Citation Nr: 1620069 Decision Date: 05/17/16 Archive Date: 05/27/16 DOCKET NO. 10-39 990 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for bilateral peripheral neuropathy of the upper extremities, to include as due to herbicide exposure or as secondary to service-connected lumbar spine, dorsal spine, and/or diabetes mellitus disabilities. 2. Entitlement to an initial rating in excess of 50 percent for acquired psychiatric disability, to include posttraumatic stress disorder (PTSD), nightmare disorder, and adjustment disorder. 3. Entitlement to an effective date earlier than February 4, 2010 for the award of service connection for acquired psychiatric disability, to include PTSD, nightmare disorder, and adjustment disorder. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Rothstein, Associate Counsel INTRODUCTION The Veteran had active duty service from September 1965 to June 1967, to include service in the Republic of Vietnam (Vietnam), and from July 1968 to August 1968. This appeal arose from a December 2009 rating decision in which the RO, inter alia, denied the Veteran's claim for service connection for peripheral neuropathy. In December 2009, the Veteran filed a notice of disagreement (NOD). The RO issued a statement of the case (SOC) in September 2010, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in September 2010. The Veteran also appeals from a May 2010 rating decision in which the RO, inter alia, denied his claim for service connection for PTSD and instead granted service connection for sleep disorder and assigned an initial rating of 10 percent, effective February 4, 2010. In September 2010, the Veteran filed a NOD as to the denial of service connection for PTSD and the assigned initial rating for sleep disorder. In a February 2013 Decision Review Officer (DRO) decision, the RO updated the Veteran's disability to reflect the diagnoses shown in the record to "acquired psychiatric condition to include posttraumatic stress disorder (PTSD) and nightmare disorder (previously rated as sleep disorder)" and granted the Veteran a higher rating of 50 percent, effective February 4, 2010. The RO also issued a February 2013 SOC regarding the same, and the Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in April 2013. In December 2013, the RO issued a supplemental SOC (SSOC), continuing a 50 percent rating for acquired psychiatric condition. In May 2015, the Board remanded the claims for service connection for peripheral neuropathy and an initial evaluation in excess of 50 percent for a psychiatric disability. During the pendency of the appeal, in a December 2015 rating decision, the RO granted service connection for symmetric polyneuropathy of the right lower extremity, assigning an initial rating of 10 percent and an effective date of November 3, 2009, and for symmetric polyneuropathy of the left lower extremity, assigning an initial rating of 20 percent and an effective date of November 3, 2009. The RO also issued a December 2015 SSOC, denying service connection for peripheral neuropathy as to the upper extremities and an initial evaluation in excess of 50 percent for a psychiatric disability. Because the Veteran has disagreed with the initial rating assigned following the award of service connection for a psychiatric disability, the Board characterized the claim in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability). Moreover, inasmuch as a higher rating for the recharacterized disability is available, and the Veteran is presumed to seek the maximum available benefit for a disability, the claim for higher rating remains viable on appeal. See Fenderson, 12 Vet. App. at 126; AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that a claim for service connection for PTSD encompasses all psychiatric disabilities reflected in the record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In this case, although the RO only adjudicated the matters of service connection for PTSD and nightmare disorder (previously characterized as sleep disorder), other psychiatric diagnoses of record also include adjustment disorder with mixed anxiety and depressed mood. Accordingly, and consistent with Clemons, the Board has expanded the Veteran's claim as reflected on the title page to include adjustment disorder. This appeal is now being processed utilizing the Veterans Benefits Management System (VBMS) and Virtual VA, paperless, electronic claims processing systems. Also, this appeal has been advanced on the Board's docket pursuant to 38 U.S.C.A. § 7107(a)(2) (West 2014) and 38 C.F.R. § 20.900(c) (2015). The Board's decision addressing the claim for a higher initial rating for his service-connected acquired psychiatric disability is set forth below. The remaining claim for service connection for bilateral peripheral neuropathy of the upper extremities is addressed in the remand following the order. The remand also addresses the claim for an earlier effective date for the award of service connection for acquired psychiatric disability-for which the Veteran has completed the first of two actions required to place this matter in appellate status. These matters are being remanded to the agency of original jurisdiction (AOJ) for further actions. VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim herein decided have been accomplished. 2. Since the February 2010 effective date of the award of service connection, the Veteran's psychiatric symptoms have included irritability, depression, insomnia, nightmares, social isolation, problems with motivation and energy, hypervigilance, hyperstartle, anger, short-term memory impairment, suspiciousness, flashbacks, and panic attacks; collectively, these symptoms are of the type and extent, frequency and/or severity (as appropriate) to result in no more than occupational and social impairment with reduced reliability and productivity. 3. The schedular criteria are adequate to evaluate the disability under consideration at all points pertinent to the claim on appeal, and the matter of the Veteran's entitlement to a total disability rating based on individual unemployability due to this disability has not been raised. CONCLUSION OF LAW The criteria for an initial rating in excess of 50 percent for an acquired psychiatric disability, to include PTSD, nightmare disorder, and adjustment disorder, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9440 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014)), includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his or her possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 - 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the AOJ. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, a March 2010 pre-rating letter provided notice to the Veteran regarding the information and evidence needed to substantiate his claim for service connection. This letter also informed the Veteran of what information and evidence must be submitted by him and what information and evidence would be obtained by VA, and also provided him with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. The May 2010 rating decision reflects the initial adjudication of the claim after issuance of this letter. Hence the March 2010 letter, in addition to meeting the notice requirements outlined in Pelegrini and Dingess/Hartman, also meets the VCAA's timing of notice requirement with respect to the claim for service connection. After the award of service connection in May 2010 and the Veteran's disagreement with the assigned rating, no additional notice for the downstream issue was required under 38 U.S.C.A. § 5103A. See VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004). However, a SOC was issued in February 2013, and SSOCs were issued in December 2013 and December 2015. Each statement set forth the criteria for evaluating mental disorders, and the timing and form of each suffices, for purposes of Dingess/Hartman. The Veteran was afforded appropriate opportunity to respond to the additional notice provided before the claims file was returned to the Board. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent evidence associated with the claims file consists of service treatment records (STRs), VA treatment records, the reports of three VA psychiatric examinations, and various written statements provided by the Veteran and his representative. In the April 2013 VA Form 9, the Veteran indicated that he had received treatment at the San Francisco VA Medical Center (VAMC) in 1968 and the Phoenix VAMC in 1973 and requested the VA obtain these records. A November 2013 RO Memorandum made a formal finding that VA outpatient treatment records from these facilities dated from June 1967 to December 1975 were unavailable for review; the Veteran was informed of this unavailability in an SSOC in December 2013. The Board finds that no further action on this claim, prior to appellate consideration, is required. The Board finds that no additional AOJ action to further develop the record in connection with this claim, prior to appellate consideration, is required. The Board also finds that there has been substantial compliance with the May 2015 remand directives. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (holding that there was no violation per Stegall v. West, 11 Vet. App. 268 (1998), when the examiner made the ultimate determination required by the Board's remand). The record indicates that the Veteran was afforded a VA examination to determine the current severity of his psychiatric condition and its effect on his social and occupational functioning in October 2015, as requested. The Board also finds that the VA examination reports of record are adequate to evaluate the Veteran's psychiatric condition. The examination reports each reflect an interview with the Veteran, a review of the record, and a psychiatric examination revealing detailed information concerning his symptomatology which addresses the relevant rating criteria. The Veteran has not alleged any worsening of his PTSD since his last VA examination, and neither he nor his representative has alleged that such is inadequate for rating. In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran was notified and made aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided. See Mayfield v. Nicholson, 20 Vet. App. 539, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the question for consideration is entitlement to a higher initial rating since the grant of service connection, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, supra. The Veteran has been assigned a 50 percent rating for an acquired psychiatric condition, to include PTSD and nightmare disorder, under Diagnostic Code 9499-9440, which indicates an unlisted mental disorder rated as chronic adjustment disorder. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. See 38 C.F.R. § 4.27. However, the actual criteria for evaluating psychiatric disorders other than eating disorders are set forth in a General Rating Formula. See 38 C.F.R. §4.130. Under the General Rating Formula, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. As the United States Court of Appeals for the Federal Circuit has explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas"-i.e. "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130. When evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "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." 38 C.F.R. § 4.126(a). Psychiatric examinations frequently include assignment of a GAF score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2015). [Parenthetically, the Board notes that the revised DSM-5, which among other things, eliminates GAF scores, applies to claims certified to the Board after August 4, 2014. See 79 Fed. Reg. 45, 093 (Aug. 4, 2014)]. In March 2010, the Veteran was first afforded a VA PTSD examination. At that time, the Veteran reported experiencing the following symptoms in connection with his combat experience in service: difficulty falling or staying asleep, irritability or outbursts of anger, and hypervigilance. He also reported that these symptoms were mild to moderate and had persisted ever since his in-service combat experience. However, the examiner indicated that these symptoms did not cause clinically significant distress or impairment in social, occupational or other important areas of functioning. In this regard, the Veteran stated that he was never married and that he did not have children. However, he stated that he had enjoyed a few romantic relationships in the past but was not currently dating, and that he had lots of friends with whom he socialized with. The Veteran reported that he was unemployed since 1985 due to service-connected back problems. On examination, the examiner noted that the Veteran's mood was good, that his thought process/content were unremarkable with no delusions, and that he understood the outcome of his behavior in regard to his judgment. The examiner indicated that the Veteran had exhibited none of the following: lack of impulse control, inability to maintain minimum personal hygiene, hallucinations, inappropriate behavior, obsessive/ritualistic behavior, panic attacks, homicidal thoughts, suicidal thoughts, episodes of violence, and problems with activities of daily living. However, during the course of the examination, the Veteran mentioned that he had some difficulty with recalling recently acquired information and simple instructions. Ultimately, the examiner concluded that the Veteran did not meet the DSM-IV criteria for a diagnosis of PTSD and diagnosed him with sleep disorder. At this examination, the Veteran was assigned a GAF score of 65. In November 2010, the Veteran presented to a VAMC for psychiatric consultation, complaining primarily of insomnia. He stated that he was also experiencing the following symptoms: depression, irritability, anger, startling at loud noises, nightmares, flashbacks, and social isolation. On examination, the psychiatrist noted the following: that the Veteran's mood was depressive and irritable; that his thought process was normal, logical and goal directed; that his thought content was normal with no delusions, feelings of helplessness or hopelessness, or obsessions; and that his judgment was fair. The psychiatrist also noted that the Veteran had no homicidal and/or suicidal ideations as well as no hallucinations. Additionally, the psychiatrist indicated that the Veteran's memory, recent and remote, was intact. The psychiatrist diagnosed the Veteran with PTSD and related mood disorder. He also assigned the Veteran a GAF score of 50. In May and August 2011, the Veteran visited the VA psychiatric clinic for supportive therapy and medication management for his PTSD and related mood disorder, presenting with continued complaints of irritability, depression, insomnia, nightmares, social isolation, and hyperstartle. In May 2011, the Veteran reported that he was attending a combat support group and was busy working on his house. At that time, the psychiatrist noted the following: that the Veteran's mood was clam; that his thought processes were normal, logical, and goal directed; that his thought content was normal with no delusions, feelings of helplessness or hopelessness, or obsessions; and that his judgment was good. The indicated that the Veteran's hygiene was fair. He also indicated that the Veteran's memory, recent and remote, was intact. However, in August 2011, the Veteran reported that he was having short term memory problems, forgetting names and numbers and getting confused while driving. At that time, the psychiatrist noted the following: that the Veteran's mood was euthymic; that his thought processes were normal, logical, and goal directed; and that his judgment was good. The psychiatrist commented that the Veteran was fairly groomed. At both visits, the psychiatrist indicated that the Veteran had no suicidal/and or homicidal ideations and no hallucinations. Also, at both visits, the Veteran was assigned a GAF score of 53. In May 2012, the Veteran again visited the VA psychiatric clinic for supportive therapy and medication management for his PTSD and related mood disorder, presenting with continued complaints of irritability, depression, insomnia, nightmares, social isolation, and hyperstartle. The Veteran indicated that he continued to attend his combat support group and that he found that it was supportive. The psychiatrist noted the following: that the Veteran's mood was irritable and caustic; that his thought processes were normal, logical, and goal directed; that his thought content was normal with no delusions, feelings of helplessness or hopelessness, or obsessions; and that his judgment was good. The psychiatrist commented that the Veteran was well groomed and had good hygiene. He indicated that the Veteran's memory, recent and remote, was intact. The psychiatrist also indicated that the Veteran had no suicidal/and or homicidal ideations and no hallucinations. At this visit, the Veteran was assigned a GAF score of 47. In December 2012, the Veteran was afforded another VA PTSD examination. The Veteran presented primarily with complaints of chronic sleep impairment-recurrent distressing dreams (sometimes as many as 10 nightmares per night) and difficulty falling and staying sleep (sleeping for 3 to 4 hours per night). While the Veteran also complained of experiencing anxiety, such anxiety manifested only in his nightmares. He denied impulsivity and any clinically significant symptoms of depression. He stated that although he was alone most of the time, he was not lonely and did not miss the presence of others. Concerning his family and social life, he reported that he was living alone and that he had not enjoyed a romantic relationship since he came back from Vietnam because he was too afraid to give birth to a child that may have birth defects due to Agent Orange. He also reported that he had no connection with his brothers (one deceased), and that both his parents were deceased. He claimed that he currently had no friends. In regard to activities of daily living, the Veteran indicated that he managed his own personal hygiene and grooming, prepared his own meals or ate out, drove, ran his own errands, and did his own chores around the house. He stated that he stays at home mostly, spending time on his computer playing games and watching television (5 hours daily). He also stated that he attended a combat support group once a week, and that he did enjoy the company of the group, although adding that, "that's plenty of interaction for me." On examination, the examiner noted the following: that the Veteran's mood was euthymic; his thought processes were normal, logical and goal directed; his thought content was unremarkable with no delusions or obsessions; and that his judgment was good. The examiner indicated that he had no suicidal and/or homicidal ideations and no hallucinations. The examiner also indicated that he communicated well and that his memory was within normal limits. The examiner ultimately concluded that he did not meet the DSM-IV criteria for a diagnosis of PTSD and diagnosed him with nightmare disorder. At this examination, he was assigned a GAF score of 55-60. The examiner also concluded that he experienced occupational and social impairment with reduced reliability and productivity. In May 2013, the Veteran went to the VA psychiatric clinic for supportive therapy and medication management for his PTSD and related mood disorder, presenting with continued complaints of irritability, depression, insomnia, nightmares, social isolation, and hyperstartle. The Veteran reported that he continued to attend his combat support group and that he found that it was supportive. He also reported having some problems with energy and motivation. At that visit, the psychiatrist commented that the Veteran's hygiene was fair. He also noted the following; that the Veteran's memory, recent and remote, was intact; that his thought processes were logical and goal directed; and that his judgment was good. The psychiatrist indicated that he had no suicidal/and or homicidal ideations and no hallucinations. At this visit, he was assigned a GAF score of 50. In October 2013, the Veteran visited the VA psychiatric clinic for supportive therapy and medication management for his PTSD and related mood disorder, presenting with continued complaints of irritability, depression, insomnia, nightmares, social isolation, and hyperstartle. The Veteran reported that his mood had been doing pretty well and that he had decent energy and motivation. He also reported that he continued to socialize with fellow veterans and that he was having some interactions with his neighbors. The psychiatrist commented that the Veteran's hygiene was fair. He also indicated the following; that the Veteran's memory, recent and remote, was intact; that his thought processes were logical and goal directed; and that his judgment was good. The psychiatrist indicated that he had no suicidal/and or homicidal ideations and no hallucinations, but some occasional flashbacks. At this visit, he was assigned a GAF score of 50. In January 2014, the Veteran again visited the VA psychiatric clinic for supportive therapy and medication management for his PTSD and related mood disorder, presenting with complaints of hypervigilance, hyperstartle, problems with motivation and energy, irritability, and nightmares. The psychiatrist noted that the nightmares were the biggest complaint. The Veteran reported that he continued to have good interactions with his peers and that he volunteered at the Salvation Army. The psychiatrist commented that the Veteran's hygiene was fair. He also indicated the following; that the Veteran's memory, recent and remote, was intact; that his thought processes were logical and goal directed; and that his judgment was good. The psychiatrist indicated that the Veteran had no suicidal/and or homicidal ideations, hallucinations, or flashbacks. In April 2014, the Veteran returned to the VA psychiatric clinic for supportive therapy and medication management for his PTSD and related mood disorder, presenting with continued complaints of hypervigilance, hyperstartle, problems with motivation and energy, irritability, and nightmares. The psychiatrist again noted that the nightmares were the biggest complaint. The Veteran reported that things were better since he had gotten a new service dog. He also reported decent social interactions with his family. The psychiatrist observed that the Veteran was well groomed and had good hygiene. He also indicated the following: that the Veteran's memory, recent and remote, was intact; that his thought processes were logical and goal directed; and that his judgment was good. He further indicated that the Veteran had no suicidal/and or homicidal ideations, hallucinations, or flashbacks. In April 2015, the Veteran again returned to the VA psychiatric clinic for supportive therapy and medication management for his PTSD and related mood disorder, presenting with continued complaints of hypervigilance, hyperstartle, problems with motivation and energy, irritability, and nightmares. The Veteran reported improved social interactions with his neighbors and that he did not feel as isolated. He also continued to report decent social interactions with his family. The psychiatrist observed that the Veteran was well groomed and had good hygiene. He also indicated that the Veteran's memory, recent and remote, were intact and that his judgment was good. He further indicated that the Veteran had no suicidal/and or homicidal ideations, hallucinations, or flashbacks. In October 2015, the Veteran underwent another VA PTSD examination. The examiner noted that the Veteran presented with the following psychiatric symptoms: recurrent, involuntary and intrusive distressing memories; recurrent distressing dreams; hypervigilance; sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep); depressed mood; anxiety; suspiciousness; and panic attacks (occurring weekly or less often). The Veteran reported that he had no contact with his brothers. He continued to report that he lived alone and that he had never been married or had children. He did indicate that he had friends what were neighbors. He stated that he took walks with his dog and the neighbor and his dogs. He also stated that he always had one or two friends. He described the following as his current activities and leisure pursuits: riding a motorcycle, prospecting, rock hunting, and fishing. On examination, the examiner noted the following: that the Veteran's mood was irritable; his thought processes were normal, logical and goal oriented; and that his thought content was unremarkable with no delusions or obsessions. The examiner also noted that he had no suicidal and/or homicidal ideations and no hallucinations. The examiner ultimately concluded that he did not meet the DSM-V criteria for a diagnosis of PTSD and diagnosed him with adjustment disorder with mixed anxiety and depressed mood. The examiner also concluded that he experienced occupational and social impairment with reduced reliability and productivity. Considering the pertinent evidence in light of the applicable criteria, the Board finds that an initial rating in excess of 50 percent for the Veteran's psychiatric disability is not warranted at any time since the February 4, 2010 effective date of the award of service connection for that disability. Collectively, the record establishes that the Veteran has experienced such psychiatric symptoms as irritability, depression, insomnia, nightmares, social isolation, problems with motivation and energy, hypervigilance, hyperstartle, anger, short-term memory impairment, suspiciousness, flashbacks, and panic attacks. The evidence of record, however, reveals that symptoms such 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 worklike setting), and inability to establish or maintain effective relationships were absent. Nonetheless, while the Veteran's reported symptoms indicate deficiencies in mood, such symptoms still do not rise to the level of severity as to result in occupational and social impairment with deficiencies in most areas. Although the Veteran has indicated that he has no close relationships with his living family and that he has never been married, he has also stated, although somewhat inconsistently, that he has friends and has had romantic relationships. In this regard, most recently, he has admitted to always having one or two friends. The record also demonstrates that he has been able to maintain good social interactions with fellow veterans and his neighbors. In addition, although the Veteran has been unemployed since 1985, he has stated that this was due to his back condition and he has not alleged that his psychiatric disability has interfered with employment. The record also shows that the Veteran has been able to independently and effectively handle daily tasks, take care of his home and pet, and engage in extra-curricular activities such as volunteering and hobbies. Moreover, the Veteran has consistently been evaluated and observed to have normal thinking and good judgment. In short, symptoms of the type and extent, frequency or severity to suggest the level of impairment contemplated in at least the next higher, 70 percent rating, simply are not shown. The Board further finds that none of the assigned GAFs, alone, provides a basis for a higher rating. As noted, the GAF scores assigned have ranged from 47 to 65-with most assigned scores assigned in the 50 to 60 range. According to DSM-IV, GAF scores from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). GAF scores from 51 to 60 are indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers). The range of scores assigned are indicative of severe to moderate symptomatology, with the majority of the scores in the 50 to 60 range consistent with the level of impairment contemplated in the assigned 50 percent rating. While the lowest score of 47 is, conceivably, indicative of significant impairment, that score was only assigned on a single occasion, and the Veteran has not manifested symptoms such as suicidal ideation or severe obsessional rituals. In this regard, the Board again reiterates that it is the actual symptoms demonstrated, and not an examiner's assessment of the severity of the disability, or any assigned GAF score, that should provide the basis for the assignment of a rating. See 38 C.F.R. § 4.126. As discussed, in this case, the Veteran's symptoms shown are consistent with the assigned 50 percent rating. In assessing the severity of the Veteran's psychiatric disability, the Board has considered the medical evidence discussed above, as well as the Veteran's assertions, to include that he is entitled to a higher rating because his symptoms are more severe than that reflected by the rating criteria. While the Veteran is certainly competent to report the nature and severity of his symptoms, such lay assertions are not considered more persuasive than the objective clinical findings which, as indicated above, do not support assignment of a higher rating for the Veteran's psychiatric disability at any point pertinent to this appeal. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993)), Moreover, while the symptoms reported by the Veteran clearly have been considered in the evaluation of his disability, as a layperson not shown to have appropriate medical training and expertise, the Veteran is not competent to establish entitlement to a particular rating on the basis of lay assertions, alone. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998); Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). The above-noted determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no pertinent point has the disability under consideration been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1)(2015). The determination of whether a claimant is entitled to an extra-schedular rating is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The first step is to determine whether the "evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. If it is determined that this is so, the second step of the inquiry requires a determination of "whether the claimant's exceptional disability picture exhibits other related factors," such as marked interference with employment or frequent periods of hospitalization. Id. at 116. Finally, if the first two steps of the inquiry have been satisfied, the third step requires referral of the claim to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether an extra-schedular rating is warranted. Id. In this case, the Board finds that schedular criteria are adequate to rate the disability under consideration at all points pertinent to this appeal. As evidenced by the above discussion, the rating schedule fully contemplates the described symptomatology, and provides for a rating higher than that assigned based on more significant functional impairment. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-9 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). The Board further notes that, pursuant to Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where evaluation of the individual conditions fails to capture all the symptoms associated with service-connected disabilities experienced. Here, however, the appeal only involves evaluation of a single disability. As the Board has fully considered all of the Veteran's psychiatric symptoms in evaluating the disability, and the evaluation of multiple service-connected disabilities is not presently at issue, the Board finds that the holding of Johnson is inapposite here. As a final point, the Board notes that the matter of the Veteran's entitlement to a total disability rating due to individual unemployability (TDIU) may be considered a component of a rating claim when such is expressly raised by the Veteran or reasonably raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, however, the Veteran was awarded a TDIU from July 29, 1991 to April 9, 2012 and special monthly compensation under 38 U.S.C.A. § 1114(s) and 38 C.F.R. § 3.3.50(i) from April 9, 2012. In addition, the record indicates the Veteran stopped working in 1985 because of his back and that he has not since applied for other employment for which he was not hired. The Veteran has not asserted, and the record does not otherwise indicate, that his service-connected psychiatric disability has actually or effectively rendered him unemployable. As such, the Board finds that the matter of the Veteran's entitlement to TDIU due to his psychiatric disability has not been reasonably raised in connection with the current claim for higher rating, and need not be addressed. For all the foregoing reasons, the Board finds that there is no basis for staged rating of the Veteran's psychiatric disability, pursuant to Fenderson, and that the claim for higher rating must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating at any pertinent point, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An initial rating in excess of 50 percent for acquired psychiatric disability, to include PTSD, nightmare disorder, and adjustment disorder, is denied. REMAND Although the Board regrets the additional delay, a review of the claims file reveals that further AOJ action on the remaining claim on appeal is warranted. Regarding the claim for peripheral neuropathy of the upper extremities, the Board finds that a VA addendum opinion is required. The Veteran underwent a VA peripheral nerves conditions examination in July 2015. As to the upper extremities, the VA examiner found no evidence of upper extremity neuropathy on examination. Accordingly, the VA examiner concluded that "there was no neurologic diagnosis in the upper extremities." However, VA treatment records dated closely in time with and since the service connection claim was filed indicate a diagnosis of peripheral neuropathy. In December 2008, the Veteran was referred to a VA neurology clinic for complaints of diffuse muscle spasms in his legs and arms as well as for marked restless legs and arms. The neurologist noted that loss of pinprick sense was found till the mid-shin. In the end, the neurologist diagnosed the Veteran with peripheral neuropathy, without specification as to the upper and/or lower extremities. In December 2009 and June 2010, the Veteran presented to the VA neurology clinic with complaints of worsening parethesis. The neurologist diagnosed the Veteran with peripheral neuropathy secondary to low Vitamin B12, again without specification as to the upper and/or lower extremities. In October 2010, however, the Veteran reported parethesis in the feet and the VA neurologist, noting that the right leg was studied with nerve conduction velocity testing, found that there was no electrophysiological evidence or large fiber peripheral neuropathy but that the Veteran may still have small fiber neuropathy. Nonetheless, an assessment of peripheral neuropathy was once again noted by the VA neurologist. However, it was unclear as to which extremities this diagnosis applied. Moreover, the Veteran continued to have complaints of claimed neuropathy as to the upper extremities after 2010, which does not appear to have been addressed by the examiner. In particular, an October 2011 VA primary care letter noted that the Veteran had complaints of numbness in both the upper and lower extremities, especially after riding his motorcycle for a prolonged period of time. Also, in December 2011, the Veteran presented to the VA primary care clinic with complaints of worsening neuropathy in his hands, feet and legs, among other things. Pursuant to McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), the requirement of the existence of a current disability for the purpose of a grant of service connection is satisfied when a veteran has a disability at the time he or she files their claim for service connection or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. Moreover, in Romanowsky v. Shinseki, 26 Vet. App. 289 (2013), the Court held that when the record contains a recent diagnosis of disability prior to a veteran filing a claim for benefits based on that disability, the report of diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time the claim was filed or during its pendency. Hence, although the July 2015 VA examiner did note the prior diagnoses of peripheral neuropathy in 2008 and in 2010 in his examination reports, it is not clear from the VA examiner's report whether the Veteran had a diagnosis of peripheral neuropathy as to the upper extremities at any time shortly prior to, at the time of, or during the pendency of the claim. As such, further medical findings in this regard are warranted. Notably, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Under these circumstances, the Board finds that further medical findings/opinion-based on full consideration of the Veteran's documented medical history and assertions, and supported by complete, clearly-stated rationale-are needed to resolve the claim for service connection for peripheral neuropathy of the upper extremities. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). On remand, the AOJ should arrange to obtain an addendum opinion from the neurologist who evaluated the Veteran in July 2015, or from another appropriate physician based on claims file review (if possible). The AOJ should only arrange for further examination of the Veteran if such is deemed necessary in the judgment of the individual designated to provide the addendum opinion. The Veteran is hereby notified that failure to report to any scheduled examination, without good cause, may result in denial of the claim for service connection. See 38 C.F.R. § 3.655 (2015). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant and death of an immediate family member. Prior to accomplishing actions responsive to the above, to ensure that all due process requirements are met, and that the record is complete, the AOJ should undertake appropriate action to obtain and associate with the claims file all outstanding, pertinent records. As for VA records, the claims file reflects that the Veteran has been receiving treatment from the South Arizona Health Care System (HCS), and that records from these facilities dated through November 2015 are associated with the file; however, more recent records may exist. The Board emphasizes that records generated by VA facilities that may have an impact on the adjudication of a claim are considered constructively in the possession of VA adjudicators during the consideration of a claim, regardless of whether those records are physically on file. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). Therefore, the AOJ should obtain from the South Arizona HCS all pertinent, outstanding records of evaluation and/or treatment of the Veteran dated since November 2015, following the current procedures prescribed in 38 C.F.R. § 3.159(c) with regard to requests for records from Federal facilities. The AOJ should also give the Veteran another opportunity to provide additional information and/or evidence pertinent to the claim on appeal, explaining that he has a full one-year period to respond. See 38 U.S.C.A. § 5103(b)(1); but see 38 U.S.C.A. § 5103(b)(3) (clarifying that VA may make a decision on a claim before the expiration of the one-year notice period). In its letter, the AOJ should specifically request that the Veteran provide, or provide appropriate authorization to obtain, any outstanding, pertinent private (non-VA) records. The AOJ's letter should also provide the Veteran with proper notice with respect to establishing service connection on a secondary basis. In this regard, while a November 2009 letter advised the Veteran of the evidence and information necessary to substantiate his claim for service connection on a direct basis, he has not been afforded notice regarding secondary service connection. Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information and, if necessary, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the VCAA. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the remaining claim on appeal. As a final matter, with respect to the claim for an earlier effective date for the award of service connection for acquired psychiatric disability, , as previously mentioned, in a September 2013 rating decision, the AOJ granted the Veteran a higher rating of 50 percent, effective February 4, 2010, for his psychiatric disability. In April 2013, the Veteran filed with the AOJ a statement clearly expressing disagreement with the effective date of the award for the claim of an acquired psychiatric disorder (previously claimed as PTSD), contained within a VA Form 9; such document constitutes a valid, timely-filed NOD with respect to this matter. To date, however, the AOJ has not yet issued an SOC with respect to this matter, the next step in the appellate process. See 38 C.F.R. § 19.29 (2015); Manlincon v. West, 12 Vet. App. 238, 240-41 (1999); Holland v. Gober, 10 Vet. App. 433, 436 (1997). Consequently, this matter must be remanded to the AOJ for the issuance of an SOC. Id. The Board emphasizes, however, that to obtain appellate review of any issue not currently in appellate status, a perfected appeal must be filed. See 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 20.200, 20.201, 20.202 (2015). Accordingly, these matters are hereby REMANDED for the following action: 1. Furnish to the Veteran and his representative an SOC addressing the claim for an earlier effective date for a psychiatric disability, along with a VA Form 9, and afford them the appropriate opportunity to file a substantive appeal perfecting an appeal on this issue. The Veteran and his representative are hereby reminded that to obtain appellate review of any matter not currently in appellate status, a timely appeal must be perfected-here, with respect to the claim referenced above, within 60 days of the issuance of the SOC. 2. Obtain from the South Arizona HCS all outstanding, pertinent records of evaluation and/or treatment of the Veteran, dated from November 2015. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with regards to requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 3. Furnish to the Veteran and his representative a letter requesting that he provide additional information and, if necessary, authorization, to obtain any additional evidence pertinent to the claim on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) records. In the letter, notify the Veteran of the evidence and information needed to substantiate the claim for service connection for peripheral neuropathy of the upper extremities secondary to service-connected disabilities. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 4. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 5. After all records and/or responses received from each contacted entity have been associated with the claims file, arrange to obtain an addendum opinion from the neurologist who evaluated the Veteran and provided the July 2015 opinion. If that individual is no longer employed by VA or is otherwise unavailable, document that fact in the claims file, and arrange to obtain medical opinion from a neurologist or appropriate physician based on claims file review (to the extent possible). Only arrange for the Veteran to undergo further VA examination, if deemed necessary in the judgment of the individual designated to provide the addendum opinion. The contents of the entire, electronic claims file, (in VBMS and Virtual VA), to include a complete copy of this REMAND, must be made available to the designated individual, and the examination report/addendum opinion should include discussion of the Veteran's documented history and lay assertions. The examiner should identify any peripheral neuropathy disability of the upper extremities, present currently or present at any time pertinent to the November 2009 claim (even if currently asymptomatic, or resolved). In addressing the above, the examiner should consider the diagnoses of peripheral neuropathy noted in the Veteran's VA treatment records, specifically those in December 2008, December 2009, June 2010, and October 2010 by the VA neurologist. Then, with respect to each peripheral neuropathy disability of the upper extremities-present currently or present at any time pertinent to the November 2009 claim (even if currently asymptomatic, or resolved)-the examiner must provide an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the disability: (a) had its onset during service or is otherwise medically related to service (to particularly include presumed in-service herbicide exposure therein); or, if not (b) was caused OR is aggravated (worsened beyond the natural progression) by his service-connected lumbar spine, dorsal spine, and/or diabetes mellitus disabilities. If aggravation is found, the examiner should attempt to quantify the additional disability resulting from aggravation. In rendering the requested opinions, the examiner must consider and discuss all relevant medical evidence and lay assertions (to include the Veteran's assertions as to in-service symptomatology). If the examiner finds reason to question the veracity of the Veteran's assertions in any regard, he or she should clearly so state, and explain why. All examination findings/testing results (if any), along with the complete, clearly-stated rationale for the conclusions reached, must be provided. 6. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. Stegall v. West, 11 Vet. App. 268 (1998). 7. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the remaining claim on appeal in light of all pertinent evidence (to include all evidence added to the VBMS and/or Virtual VA file(s) since the last adjudication) and legal authority. 8. If the benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate SSOC that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). This REMAND 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). The AOJ is reminded that this appeal has been advanced on the Board's docket. ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs