Citation Nr: 1643785 Decision Date: 11/17/16 Archive Date: 12/01/16 DOCKET NO. 09-45 648 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for right ear hearing loss. 2. Entitlement to service connection for left ear hearing loss. 3. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to October 23, 2006, and in excess of 50 percent thereafter. 4. Entitlement to a total disability rating based on unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G. Slovick, Counsel INTRODUCTION The Veteran served on active duty from August 1965 to October 1967. These matters come before the Board of Veterans' Appeals (Board) on appeal from March 2006 and June 2006 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. The issues on appeal were remanded by the Board in September 2015 for further development, that development has been completed and the appeal is ready for adjudication. In an April 2006 statement, the Veteran indicated that he wished to be considered for a total disability rating based on individual unemployability (TDIU). Under Rice v. Shinseki the Board has jurisdiction over a TDIU claim as part and parcel of the Veteran's increased rating claim. Rice v. Shinseki, 22 Vet. App. 447 (2009) (holding that a request for TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, is part of a claim for increased compensation). This issue has been separately characterized in the issues above in accordance with that decision. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The preponderance of the evidence weighs against a finding that the Veteran has right ear hearing loss for VA purposes at this time. 2. Left ear hearing loss had its onset during active duty service due to combat noise exposure. 3. From September 15, 2005, the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas; total impairment is not shown. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right ear hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2015). 2. The criteria for entitlement to service connection for left ear hearing loss have been met. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309 (2015). 3. From September 15, 2005, the criteria for a 70 percent rating, but not greater, for service-connected PTSD are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.126, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103 (a); 38 C.F.R. § 3.159 (b). In accordance with 38 C.F.R. § 3.159 (b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the required notice should be furnished prior to the issuance of the appealed rating decision, any initial errors of notice will not be prejudicial if: 1) corrective actions (e.g., issuance of a post-adjudication notice letter containing the required information) are taken, and 2) the appeal is readjudicated (e.g., in a Supplemental Statement of the Case). See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). In this case, the Veteran was furnished with notice letters in April 2006 and August 2008 that were fully compliant with the provisions of 38 C.F.R. § 3.159 (b) and issued prior to the appealed rating decision. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159 (c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159 (c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159 (c)(4). The RO/AMC has substantially complied with the Board's September 2015 remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In this case, the Veteran's relevant service and post-service treatment records have been obtained, and he has been afforded comprehensive VA examinations in conjunction with his claims. No further efforts are needed to ensure compliance with VA's duty to assist. II. Service Connection The Veteran contends that service connection is warranted for bilateral hearing loss because it was incurred due to active-duty combat noise exposure in the Republic of Vietnam. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303 (a). When a chronic disease (such as sensorineural hearing loss) is shown in service sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). Service connection may only be granted for a current disability; when a claimed condition is not shown, there may be no grant of service connection. See 38 U.S.C.A. § 1131 (West 2002); Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). " In the absence of proof of a present disability there can be no valid claim." See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Hearing impairment is considered a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2015). Under 38 U.S.C.A. § 1154 (b), VA has created a presumption regarding the in-service incurrence or aggravation of a disability claimed to be the result of combat service. When a veteran has engaged in combat with the enemy during active service, VA must accept satisfactory lay or other evidence that is "consistent with the circumstances, conditions or hardships of such service." 38 U.S.C.A. § 1154 (b). This evidence serves as "sufficient proof of service-connection of any disease or injury alleged to have been incurred in or aggravated by such [combat] service." 38 U.S.C.A. § 1154 (b); 38 C.F.R § 3.304 (d). The combat presumption applies not only to combat injuries but also to the consequences of those injuries, at least in service. Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012) (holding that the Board was required to apply the section 1154(b) presumption to both the veteran's claimed acoustic trauma during service and the separate question of whether he suffered permanent hearing loss while on active duty). Even where the combat presumption applies, a veteran must still show that a causal relationship exists between the present disability and the in-service injury or disease. Id. at 999 n.9. Every reasonable doubt must be resolved in the veteran's favor, and service connection of injuries or diseases linked to combat may be rebutted only by clear and convincing evidence. 38 U.S.C.A. § 1154 (b). Service treatment records are silent as to any complaints of or symptoms of hearing loss. The Veteran's August 1965 report of medical examination for enlistment included audiological testing which revealed hearing tested as follows: A 500 B 1000 C 2000 D 3000 E 4000 RIGHT 15 10 5 15 5 LEFT 15 15 5 15 5 The Veteran's October 1967 report of medical examination demonstrated normal hearing using whisper tests. In June 2008, the Veteran stated that he had had hearing problems since being heavily mortared at Khe Sanh and Dong Ha. The Veteran is shown to have served in combat and noise exposure in service is conceded. The Veteran was afforded a VA examination in March 2016. His puretone thresholds, in decibels, were as follows: A 500 B 1000 C 2000 D 3000 E 4000 RIGHT 25 25 10 10 30 LEFT 50 45 35 30 40 Speech discrimination was 96 percent bilaterally. During his examination, the Veteran described difficulties hearing from his left ear and hearing his grandchildren. After the Veteran's physical examination, the examiner diagnosed the Veteran with sensorineural hearing loss in the right ear and mixed hearing loss in the left ear. After a review of the claims file and examination of the Veteran, the examiner concluded that it was not at least as likely as not that the Veteran's right ear hearing loss was due to service. The examiner explained that the Veteran was 70 years old and had been discharged in 1967. The examiner stated that although combat noise exposure was conceded, there was no evidence of hearing loss occurring in the service or within a year of service and the Veteran's hearing loss was not typical of a noise induced hearing loss. The examiner stated that there was not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss could develop much later in one's lifetime. The examiner stated that definitive studies had not been performed but based on the anatomical and physiological data, it was unlikely that such delayed effects occurred. Regarding the Veteran's left ear, the examiner noted that the Veteran's left ear hearing loss was not as likely as not caused by or a result of military service. It was noted that present hearing loss for the left ear was a mixed hearing loss which did not appear to be the result of a noise traumatic event in the service and was of an unknown etiology. While clearly the Veteran was exposed to loud noise during service, the Board has reviewed the evidence of record and finds that the Veteran has not demonstrated that he has right ear hearing loss for VA purposes at this time.38 C.F.R. § 3.385. As demonstrated above, the Veteran is neither shown to have an auditory threshold of 40 decibels or greater between 500 and 4000 Hertz, nor is speech recognition shown to be less than 94 percent. The Board notes that the Court has held that Congress specifically limited entitlement to service connected benefits to cases where there is a current disability. "In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus service connection for right ear hearing loss is not warranted. Regarding the Veteran's left ear hearing loss, however, the Board finds that the combat presumption of an in-service injury applies to the current claim. Given that the Veteran served in combat in Vietnam and has reported that he experienced hearing loss since that time, the Board finds that the evidence establishes the presence of an in-service injury, i.e. acoustic trauma. The Board further finds that the combat injury resulted in a chronic disability while on active duty. Reeves, 682 F.3d at 999. Consequently, because the Veteran has reported the onset of permanent hearing loss during active duty, 38 U.S.C.A. § 1154 (b) also applies to his contentions regarding the onset of hearing loss during service. See id. Given that the evidence demonstrates the onset of permanent hearing loss and the Veteran's report of continuous observed symptoms of a chronic disability since that time, service connection is established. 38 C.F.R. § 3.303 (b). The record contains some evidence weighing against the claim for service connection for left ear hearing loss, namely the findings of the March 2016 VA examiner, but the Board finds it does not constitute clear and convincing evidence necessary to rebut the combat presumption. Thus, the combat presumption of 1154(b) is not rebutted. As a right ear hearing loss disability for VA purposes is not shown, service connection is not warranted. Service connection is warranted for left ear hearing loss. III. Increased Ratings for PTSD When evaluating the level of disability of a mental disorder, the rating agency shall consider the extent of social impairment, but shall not assign an evaluation based solely on the basis of social impairment. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only insofar as it affects earning capacity. 38 C.F.R. §§ 4.126, 4.130. PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. Ratings are assigned according to the manifestation of particular symptoms, but the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment from PTSD with major depression under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in Diagnostic Code 9411. PTSD is rated under the General Rating Formula for Mental Disorders. Under these criteria, a rating of 30 percent is warranted if 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, or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating 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 rating is warranted 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 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, Code 9411. The GAF scale is a scale of psychological, social, and occupational functioning a hypothetical continuum of mental health and illness. Assessments on the GAF scale are not to include impairment in functioning due to physical or environmental limitations. Clinicians have assigned the Veteran GAF scores ranging from 37 to 66. GAF scores of 31 to 40 are for some impairment in reality testing or communication (e.g. depressed man avoids friends, neglects family, and is unable to work). GAF scores of 41 to 50 are for serious symptoms (e.g., suicidal ideation, severe obsessional rituals) or serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job). GAF scores of 51 to 60 are for moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social or occupational functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores from 60 to 70 indicate 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). 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 certified the Veteran's appeal to the Board in October 2015, and therefore the claim is governed by DSM-V. The Board notes that the use of GAF scores has been abandoned in the DSM-V because of, among other reasons, "its conceptual lack of clarity" and "questionable psychometrics in routine practice." See Diagnostic and Statistical Manual for Mental Disorders, Fifth edition, p. 16 (2013). In this case, however, DSM-IV was in use at the time many of the medical entries of record were made. Thus, the GAF scores assigned remain relevant for consideration in this appeal. Analysis In a March 2006 rating decision, the RO awarded service connection for PTSD with a disability rating of 30 percent effective September 15, 2005. In an October 2008 rating decision, the RO assigned an increased 50 percent disability evaluation, effective October 23, 2006. The Veteran contends that his PTSD warrants higher disability ratings for all periods on appeal. At a November 2005 VA examination, the Veteran stated that he was not the same after his service. He noted that his first wife divorced him in 1973 and second wife divorced him in 2003 due to severe interpersonal difficulties, it was noted that these same difficulties were demonstrated in work. The Veteran reported losing about fifteen to twenty days of work a year because he did not feel like going to work. Recurrent intrusive recollections, recurrent dreams, and avoidance symptoms were noted. Social adjustment was described as poor and occupational adjustment was better in that the Veteran maintained over thirty years of work but the Veteran had a job where he was able to shelter himself from others. There was no thought process or communication impairment. The examiner stated that the Veteran's symptoms had been of a moderate severity on a daily basis. Behavior was adequate although there was mild to moderate psychomotor agitation. Personal hygiene was well kept and the Veteran was able to take care of his personal needs. The examiner stated that, for the most part, the Veteran remained mildly to moderately socially isolated. The Veteran was found to have normal speech, there were no hallucinations or delusions present or obsessive or ritualistic behavior. Mood was anxious and depressed. The Veteran denied suicidal or homicidal ideations, intentions or plans. Affect was congruent, thought processes were normal and the Veteran was fully oriented. There were no cognition or memory deficiencies and concentration and attention were moderately impaired. Insight and judgment were adequate. A GAF score of 66 was assigned. In an April 2006 letter from the Veteran's VA clinical psychologist, Dr. M.M. noted that he had treated the Veteran since December 2005. Dr. M.M. stated that the Veteran was attending individual and group psychotherapy for PTSD and major depressive disorder as well as by a private psychiatrist for medication management. It was noted that the Veteran suffered from persistent re-experiencing of trauma through nightmares and night terrors several times per night, flashbacks several time per day, and intense psychological distress. Dr. M.M. stated that the Veteran continued to have avoidance symptoms and trouble with crowds due to heightened arousal level and a feeling of detachment from others. The Veteran had trouble sleeping and hypervigilance. Dr. M.M. assigned diagnoses of PTSD and Major Depressive disorder with a GAF score of 37, noting that his primary diagnosis was PTSD. The claims file includes multiple letters from the Veteran's family members dated in March 2006 and April 2006 in which it was noted that the Veteran had trouble with sleeping, depression, mood swings, anger problems and isolation as well as two failed marriages. Additional letters were submitted from fellow Veterans in the Veteran's therapy group which noted the Veteran's symptoms of PTSD to include a fellow group therapy member noting that the Veteran broke down and sobbed during group treatment and had to stop and gain his composure. Symptoms of irritability and reports of as well as trouble sleeping were also described. A February 2008 group treatment note assigned a GAF score of 42 for the Veteran. It was noted that the Veteran reported difficulty coping with flashbacks and difficulty managing his irritability which caused him to isolate from others. Appearance and behavior were appropriate, speech was normal, attention and concentration were adequate, suicidal and homicidal ideation were not reported. In a June 2008 group therapy treatment note the Veteran was found to have appropriate appearance and behavior, speech was coherent and attention and concentration were adequate, mood was congruent with affect and suicidal and homicidal ideation were not reported. A GAF score of 40 was assigned. In an August 2008 VA examination, the Veteran indicated that his symptoms had increased since his last, November 2005, VA examination. The Veteran reported awakening in the middle of the night, flashbacks, intrusive recollections and persistent symptoms of increased arousal with irritability and social isolation. The reported frequency of the symptoms was daily with a moderately high severity. The Veteran reported a worsening of social functioning. He stated that his family members were concerned about his dreams and that he woke up in the middle of the night becoming irritable, restless or combative. Mental status examination revealed adequate behavior with good eye contact. The Veteran maintained good hygiene. Speech was normal and no hallucinations or delusions were present. There were no obsessions, compulsions or phobias detected. Mood was anxious with depressive symptomology. Affect was appropriate to thought content and mood. The Veteran denied suicidal or homicidal ideations, intentions, or plans. Thought processes were normal. The Veteran was fully oriented to person, place time and purpose. Insight and judgment were well preserved. The examiner noted that after reading the claims file and medical literature that since the Veteran's last examination, the Veteran's PTSD was worse. It was noted that the Veteran had an overlapping depression which was linked to post-traumatic stress disorder and that both conditions had increased in severity since the Veteran's last examination. A GAF score of 58 was assigned. In a March 2009, the Veteran's psychologist, Dr. A.S., wrote a letter in support of the Veteran's claim. In the letter it was noted that the Veteran was being treated in the context of group psychotherapy and that prior to that time the Veteran was treated one-on-one. It was noted that the Veteran was not currently employed, he reported feelings of extreme anger and an inability to tolerate frustrating interactions with coworker and would frequently throw objects and yell out of anger. He had stated that he did not feel he could tolerate any amount of frustration. It was also noted that the Veteran had severely impaired concentration. He stated that he was doubtful that the Veteran could function effectively in a work environment. Dr. A.S. stated that the Veteran frequently experienced daily dissociative flashbacks accompanied by visual hallucinations. He stated that he often saw corpses on the street when driving. It was also noted that the Veteran's condition was chronic, severe, and permanent. A GAF score of 38 was assigned. An October 2009 mental health clinic outpatient treatment note included the Veteran's reports of intrusive flashbacks and slightly better sleep with medication but he stated that he remained irritable and edgy during the day and felt depressed much of the time. He continued to have an increased startle response and hypervigilance and noted that his motivation and concentration were affected by his mood though he was not suicidal. Mental status examination revealed that the Veteran was oriented, had good hygiene and depressed affect and mood. The Veteran had normal speech and was attentive. Memory was intact, there were no hallucinations or delusions and thought process was normal. There was fair impulse control, and no suicidality or homicidality. An October 2010 treatment note demonstrated significant hyperarousal, hypervigilance and re-experiencing as well as significant sleep disturbance. A GAF score of 55 was assigned. In a February 2011 treatment note, the Veteran stated that his Cymbalta did not help him sleep. The Veteran was found to be talkative with poor to fair eye contact and a bad mood. The Veteran had no suicidal or homicidal ideation and no hallucinations, judgment was fair insight was poor to fair. Cognition was grossly intact, impulse control was fair. The Veteran's treating psychiatrist and the Veteran agreed to a trial of increasing Cymbalta. In an April 2011 mental health clinic treatment note, a GAF score of 58 was assigned. It was noted that the Veteran's Cymbalta was increased. It was noted that the Veteran stated that the Cymbalta helped his back pain and mood. The Veteran stated that the only difference he noticed with new medication was that he may have a day or two where he noted that it was a great day. In a June 2011 treatment note, the Veteran reported that he had some benefit from the increase from 60 to 90 milligrams of Cymbalta but no additional benefit at 120 mg. The Veteran stated that he still felt weird or down a lot and unmotivated. The Veteran stated that his back starting bothering him again which contributed but was not totally responsible for his mood. The Veteran had regular speech, good eye contact, his mood was down, thought process was normal, there were no suicidal or homicidal ideation or hallucinations. Judgment, insight and impulse control were good. Cognition was grossly intact. In an August 2011 treatment record the Veteran reported getting a little more sleep and fewer nightmares. The Veteran was on Remeron for a little over a month and stated that he was a bit tired but the benefit outweighed the side effects. Speech was normal there was good eye contact, affect was constricted thought process was normal. Judgment and insight were fair, impulse control was good. A GAF of 60 was assigned. A May 2012 treatment note reported that the Veteran's Cymbalta was helping with pain and sleep and that he sometimes had five hours of sleep but that he still had bad dreams. The Veteran stated that at times he felt good but after a while thoughts of Vietnam came to mind. The Veteran reported that he felt pretty good, affect was stable, thought process was normal, there were no hallucinations, suicidal or homicidal ideation. Judgment and insight were good and impulse control was fair. A GAF score of 62 was assigned. In a January 2013 treatment note the Veteran reported that he felt his Cymbalta was still effective. Mental status examination demonstrated no suicidal or homicidal ideation and no hallucinations, judgment and insight were fair and impulse control was good. A September 2013 treatment record noted that the Veteran was stable on his dose of Cymbalta. A GAF of 65 was assigned. A suicide risk screen was negative, the Veteran reported no suicidal thoughts at the time of his visit, no suicidal thoughts within the last two months and no suicide attempts. At his March 2016 VA examination, the Veteran was found to have an occupational impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal behavior, self-care and conversation. During his examination, the examiner stated that he lived with his daughter and grandchildren. The Veteran stated that he retired in 2003. He explained that most of the time was taken up raising his daughter's children who he home schooled. The Veteran described constant nightmares which had occurred for fifty years. The Veteran reported nightmares every other night. He stated that he thought about Vietnam every day which were triggered by anything related to the military, the news and ads for VA hospitals. The Veteran stated that he had friends but that he did not trust them. The Veteran was found to have a depressed mood, anxiety, suspiciousness, chronic sleep impairment and disturbances of motivation and mood. On examination, the Veteran was found to have appropriate hygiene and eye contact. Affect was appropriate and the Veteran was oriented in all spheres. Speech was goal directed and coherent and there was no overt evidence of a thought disorder, psychosis or delusional beliefs. The Veteran denied hallucinations and current suicidal ideation or desire to harm anyone else. Following a thorough review of the record, the Board finds a 70 percent disability rating is most appropriate for the entirety of the appeal period. The Veteran is shown throughout the appeal period to have difficulty in personal relationships and social relationships. The Veteran is shown to isolate himself and avoid others. The evidence demonstrates irritability, depression, anger problems and hypervigilance. While some evidence indicates moderate symptomology, as described by the November 2005 VA examiner, and the Veteran appears to have benefited from a change in his medication regime around April 2011, overall the Veteran is shown to have deficiencies in most areas. The Board finds most significant the April 2006 findings of Dr. D.M. which describe severe symptoms as well as the Veteran's 2008 group treatment findings, noting low global assessment of functioning scores, irritability and isolation. Further, the August 2008 VA examiner's findings that the Veteran's depression overlaps his PTSD and that both disorders have increased in severity since his last examination suggest severe impairment. Those findings are confirmed by the March 2009 letter from Dr. A.S. which also demonstrates increased symptoms to include extreme anger, severely impaired concentration and visual hallucinations, all of which warrant a higher, 70 percent disability rating. At no time during their period on appeal is a higher, 100 percent disability rating warranted. There is no demonstration of gross impairment in thought processes or communication, persistent hallucinations, grossly inappropriate behavior a persistent danger to self or others or an intermittent ability to perform activities of daily living nor is there memory loss of such a severity where the Veteran is disoriented to time, place or people. The Veteran is shown to have difficulty with social relationships but is found to have a good relationship with his children and grandchildren overall. Moreover, the Veteran's last VA examiner found the Veteran's functional impairment appearing to be moderate, thus a 100 disability rating is not warranted. While the Veteran may well suffer from some symptoms consistent with a higher evaluation during this period, 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 70 percent rating, but no higher, for PTSD pursuant to Diagnostic Code 9411 is warranted from September 15, 2005. The ratings now assigned are based on all the evidence of record rather than any isolated medical finding or assessment of level of disability. 38 C.F.R. § 4.126 (a). Extraschedular Rating The Board has also considered whether referral for extraschedular ratings for the Veteran's PTSD is appropriate during any period of the appeal. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. See 38 C.F.R. § 3.321 (b)(1) (2015); Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the rating criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular rating is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular rating does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Related factors include "marked interference with employment" and "frequent periods of hospitalization." When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 Compensation Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Here, the Board finds that the first Thun element is not satisfied for the Veteran's PTSD. During the pendency of the appeal, the Veteran's service-connected PTSD has been manifested by signs and symptoms such as sleep impairment, anxiety, irritability and depression. These signs and symptoms, and their resulting impairment, are contemplated by the rating schedule. The diagnostic codes in the rating schedule corresponding to mental disorders provide disability ratings on the basis of occupational and social impairment, and overall impairment. See, e.g. 38 C.F.R. §§ 4.130, Diagnostic Code 9411. The Board concludes that the schedular rating criteria reasonably describe the Veteran's disability. There is nothing exceptional or unusual about the Veteran's PTSD symptoms because the rating criteria reasonably describe his disability levels and symptomatology. Thun, 22 Vet. App. at 115. As the schedular rating criteria reasonably describe the severity and symptoms of the Veteran's PTSD, referral for extraschedular consideration is not required at any time during the pendency of the appeal. Furthermore, the disability picture is not so exceptional to warrant referral even when the Veteran's service-connected disabilities are considered in the aggregate. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular 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. However, in this case, there are no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple conditions. ORDER Service connection for right ear hearing loss is denied. Service connection for left ear hearing loss is granted. From September 15, 2005, a 70 percent rating, but not greater, for PTSD is granted. REMAND As noted in the Introduction section, in an April 2006 statement, the Veteran indicated that he was unable to work due to his service-connected disabilities. The Board finds he raised the issue of entitlement to a TDIU. See Rice, 22 Vet. App. 447. Accordingly, the Veteran should be sent an updated notice letter under 38 U.S.C.A. § 5103 and 38 C.F.R. § 3.159 that advises him of what is needed to substantiate a claim for a TDIU. In addition, the Veteran should be asked to complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, to obtain relevant employment information. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran an updated notice under 38 U.S.C.A. § 5103 and 38 C.F.R. § 3.159 that advises him of the evidence needed to substantiate a claim for a TDIU and send him a copy of VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. Request the Veteran complete VA Form 21-8940, to obtain relevant employment information and to authorize VA to contact his employers for additional information regarding his employment. 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraph, adjudicate the matter of TDIU and provide the Veteran and his representative a statement of the case if the matter is not resolved to the Veteran's satisfaction. The appellant has the right to submit additional evidence and argument on the matter 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). ______________________________________________ M. H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs