Citation Nr: 1636769 Decision Date: 09/20/16 Archive Date: 09/27/16 DOCKET NO. 11-21 698 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to a rating in excess of 30 percent for dysthymia. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Veteran represented by: Robert V. Chisholm, Attorney ATTORNEY FOR THE BOARD M. C. Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1969 to March 1993. These matters come to the Board of Veterans' Appeals (Board) on appeal from a May 2010 rating decision that was issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In September 2012, the Veteran withdrew his request for a Board hearing; thus, the hearing request is considered withdrawn. See 38 C.F.R. § 20.704(e) (2015). In an August 2014 decision, the Board denied the Veteran's claim for a schedular rating in excess of 30 percent for his service-connected psychiatric disability. The Veteran appealed the Board's August 2014 decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2015 Memorandum Decision, the Court vacated the August 2014 Board decision, concluding that the Board failed to consider favorable evidence when it declined to award a disability rating in excess of 30 percent, and remanded the matter to the Board for readjudication. In March 2016, the Veteran submitted a Notice of Disagreement (VA Form 21-0958) with the RO's August 2015 and September 2015 proposals to sever service connection for erectile dysfunction, the evaluation of prostatitis, and special monthly compensation. Given the fact, however, that a May 2016 rating decision effectuated the proposal, the Board finds that the March 2016 Notice of Disagreement was premature and no further action is warranted at this time. In a statement that was submitted by his attorney in May 2016, the Veteran waived his right to initial RO review of new evidence. Thus, no additional action is warranted in this regard. See 38 C.F.R. § 19.31 (2015). In a written statement received in June 2016 , the Veteran appears to have raised the issues of entitlement to service connection for emphysema and sleep apnea, to include as secondary to service-connected antecedent granulomatous disease. The Veteran is advised that his statements do not meet the standards of a complete claim under 38 C.F.R. § 3.150(a). On remand, the AOJ should notify the Veteran as to the procedures required under 38 C.F.R. § 3.155 for filing a claim for VA benefits. In the present decision, the Board grants a schedular rating of 50 percent for dysthymia for the period from February 10, 2009. The issues of the Veteran's entitlement to a schedular rating in excess of 50 percent for dysthymia and to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT For the period from February 10, 2009, the Veteran's service-connected psychiatric disability has been productive of occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for a disability rating of 50 percent for dysthymia have been met for the period from February 10, 2009. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9433 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION A. Relevant Legal Principles Disability ratings are determined by applying the rating criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule) and represent the average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10 (2015). In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA compensation as well as the whole recorded history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2 (2015); see generally Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria for that rating. 38 C.F.R. § 4.7 (2015). Otherwise, the lower rating is assigned. Id. Additionally, while it is not expected that all cases will show all the findings specified, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2015). The Board has considered whether separate ratings for different periods of time are warranted based on the facts, which is a practice of assigning ratings that is referred to as "staging the ratings." See Hart v. Mansfield, 21 Vet. App. 505 (2007). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, pyramiding, or evaluating the same manifestation of a disability under different diagnostic codes, is to be avoided. See 38 C.F.R. § 4.14 (2015). Thus, separate ratings under different diagnostic codes are only permitted if, for example, those separate ratings are assigned based on manifestations of the Veteran's disability that are separate and apart from manifestations for which the Veteran has already been rated. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the individual's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a) (2015). In addition, the evaluation must be 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. Id. The General Rating Formula for Mental Disorders, which is set forth in 38 C.F.R. § 4.130, provides in pertinent part: A 30 percent evaluation is warranted where there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is warranted where there is 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted where there is 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. This rating schedule is based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The Board notes that Veteran's claims file also includes evaluations based on the DSM-IV, which contains a global assessment of functioning (GAF) scale with scores ranging between zero and one hundred percent. The scores represent the psychological, social, and occupational functioning of an individual with regard to their mental health with higher functioning persons scoring higher on the scale. A GAF score between 41 and 50 is assigned when there are 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). American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed., 1994). A GAF score between 51 and 60 is assigned when there are 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). Id. A GAF score of 61 to 70 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. Id. VA regulations require that when the symptoms and/or degree of impairment due to a Veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. See Mittleider v. West, 11 Vet. App. 181 (1998). B. Facts and Analysis By way of background, in a January 2009 rating decision, the RO granted service connection for dysthymia and assigned a 10 percent rating, effective November 10, 2008. The Veteran did not appeal that decision, and thus, it is final. See 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 3.156(b), 20.201 (2015); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2011). The Veteran filed a claim for an increased rating in February 2010, and in the May 2010 decision that is the subject of the present appeal, the RO increased the Veteran's rating to 30 percent, effective February 10, 2010. In reviewing the evidence, should the Board determine that an increase in the Veteran's disability occurred within one year of the date that the Veteran's February 2010 claim was received by VA, the effective date of any such increase shall be the earliest date as of which such increase in disability was ascertainable. 38 U.S.C.A. § 5110(b)(2) (West 2014). Here, in a statement that was received by VA in February 2009, the Veteran reported that he has nightmares two to three times per week, disturbed sleep patterns, flashbacks to in-service experiences, a short temper and irritability that cause irrational thinking and reasoning, difficulty in understanding complex commands at work, long-term memory loss, and difficulty in establishing and maintaining effective work and social relationships. He also reported that he is paranoid around large crowds, lacks the desire to socialize, and isolates himself at home. A September 2009 VA neurological disorders examination report documents the Veteran's report that he gets headaches that are aggravated and worsened by his anger. He reported that he gets headaches two to three times per week and he leaves work when they occur. He reported taking thirty days off from work during the previous year. Notably, in March 2009, VA received a "Certification by Employee's Health Care Provider for Employee's Serious Illness-[Family and Medical Leave Act (FMLA)]" that indicates that the Veteran has been treated for headaches that were not incapacitating and lasted for two to four hours per episode. Notably, the reviewing clinician reported that the Veteran was not required to take leave from work on an intermittent basis or work on a reduced schedule as a result of his headaches or treatment for headaches, and the Veteran was able to perform the functions of his position. In September 2009, VA also provided an examination to determine whether the Veteran has posttraumatic stress disorder (PTSD) that is etiologically related to his period of active service. At that time, a VA examiner diagnosed the Veteran with dysthymic disorder, alcohol abuse, and subthreshold PTSD. His psychomotor activity, speech, thought process, and thought content were unremarkable; his attitude was cooperative, friendly, relaxed, and attentive; he demonstrated blunted and flat affect, good impulse control, and normal remote, recent, and immediate memory; his attention and orientation were intact; and he was without delusions, hallucinations, inappropriate behavior, obsessive/ritualistic behavior, panic attacks, homicidal thoughts, suicidal thoughts, and episodes of violence. In addition, he demonstrated that he was able to maintain minimum personal hygiene. Further, in assessing the Veteran's judgment and insight, the examiner noted that the Veteran understood the outcome of behavior and that he had a problem. At that time, the Veteran reported having difficulty staying asleep at night, having nightmares, and that he sometimes felt lonely, disappointed, and frustrated. He also reported that he does not socialize or make friends because he does not trust people and does not like to be around people. With regard to his occupational history, the September 2009 examiner noted that the Veteran was employed full-time as a mail handler. He was assigned a GAF score of 65 at that time and the examiner noted that the Veteran's mental disorder symptoms were not severe enough to interfere with his occupational and social functioning. In February 2010, the Veteran presented to a non-VA hospital with suicidal ideation due to marital problems after he called a family member to say good bye and was found with a loaded gun. At that time, he denied homicidal ideation and auditory or visual hallucinations. Records of his hospitalization indicate that the Veteran had a prior suicide attempt in 1991. Also in February 2010, a clinician noted that the Veteran appeared very relaxed upon evaluation, but had a GAF score of 20 on admission. A Psychiatric Intake/Discharge Summary of his one-day hospitalization documents an admission GAF score of 35 and a discharge GAF score of 55. The Veteran reported that he has had periods where he has felt moody and had suicidal ideation in February 2010 with regard to shooting himself, but had no intent in following through with it and does not intend to harm himself. He denied manic or psychotic symptoms. The reporting clinician noted that the Veteran had minor depressive symptoms, but did not have a major psychotic syndrome, did not have suicidal ideation at that time, and was not an imminent danger to himself or others. Additionally, the Veteran was very pleasant and cooperative, provided answers that were appropriate to the questions asked, was alert and oriented, and did not demonstrate any deficits in attention, recall, short-term memory, or long-term memory. The Veteran reported that he was looking forward to retirement because his job was "not especially rewarding." Non-VA treatment records dated in February 2010 also document a history of anxiety and panic attacks. In March 2010, VA provided another examination. The March 2010 examiner noted that the Veteran was drinking heavily and in possession of a gun when intended to commit suicide in February 2010. The Veteran reported being withdrawn, having difficulty getting restful sleep, having moderate energy and concentration, and experiencing significant guilt. He reported moderate consumption of alcohol. The examiner reported that the Veteran's symptoms at that time indicate that there was a "temporary increase" in the Veteran's level of dysthymia in comparison to previous VA examinations. Notably, the Veteran did not have homicidal or suicidal thoughts at the time of the examination. Further, similar to the symptoms noted during the September 2009 examination, the March 2010 examination report indicates that the Veteran was clean and appropriately dressed, and demonstrated unremarkable psychomotor activity, unremarkable thought process, unremarkable thought content, spontaneous and clear speech, affect appropriate to content of thought, dysphoric mood, and intact attention and orientation. Additionally, he did not have panic attacks at that time. The March 2010 examiner noted that the Veteran worked full-time as a mail handler and lost over thirty days of work during the previous twelve-month period due to headaches in addition to feeling "run down" and depressed. The Veteran reported that he did satisfactory work and had not been written up for work deficiencies. Further, his sick leave did not exceed the amounts allowed. The examiner indicated that there was no evidence of the following: total occupational and social impairment due to mental disorder signs and symptoms; mental disorder signs and symptoms that resulted in deficiencies in judgment, thinking, family relations, work, mood, or school; and reduced reliability and productivity due to mental disorder symptoms. The examiner concluded that the Veteran demonstrated occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to mental disorder signs and symptoms with generally satisfactory functioning (routine behavior, self-care, and normal conversation), and assigned a GAF score of 59. In support of this finding, the examiner explained that the Veteran was working full time, performing satisfactorily at work, and has used sick leave because of his depressive symptoms, which indicates intermittent periods of inability to perform occupational tasks. In a September 2010 letter, non-VA psychologist Dr. J.H. noted that he initiated treatment of the Veteran in March 2010, at which time the Veteran reported several symptoms of depression and anxiety, difficulty sleeping, loss of appetite, and a history of dysthymia. Dr. J.H. reported that the Veteran has expressed considerable distrust of others, has expressed animosity and distrust toward his wife, and continues to be fairly depressed, angry, withdrawn, and suspicious. Dr. J.H. assigned a GAF score of 50 and documented diagnoses of recurrent major depressive disorder and personality disorder not otherwise specified (NOS). November 2010 and October 2011 VA treatment records document negative depression screenings because the Veteran indicated that he did not have little interest or pleasure in doing things and did not feel down, depressed, or hopeless. In June 2011, the Veteran reported that he retired in July 2010 because he has difficulty adapting to stressful circumstances, including a work or a work-like setting, and is unable to establish and maintain effective relationships. In March 2012, another VA examiner endorsed that the Veteran has occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner also endorsed that the Veteran had depressed mood and demonstrated suspiciousness at that time. Notably, the examiner did not endorse panic attacks, near-continuous panic or depression, impaired memory, flattened affect, abnormal speech, abnormal thought process, disturbances of motivation and mood, impaired judgment, impaired abstract thinking, difficulty in understanding complex commands, neglect of personal appearance and hygiene, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances (including work or a work-like setting), and suicidal ideation. The examiner assigned a GAF score of 55. With regard to his social functioning, the Veteran reported in March 2012 that he was in contact with his children and extended family, and he reported that he goes out to eat with his wife "every now and then." He denied engaging in any social activities with friends and acquaintances. Additionally, with regard to his occupational functioning, he reported that he was not employed, as he retired in June 2010. Post-retirement, the Veteran has spent time doing puzzles, working around his house, and going fishing "every now and then." In April 2012, a non-VA clinician noted the Veteran's history of depression and a suicide gesture two years prior. Notably, at that time, the Veteran denied being depressed and denied feelings of hopelessness or worthlessness. The evaluating physician noted that the Veteran no longer appeared depressed and was competent to handle his own affairs, to include his financial affairs. In January 2013, VA received a statement in which the Veteran reported that loss of sleep and his headaches contribute to his irritability, short temper, and irrational thinking. In a September 2014 Application for Increased Compensation Based on Unemployability (VA Form 21-8940), the Veteran reported that his prostate cancer and incontinence prevent him from securing or following a substantially gainful occupation. He reported that these conditions affected his full-time employment in March 2010, he last worked full-time at the end of June 2010, and he became too disabled to work at the end of July 2010. An October 2014 Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192) indicates that the Veteran last worked in July 2010 and his employment was terminated due to prostate cancer and incontinence. In June 2016, the Veteran submitted another Application for Increased Compensation Based on Unemployability in which he reported that all of his service-connected conditions prevent him from securing or following any substantially gainful occupation, his disability affected his full-time employment in March 2005, he last worked full-time at the end of June 2010, and he became too disabled to work at the end of June 2010. June 2013 and June 2015 VA treatment records document negative depression screenings because, again, the Veteran indicated that he did not have little interest or pleasure in doing things and did not feel down, depressed, or hopeless. In an affidavit dated in March 2016, the Veteran reported that he left his job because of his service-connected dysthymia, he was constantly irritable at work due to numerous disagreements with his supervisor, he engaged in loud arguments with his supervisor on several occasions because his supervisor increased his work load, his work was extremely stressful because of his anxiety problems, he was having trouble completing the work assigned, and he became overwhelmed by his duties. In addition, in the March 2016 affidavit, the Veteran reported that there are days when he has trouble getting out of bed, he has significant trouble sleeping, he regularly experiences anxiety, he stays at home whenever possible, he and his wife never go out to eat or do any other public activities due to his depression and anxiety, he is extremely paranoid and suspicious of other people, and he has problems with memory loss such that he cannot remember what he has done three hours prior or conversations with his wife. In May 2016, the Veteran was evaluated by non-VA psychologist Dr. M.J. who noted that the Veteran retired in June 2010 due to psychiatric symptoms and interpersonal difficulties, and that the Veteran has suffered from occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood since February 2010. In support of this finding, the psychologist noted that treatment records document conflicts with his supervisor, demonstrated frequent absenteeism and difficulty adapting to stress, marital discord, a complete lack of social network or friends, suicidal ideation with plan that resulted in emergency hospitalization, and additional factors. Additionally, Dr. M.J. opined that it is more likely than not that the Veteran became unable to secure and follow substantially gainful employment due to his service-connected psychiatric disability on or about February 2010, which was when his psychiatric symptoms worsened as a result of interpersonal and marital discord. In May 2016, the Veteran was alert and oriented to person, place, and time; demonstrated a normal rate and rhythm of speech; demonstrated adequately organized thoughts; did not demonstrate hallucinations or illusions/delusions; was able to provide the exact date, his current address, and detailed information about current events; did not demonstrate word-finding problems or circumlocutions in spontaneous speech; and was polite and appropriate at all times. He did, however, appear to mix up some dates, and demonstrated dysthymic affect with expressed frustration, anger, and sadness when discussing his symptoms and history. He reported having few activities, spending his time at home most days, and "just sit[ting]" or pacing in his yard most days. He reported that his mood is "up and down" and he does not have the energy or motivation to do much. He also reported that he spends five to six days per month completely inactive because it is "hard to even get out of bed" on those days. On other days, his activities are limited. Although his wife does most of the housework, he will assist with specific tasks when asked. He does jigsaw puzzles and goes fishing alone or with his wife. He does not attend church or belong to any social clubs, has no community involvement, and has no friends. Occasionally, he sees his two daughters, but rarely sees his son. Dr. M.J. noted intermittent symptoms of anxiety and frustration, constant fatigue; interrupted sleep, and severe self-reported symptoms of depression. Dr. M.J. also noted moderate symptoms of pessimism, worthlessness, irritability, and decreased concentration; and mild symptoms of sadness, punishment, crying, indecisiveness, and anxiety. Notably, the Veteran did not express any suicidal ideation. As of May 2016, the Veteran remained independent in all basic self-care activities and had an intermediate level of functional independence. More specifically, the Veteran was not impaired with regard to his mobility or self-care, but was moderately impaired in "life activities" and severely impaired with regard to his cognition, ability to get along with people, and participation. Dr. M.J. noted a long history of mood disturbance, insomnia, interpersonal distrust, social isolation, and difficulty relating to others, and indicated that the symptoms of the Veteran's previous dysthymia, major depressive disorder, and adjustment disorder diagnoses are overlapping and indistinguishable, and better characterized by the updated DSM-5 diagnosis "persistent depressive disorder," which is a chronic form of major depressive disorder. Dr. M.J. observed that the Veteran's overall level of function appeared to decline during the period 2009 to 2012 because his GAF scores declined from 65 in 2009 to an average rating of 54.5 in 2010 to a rating of 55 in 2012 (not including ratings during acute exacerbation of symptoms associated with hospitalization). According to Dr. M.J., "these ratings were based solely on the presence of symptoms of dysthymia and not on the concomitant symptoms of [currently nonservice-connected] PTSD, which were also present and also disabling." Further, Dr. M.J. noted that the Veteran's "disability ratings from 2009 to the present time underestimate his level of functional disability because they do not include symptoms of PTSD, which are indistinguishable from depression, and which contributed to his occupational and social dysfunction." It is after careful review of the evidence that the Board finds that the preponderance of the evidence demonstrates that disability due to the Veteran's PTSD has approximated the schedular criteria for a disability rating of 50 percent for the period from February 10, 2009. In so finding, the Board looked to the frequency, severity, and duration of the Veteran's impairment, and not transient symptoms, to assess his disability picture. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). In assigning the 50 percent rating, the Board notes that the Veteran's psychiatric disability has been productive of or characterized by symptoms including blunted and flat affect, reported difficulty in understanding complex commands, reported short- and long-term memory problems, motivation problems, and difficulty in establishing and maintaining effective work and social relationships during the period from February 10, 2009. Additionally, in exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology because the schedular criteria contemplate a wide variety of manifestations, to include those shown by the Veteran, and contemplate levels of disability that are more severe than what is currently shown by the evidence. Furthermore, the evidence does not show that the Veteran's service-connected disabilities, in the aggregate, have presented such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards at this time. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). The Board does not doubt that symptoms and limitations caused by the Veteran's service-connected disabilities have had an adverse impact on the Veteran's ability to work; however, loss of industrial capacity is the principal factor in assigning schedular disability ratings. See 38 C.F.R. §§ 3.321(a), 4.1. Again, 38 C.F.R. § 4.1 specifically provides that the schedular criteria are adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. The Board finds, however, that the evidence that is currently of record does not show that referral for extraschedular consideration under 38 C.F.R. § 3.321 is warranted at this time. ORDER Subject to the applicable regulations concerning the payment of monetary benefits, a disability rating of 50 percent is granted for dysthymia for the period from February 10, 2009. REMAND As acknowledged previously, the matter of the Veteran's entitlement to a rating in excess of 50 percent for dysthymia and a TDIU remain before the Board. Generally, VA is required to assist the Veteran in obtaining evidence necessary to support his claim and afford an examination to assess the current nature, extent, and severity of a service-connected disability when there is evidence that the Veteran's level of disability worsened since the last examination. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(2); Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Thus, because the recent evidence of record, to include the Veteran's March 2016 affidavit and the report of Dr. M.J.'s May 2016 evaluation, indicates that the Veteran's condition may have worsened since his last VA mental disorders examination in March 2012, the Board finds that an additional examination must be provided on remand. Further, as the matter of the Veteran's entitlement to a TDIU is inextricably intertwined with the matter of his entitlement to an increased rating for dysthymia, the Board finds that the claim for a TDIU must be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (issues are inextricably intertwined when a decision on one issue would have a significant impact on another issue). Accordingly, the case is REMANDED for the following action: 1. Associate with the claims folder, physically or electronically, all records of the Veteran's recent and pertinent VA treatment. If no records are available, the claims folder must indicate this fact. Any additional records identified by the Veteran during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the Veteran, and associated with the claims file. 2. After the above development has been completed, schedule the Veteran for an examination to determine the nature and severity of his service-connected psychiatric disability. The frequency and severity of all symptoms should be reported. Specifically, the examiner should indicate whether the Veteran has demonstrated any of the following symptoms and, if so, note the frequency and severity of the symptom: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is 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 an inability to establish and maintain effective relationships. In addition, the examiner should provide an opinion as to whether symptoms of the Veteran's service-connected psychiatric disability (currently identified by VA as dysthymia) can be separated from symptoms of his reported posttraumatic stress disorder, which is a nonservice-connected condition. To the extent that his psychiatric symptoms can be attributed to different disabilities, indicate which symptoms are attributable to his service-connected psychiatric disability. Lastly, the examiner should provide an opinion as to the impact of the Veteran's psychiatric disability on his ability to obtain and retain employment, i.e., the impact of his psychiatric symptoms on his ability to communicate, concentrate, etc. Thereafter, the examiner should provide an opinion as to the impact of all of the Veteran's service-connected disabilities on his ability to obtain and retain employment. The claims folder should be made available to and reviewed by the examiner, and the examiner should set forth a complete rationale for all findings and conclusions in a legible report. 3. Readjudicate the claims on appeal. If the benefits requested on appeal are not granted in full, the Veteran and his representative should be furnished a Supplemental Statement of the Case and provided an opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. By this remand, the Board intimates no opinion as to any final outcome warranted. The Veteran 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). ______________________________________________ S. C. KREMBS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs