Citation Nr: 1620449 Decision Date: 05/19/16 Archive Date: 05/27/16 DOCKET NO. 10-22 824A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent disabling, for the period prior to August 30, 2013, and in excess of 70 percent disabling thereafter, for posttraumatic stress disorder. 2. Entitlement to a total disability rating based on individual employability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and G.M. ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The Veteran served on active duty from October 1963 to November 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. The Veteran has since moved and his case is now in the jurisdiction of the RO in San Diego, California. The Veteran was afforded a hearing before the undersigned Veterans Law Judge in February 2013. The transcript of this hearing has been associated with the claims file. The record, specifically the January 2013 Statement from the Veteran, raises a claim of entitlement to service connection for the Veteran's fibromyalgia as secondary to his PTSD. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Thus, the Board does not have jurisdiction over it, and this issue is REFERRED to the AOJ for appropriate action. The claims were previously before the Board in April 2013 when they were remanded for additional development. In a November 2013 rating decision the RO granted entitlement to an evaluation of 70 percent disabling for PTSD, effective August 30, 2013. As this does not represent a complete grant of the benefit sought on appeal, the issue remains on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The issues of entitlement to an evaluation in excess of 70 percent disabling, for the period beginning August 30, 2013, for PTSD and 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 1. During the period prior to August 30, 2013, the Veteran's PTSD manifested adequate hygiene and grooming, pressured or pushed or rambling speech, anxious mood, sleep impairment, irritability, anger, social isolation, motivation and concentration reported as adequate to marginal to adequate, and memory and cognitive skills reported as limited/mild to moderate to adequate. 2. During the period prior to August 30, 2013, there were no impairments of perception or sensorium, thought process, thought content, delusions, hallucinations, suicidal or homicidal ideation, obsessive or ritualistic behavior, panic attacks, impulse control, insight, or judgment. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 30 percent disabling for PTSD, for the period prior to August 30, 2013, have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist With respect to the Veteran's claim herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). II. Higher Evaluation The Veteran seeks an initial evaluation in excess of 30 percent disabling, for the period prior to August 30, 2013, and in excess of 70 percent disabling thereafter, for PTSD. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's PTSD disability is currently evaluated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. When evaluating a mental disorder, consideration shall be given to the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation will be based on all the evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of examination. It is the responsibility of the rating specialist to interpret reports of examinations in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Under the provisions of Diagnostic Code 9411 a rating of 30 percent is assignable for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (such as forgetting names, directions, recent events). A rating of 50 percent is assignable for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per 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 rating of 70 percent is assignable for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. A rating of 100 percent is assignable 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. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Psychiatric examinations frequently include assignment of a GAF score, which is defined by DSM-IV as number between zero and 100 percent, that represents the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. Higher scores correspond to better functioning of the individual. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the rating issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). GAF scores ranging between 61 to 70 reflect 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, and has some meaningful interpersonal relationships. Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). GAF scores ranging from 51 to 60 reflect more 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. GAF scores of 41-50 indicate 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). Id. VA had previously adopted the American Psychiatric Association: Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), for rating purposes. VA implemented DSM-5, effective August 4, 2014, and the Secretary, VA, determined that DSM-5 applies to claims certified to the Board on and after August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). As the Veteran's increased rating claim was originally certified to the Board in 2012 (prior to August 4, 2014), the DSM-5 is not applicable to this case. Effective August 4, 2014, VA also amended the regulations regarding the evaluation of mental disorders by removing outdated references to DSM-IV. The amendments replace those references with references to the recently updated DSM-5. However, according to the DSM-5, clinicians do not typically assess GAF scores. The DSM-5 introduction states that it was recommended that the GAF be dropped from DSM-5 for several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice. In the rating action on appeal, service connection was granted and an initial 30 percent rating assigned, effective August 31, 2009, the date of claim for service connection. During the entire period prior to August 30, 2013, the Veteran was diagnosed with PTSD. In a June 2009 VA treatment note the Veteran reported that he was retired. He did not keep jobs. He did not like making friends at work because he lost many friends in Vietnam. Mental status examination (MSE) revealed the Veteran to have adequate hygiene and grooming and dress consistent with situation. The Veteran was cooperative and reasonable. There was psychomotor agitation. He was alert, attentive and oriented to person, place, time, and situation. Speech was pressured/pushed. Mood was anxious, very restless, tense, uptight, and ill at ease. Affect was congruent with mood. Perception/sensorium were within normal limits. Thought process and association were within normal limits, not flighty and not circumstantial. Thought content was within normal limits except the Veteran could be a little bit paranoid. Insight and judgment were good. Memory was intact but he claimed he forgot things. He was assigned a GAF score of 53. In an August 2009 VA treatment note the Veteran reported that he had been out of work for over a year and that this had exacerbated his PTSD symptoms and depression. An August 2009 VA treatment note identified a GAF score of 47. The Veteran was afforded a VA medical examination in September 2009. The Veteran reported that he last worked in October 2007 and that he stopped working because of colon cancer. He tried working for three months after the colon cancer until he developed a hernia and neuropathy of the feet from the chemotherapy and could hardly walk. The Veteran reported that he did not have people over to socialize. He did go to movies and restaurants. He got anxious when he was around others and needed to know where the exit is. MSE revealed no impairment of thought process or of communication. There were no delusions or hallucinations. He had good hygiene and grooming. He was pleasant, cooperative, intense and tense. Mood was appropriate to thought content. Eye contact was good. There was no inappropriate behavior. He was not homicidal and there was no suicidal ideation. He was oriented to person, place, time, and situation. Long term memory was good. Short term memory was noted to forget things. He described concentration problems. There was no history of obsessive or ritualistic behavior. Speech was goal oriented and logical with good tone and rhythm. There were no panic attacks or impaired impulse control. He had sleep impairment. He was able to abstract and conceptualize. Comprehension and coordination were good and perception was normal. There were no signs or symptoms of psychosis. Insight and judgment were good. A GAF score due to PTSD of 43 was assigned. In a VA treatment note dated in November 2009, MSE revealed the Veteran to be alert and oriented times three, cooperative, and fairly groomed and nourished. Affect was reactive and mood was congruent. Speech was within normal limits, no thought disorder. He denied suicidal and homicidal plan and intent. Cognitive function was fair. In a January 2010 VA treatment note, MSE revealed the Veteran to be alert and oriented times three, cooperative, fairly groomed and nourished. Affect was full range and mood was congruent. Speech was spontaneous, coherent, and goal oriented. He denied thought disorder, suicidal ideation, and homicidal plan or intent. Memory, insight, and judgment were fair. In a May 2010 VA treatment note the Veteran was noted to be alert and oriented in all spheres. He was appropriately dressed, cooperative, and made good eye contact. Affect was anxious and mood congruent. Thoughts were organized and goal directed. There was no psychosis. He did not endorse suicidal or homicidal ideation, plan, intent, or history. He had headaches and flashbacks. He endorsed insomnia, irritability, anxiety, variable depressed mood, and being withdrawn. Insight and judgment were adequate. A GAF score of 60 was assigned. The Veteran underwent a mental health initial evaluation in July 2010. The Veteran reported dealing with depression, but had never been suicidal. He had been paranoid and afraid to go places by himself. He admitted anxiety, anger, yelling, cursing and, in the past, getting physical. MSE revealed the Veteran's appearance to be neat. His speech was normal and calm. Behavior was appropriate and cooperative. His mood was calm. Affect was appropriate and thought content, insight, judgement, and abstraction were normal. There were no evidence hallucinations. The Veteran denied homicidal and suicidal thoughts. A GAF score of 60 was assigned. In a September 2010 VA treatment note the Veteran reported social isolation, new to town with no friends. MSE revealed the Veteran to be alert, oriented to place, person, and time, to have a dysphoric mood, and a congruent affect. There were no auditory hallucinations, visual hallucinations, thought disorder, paranoid ideations, suicidal ideations, or homicidal ideations. He exhibited good impulse control and judgment, and he had insight. In a VA treatment note dated in December 2010 the Veteran reported a recurrence of nightmares and complained that the sleep medication that he was prescribed put him to sleep but by morning he felt drowsy. MSE revealed the Veteran to be alert, oriented to place, person, and time, to have a dysphoric mood, and a congruent affect. There were no auditory hallucinations, visual hallucinations, thought disorder, paranoid ideations, suicidal ideations, or homicidal ideations. He exhibited good impulse control and judgment, and he had insight. In a February 2011 VA mental health medication management note MSE revealed the Veteran to be alert, oriented to place, person, and time. Mood was dysphoric and affect was congruent. No hallucinations, paranoid ideations, thought disorder, or suicidal or homicidal ideation were found. In a June 2011 VA mental health consult note the Veteran reported sleep impairment. He had anger issues and was verbally aggressive when angry, but not physically aggressive/violent when angry. He had not worked in two years and was on disability. He had worked for 40 years as a security technician. MSE revealed the Veteran to be alert and oriented times three. He had fair hygiene and grooming. There was no psychomotor agitation or retardation. There were no abnormal movements. The Veteran was calm, cooperative and nice. He made good eye contact. Speech was regular in rate, rhythm, and volume. Thought was linear and goal directed. There were no hallucinations, delusions, paranoia, or obsessions. There was no suicidal or homicidal ideation or plan. Perception was normal. Affect was euthymic and mood was "ok." Cognition was normal. Judgment and insight were good. The examiner assigned a current GAF score of 65; and a GAF score of 70 as the highest GAF during the prior year. In another June 2011 VA mental health consult note the Veteran reported anxiety, nervousness, feeling more tense, and problems with irritability, sleep, concentration, and energy. MSE revealed that the Veteran had appropriate dress and grooming. Motor activity was normal. He was cooperative and polite and had good eye contact. Speech was regular in rate and normal in volume. He denied suicidal and homicidal ideation, and audio and visual hallucinations. His mood was angry and his affect was normal. He was alert and oriented times four. In a VA treatment note dated in July 2011 MSE revealed the Veteran to be alert and oriented times four. His activity level, cooperation, spontaneity, insight, judgment, and memory and cognitive skills were adequate. He had no suicidal or homicidal ideation. Speech was goal directed. He had both anxiety and depression. Motivation and concentration were adequate to marginal. There were no hallucinations or delusions. In August 2011 the Veteran was reported to do part time consulting work. In a September 2011 VA treatment note MSE revealed the Veteran to be alert and oriented times three. Activity level, cooperation, abstraction, motivation, and concentration were adequate. Spontaneity was "ok." He had no suicidal or homicidal ideation. Speech was directed and rambling. There were no hallucinations or delusions. In a VA treatment note dated in November 2011 MSE revealed the Veteran to be alert and oriented times three. Activity level, cooperation, abstraction, motivation, and concentration were adequate. There was no suicidal or homicidal ideation. Memory and cognitive skills were limited/mild to moderate. Insight and judgment were limited/adequate. Spontaneity was "ok." Speech was directed and rambling. There were no hallucinations or delusions. In a December 2011 VA treatment note MSE revealed the Veteran to be alert and oriented times three. Activity level, cooperation, abstraction, spontaneity, motivation, and concentration were adequate. He had no suicidal or homicidal ideation. Speech was directed. He was anxious and occasionally depressed. There were no hallucinations or delusions. In a VA treatment records dated in February 2012 the Veteran was noted to be alert and oriented times four and times two. Activity level, cooperation, abstraction, spontaneity, motivation, concentration, insight and judgment were adequate. There was no suicidal or homicidal ideation. Memory and cognitive skills were limited/adequate. Speech was directed. There were no hallucinations or delusions. The Veteran was afforded a VA medical examination in February 2012. The examiner summarized the Veteran's level of occupational and social impairment due to his mental diagnoses as resulting in occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran indicated that he had last worked as a security technician in 2007. He had been fired from several jobs because he tended to argue a lot with his supervisors and coworkers. The Veteran reported that he had diminished social functioning. He was married and lived with his wife and adult son. The Veteran's symptoms were reported as depressed mood, anxiety, chronic sleep impairment, and mild memory loss. In a VA treatment note dated in March 2012 the MSE showed the Veteran to be alert with limited memory. He was oriented times two and had no active psychosis. Activity level, cooperation, insight, judgment, motivation, and spontaneity were adequate. He had no suicidal or homicidal ideation. Speech was directed. Abstraction and concentration were limited adequate. There were no hallucinations or delusions. In a June 2012 VA treatment note MSE revealed the Veteran to be irritable with no active psychosis. Activity level, cooperation, insight, judgment, abstraction, spontaneity, motivation, and concentration were adequate. There was no suicidal or homicidal plan or intent. Memory and cognitive skills were limited/adequate. Speech was directed. He admitted depression and anxiety. There were no hallucinations or delusions. In a June 2012 VA treatment note the Veteran reported that he last worked prior to being diagnosed with cancer. He was working as a security technician. He tried to go back to work but argued with his boss a lot. He related that this was due to his PTSD. In a June 2012 VA treatment note the Veteran was reported to indicate that he was not working and that he was unemployable due to PTSD and other problems. In an August 2012 VA treatment note the MSE revealed the Veteran to be alert and oriented times four. Activity level, cooperation, insight, judgment, abstraction, spontaneity, motivation, and concentration were adequate. There was no suicidal or homicidal plan or intent. Memory and cognitive skills were limited/adequate. Speech was directed. There were no hallucinations or delusions. In an October 2012 VA treatment note the MSE revealed the Veteran to be alert and oriented times four. Activity level, cooperation, insight, judgment, abstraction, spontaneity, and motivation were adequate. There was no suicidal or homicidal plan or intent. Memory and cognitive skills were limited/adequate. Speech was directed. He was more anxious than depressed. Concentration was limited/adequate. There were no hallucinations or delusions. In a VA treatment note dated in February 2013 the Veteran was noted to discuss symptoms of anger, frustration, anxiety, fear, sadness, and pain. In a statement dated in March 2013 the Veteran contended symptoms of panic attacks, depression, impaired impulse control, periods of violence, and inability to maintain effective relationship. In a June 2013 VA treatment note MSE revealed the Veteran to be cooperative. Speech was within normal limits. He was dysthymic. Thought process and content was coherent and organized. There was no suicidal or homicidal ideation. There were no hallucinations. He was alert and oriented times three and his memory was adequate. Judgment and insight were good. He was assigned a GAF score of 65. In an August 2013 VA treatment note the MSE showed the Veteran to be cooperative. Speech was within normal limits. Mood and affect were reported as "anxiety," dysthymic, and broad. Thought process and content was coherent and organized. There was no suicidal or homicidal ideation. There were no hallucinations. He was alert and oriented times three and his memory was fair. Judgment and insight were good. The Veteran was assigned a GAF score of 62. SSA records show that the Veteran has been considered disabled for SSA purposes since June 2008 as a result of status post ventral hernia surgery and peripheral neuropathy of the hands and feet. In his own statements as part of the SSA application in October 2009, the Veteran reported the effects of symptoms related to the hernia surgery and peripheral neuropathy (both reportedly results of colon cancer surgery). He did not report the effects of any psychiatric symptoms. Entitlement to an evaluation in excess of 30 percent disabling, for PTSD, for the period prior to August 30, 2013, is not warranted. During the period prior to August 30, 2013, the Veteran's PTSD manifested adequate hygiene and grooming, pressured or pushed or rambling speech, anxious mood, sleep impairment, irritability, anger, social isolation, motivation and concentration reported as adequate to marginal to adequate, and memory and cognitive skills reported as limited/mild to moderate to adequate. During the period he lived with his wife and his adult son. During the period prior to August 30, 2013, there were no impairments of perception or sensorium, thought process, thought content, delusions, hallucinations, suicidal or homicidal ideation, obsessive or ritualistic behavior, panic attacks, impulse control, insight, or judgment. Although the Veteran was noted to have some motivation, memory and concentration problems, these were not described in severity as retention of only highly-learned material or forgetting to complete tasks. Also, memory loss described by the Veteran was no more severe than forgetting names, directions, or recent events, symptoms associated with an evaluation no higher than 30 percent disabling. He had anger issues and was verbally aggressive when angry, but not physically aggressive/violent when angry. Although the record during this time period includes two GAF scores identified in the 40's and a single GAF score in the 50's, indicating serious and moderate symptoms, the reported symptoms do not reveal suicidal ideation, severe obsessional rituals, flattened affect, circumstantial speech, occasional panic attacks, or moderate or serious impairment in social or occupational functioning. In addition, the majority of the GAF scores range from 60 to 65, representing mild to moderate symptomology. In February 2012 a VA examiner characterized the occupational and social impairment related to the Veteran's mental diagnosis as "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." That characterization is consistent with an evaluation of 30 percent. In addition, at no point prior to August 30, 2013, did the Veteran's PTSD manifest flattened affect; circumstantial, circumlocutory, or stereotyped speech; speech intermittently illogical, obscure, or irrelevant; panic attacks; difficulty in understanding complex commands; impaired judgment; impaired abstract thinking; suicidal ideation; obsessional rituals which interfere with routine activities; spatial disorientation; or neglect of personal appearance and hygiene or symptoms of similar severity, frequency and duration. Vazquez-Claudio, 713 F.3d 112. At no point prior to August 30, 2013, did the Veteran's PTSD manifest total occupational and social impairment. As the preponderance of the evidence is against a finding that the Veteran's PTSD manifests symptoms reflective of an evaluation greater than 30 percent disabling, entitlement to a higher evaluation prior to August 30, 2013, is denied. The Board finds that the record does not reflect that the Veteran's PTSD disability is so exceptional or unusual as to warrant the assignment of a higher rating on an extraschedular basis. See 38 C.F.R. § 3.321(b)(1). The Schedule of Ratings for Mental Disorders provides broad criteria with non-exhaustive examples. The discussion above reflects that the symptoms of the Veteran's PTSD disability are contemplated by the applicable rating criteria. The Veteran's PTSD is manifested by occupational and social impairment. The applicable diagnostic code used to rate the disability provides for ratings based upon occupational and social impairment. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER An initial evaluation in excess of 30 percent disabling, for the period prior to August 30, 2013, is denied. REMAND The most recent treatment record associated with the claims file is dated in September 2013. Prior treatment notes indicate that the Veteran was consistently treated for his psychiatric disability with medication by VA. As such, remand is necessary to obtain complete VA treatment records regarding the Veteran dated since September 2013. 38 C.F.R. § 3.159. VA is required to conduct an accurate and descriptive medical examination based on the complete medical record. 38 C.F.R. §§ 4.1, 4.2; Green v. Derwinski, 1 Vet. App. 121 (1991). As this remand orders attempts to obtain and associate with the claims file additional, up to date, treatment records regarding the Veteran's treatment for PTSD, the Veteran must be afforded a VA medical examination regarding the current severity of his PTSD disability. As the Veteran's claim for entitlement to a TDIU may be impacted by the outcome of his appeal for a higher evaluation for PTSD, for the period beginning August 30, 2013, these issues are intertwined. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Thus, the Board is unable to review the claim for TDIU until the claim for a higher evaluation for PTSD, for the period beginning August 30, 2013, is adjudicated. Accordingly, the case is REMANDED for the following action: 1. Attempt to obtain and associate with the claims file all VA treatment records regarding the Veteran dated since September 2013. Any additional pertinent records identified by the appellant during the course of the remand should also be obtained, following the receipt of any necessary authorizations from the appellant, and associated with the claims file. 2. After completion of the foregoing, schedule the Veteran for an appropriate VA examination to determine the severity of his service-connected PTSD disability. Copies of all pertinent records should be forwarded to the examiner for review. All indicated testing should be carried out and the results recited in the examination report. The examiner is requested to delineate all symptomatology associated with, and the current severity of the PTSD disability. The appropriate Disability Benefits Questionnaire (DBQs) should be filled out for this purpose, if possible. 3. Thereafter, readjudicate the claims of entitlement to a higher evaluation for PTSD, for the period beginning August 30, 2013, and entitlement to a TDIU. If the claims remain denied, issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. 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). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs