the instant document, VA provided adequate notice in letters sent to the Veteran in August 2012, September 2012, and February 2013. In November 2015, Veteran was provided an opportunity to testify at a hearing before the undersigned Veterans Law Judge. During that hearing, the undersigned Veterans Law Judge identified all of the issues on appeal. The hearing focused on the elements necessary to substantiate those claims and the Veteran, through his testimony and questioning by his representative, demonstrated actual knowledge of the elements necessary to substantiate the claims. As such, the Board finds that VA complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The Board also finds VA has satisfied its duty to assist the Veteran in the development of the claims. VA has obtained all identified and available service and post-service treatment records for the Veteran. The Veteran underwent VA examinations in October 2012 and March 2013 to assess the severity of his PTSD. Each VA examination included a review of the claims folder and a history obtained from the Veteran, and examination findings were reported, along with a diagnosis and opinions, which were supported in the record; these VA examination reports are therefore adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). It appears that all obtainable evidence identified by the Veteran relative to his claims has been obtained and neither he nor his representative has identified any other pertinent evidence which would need to be obtained for a fair disposition of this appeal. No further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002). The Board concludes that VA has satisfied its duty to assist the Veteran in apprising him as to the evidence needed, and in obtaining evidence pertinent to his claims under the VCAA. No useful purpose would be served in remanding this matter for yet more development. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). II. Higher Ratings for PTSD Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, when the current appeal arose from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to compensate entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The RO has assigned staged ratings for PTSD since service connection became effective in March 2012, granting a 10 percent rating prior to March 25, 2013, and a 50 percent effective on and after March 25, 2013. The Veteran essentially contends he should be entitled to higher ratings for his PTSD. The Veteran's PTSD has been rated under DC 9411, which provides that a 10 percent disability rating is assigned for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous mediation. 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). 38 C.F.R. § 4.130, DC 9411. A 50 percent rating is warranted for PTSD where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereo-typed speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks), impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for PTSD when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, 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); and the inability to establish and maintain effective relationships. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The "such symptoms as" language in 38 C.F.R. § 4.130 means "for example" and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Mauerhan, 16 Vet. App. at 442. Accordingly, while each of the examples needs not be proven in any one case, the particular symptoms must be analyzed in light of those given examples. Put another way, the severity represented by those examples may not be ignored. Each particular rating "requires sufficient symptoms of the kind listed in the [] requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). In a September 2012 statement, the Veteran reported vivid memories of service and that he is reminded every day. He stated he did not investigate PTSD as he did not want that stigma. He reported that his anger and defensiveness had never been as strong as it was now. He reported a difficult time with social settings and that he would prefer to be alone or with his family and just feel safe with no confrontational situations. In September 2012, the Veteran's wife reported that the Veteran was there for her for anything she might need and that he confided in her about things he did not feel comfortable talking to other people about. She indicated he was a remarkable father to their children, had always been there for their kids or any other family member, and was a protector. She indicated he also had serious issues which she believed were directly related to his Vietnam experiences. In that regard, she reported he had an inability to get close to people, and that even though he was a nice person, and gracious and sincere, when he felt uncomfortable he pushed people away and became almost reclusive and did not like to talk. She also reported witnessing the Veteran let his anger and rage get the best of him, including his negative reaction to other drivers. Finally, she reported that many of the Veteran's family and friends believe that over the years, instead of facing and addressing the problems from his military time, he suppressed many of his Vietnam experiences. She claimed that his stress levels continued to climb, and that his cardiac issues as well as his high blood pressure became the manifestations of his repressed PTSD. In a statement dated in September 2012, the Veteran's children indicated their belief that the Veteran's exposure to Agent Orange had a huge impact on his health, and that his coronary artery disease and peripheral artery disease directly resulted from this exposure. They also noted that the Veteran had undergone triple-bypass heart surgery and had a stent placed in the popliteal artery behind the knee, and that they had seen the Veteran slow down to the point that it seemed difficult to perform routine activities, and his energy level was half of what it was a few years ago. In a letter received in September 2012, Dr. BG indicated he was a psychiatrist, and was a customer and friend of the Veteran. Dr. BG noted that the Veteran was a barber and had cut his hair since 1984, and that they became friends early in their client-customer relationship. Dr. BG noted that the Veteran cut his hair in a private area behind a closed door, and that while the Veteran's PTSD did not affect his barbering, because of the almost immediate friendship they developed, Dr. BG visits to the Veteran's barber shop were a mixture of barbering, friendship, and unofficial psychiatric intervention. Dr. BG indicated he ascertained almost immediately that the Veteran had PTSD, and noted he had an avoidance to seek help in a traditional way. Dr. BG indicated that he provided diagnostic and informal treatment of the Veteran's PTSD, but did not prescribe medication to the Veteran, although he did make suggestions when appropriate that the Veteran could follow up on with his personal physician. Dr. BG noted that he was writing the statement utilizing his professional knowledge and impressions from these informal therapy sessions to document conclusions that the Veteran demonstrated behavior supporting a long standing diagnosis of PTSD. Dr. BG wrote in the past tense, given how much of the letter was drawing on the past, but noted that it continued to the present. Dr. BG stated that the Veteran would often talk about his sleep difficulties and would wake up in the middle of the night and not be able to fall asleep again, and that sometimes this would be non-specific memories and a sense of dread, but that other times specifics would haunt him. Dr. BG noted that the Veteran would report having recurring, involuntary, intrusive memories of these events, which resulted in recurrent nightmares and frequently disrupted sleep and midnight awakenings, and that once awakened he had flashbacks where he felt he was there again. Dr. BG noted that the Veteran described his attempts to lead a normal life by avoiding thoughts, feelings, and physical sensations that might bring up memories of the traumatic events, but also he had difficulty remembering the important parts of the traumatic events that frustrated him. Dr. BG noted that the Veteran tried hard to be involved with the important people in his life, especially his wife and children, but this was often be impossible, and that he also talked about not being able to feel love and happiness, all of which combined to make him feel out of place and alone and that his life might be cut short. Dr. BG noted that the Veteran's sleep problems led to significant problems with having to function during the day, and that his worst problems were when he found himself very irritable and had bursts of anger, but fortunately he had a separate area at work. Dr. BG indicated that over the years, he had come in at times that the Veteran had just regained enough control to continue working and not reveal his difficulties to his co-workers and employees, and the Veteran would tell him how helpful he was and how much more difficult it was handling such episodes alone. Dr. BG also noted that the Veteran would vent over and over again and tell of recent times when he suddenly felt on guard because danger was present, making him jumpy and easily startled. Dr. BG indicated that it was well known that untreated and undiagnosed PTSD can, and usually does, result in blood pressure and cardiac problems. Dr. BG concluded that the Veteran suffered significantly from PTSD. On a VA examination in October 2012, the diagnosis was PTSD and a GAF (global assessment of functioning) score of 75 was assigned. The examiner noted that the Veteran's level of occupational and social impairment was best characterized as due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress; or, symptoms controlled by medication. It was noted that the Veteran was married since 1972 and had three children and he also had contact with his extended family. The Veteran reported that he and his wife used to do a lot of social activity, but now he did maybe a dinner a month with friends and mostly just with family. It was noted that the Veteran was employed part time, but worked 40 hours a week. He owned his own business for 38 years and now works in his daughter's salon. During free time, he worked in the yard, played golf sometimes, and had a motorcycle that he rides, which put his mind at ease. He reported having a very good friend who was a psychiatrist who he has been able to interact with and who had helped. He denied any mental health prescribed medication except to sleep. On mental status examination, he was oriented and his mood was described as "so so" and sometimes a little depressed. He had good relationships, but was kind of stand-offish. He saw people all day, most days, and could interact with them, but it was more of a strain now than ever. His insight and judgment were intact. He reported that some nights he could not sleep and had recurring nightmares. When asked how PTSD stressors have continued to affect him, he said he always checked things out first and was very protective of his family. He was more argumentative than he ever before, and had a lot of stressful situations. He reported being less social than before and that he avoided talking to anyone about his military experiences, including his family. In a statement dated in January 2013, the Veteran's daughter reported she was the second generation owner of her father's hair salon. She reported that daily life for the Veteran had continued to worsen, even since her last letter, and that he could only stand about half the time he used to, due to the continuous pain in his legs and ankles. She claimed that his peripheral artery disease, which both his physicians and his family believed resulted from exposure to Agent Orange, seemed to constantly pain him and affect his behavior. She reported that the Veteran had consistently worked a nine to twelve hour day in the past, but had a problem maintaining those hours after his heart surgery and PTSD issues. She reported that she worked with her dad everyday and that his pride drove him forward, even thought it was not healthy for him, and that she had to cut his hours for his sake. Received in February 2013 was a statement from the Veteran's wife in which she reported that the Veteran had always been the solution to many of the issues in their lives, and that raising their family was their first priority and that the Veteran sometimes had to work twelve to fourteen hour days to accomplish that. She reported that due to his current ongoing physical problems, his legs and ankles were unbearably painful, because his veins had been harvested for his heart surgery and the stent in the other leg. She reported that there was another artery blocked in his left leg, and that it had become almost impossible for him to keep up with this rigid work regime and his ability to stand had been compromised extensively. In a statement dated in February 2013, Dr. BG indicated strong disagreement with the evaluation of the Veteran's PTSD at 10 percent. Dr. BG claimed he was qualified to address this condition because he was a psychiatrist, currently retired, and a former professor and had treated patients at the Omaha VA Medical Center for PTSD. Dr. BG reported that the Veteran continued to have flashbacks of service and disruptive dreams, and that his service experiences continued to cause him to avoid thought, feelings, and conversations associated with that event, which led to diminished interest in or participation in significant activities. Dr. BG also noted that the Veteran's service experience led to persistent sleep difficulties, unexpected irritability at home and at work, outbursts of anger and difficulty concentrating. Dr. BG opined that this had significantly impaired his social activities and occupational endeavors, as evidenced by letters from his family members and daughter who worked side-by-side with him. Dr. BG noted that since the original submission of material, the Veteran feared his life was going to be cut short as a consequence of his PTSD. Dr. BG also noted that the Veteran's difficulty in performing his work had increased. Dr. BG noted that the Veteran's psychiatric condition was not helped by the "inconceivable conclusions drawn by the evaluators that his peripheral arterial disease is not connected to his other vascular problems, all traceable back to a combination of exposure to Agent Orange and the horrors of war and combat". Dr. BG stated that the Veteran continues to suffer from PTSD from his service in Vietnam that significantly impairs and devalues his life and is a contributing factor in his other medical disorders. In a February 2013 letter, Dr. BG indicated that in his most recent letter with regard to the Veteran's PTSD, he omitted rating the degree of intensity. Dr. BG opined that the Veteran's PTSD intensity rating, utilizing the National Center for PTSD's Clinician-Administered PTSD Scale for DSM-IV, was a 3 on a scale of 1-3, indicating "severe, considerable distress, marked disruption of activities". On a VA examination March 2013, the diagnosis was PTSD and a GAF score of 60 was assigned. The examiner indicated that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran reported that he and his wife might go out once a month, for a dinner or something, and that other than that it was just with the kids at their house. He was employed at the present time, on a part time basis, and worked about 30 hours a week. He reported having issues being around people, stating that it was his life, but now he would rather be on his own and away from the limelight. He worked as a barber and worked with chemotherapy patients with hair loss. He reported that when not at work, he spends his time around the house, has a motorcycle that he rides, and plays golf. He only took prescribed medication for sleep. On mental status examination, it was noted that he was reserved but cooperative and pleasant, and was oriented in all spheres with intact attention and concentration. He described his mood as distant and removed, that this was not a joyous time and he had a lot of anger, that it was hard at times to get along, that it was difficult for his wife to see the lack of communication which they had before, and that there were moments when he was kind of up, but most of the time he went to work, performed on stage for the people that came in, and then went home. He indicated that it was beginning to haunt him with the way he stayed away from people. The Veteran wondered how long he would survive with all the physical problems he had, and was worried about the procedure he had coming up in two weeks because a friend had a similar procedure and died. It was noted that his insight and judgment were intact. He reported he slept for a couple of hours, then after an hour or two awakens, and may be up for an hour or two, despite taking medication for sleep. He could not shut his brain off and had recurring nightmares. He reported having more daytime memories of incidents that happened during the military, and that it was difficult for him to talk about the military experiences, especially if it was someone that had not been there. He reported a few incidents in the past couple of years, to include once when he was mowing his lawn and kids drove by and threw firecrackers at him and h was ready to hit the ground and they came back and threw more firecrackers, and he went after them and pinned them to the curb, and threatened them. He reported another incident when a guy drove through his yard in the middle of winter, in the snow, and the Veteran lashed out and got even. He reported that his thought process on living was different than before, that he did not have the same desire he had before, and that being around people has changed. He reported he no longer went to out to eat, and no longer hunted. He became tearful when talking about his symptoms. He reported that over the years he has been extremely busy, having two adopted sons and having to care for his aging mother, and did not have time to think about the things that he now finds to be very bothersome to him related to his military experiences. His symptoms included depressed mood, anxiety, and chronic sleep impairment. He reported that when he came back from the military he buried himself in work, which had worked well up until a couple of years ago. The Veteran also reported that he had just sort of removed himself from everything. An October 2014 letter from Dr. BG noted worsening of the Veteran's psychiatric status regarding his PTSD diagnosis. Dr. BG stated that the Veteran's occupational impairment had continued to degrade, and he had to depend more and more on his daughter, who fortunately had a major role in the day to day business responsibilities, and that the Veteran had become more erratic in his personal appearance and hygiene, and his daughter had been able to persuade him to redress those issues, but on some occasions his increased impairment in impulse control and irritability had resulted in the Veteran temporarily removing himself from the salon. Dr. BG noted that the Veteran's speech, in or out of the workplace, had degraded since the last observations to now include episodes where his speech was illogical and/or obscure, and the Veteran became irritable when confronted. Dr. BG opined that this impulse control was directly related to his PTSD and had, on occasion, resulted in episodes of unprovoked irritability and even violence to objects, but not individuals. Dr. BG indicated discussing suicidal ideation with the Veteran and felt confident that the Veteran was not a danger to himself or others, but that further deterioration was made more likely in part due to his feelings of being unfairly treated by the government he risked his life for. Dr. BG believed the Veteran would keep the agreement to contact him if such feelings became more frequent or intrusive. Dr. BG also stated that a successful conclusion of the Veteran's appeal for greater assistance would be likely to render any such deterioration improbable. Dr. BG found the Veteran's PTSD severe, with considerable distress and marked disruption of activities. Dr. BG concluded that the Veteran's condition had worsened since his initial report to the degree he was concerned for the Veteran's wellbeing and wellbeing of others. VA treatment records showed that in October 2014, the Veteran was seen for follow up and reported he had increased PTSD symptoms, and that the Trazadone had helped but he was still having flashbacks and vivid memories of Vietnam. He also noticed he was more short tempered and wanting to be isolated, and did not like much social contact. He denied suicidal or homicidal ideation, and reported he was happily married with grown children. He reported having a client that was a psychiatrist that he talked to routinely and did not feel he would benefit from talking to someone there or getting into group therapy. In July 2015, he was seen for follow up, and his PTSD was assessed as doing well on Trazadone. In September 2015, he reported he had to cut back in working hours because of his neuropathy and PVD, and was only doing about 30 hours a week in his salon. In October 2015, he complained of depression, increased anxiety and nightmares, and stated it had been hard because he has been off work now for 6 weeks, and going into surgery he thought he would only be off 3 to 4 weeks. He reported a lot of down time and increased time for thoughts. He had been having a lot of his Vietnam images and events come back into his mind, and he woke up in the middle of the night feeling anxious and nervous. He felt down and depressed as well, and was tearful that day. It was noted that his symptoms had started to affect his family as well. The diagnoses included PTSD/depression/anxiety, and the examiner noted having a long discussion with the Veteran regarding treatment options, and encouragement was given and coping skills were discussed. The plan was to start him on Cymbalta, hoping this would help his depression and anxiety, but also with some of his chronic pain. He was to continue Trazadone for sleep. A consultation request was placed to the PTSD clinic, and the Veteran agreed with this. At the November 2015 hearing, the Veteran testified that he had bypass surgery in his leg about 10 weeks prior and that it was debilitating because he was not able to do his usual work in the hair business, which required standing. He testified that he had basically passed off his hair business to his daughter. With regard to PTSD, he testified that there were many things he could do in the past which he did not do anymore, including interacting with clients, which was part of his social life. He testified that he did not have the social life he had in the past, and while he was not a recluse, he did not interact with a lot of people because he did not like being around people. He testified that it was hard to go through the physical side of his problems and then be on stage and be happy, because it did not work. He testified that he and his wife did not do much and did not go out a lot, that he had short term memory loss, and that he needed two medications to help him sleep at night. He claimed he had to curtail 90 percent of the things he did before, because of his physical problems, and that it was the mental part of things that really got to him. He also testified that with regard to hobbies, he had a motorcycle that he did not ride anymore because it was very difficult to do, and that he had anger that he had been dealing with through his psychiatrist friend, who was helping him get through a lot of stuff and to view things as not as important to him as they used to be. He testified that he met with someone at the VA two weeks prior about his PTSD and options for therapy and groups. Received at the hearing, along with a waiver of review by the AOJ, was another letter from Dr. BG in which he indicated a worsening of the Veteran's psychiatric status, which related to the worsening of his physical conditions, specifically his ischemic heart disease and peripheral artery disease. Dr. BG opined that these conditions now rendered the Veteran totally disabled from being able to perform his prior occupation, which had clearly worsened his psychiatric condition. Dr. BG noted that the Veteran's pain and discomfort from his peripheral neuropathy have led to social withdrawal compatible with his psychiatric conditions, and besides not having the social interaction that would come with work, he is also socially withdrawn in his personal life and the composite of all these factors negatively impacts his lifestyle to a degree even greater than before. Dr. BG noted that the lack of successful intervention in the case of his physical and medical conditions had led to an increased downward spiral in his mental condition, and that he was recently placed on another medication, but that in spite of these attempts at alleviation of his symptoms, his condition as worsening. Dr. BG opined that medications could not alter the fact that the Veteran was convinced that his service in Vietnam and exposure to Agent Orange were the root cause of his suffering. Dr. BG opined that medications and psychotherapy alone were not sufficient to relieve the Veteran's condition, but that the lack of recognition of the interrelatedness of these issues and impairments and resistance to compensate for them was worsening the Veteran's condition and the only solution was a full and adequate form of compensation. The Board finds, initially, that a 50 percent evaluation is warranted prior to March 25, 2013. Although the symptoms as reported and assessed in the 2012 VA examination do not fully support this assignment, the Board notes that the 2013 VA examination supports the assignment of a 50 percent evaluation and that some of the examples that the Veteran provided happened in the past few years. This includes acts of physical violence and anger, which more nearly approximate a 50 percent evaluation. Additionally, the period for which the 10 percent evaluation was assigned is merely one year prior to the effective date of the 50 percent evaluation. Resolving the benefit of the doubt in favor of the Veteran, it is unlikely his symptoms worsened so severely during a one year time period. Accordingly, a 50 percent evaluation is for assignment throughout the appellate period. Thus, only an evaluation in excess of 50 percent is considered below. First, as to social impairment, the Veteran's PTSD does not manifest in an inability to establish and maintain effective relationships. The Veteran reports that he does not enjoy social settings, self-isolates, and prefers to be alone. He has also consistently reported, however, a good relationship with his wife and family, that he spent time working and went to dinner maybe once a month with friends, and maintained a friendship with a client. This does not demonstrate an inability. Additionally, he reported diminished interest in activities, but also reported that he worked in the yard, played golf, and rode his motorcycle, although in 2015 he reported he was no longer doing that. Second, as to occupational impairment, the Veteran, his family, and Dr. BG all noted difficulty with working. The Veteran worked in an isolated space and sometimes had difficulty with co-workers. But he continued working, although he reduced his hours and eventually stopped working due to his physical ailments. This is more akin to reduced reliability and productive, rather than difficulty adapting to stressful circumstances, including work. Third, throughout the period, the Veteran reported problems with his sleep, nightmares, vivid and intrusive memories, irritability and anger, concentration, diminished interest in activities, isolative behaviors, and avoidance behaviors. With regard to the Veteran's mood, the Board notes that impairment of his mood has been shown as there have been indications he was depressed. With regard to judgment and thinking, however, no impairment has been shown by the objective record; likewise, the VA examination report 2013 showed his judgment and thinking were intact. But the Veteran's symptoms are not of "similar severity, frequency, or duration" of those listed for the 70 percent evaluation. See Vazquez-Claudio, 713 F.3d at 118. The Board notes that the Veteran has denied suicidal ideation. There has been no report by the Veteran or finding of any obsessional rituals which interfere with routine activities. On the VA examination, the Veteran's speech was found to be normal, but Dr. BG recently reported that the Veteran basically self-reported that his speech has been occasionally illogical and/or obscure, but Dr. BG indicated this had not been evident in their interactions. Additionally, while depression has been noted, there have been no reports or findings of near-continuous panic or depression affecting the ability to function independently, appropriately and effectively. Dr. BG has noted that the Veteran had impaired impulse control, with episodes of unprovoked irritability with periods of violence toward objects but not individuals. The Veteran was found to be oriented on all objective examinations. Dr. BG noted that the Veteran had been erratic in his personal appearance and hygiene, but his daughter had been able to persuade him to address those issues. In summary, the Veteran's PTSD manifestations more nearly approximate the criteria for a 50 percent rating. With consideration of the Veteran's complaints, symptoms, and clinical findings of record, the Board concludes that his PTSD manifestations do not approximate the criteria for a 70 percent rating for this period. 38 C.F.R. § 4.130, DC 9411. Thus, he is not entitled to a rating in excess of 50 percent. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, supra. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). In particular, the Board has considered referral for extraschedular consideration. However, in this case, the Board finds that the record does not show that the PTSD is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Thun, 22 Vet. App. 111; VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned evaluation with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Veteran's symptoms are contemplated by the rating criteria, which expressly recognized social and occupational impairment to all psychiatric symptoms. As discussed above, there are higher evaluations available, but the Veteran's disability is not productive of such manifestations. As such, it cannot be said that the available schedular evaluations for this disability are inadequate. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected PTSD under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Thun, 22 Vet. App. 111; Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). ORDER Service connection for a left knee disorder is denied. A rating of 50 percent for PTSD, prior to March 25, 2013, is granted. A rating in excess of 50 percent for PTSD, throughout the appeal period, is denied. REMAND Remand is required regarding the left knee disorder for a VA examination. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. See 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015). VA's duty to assist includes providing a medical examination when is necessary to make a decision on a claim. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006). Here, in his original claim, the Veteran reported knee symptoms beginning in May 1969, during service. In a September 2012 record, the Veteran reported that he was sent to Fort Ord for basic training and then infantry AIT (Advanced Individual Training). He claimed that after a particularly vigorous training session, where he injured his knee, he received medical treatment and was classified with a category 3 profile that was a non-combat arms MOS. Service treatment records are silent for any complaints. In an August 2012 statement, the Veteran reported current left knee symptoms since service. Thus, the Veteran's competent lay statements indicate recurrent symptoms of disability, establish an in-service event, and based on continuous symptoms, at least indicates an association between service and the symptoms. Accordingly, an examination is required. Remand is required regarding peripheral artery disease (PAD) and peripheral neuropathy (PN) of the bilateral upper extremities and left lower extremity for adequate examinations and opinions. The Veteran contends that his PAD is secondary to his service-connected coronary artery disease (CAD). He also contends that his PN is due to Agent Orange exposure, as well as secondary to the service-connected CAD. He has also contended that his peripheral neuropathy symptoms started within one year of his discharge from service. Further, at the November 2015 Board hearing, the Veteran testified that his physicians had suggested that PN and PAD could be related to CAD and Agent Orange exposure. The record reflects that the Veteran had active military service in the Republic of Vietnam during the Vietnam era, and is presumed to have been exposed to Agent Orange and/or other herbicide agents. Additionally, the Board notes that a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). A claimant is entitled to service connection on a secondary basis when it is shown that a service-connected disability aggravates a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). On a VA examination in October 2012, it was noted that the Veteran underwent coronary artery bypass graft for his service-connected CAD in 2011. It was also noted that he had peripheral vascular disease and that in October 2011, he had undergone stent placement to the left leg for symptoms of arterial occlusion with claudication. The examiner opined that although PAD and CAD shared common risk factors, and, to some extent, common pathogenesis, there was no medical evidence to support that ischemic heart disease, including CAD, in any way, caused, resulted in, or aggravated his PAD. In a letter dated in February 2013, Dr. BG opined that the Veteran's ischemic heart disease and PAD were "related to each other pathophysiologically an (sic) due to the commonality of their causation by Agent Orange." In subsequent letters, Dr. BG suggested a nexus between PN and PAD and exposure to Agent Orange. On a VA examination in March 2013, it was noted that the Veteran had a claim for neuropathy of the right lower extremity secondary to a vein harvest from the right lower extremity to facilitate coronary artery bypass graft (CABG). The examiner opined that it was at least as likely as not that the Veteran's neuropathic symptoms were due to or a result of his vein harvest procedure done in 2011 to facilitate the CABG for ischemic heart disease. The examiner indicated that this opinion was based on examination and clinical presentation that demonstrated PN and neurologic symptoms in a distribution that would be consistent with disruption of the nerve proximal to the symptoms that was at least as likely as not caused by the incision and surgical procedure to harvest the vein. By May 2013 rating decision, the RO granted service connection for peripheral neuropathy of the right lower extremity, as secondary to the service-connected CAD. Regarding PAD, there are conflicting opinions of record, none of which are fully inadequate. Regarding PN, there are no adequate etiological opinions of record. Accordingly, examinations and opinions are warranted. Considering the record on appeal, including the Veteran's contentions and the competent medical evidence from Dr. BG, the Board finds that a VA examination/opinion is in order to address whether the Veteran's PAD is related to the service-connected CAD, as well as whether his PN of the right and left upper extremity and left lower extremity is related to the service-connected CAD and/or exposure to Agent Orange. Third, remand regarding the service-connected peripheral sensory neuropathy of the right lower extremity is required for a current examination. See Snuffer v. Gober, 10 Vet. App. 400, 402-403 (1997). The Veteran testified at the November 2015 Board hearing that he had bypass surgery in his leg about 10 weeks prior and that it was debilitating because he was not able to do his usual work in the hair business, which required standing. He testified that over the past six months his neuropathy had gotten worse and that his leg hurt from the surgery. Therefore a new examination is necessary. Finally, as noted above, the record has raised an inferred claim for TDIU, based specifically on the Veteran's testimony and letters submitted from Dr. BG. Because the Veteran has not received appropriate notice regarding the TDIU issue, and the TDIU issue is inextricably intertwined with issues on appeal, the claim for a TDIU rating must also be remanded. Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, the case is REMANDED for the following action: 1. Develop the Veteran's claim for TDIU. 2. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 3. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected right lower extremity peripheral neuropathy. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire shall be used. 5. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the nature and etiology of his peripheral artery disease and peripheral neuropathy. The entire claims file should be made available to and be reviewed by the examiner, and it should be confirmed that such records were available for review. Any indicated tests and studies must be accomplished. All clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide the following opinions: a. whether it is at least as likely as not (i.e., a 50 percent or greater degree of probability) that the PAD may be caused or aggravated (permanently worsened) by his CAD. b. whether it is at least as likely as not (i.e., a 50 percent or greater degree of probability) that the PAD may be caused by his presumed Agent Orange exposure, despite it not being a presumptive disease. b. whether it is at least as likely as not (i.e., a 50 percent or greater degree of probability) that the PN of the right and left upper extremities and left lower extremity may be caused or aggravated (permanently worsened) by his CAD. c. whether it is at least as likely as not (i.e., a 50 percent or greater degree of probability) that the Veteran's PN of the right and left upper extremities and left lower extremity had an onset during the first post-service year. d. whether it is at least as likely as not (i.e., a 50 percent or greater degree of probability) that the Veteran's PN of the right and left upper extremities and left lower extremity are otherwise related to his presumed Agent Orange exposure. 6. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2015). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 7. Review the examination report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 8. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. See 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 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). ____________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs