Citation Nr: 1624130 Decision Date: 06/15/16 Archive Date: 06/29/16 DOCKET NO. 07-24 862 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD), and a rating in excess of 50 percent from September 22, 2009. 2. Entitlement to service connection for a chronic cervical spine disability, claimed as a neck injury. 3. Entitlement to service connection for a right ankle strain. 4. Entitlement to service connection for a left wrist cyst. 5. Entitlement to service connection for bronchial asthma, claimed as undiagnosed illness with respiratory difficulties. 6. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Arizona Department of Veterans Services ATTORNEY FOR THE BOARD W. R. Stephens, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Marine Corps from February 1988 to February 1992. The Veteran was awarded the Combat Action Ribbon for combat service in Kuwait. These issues come before the Board of Veterans' Appeals (Board) on appeal from a December 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The December 2006 rating decision denied service connection for the above noted claims, and awarded service connection for PTSD with an initial evaluation of 30 percent. During the course of this appeal, a subsequent February 2011 rating decision awarded an increased evaluation of 50 percent, effective September 22, 2009. These matters were previously remanded by the Board in October 2009 and July 2011 for further development. In the July 2011 Remand, the Board determined that the Veteran had submitted evidence regarding unemployability and that a claim for a TDIU had been raised by the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Since that Remand, entitlement to TDIU was denied in a June 2013 rating decision. However, as the issue of TDIU is part and parcel of an increased rating claim, it is before the Board. See id. This appeal was processed using Virtual VA (VVA) and the Veterans Benefits Management System (VBMS) processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The service connection claims on appeal and the issue of entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT For the entire period on appeal, the Veteran's PTSD is manifested by symptoms such as sleep impairment, reduced memory, intrusive recollections, nightmares, irritability, depressed mood, anxiety, feelings of detachment, avoidance of crowds, diminished interest in significant activities, hypervigilance, and difficulty in establishing and maintaining effective work and social relationships, resulting in occupational and social impairment with reduced reliability and productivity, but less than deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating of 50 percent for PTSD, but no higher, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2015). 2. The criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Compliance with Stegall As noted in the Introduction, the Board most recently remanded the Veteran's increased rating claim for PTSD in July 2011. With respect to that claim, the Board's remand instructed the RO to: (1) attempt to obtain State Unemployment Administration records; (2) attempt to obtain private treatment records previously referenced by the Veteran; (3) request clarification as to whether the Veteran sought to continue his PTSD appeal; (4) schedule the Veteran for a VA psychiatric examination; and (5) readjudicate the claims. VA sent a March 2012 letter requesting that the Veteran identify any additional treatment and provide the necessary authorization and clarify if he sought to continue his PTSD claim. VA sent a March 2012 letter requesting State Unemployment records. In addition, VA sent follow up letters to the Veteran requesting updated authorization forms for private treatment records, to which the Veteran did not respond, and sent subsequent letters which ultimately led to obtaining state unemployment records. The Veteran also clarified that he sought to continue his increased rating PTSD claim. The Veteran was scheduled for and attended a May 2013 VA PTSD examination. He was scheduled for an additional PTSD examination in November 2013, but failed to appear without good cause. The RO readjudicated the claims in an August 2014 Supplemental Statement of the Case (SSOC). As a result of these steps taken, the Board finds that there has been compliance with its previous remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where remand orders of the Board are not followed, the Board errs as a matter of law when failing to ensure compliance). II. VA's Duties to Notify and Assist VA's duty to notify was satisfied by a September 2006 letter and subsequent letters. See 38 U.S.C.A. §§ 5102, 5103, 5103A; 38 C.F.R. § 3.159; see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The duty to assist requires VA to seek relevant records and to obtain a medical opinion when required. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In assisting the claimant in the procurement of service and other relevant records, VA will make as many requests as are necessary to obtain relevant records from a Federal department or agency, and will make "reasonable efforts" to obtain relevant records not in the custody of a Federal department or agency. VA has satisfied its duty to seek relevant records. VA has obtained and associated available service treatment records, VA treatment records, identified private treatment records, and identified state unemployment records with the file. The record does not indicate and the Veteran has not notified VA that additional VA medical records or relevant social security medical records exist. The Veteran has referenced private treatment at N.H.S. and from Dr. W. The Veteran submitted an authorization form in April 2012 for Dr. W, however, as he was notified by VA in June 2014 notice letter, this authorization form was outdated. Since the Veteran identified private psychiatric treatment at N.H.S. and from Dr. W., VA has made appropriate efforts to obtain authorization for such records. However, the Veteran has not replied. Thus, the Board finds that VA has made reasonable efforts to obtain such records. The duty to assist includes providing an examination when one is required by law. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006) (provides an analysis of when an examination is required). When VA determines to provide an examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The opinion must be adequately supported and explained. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). A VA examination for PTSD was most recently afforded in May 2013. The record does not suggest and the Veteran has not alleged that this examination is inadequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Additionally, the evidence of record does not suggest that the Veteran's PTSD has worsened in severity since the May 2013 examination, and thus a new examination is not necessary. For reasons that remain unclear to the Board, the Veteran was scheduled for an additional examination in November 2013 for PTSD. The Veteran failed to report to this examination and did not provide good cause. However, as the Veteran did report to the May 2013 examination, and further as there is no indication that the Veteran's condition has worsened since that May 2013 examination, the evidence of record is fully adequate for the purposes of determining the extent of the Veteran's disability during the period on appeal in light of the applicable diagnostic criteria. See id. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), reversed on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). III. Increased Rating PTSD Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of a veteran. 38 C.F.R. § 4.3. In cases where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7. Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. However, staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD is currently assigned an initial 30 percent rating under Diagnostic Code 9411, effective June 26, 2006. The Veteran's disability is assigned an evaluation of 50 percent effective September 22, 2009. Diagnostic Code 9411 pertains specifically to the primary diagnosed disability in the Veteran's case (PTSD). In any event, with the exception of eating disorders, all mental disorders including PTSD are rated under the same criteria in the rating schedule. Therefore, rating under another diagnostic code would not produce a different result. Moreover, the Veteran has not requested that another diagnostic code be used. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 9411. The criteria for a 30 percent rating are as follows: Occupational and social impairment with an 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; and mild memory loss (such as forgetting names, directions, and recent events). The criteria for a 50 percent rating are as follows: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are as follows: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. The criteria for a 100 percent rating are as follows: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The "such symptoms as" language of the diagnostic codes for mental disorders 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). However, as the Court also pointed out in that case, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous." Id. The Court went on to state that the list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Id. 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. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as indicating 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). A GAF score of 61 to 70 is indicative of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the DSM-IV and replace them with references to the recently updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094 . The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). The RO originally certified the Veteran's appeal to the Board in May 2009; therefore the claim is governed by DSM-IV. Factual Background October 2006 private hospital records document anxiety, depression, orientation to all spheres, suicidal thoughts, agitation, and paranoia. The Veteran denied hallucinations, suicidal attempts or plan, self-injury, and confusion. An October 2006 Vet Center mental status evaluation documented neat appearance, friendly and cooperative manner, above average intelligence, appropriate speech, orientation to all spheres, normal memory, appropriate affect, relaxed motor activity, and good judgment. There was evidence of delusions, disorganized thinking, and hallucinations. Appetite was poor, energy level was average, there was sleep impairment, and there was suicidal and homicidal ideation. The Veteran reported suicidal ideation due to separation from his wife and homicidal ideation of criminals. The Veteran reported being uncomfortable around crowds, but interacts normally with close friends. He is easily brought to tears and angered, lacking patience. The Veteran was married, but separated from his wife. He reported one son and four daughters from that marriage. He worked as a police officer. He denied legal or substance issues. The Veteran experienced depression and states of anger and aggression. The examiner noted a positive personality, described as "happy-go-lucky" and with a "sense of humor." A GAF score of 50 was recorded. It appears the examiner used psychological testing from June 2006 in his assessment. At an October 2006 VA examination, the Veteran reported an increase of symptoms and that he recently began taking Zoloft again. He reported sleep impairment, recurring nightmares about combat, intrusive thoughts and reaction to planes flying over. The Veteran reported getting divorced from his wife in 2001. He reported having a current girlfriend, but reported relationships with many women which he believes in consistent with his "risk-taking behavior." He reported one previous arrest for unintentionally cashing a bad check. At the time of examination, the Veteran was working for the Navajo Police Department. The Veteran reported some difficulty with the job, which lead to increased stress. The Veteran described his socials relationships as being rather disturbed. He reported relationships with many women and did not feel he acted very responsibly. He reported being close to his children from his marriage and sees them every other weekend and participates in their activities. The Veteran reported leisure activities of playing the guitar and a little trio. He also reported that he loves to drink beer, about 12 beers every two weeks. He denied a substance abuse problem. The Veteran reported six outpatient visits for psychiatric care and four to five hospital visits. The Veteran denied any suicide attempts or suicidal ideation, but reported that he feels worthless. He does not believe he is living up to his potential. He at times has extreme anxiety, which manifests in anger. He reported periodic homicidal ideation against his police lieutenant. He denied paranoid ideation, delusions, or hallucinations. He keeps a gun by his bedside and reported hearing occasional explosions when others did not hear it. The examiner noted that the Veteran made eye contact. He was mostly serious, did not exhibit any inappropriate behavior. The Veteran had been avoiding work for 2 weeks, but was going to return at the end of the week. He felt that he was getting better, but had difficulty with eating habits sometimes not eating for two to three days. He becomes avoidant and does not want to leave his home. He was oriented to all spheres. He reported an excellent memory, had no cognitive defects, no evidence of obsessive-compulsive or ritualistic behavior. He reported being clean and neat. Speech was normal. Veteran reported anxiety once to twice daily, but denied panic attacks. He described himself as not trusting. A GAF score of 40 was recorded, but the examiner stated that a score of 45 would be more consistent with the previous year. An October 2009 letter from a VA examiner to the Veteran's supervisor states that the Veteran completed the Evaluation and Brief Treatment of PTSD Unit program between September 22 and October 9, 2009. Impaired sleep was reported, which the examiner noted can lead to depressed mood, irritability, anxiety, poor decision-making, communications with others, and performance of other tasks. The examiner wrote to support the Veteran's request for a modified schedule, to avoid night shifts when possible. VA treatment records from October 2009 to February 2010 document marital problems, anxiety, dissatisfaction in work, extreme re-experiencing issues, avoidance, and addictive behaviors with drinking and sex. The Veteran was generally appropriately dressed, had normal motor movement, no homicidal or suicidal ideation, fully oriented, denies hallucination and delusions. In a January 2010 treatment note the Veteran did state he had fleeting suicidal ideation without plan or intent. GAF scores of 45 were record in October 2009 and of 50 in December 2009. The record indicates that the Veteran received a DUI in January 2010. In a March 2010 statement, the Veteran states that the DUI was due to his PTSD. February 2010 private treatment records note flashbacks and severe restlessness, tension, and anxiety. The Veteran reported feeling numb without guilt or consciousness and being very irritable. He has period of "high moods," during which he is impulsive at work and home. He denied suicidal intention and history of attempts. The examiner reported that he was edgy, irritable, and agitated with mood congruent affect and psychomotor agitation. He denied intent to hurt others. GAF scores of 50, 55, and 60 were documented. A February 2010 letter from a private psychologist to the Veteran's employer concludes that the Veteran was unable to function at work due to his PTSD. She noted that the Veteran's behavior at work was likely to be unpredictable. A March 2010 statement from a private counselor states that the Veteran suffers "the full range of symptoms associated with PTSD," including intrusive thoughts, hyperarousal, hypervigilance, isolation, avoidance, depression, sleep impairment, anger issues, startle response, difficulties with relationships, anxiety, and lack of concentration. The Veteran self-medicates with alcohol. The Veteran had reported feeling on edge, being angry, hearing voices, and seeing images that he could not explain. The file contains a May 2010 Notice of Termination from the Police Department employing the Veteran for a Sexual Harassment offense, specifically displaying pornographic pictures at work. In a May 2010 statement, the Veteran contends that this behavior was a result of his PTSD. At the May 2013 VA examination, the Veteran reported a positive relationship with his family members. He has four children with his wife, is close to two of them and neutral with the other two. He and his wife have been separated twice, the current separation lasting for three months. He has another child with another woman, who he has not seen in four years. The Veteran has one friend that he texts and calls and visits occasionally. He enjoys playing guitar and driving. The Veteran reported being employed full-time answering phones. The examiner documented the following symptoms: depressed mood, anxiety, chronic sleep impairment, and mild memory loss. The Veteran reported living with his mother and her boyfriend. The Veteran was casually dressed with adequate hygiene, normal behavior, normal speech, restricted affect, anxious and dysphoric mood, and normal thought process. He denied delusions and obsessions. He reported occasional suicidal ideation, however denied intent and plan. He reported homicidal ideation as a police officer regarding a politician, but lacked plan and intent. The Veteran reported seeing a mist coming from someone's arm that was not there and hearing jets, helicopters, and explosions that are not there. He sleeps with a rifle by his head to feel safe, needs four to five cups of coffee to keep working, and his appetite fluctuates. He reported that sadness feels like it is always there. He lacks motivation to do things. Anger is triggered when "someone puts him down, especially in front of his kids." He experiences symptoms four days a week and feels okay two days a week. The examiner concluded that the Veteran's PTSD symptoms resulted in occupational and social impairment with reduced reliability and productivity. A GAF score of 59 was recorded. The Board has reviewed additional VA treatment records and private record submitted throughout the entire period on appeal which document similar symptoms as described above. A December 2013 GAF score of 45 is also of record. Analysis As noted, the Veteran's PTSD is currently assigned an initial 30 percent rating and an evaluation of 50 percent effective September 22, 2009. Upon careful review of the evidence of record, the Board finds that the objective medical evidence and the lay statements regarding the Veteran's symptomatology, more nearly approximates symptoms associated with a 50 percent disability rating for the entire period on appeal. Accordingly, the Board finds that an increased initial rating of 50 percent is warranted; however, a rating in excess of 50 percent for any time period on appeal is not warranted. The Board finds that the preponderance of the evidence is against an evaluation in excess of 50 percent for any period. Neither the lay nor the medical evidence of record more nearly approximates the frequency, severity, or duration of psychiatric symptoms required for a 70 percent disability evaluation based on occupational and social impairment, with deficiencies in most areas. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411. The Board has considered the private treatment records and VA treatment records, including all VA examination reports, and lay statements by the Veteran regarding the impact of his PTSD on his occupational and social impairment during this time period. During this period, the Veteran has exhibited a variety of symptoms, including but not limited to sleep impairment; reduced memory; intrusive recollections; nightmares; fatigue; irritability; depressed mood; anxiety; feelings of detachment; avoidance of crowds; diminished interest in significant activities; hypervigilance; difficulty establishing and maintaining effective work and social relationships; and suicidal and homicidal ideation. There have been no reported delusions or hallucinations; spatial or any other type of disorientation; intermittently illogical, obscure or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; the neglect of personal hygiene; or the inability to establish and maintain effective relationships. The Board notes that the Veteran has reported seeing mist coming from someone's arm when it was not there and hearing sounds that nobody else hears. However, there is no medical evidence of record suggesting that the Veteran has experienced hallucinations or delusions. While it is documented that the Veteran has had some difficulty in his relationship with his wife, including two separations, they are still married and the evidence suggests there relationship is somewhat stable. The evidence of record shows that the Veteran maintained a good relationship with two of his children and a decent relationship with two other children. At the May 2013 VA examination, the Veteran reported that he lives with his mother and her boyfriend, suggesting an at least stable relationship. Overall, the evidence of record suggests that the Veteran is capable of maintaining social relationships. While the Veteran's social relationships are no doubt impaired to some degree by his symptoms of PTSD, the criteria of a 70 percent evaluation describe an "inability" to establish and maintain effective relationships. The evidence suggests that while the Veteran may have difficulty establishing and maintaining some relationships, there is no evidence at any time during the period on appeal that he has had an inability to do so. A difficulty in doing so is clearly considered by the 50 percent evaluation assigned for this period. The Board notes that the Veteran has some documented symptoms of irritability during this time period. While the Board does not question the Veteran's report of irritability, there is no indication in the record that the Veteran's irritability has resulted in violence at any other time. His judgment and thought process appears to have been normal and intact. Thus, the Board concludes when that when the Veteran's symptoms consistent with irritability during this period are more consistent with a 50 percent evaluation. In terms of the Veteran's mood, during this time period the Veteran has reported symptoms of depression and anxiety. However, there is no indication that these symptoms have amounted to a severity, frequency, or duration consistent with near-continuous panic or depression affecting the Veteran's ability to function independently, appropriately, and effectively. There is no indication during this time period that the Veteran was suffering from near continuous panic or depression which would affect his ability to function independently, appropriately, and effectively. The Board finds that a 50 percent evaluation accounts for such effects on his mood, as displayed by the Veteran during this time period. The Board does note consistent reports of suicidal and homicidal ideation without intent or plan throughout the entire period. The Board takes the report of suicidal or homicidal ideation seriously, and acknowledges that these are severe symptoms apparently associated with PTSD. However, when viewing the other evidence of record, the Board finds that such symptoms by themselves do not warrant a rating in excess of 50 percent. While these symptoms are criteria associated with a higher disability rating, when evaluating the Veteran's social and occupational impairment resulting from his PTSD, such impairment is more consistent with social and occupational impairment contemplated by a 50 percent evaluation. Such an assessment is supported by the VA medical examinations of record, to include the examination report by the VA examiners who have reported the suicidal and homicidal ideation. Again, the Board does not take these symptoms lightly, but also notes that the Veteran has consistently denied any intent, plans, or attempts. The Veteran has asserted that his PTSD impacted his employment during this time period, and the Board finds that the medical evidence of record does support this. The Veteran lost his job as a police officer and was arrested for a DUI during the period on appeal, potentially due in part to his symptoms of PTSD. However, the record does not indicate that he became unemployable entirely as a result of his symptoms of PTSD during this time period. Conversely, at his most recent May 2013 VA examination the Veteran reported full-time employment. All VA examination reports have concluded that the Veteran's PTSD did not prevent him from maintaining employment. As a result, the Board acknowledges that the Veteran's PTSD no doubt had some occupational impairment during this time period, but the record does not indicate that it reached the level of deficiency consistent with a 70 percent evaluation during this period. When weighing the medical evidence of record, the Board finds that it does not show manifestations of symptoms that are consistent with a deficiency in occupational and social impairment consistent with a 70 percent evaluation. Furthermore, the Board notes the various GAF scores taken during this period. While not dispositive of the Veteran's condition, they do provide insight into the severity of the Veteran's PTSD during this period. As previously noted, GAF scores from 51 to 60 represent moderate symptoms, such as flat affect and circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school function; and scores ranging from 41 to 50 reflect serious symptoms. A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). The Veteran's documented GAF scores ranged from 40 to 60 during this period. While the Board notes that some of these GAF scores are consistent with serious symptoms, GAF scores are only a piece of the evidence useful in determining the occupational and social impairment of PTSD, and are not dispositive. When considering these GAF scores in light of the other medical and lay evidence of record, the Board finds that they are consistent with a 50 percent evaluation. Thus, the Board finds that the Veteran does not have occupational and social impairment, with deficiencies in most areas. He does have some deficiencies in several areas, but the greater weight of evidence demonstrates that it is to a degree that is contemplated by the 50 percent rating assigned herein. Furthermore, even resolving any reasonable doubt in the Veteran's favor, the Board finds that he does not meet the requirements for an evaluation greater than the assigned 50 percent schedular rating. Thus, the Board finds that an increased initial rating of 50 percent is warranted. However, an increased rating in excess of 50 percent is not warranted for any period on appeal. While the Veteran may well suffer from some symptoms consistent with a higher evaluation, the Board's duty in evaluating mental health disabilities is not to focus on the presence or absence of specific symptoms corresponding to a particular rating, but rather the overall effect of all symptoms, due to the severity, frequency, and duration of such symptoms, on the Veteran's occupational and social impairment. Although the evidence shows that there have been some instances during this period when the Veteran's PTSD seems to have fluctuated in severity, the Board finds that the 50 percent rating, but no higher, for PTSD pursuant to Diagnostic Code 9411 is warranted for this period. This is consistent with VA's determination to handle cases affected by change in medical findings or diagnosis so as to produce the greatest degree of stability of disability evaluations consistent with the laws and regulations governing disability compensation and pension. See 38 C.F.R. § 3.344(a). IV. Extra-Schedular Analysis The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis for both periods. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence 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 PTSD with the established criteria found in the rating schedule for these disabilities show that the rating criteria reasonably describes the Veteran's disability level and symptomatology. Specifically, for the entire period, the Veteran's psychiatric symptoms include depression, anxiety, sleep impairment, memory loss, intrusive recollections, nightmares, fatigue, irritability, and disturbances of motivation and mood. While many of the Veteran's symptoms are specifically contemplated by the rating criteria, some are not. That said, the Board expressly finds that they are on par with the level of severity contemplated by the rating criteria, and are not so far outside the realm of the rating criteria so as to warrant extra-schedular consideration. In short, the Veteran's entire disability picture has been considered, and his symptoms are contemplated by the schedule. The Board also notes that a Veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. Johnson v. McDonald, 762 F.3d 1362, 1366 (Fed. Cir. 2014). In this case, in addition to the disability addressed herein, the Veteran is in receipt of a 10 percent evaluation for tinnitus and a noncompensable evaluation for left ear hearing loss. The record reflects that the Veteran has at no point during the current appeal indicated that his service-connected psychiatric disorder results in further impairment when viewed in combination with these other service-connected disabilities. In short, there is nothing in the record to indicate that the Veteran's disability has caused impairment over and above that which is contemplated in the assigned schedular ratings. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board, therefore, has determined that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not warranted. ORDER Entitlement to an initial rating of 50 percent, but no higher, prior to September 22, 2009, for posttraumatic stress disorder (PTSD) is granted, subject to regulations applicable to the payment of monetary benefits. Entitlement to an increased rating in excess of 50 percent at any time during the appeal for posttraumatic stress disorder (PTSD) is denied. REMAND In July 2011, the Board remanded the Veteran's service connection claims, in part, for VA examinations to determine the nature and etiology of his claimed cervical spine disability, right ankle disability, left wrist disability, and asthma. Of record is a May 2013 letter sent to the Veteran informing him that the VA medical center would be scheduling him for examinations. The Veteran was scheduled for and attended May 2013 VA examinations for conditions which are not currently on appeal and were decided in a June 2013 rating decision. A document of record indicates that the Veteran failed to report to November 2013 VA examinations for his service connection claims on appeal. Crucially, however, there is no documentation of record that the Veteran was notified of the November 2013 VA examinations. While the subsequent August 2014 Supplemental Statement of the Case (SSOC) referenced the Veteran failing to report for the VA examination and the Veteran has not since responded indicating a good cause for missing the examination in accordance with 38 C.F.R. § 3.655(a), there still remains no evidence that the Veteran was notified of the VA examinations. As such, remand is required in order to reschedule the necessary VA examinations, which the Veteran must be provided notice of. In reaching this finding, the Board acknowledges the Court's finding in Kyhn v. Shinseki, 716 F.3d 572 (Fed. Cir. 2013) with regard to the presumption of regularity for notification of examinations. However, the Board finds that remand is necessary under these particular circumstances, in part due to the potential confusion caused by the May 2013 letter sent to the Veteran and his attendance at May 2013 VA examinations. In short, even if the Veteran was properly notified of his November 2013 VA examinations, it may have been unclear as to why new examinations were scheduled. Thus, in deference to the Veteran, remand is appropriate in order to afford him another opportunity to attend the necessary VA examinations. The Board takes this opportunity to advise the Veteran that his cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examinations, is critical. The Veteran is also advised that failure to report for any scheduled VA examination without good cause will result in his claim being decided based on the evidence of record. See 38 C.F.R. § 3.655(b). The Board notes that adjudication of a TDIU claim is dependent upon consideration of the impact of service connected disabilities on the ability to secure and follow substantially gainful employment. The adjudication of the Veteran's service connection claims on appeal are critical to the determination as to whether the Veteran is entitled to TDIU. Any decision on TDIU is inextricably intertwined with this pending claim, and so adjudication of TDIU entitlement at this time would be premature. Harris v. Derwinski, 1 Vet. App. 180 (1991). In reaching this finding that TDIU is intertwined with his service connection claims, the Board notes that the most recent evidence regarding his employment is from his May 2013 VA psychiatric examination at which he reported he was employed full-time. The Veteran failed to submit a VA Form 21-8940 Application for TDIU which was sent to the Veteran by VA in a March 2013 letter. While the most recent evidence of record with respect to employment indicates that the Veteran was employed full-time, the potential for service connection of the conditions currently remanded make a decision on his TDIU claim at this time inappropriate. Accordingly, the case is REMANDED for the following action: 1. Send notice to the Veteran requesting that he identify any additional private or VA treatment records for his claims being remanded. Request that he forward any additional records to VA to associate with the claims file or provide VA with authorization to obtain such records. If the Veteran is receiving regular VA treatment, obtain the updated medical records and associate them with the claims file. 2. Send the Veteran appropriate notice with respect to his TDIU claim, and request that he complete a VA Form 21-8940. 3. Schedule the Veteran for VA examinations with an examiner(s) of appropriate expertise to provide an opinion as to the etiology of the Veteran's claimed cervical spine, right ankle, left wrist, and respiratory disabilities. The claims file and a copy of this Remand must be made available to and be reviewed by the examiner in conjunction with the examination. The examination report must indicate that the claims file was reviewed in conjunction with the report. Based on a review of the record, the examiner should: Provide an opinion as to whether it is at least as likely as not (i.e. probability of 50 percent or greater) that any diagnosed cervical spine, right ankle, left wrist, or respiratory disability is causally or etiologically related to the Veteran's period of active service, to include as due to undiagnosed illness, or otherwise related to service. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Note that the Veteran is in receipt of the Combat Action Ribbon for his service in Iraq; as such, the law allows for his lay testimony of injuries sustained in service to be sufficient evidence to establish the events in-service, despite a lack of documented medical treatment for the same in the service treatment records. 4. The Veteran is to be notified that it is his responsibility to report for the scheduled examination and to fully cooperate in the development of the claims. 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). 5. Review the claims file to ensure that all of the foregoing requested development is completed, and arrange for any additional development indicated, to include consideration of 38 C.F.R. § 4.16(b). Then readjudicate the claim on appeal. If the benefit sought remains denied, issue an appropriate Supplemental Statement of the Case and provide the Veteran and his representative the requisite period of time to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ BETHANY L. BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs