Citation Nr: 1702167 Decision Date: 01/26/17 Archive Date: 02/09/17 DOCKET NO. 11-19 021 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for third degree burn scar with skin grafting and tenderness, right anterior thigh. 2. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 3. Entitlement to a rating in excess of 30 percent for residuals of a gunshot wound of the left thigh. 4. Entitlement to an initial rating in excess of 10 percent for impairment of thigh, residual of traumatic arthritis of the left hip. 5. Entitlement to a rating greater than 10 percent for traumatic amputation at the DIP joint, left middle finger. 6. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Osborne E. Powell, Jr., Attorney-at-Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD G. E. Wilkerson, Counsel INTRODUCTION The Veteran served on active duty from February 1970 to October 1971. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina (Agency of Original Jurisdiction AOJ)). In December 2013, the Veteran testified during a hearing before a Decision Review Officer (DRO) at the RO. A transcript of the hearing is associated with the claims file. In September 2015, the Board remanded these matters to the AOJ for additional development - namely, to provide the Veteran with the requested Board hearing. In June 2016, the Veteran testified during a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is also associated with the claims file. In August and November 2016, the Veteran submitted notices of disagreement with respect to recent rating decisions denying service connection for lumbar spine disability, right knee disability, peripheral neuropathy of the upper and lower extremities, ischemic heart disease, and sleep apnea, as well as reducing the rating for his service-connected left knee disability. VA's Veterans Appeals Control and Locator System (VACOLS), which is an automated database for tracking appeals, reflects that the AOJ has acknowledged the NOD, is continuing to develop the claims and will issue the Veteran a Statement of the Case (SOC) if any claim is not granted in full. As such, the situation is distinguishable from Manlincon v. West, 12 Vet. App. 238 (1999), where a NOD had not been recognized. As VACOLS reflects that the NOD has been recognized and that additional action is pending, Manlincon is not applicable in the present case. Therefore, these claims remain under the jurisdiction of the AOJ at this time. This appeal was processed using the Virtual VA and Veteran Benefit Management System (VBMS) paperless claims processing systems. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of these electronic records. The issues of entitlement to increased ratings for residuals of gunshot wound to the left thigh and impairment of thigh residuals of traumatic arthritis of the left hip are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. In a written statement received dated June 29, 2016, the Veteran withdrew from appeal the matter of entitlement to service connection for third degree burn scar with skin grafting and tenderness, right anterior thigh. 2. The Veteran's service-connected PTSD has been productive of occupational and social impairment with deficiencies in work, family relationships, thinking and mood. 3. During the hearing in June 2016, the Veteran expressed that he wished to withdraw from appeal the matter of entitlement to an increased rating for traumatic amputation at the DIP joint, left middle finger. 4. The Veteran meets the schedular requirement for TDIU, and the combined effects of his service-connected disabilities render him unemployable. CONCLUSIONS OF LAW 1. The criteria for withdrawal of appeal with respect to the claim of entitlement to service connection for third degree burn scar with skin grafting and tenderness, right anterior thigh are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2016). 2. The criteria for a 70 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2016). 3. The criteria for withdrawal of appeal with respect to the claim of entitlement to an increased rating for traumatic amputation at the DIP joint, left middle finger are met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2016). 4. The criteria for an award of TDIU are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.16(a) (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014)) redefined VA's duty to assist the Veteran in the development of a claim. VA regulations for the implementation of VCAA were codified as amended at 38 C.F.R. § 3.159 (2016). With respect to the claim for TDIU, to the extent that the action taken herein below is favorable to the Veteran, a discussion of the VCAA is not required at this time. In regard to the remaining claims herein decided, under the VCAA, VA 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; (3) that the claimant is expected to provide; and (4) must request that the claimant provide any evidence in his possession that pertains to the claim. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The United States Court of Appeals for Veterans Claims (Court) has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a July 2011 pre-rating letter, the AOJ notified the Veteran of the evidence needed to substantiate the claim for an increased rating for PTSD. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The Veteran was also informed of the disability rating and effective date elements of his claim in the notice letter. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, VA obtained the Veteran's service treatment records and all of the identified post-service private and VA treatment records. Social Security Administration (SSA) records have also been obtained. The Veteran was also provided with various VA examinations as to his disabilities on appeal. As these examinations were based on review of the Veteran's symptoms and complaints, discuss his disability in relation to the pertinent rating criteria, they are adequate for adjudication purposes. In addition, the Veteran has presented his own PTSD evaluation which addressed the effects of his PTSD on his employability which supplements the need for additional examination. The Veteran also presented testimony at a Board hearing in June 2016. During the hearing, the Veterans Law Judge clarified the issue and explained the basis for rating disabilities and for award of a TDIU. His functional impairment and manifestations were addressed. The Veteran was provided an opportunity to submit additional evidence. The actions of the Veterans Law Judge supplement VCAA and comply with any duties owed during a hearing. 38 C.F.R. § 3.103. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The claims discussed below are thus ready to be considered on the merits. II. Withdrawn claims The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2014). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2016). Withdrawal may be made by the appellant or by his or her authorized representative. Id. During the hearing in June 2016, the Veteran expressed that he wished to withdraw from appeal the matter of entitlement to an increased rating for traumatic amputation at the DIP joint, left middle finger. The transcript has been reduced to writing and is of record. See Tomlin v. Brown, 5 Vet. App. 355, 357-58 (1993). In a written statement received dated June 29, 2016, the Veteran withdrew from appeal the matter of entitlement to service connection for third degree burn scar with skin grafting and tenderness, right anterior thigh. Hence, there remain no allegations of error of fact or law for appellate consideration with regard to these claims. Accordingly, as the Board does not have jurisdiction to review the appeal as to this matters, they must be dismissed. III. Increased Rating - PTSD Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). The Veteran contends that he is entitled to a higher rating for the service-connected PTSD, which is rated as 50 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. This Diagnostic Code provides that PTSD should be rated under the General Rating Formula for evaluating psychiatric disabilities other than eating disorders. Under the general formula, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir. 2013) the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders (DSM-V), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). To the extent that the medical evidence reflects diagnoses of other psychiatric disorders, where it is not possible to distinguish the effects of nonservice-connected conditions from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). VA treatment records dated in 2009 show diagnosis and treatment of PTSD with symptoms of anxiety, difficulty sleeping, nightmares, and isolation, and indicate that the Veteran participated in group and individual therapy. A May 2009 clinical intake report from Professional Counseling and Consultation Services notes current symptoms/behavioral observations as: anxiety, avoiding people, depression, attention problems, hallucinations, difficulty concentrating, anger and irritability, mood swings, loneliness, phobias, and work problems. The Veteran reported that he lived with his wife and had 1 friend. With respect to activities, he watched television. On VA examination in July 2009, the Veteran reported that he got tension headaches and felt dizzy with chest pain when he was upset. He sought treatment at VA for medication management, which helped with his sleep and concentration. He also sought private individual counseling and VA group counseling. The Veteran reported that he had not worked since 2005, when he was laid off due to downsizing. He indicated that the only problems he was having on the job had to do with his legs. He reported problematic use of alcohol until 8 years ago. He reported good relationship with his children and grandchildren. He described a fairly good relationship with his wife, but sometimes he was withdrawn. He had one close friend that he saw twice a week. He watched television and went to church twice a month. Present risk factors included anxiety, depression, agitation/irritability, and difficulty sleeping with night sweats and occasional obsessive-compulsive behavior like checking the doors. The examiner concluded by noting that the Veteran was reliving traumatic events in service through illusions, hallucinations, and dissociative flashbacks. He felt detached and estranged from others. He had difficulty falling and staying asleep at night. He had outbursts of anger, difficulty concentrating, and was suspicious of others. Diagnoses of PTSD and major depressive disorder, along with a GAF score of 47, were assigned. On mental status examination, the Veteran was alert, oriented and attentive. His mood appeared to be dysphoric and his affect was constricted. His speech was of regular rate and rhythm. There was some mild evidence of psychomotor agitation. His eye contact was good, and he was generally cooperative and pleasant with the examiner. His thought process was logical and coherent. Thought content was devoid of any current auditory or visual hallucinations. No evidence of delusional content was noted. He denied thoughts of hurting himself or hurting others. He denied a history of suicide attempts, and said that the last time he was physically aggressive with someone was about 7 years ago. His memory was severely impaired for immediate information, but he was more intact for recent and remote events. He offered a concrete interpretation of a proverb. He was able to spell world backward. He had fair insight into his current condition. The examiner diagnosed PTSD and alcohol abuse in remission, and assigned a GAF score of 54. He noted that the Veteran exhibited moderate to considerable symptoms associated with PTSD. He reported intrusive thoughts of combat 3 times a month, and described psychological and physiological reactivity to loud noises. The Veteran said he did not want to talk about Vietnam except with other Vietnam veterans, and said that he tried to avoid thinking about it, avoided crowds, and avoided war coverage and movies. He indicated that he was hypervigilant. He reported problems with irritability and said that he slept for approximately 5 hours but never got more than 4 hours at a time. He reported problems with concentration and an exaggerated startle response. In addition, the examiner determined that the Veteran was moderately, to at times, considerably impaired in social adaptability. He was moderately to considerably impaired in workplace setting as well, given his problems with memory. VA treatment records reflect that the Veteran entered inpatient treatment secondary to anxiety in August 2010. He reported that he had experienced an increase in symptoms, which resulted in sleep problems, loss of interest, and isolation. He reported good relations with his family and they were a good source of support. He stated that he enjoyed reading the bible, watching sports, and talking with an old friend. On mental status examination at that time, appearance grooming and hygiene were appropriate, behavior was appropriate, there was no psychomotor agitation or retardation, speech was normal, mood was anxious, affect was congruent to mood, the Veteran denied suicidal ideation, thought process was linear and goal-directed, there were no hallucinations or delusions, memory was intact, and insight and judgment were fair. Diagnosis of PTSD and a GAF score of 64 were assigned. GAF scores during treatment ranged in the 60s. GAF score at discharge in February 2011 was 67, and it was noted that the Veteran reported better coping and mechanisms to address his anxiety. On VA examination in July 2011, the Veteran reported that he had sleep and concentration problems. The Veteran reported that he saw a doctor for group counseling twice a month and individual therapy once every 3 months. He also was prescribed Trazodone, which he indicated helped with sleep and concentration. The Veteran indicated that he last worked in July 2005 for a textile company. He said he was there for 33 years and ended up as a supervisor, but he was laid off because there was a reduction of force. He denied that he missed any time from work because of PTSD. He did report that he was irritable, but he said he was able to manage it and working the third shift helped. The Veteran also endorsed problems with concentration, which caused mistakes. He drew Social Security disability because of pain in his legs and knees. The Veteran reported a history of alcohol use, but he had not used any in 10 to 12 years. The Veteran reported that he was married to his fourth wife, and had a fair relationship with his wife, though sometimes he could be irritable and withdrawn. With respect to his 3 children, he indicated that he had a fair to good relationship with them. He said he sometimes could be irritable and withdrawn with them as well. He had a good relationship with his grandchildren and had a close friend he saw 3 to 4 times a week. As for other activities, he read, watched television, and went to church once a month. He and his wife occasionally went out to dinner. On mental status examination, the Veteran was alert, oriented, and attentive. His mood appeared dysphoric and his affect was constricted. His speech was of regular rate and rhythm. There was no evidence of psychomotor agitation or retardation. His eye contact was good. He was cooperative and pleasant with the examiner. His thought process was logical and coherent. His thought content was devoid of current auditory or visual hallucinations. There was no evidence of delusional content. He denied recurrent thoughts of hurting himself or hurting others. His memory was intact for immediate, recent, and remote events. He was able to concentrate well enough to spell world backwards, but not to interpret a proverb. He had fair insight into his current condition. The examiner diagnosed PTSD and alcohol abuse in remission, and assigned a GAF score of 54. He noted that the Veteran exhibited moderate to considerable symptoms associated with PTSD. Specifically, he reported intrusive thoughts of his trauma once every 2 weeks, nightmares 4 times a month, and psychological and physiological reactivity to loud noises, or if he saw somebody get hurt. He tried to avoid talking about his trauma except in group. He avoided crowds and news about the war. His affect was constricted, and he described emotional detachment from others and less interest in activities. He was irritable and he had trouble concentrating. The Veteran described an exaggerated startle response and hypervigilance. He denied symptoms of depression. He denied periods of remission. The examiner further noted that the Veteran's social adaptability and interactions with others appeared to be moderately to considerably impaired. His ability to perform job duties in a reliable and flexible and efficient manner appeared to be moderately to considerable impaired. Overall, he estimated his level of disability to be in the moderate to considerable range. However, the examiner did not find that the Veteran's PTSD rendered him unable to obtain and maintain employment, but it did result in moderate to considerable impact on his abilities to work given his problems with concentration and irritability and disturbed sleep. It would make both sedentary and physical labor moderately to considerably difficult. In a November 2013 PTSD disability benefits questionnaire and accompanying statement, VA psychologist Dr. M. wrote that the Veteran had been under her care and treatment for chronic, severe PTSD and major depressive disorder secondary to PTSD since October 2010. She indicated that he had regularly monitored the Veteran's psychiatric condition, to include regular administration of psychological testing, as well as regular assessment of his psychiatric status and his social/occupational functioning. She noted review of VA administrative documents, VA examinations reports, and VA medical records in conjunction with the examination. She found that the Veteran's 50 percent rating did not accurately reflect the persistent severity of the Veteran's PTSD, nor did it reflect the persistent depression secondary to PTSD had on his psychiatric condition. She noted that benefit from medication had been modest at best, and the Veteran's symptom frequency was daily, and in the severe range. Dr. M. found that the Veteran experienced total occupational impairment as a result of such symptoms such as dissociative flashbacks during which he felt like he was in Vietnam and during which he experienced disorientation to time and place. Additionally, his social and occupational functioning were significantly impaired by deficiencies in the areas of work, family relations, judgment, thinking and mood due to such symptoms as persisted depression and episodes of panic attacks that affected his ability to function appropriately or effectively, difficulty adapting to stressful circumstances including work, and inability to establish and maintain effective relationships. Dr. M further indicated that the Veteran's symptoms, including episodes of dissociation, panic attacks, impaired cognitive functioning, and inability to maintain effective/appropriate relationships with others attested to the difficulties the Veteran would be likely to experience in a work setting. In the accompanying DBQ, Dr. M. noted that the Veteran had been married since 2005 to his fourth wife. He had maintained contact with his 3 children. He had worked at a textile mill for 32 years, but left in 2005 because of increased PTSD symptoms. The Veteran reported that he withdrew and isolated himself from others to avoid panic attacks and easy escalation of anger and distress. Symptoms included depressed mood, anxiety, panic attacks, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, chronic sleep impairment, mild memory loss, flattened affect, impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a worklike setting, inability to establish and maintain effective relationships, and disorientation to time and place. The examiner administered a mini-mental status examination (MMSE), and was oriented to time and place at the time of administrated. The Veteran was able to register 3 words, and remembered 3 at delayed recall. Attention and calculation skills were impaired. He was able to perform serial 7's but made 2 errors. Language skills were intact, and evidence of anxiety was noted on performance of visual-spatial tasks. Performance on digits forward was just within norms for someone of his age and education; however, performance was negatively impacted by anxiety. Performance on digits backward also was just within norms, with lowering of scores attributed to anxiety that impaired multi-level processing skills, i.e., he was not able to consistently manage more than 1 information set at a time. Performance on the word list produced a score of 28 out of 36. Registration was significantly impaired; however, he did appear to benefit from practice. Overall, impairment in short-term memory functioning reflected cognitive deficits consistent with anxiety and depression that negatively impacted attention, focus, and concentration. Dr. M. diagnosed PTSD and major depressive disorder, recurrent, secondary to PTSD. A GAF score of 45 was assigned. The examiner indicated that testing showed depression in the severe to extremely severe range. Dr. M. indicated that symptoms attributable to PTSD included recurrent and distressing recollections and dreams of Vietnam, acting or feeling as if the traumatic events were recurring with intense psychological distress and physiological reactive at exposure to internal or external cues, efforts to avoid thoughts , feeling or conversations associated with the trauma, feelings of detachment or estrangement from others, restricted range of affect, difficulty falling or staying asleep, irritability or outburst of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. Symptoms attributable to depressive disorder included depressed mood most of the day, almost daily, markedly diminished interest or pleasure in activities, fatigue and loss of energy, feelings of worthlessness, insomnia, and diminished concentration. Dr. M. checked the box noting that the disability was productive of total occupational and social impairment; however, she found a more accurate assessment would reflect that the Veteran's occupational impairment was total, but his social impairment was deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. A September 2012 VA treatment group note reflected a GAF score of 52. During the Veteran's December 2013 DRO hearing, the Veteran testified that that he experienced intrusive recollections of the events of Vietnam and he also endorsed panic attacks. The Veteran also endorsed night sweats and nightmares, and noted that he got 4.5 hours of sleep at night. The Veteran also reported concentration problems. He also indicated that he experienced visions/hallucinations. He checked the doors and windows in the house at night. The Veteran also endorsed episodes of depression. A December 2013 VA examination report reflected that the Veteran lived with his wife and had 3 grown children. He indicated that he had not worked since he was laid off in 2005. He averaged 3 to 4 hours of sleep per night, and he experienced nightmares and nightsweats. He reported intrusive thoughts, avoidance behavior, hypervigilance, exaggerated startle response, detachment, difficulty in public, and difficulty in relating to others. He noted that he had one close friend who he spoke to daily on the phone. He played cards on the computer in his free time. He discussed anxiety and worry. He reported having panic attacks on occasion, the last occurring 2 months prior when his grandchildren were visiting. He reported anger and irritability, but denied physical violence. The Veteran had variable periods of depressed mood. He indicated that when he got down, it lasted for about an hour and his wife took him out and they drove around, which seemed to help. The Veteran had limitations due to chronic medical conditions, and had difficult standing for long periods of time. He reported some difficulty with chronic pain. He had lower energy and motivation. There had been some mild difficulty with concentration. The examiner noted that symptoms associated with the Veteran's diagnosis included depressed mood, anxiety, panic attacks that occurred weekly or less often, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing effective work and social relationships. On mental status examination, the Veteran was alert and oriented. He was cooperative with the evaluation. Affect was full range, and mood was mildly blunted. Speech was fluent. Mental status was within normal limits. The examiner diagnosed PTSD, and found that the disability was productive of occupational and social impairment with reduced reliability and productivity. She noted that she reviewed the previous VA examination reports, and found no significant increase in severity of PTSD (which includes symptoms of depressed mood) since that previous examinations. She found that the Veteran's PTSD, while productive of occupational impairment, did not render the Veteran unable to secure or maintain substantially gainful employment. An August 2015 report from Dr. L. noted that he performed a 90-mintue psychological evaluation, review of medical records, and psychological testing. The Veteran reported that he worked for 34 years following service, quitting in July 2005 to have a knee replacement. The Veteran endorsed nightmares, intrusive recollections, avoidance symptoms, feeling of detachment around others, decreased interest in activities, irritability, difficulty concentrating, hypervigilance, sensitive startle response, and loss of energy. He denied suicidal thoughts, intentions, or plans. On mental status examination, the Veteran was alert and affect was flat. He reported that his mood was depressed. He was casually dressed and appropriately fashioned. Eye contact was described as fair. His speech was laconic. Psychomotor activity was slow. There was a negligible degree of conceptual disorganization evident. His thought content was characterized by no significant preoccupations. Regarding perceptual functioning, he denied hallucinations and none was evident. Attitude could be described as cooperative but discouraged. Insight and judgment appeared fair. He demonstrated difficulty maintaining attention throughout the interview, but no difficulty controlling impulses. The examiner noted that testing revealed that the Veteran reported experiencing severe levels of depression. The Beck Anxiety Inventory indicated that the Veteran reported experiencing severe levels of anxiety. Attention testing showed that the Veteran performed in the impaired range on this test. Dr. L. indicated that the Veteran had demonstrated total occupational and social impairment. A diagnosis of PTSD was assigned. Dr. L. indicated that the Veteran's severe anxiety and inability to concentrate prevented him from maintaining effective relationships and engage in constructive activities such as work, school, and family relationships. He had experienced near-continuous anxiety and depression, which had been worsened by his progressively worsening pain. Dr. L. noted that the neurocognitive assessment was limited but demonstrated significantly impaired attention for both auditory and visual attention. This impairment alone prevented him from gainful employment. Likewise, validity measures on other tests showed that his self-reported emotional distress was valid. He presented with severe levels of anxiety and depression. With respect to employability, Dr. L. opined that the Veteran was unable to seek, gain, and hold employment since November 2005. He noted that the reported progression of pain after his knee replacement surgery more likely than not aggravated his emotional symptoms and inattention. Dr. L. also completed a PTSD Disability Benefits Questionnaire (DBQ) in August 2015. He noted that he reviewed the Veteran's claims file, counseling intake form from 2009, VA examination reports, and the reports from other psychologists. He noted that the symptoms that applied to the Veteran's condition included depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function, chronic sleep impairment, impairment of short and long term memory, flattened affect, difficulty in understanding complex commands, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and in adapting to stressful circumstances, and intermittent inability to perform activities of daily living. He indicated that the Veteran's symptoms were aggravated by pain. Dr. L. noted diagnosis of PTSD aggravated by chronic pain. A GAF score of 47 was assigned. He found the disability to be productive of total occupational and social impairment. A June 2015 VA mental health note reflected that the Veteran endorsed anxiety "all of the time." He reported that he avoided crowds, and irritable, and often felt hopeless. He denied suicidal/homicidal ideation, psychosis or mania, but energy and interest were low and he felt depressed. Trazadone helped with sleep, but he got up and night to check the locks. Mood was hopeless, anxiety was constant, avoidant, and irritable, but there was no paranoia. Sleep disturbance was fragmented. After discussion, it was noted that the Veteran was to start Sertraline for mood and anxiety. A June 2015 VA social work assessment note indicated that the Veteran presented as guarded and constricted. Mood/affect was somewhat flat, subdued, yet appropriate for the situation. Speech was logical, clear, and coherent. Thought process was linear, goal-directed, and circumstantial. He was devoid of perceptual/cognitive disturbances. Judgment/insight were poor/fair. He said he continued to exhibit anger/irritability/short temper. Memory as it related to his current, remote, and intermediate recall was poor/fair. He was able to process his experiences of his tour in Vietnam. The social worker noted that the Veteran continued to exhibit PTSD symptoms, fear of imminent overwhelming danger, irritability, social withdrawal, easy startle, poor sleep and nightmares, depressive mood. He endorsed intrusive thoughts on a daily basis, hypervigilance, isolation and avoidance, anhedonia, insomnia/nightmare, triggers, flashbacks, intrusion, avoidance, and sensitivity. He had some audio/visual hallucination and some periodic passive suicidal/homicidal thoughts. A diagnosis of PTSD and GAF score of 50 was assigned. On VA treatment in September 2015, December 2015 and March 2016, the Veteran reported significant improvement in anxiety issues: he was less on guard, less irritable, and more calm. His mood was better. He denied hopelessness, suicidal or homicidal ideation, psychosis, or mania. He continued to deal with chronic pain, which was getting worse. He continued to have frequent nightmares which were troublesome. He got great joy from his grandson and had a stable marriage. A mental status examination revealed that he was well-groomed, attentive, and cooperative. Speech was fluent and there were no noticeable concentration, language, or communication difficulties. Both short and long term memory was intact. Mood was irritated. He was alert and oriented. Affect was euthymic. Thought process was organized and logical. Insight and judgment were described as good. In a June 2016 statement, Dr. B. noted that the Veteran had been his patient for at least 2 years and had been seen by therapists as well. He carried a diagnosis of PTSD and well as depression, insomnia, and nightmares all related to his PTSD. Dr. B. wrote that treatment providers were working together to achieve remission of symptoms, but to date his remission had been modest at best. He was still experiencing extreme stress related to his condition. The stress interfered with his functioning and was a major contributor to his ongoing issues with PTSD. His condition limited the quality of his life, and he was limited on his activities based on grossly inappropriate behavior, difficulty adapting to stress, impaired impulse control, unprovoked irritability, panic attacks, difficulty with work and social relationships, occupational and social impairment, depressed mood, sleep impairment, nightmares, and anxiety. During the Veteran's June 2016 Board hearing, he testified that he participated in individual and group therapy. He related symptoms of sleep difficulties, nightmares, panic attacks, impaired concentration, and flashbacks. He indicated that his symptoms had worsened since he was laid off. The aforementioned evidence reflects that the Veteran's PTSD has been manifested by difficulty sleeping, irritability, anger, anxiety, depression, panic attacks, isolative behavior, lack of concentration, memory impairment and difficulty maintaining relationships. In the opinion of the Board, the frequency, severity and duration of these symptoms have been productive of occupational and social impairment with deficiencies in work, family relationships, judgment and mood. Such symptomatology is consistent with a higher 70 percent rating. In so finding, the Board acknowledges that while the Veteran's symptoms and severity have varied with periods of improvement, as documented on examination and in treatment records, many evaluations have indicated that the Veteran's suffers from severe depression and/or panic that had caused significant social withdrawal and inability to maintain effective relationships outside of the relationship with his wife and children. While not all of the symptoms supportive of a 70 percent rating have been documented, the overall picture supports a finding of deficiencies in most areas such as work, family relations, thinking, and mood. However, at no point during the period of the appeal, is the service-connected PTSD shown to have met the criteria for the higher rating of 70 percent. As noted, a 100 percent rating requires total occupational and social impairment due examples such as gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closes relatives, own occupation, or own name. The mental status examinations in both formal examinations and in the clinic setting demonstrate some impairment of short and long-term memory, but have consistently demonstrated the Veteran to be oriented with no significant impairment of speech or communication. While Dr. M. noted disorientation to time and place during flashbacks, the frequency and duration of such episodes are not shown to result in total occupational and social impairment. The Veteran has consistently been shown to be oriented in treatment and on examination. He has reported occasional images, but has otherwise denied chronic/persistent suicidal or homicidal ideations or auditory hallucinations. His memory, while impaired, did not extend to the point of memory loss for names of closes relatives, own occupation, or own name on mental status examination. There is no lay or medical evidence that the Veteran presents as a persistent danger of hurting self or others. His hygiene is reported as maintained. With respect to social functioning, the record reflects that the Veteran is socially withdrawn and isolative with only one good friend; however, he reports fair to good relationships with his wife, children, and grandchildren though with occasional periods of strain or irritable. He occasionally attended church and group therapy. Thus, it cannot be said that he has total social impairment, despite Dr. L.'s finding of total social impairment. Such finding is not supported in the record and is clearly outweighed by the lay and medical evidence discussed above. The Board further finds that none of the GAF scores assigned during this period, alone, provide a basis for assigning a rating in excess of 70 percent for PTSD. As indicated, the Veteran has been assigned GAF scores ranging from 47 to 67. These scores reflect some residual occupational and social functioning. According to DSM-IV, a GAF score ranging from 41 to 50 reflects severe 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), while a GAF score ranging from 51 to 60 reflects 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). Thus, to the extent that the Veteran has been assigned scores in the moderate to severe range, such scores are consistent with the 70 percent rating assigned. In sum, the record does not support of a finding of both occupational and social impairment which is total in degree. In so finding, the Board has considered the Veteran's statements regarding the severity of his psychiatric symptoms and the medical opinions of "total" occupational impairment. As addressed below, the Board finds that the Veteran's PTSD contributes to his employability but nonetheless the weight of the lay and medical evidence weighs against a finding of total occupational and social impairment. Certainly, as a lay person, the Veteran is competent to attest to the symptoms that he experiences. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Generally, he has been credible with his testimony supporting a 70 percent rating as well as TDIU rating (as addressed below). However, as it pertains to the specific criteria for a 100 percent schedular rating under Diagnostic Code 9411, the totality of the lay and medical evidence - when considering the type, severity and frequency of symptoms - weighs against a finding of "total" occupational and social impairment, or a level of disability more nearly approximating "total" occupational and social impairment. Regardless, with respect the overall severity of PTSD, the Board finds the medical impressions and opinions to be far more probative of the degree of impairment than the lay statements as it pertains to the extent of the overall psychological, occupational and social impairment due to PTSD. As to consideration of referral for an extraschedular rating, such consideration requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the 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 evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Director of Compensation Service to determine whether an extraschedular rating is warranted. The discussion above reflects that the symptomatology associated with the Veteran's disabilities is fully contemplated by the applicable rating criteria. The symptomatology reported by the Veteran and shown on examination is contemplated by the rating criteria used to assign disability evaluations, and there is no characteristic or manifestations shown that is outside the purview of the applicable rating criteria or is so exceptional as to render the criteria in applicable. Rather, the criteria provide examples for particular ratings and the Board may consider all factors in assigning a scheduler rating. Therefore, referral for consideration of an extraschedular rating for PTSD is not warranted. 38 C.F.R. § 3.321 (b)(1). Additionally, the Veteran has not alleged or indicated that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Nonetheless, the Board will revisit this issue when the other increased rating claims are decided after further development. Accordingly, the Board finds that a 70 percent rating for PTSD, but no higher for any time during the appeal period, is warranted. In reaching this decision, the Board has considered the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). IV. TDIU The Veteran also contends that he is precluded from working due to his service-connected disabilities. Total disability ratings for compensation based on individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Where these percentage requirements are not met, entitlement to the benefits on an extraschedular basis may be considered when the veteran is unable to secure and follow a substantially gainful occupation by reason of service- connected disabilities. 38 C.F.R. § 4.16(b). The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment cause by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In order for a veteran to prevail in his claim for TDIU, the record must reflect circumstances, apart from non-service-connected conditions, that place him or her in a different position than other veterans who meet the basic schedular criteria. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question is whether the veteran, in light of his or her service-connected disorders, is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. See Van Hoose, 4 Vet. App. at 361. In Geib v. Shinseki, 733 F.3d 1350 (2013), the Federal Circuit held that VA's duty to assist did not require obtaining a single medical opinion regarding the combined impact of all service-connected disabilities. "Indeed, applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner." Id. at 1354. Here, the Veteran is service-connected for PTSD (now rated as 70 percent disabling), residuals of gunshot wound of the left thigh (rated as 30 percent disabling), diabetes mellitus (rated as 20 percent disabling); traumatic amputation at the DIP joint, left middle finger (rated as 10 percent disabling); residual scars of the left posterior thigh and left middle finger (rated as 10 percent disabling); traumatic arthritis of the left hip (rated as 10 percent disabling); painful scars of the left posterior thigh (rated as 10 percent disabling); chondromalacia with degenerative joint disease of the left knee (rated as 40 percent disabling from June 2011, and as 10 percent disabling from January 2017); and impairment of the thigh, residual of traumatic arthritis of the left hip, rated as noncompensable. Notwithstanding the Board's decision with regard to the claim for an increased rating for PTSD above, the Veteran has been assigned a combined 90 percent rating from June 2011, and combined 80 percent rating from January 2017. Hence, the Veteran meets the criteria for schedular TDIU rating per 38 C.F.R. § 4.16(a) for all periods relevant to the appeal. On the Veteran's July 2011application for TDIU, along with previous applications for TDIU, he reported that he last worked in July 2005 as a supervisor in a textile factory. He indicated that he had completed high school, with no additional education or training. In various written statements and during his hearing testimony, the Veteran has reported that while he was laid off from work due to workforce reduction, his service-connected disabilities-particular his left leg disability and his PTSD-prevented him from gaining and maintaining any subsequent employment. In addition to the above-discussed medical evidence, an SSA adjudicative decision dated in July 2008 reflects that the Veteran was found disabled as of November 2005. Severe impairments were bilateral degenerative joint disease of the knees and hypertension. While the administrative law judge found that the Veteran retained the capacity for sedentary work, the demands of his past relevant work as a cloth inspector exceeded his residual functional capacity. On VA examination in August 2011, the examiner was asked to opine as to whether the Veteran's service-connected disabilities rendered him unable to secure and maintain substantially gainful employment. After physical examination, the examiner noted that the Veteran's gunshot wound residuals, degenerative joint disease of the left knee and the left him did not render him unable to secure and maintain a substantially gainful physical and sedentary type of employment. However, the Veteran's nonservice-connected total right knee arthroplasty might be a factor in accomplishing physical employment. Regarding his service-connected disabilities, the examiner noted that the Veteran worked satisfactorily for 33 years in textile manufacturing, which was a physical type of employment, and was laid off for reasons not related to any physical type or problems connected to the service-connected disabilities. During the Veteran's December 2013 DRO hearing, the Veteran testified that though he was laid off in 2005, he believed that he could no longer work due to problems with his left leg and his PTSD. He noted that his legs gave way, and his PTSD interfered with his ability to get along with others. He was withdrawn and isolated in order to avoid distress and conflict with others. A February 2014 report from Dr. A. notes that he had reviewed the claims file including VA treatment records and VA examination reports. He found that, when considering the totality and sum of the combined effects of the Veteran's physical and mental disabilities, including PTSD, severe depression, chondromalacia of the left knee, residuals of gunshot wound of the left thigh, arthritis of the hip, a left middle finger injury, the Veteran's service-connected disabilities prevented him from seeking, securing, and maintaining substantially gainful physical or sedentary employment. Dr. A. indicated that the Veteran's service-connected physical disabilities of the lower extremities would limit him to employment that did not require prolonged standing or walking, and would interfere with his ability to sit for long periods. He would be limited to lifting no more than 20 pounds. The left middle finger injury would limit employment that required fine manipulation of the left hand. Furthermore, his severe PTSD caused problems with concentration, disorientation to time and place, persistent depression, episodes of panic attacks, and overall difficulty adapting to stressful circumstances-also limiting sedentary employment. Therefore, based on the overall medical record, Dr. A. found that the evidence supported the award of a TDIU as early as the date of his TDIU claim in June 2011. The medical evidence of record suggests that the Veteran is limited in his ability to perform physical activity, particularly with respect to his service-connected left leg impairment (including left thigh, hip, and knee disabilities), and that he is occasionally unable to perform work-related tasks and impairment with social interaction with others due to his service-connected PTSD. These impairments are incompatible with his previous work history of working as a supervisor in a textile factory, which would undoubtedly require physical activity and interaction with others. As a result of these work limitations caused by service-connected disabilities as reflected in the overall 80/90 percent combined disability rating, and in consideration of the various private opinions of record regarding the severity of the Veteran's service connected disabilities and their impact on his employability, the Board resolves reasonable doubt in favor of the Veteran by finding that his service-connected disabilities have rendered him unable to secure or follow substantially gainful employment. Therefore in resolving all doubt in the Veteran's favor, the Board concludes TDIU is warranted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 55-56. ORDER The claim of entitlement to service connection for third degree burn scar with skin grafting and tenderness, right anterior thigh is dismissed. A 70 percent rating for PTSD is granted, subject to the controlling regulations applicable to the payment of monetary benefits. The claim of entitlement to an increased rating for traumatic amputation at the DIP joint, left middle finger is dismissed. Entitlement to a TDIU is granted, subject to controlling regulations governing the payment of monetary awards. REMAND The Board's review of the record reveals that additional development on the remaining claims on appeal is warranted, even though such will, regrettably, further delay an appellate decision on these matters. The Veteran seeks a higher disability rating for his service-connected gunshot wound residuals, left thigh. He is currently assigned a 30 percent under Diagnostic Code 5313, for injury to Muscle Group (MG) VIII. However, a VA examination in February 2010 identified an entry wound injury to MG VIII as well as an exit wound injury involving MG XV - the gracilis muscle. The most recent examination, dated December 2013, did not evaluate an injury to MG XV. At this time, the Board must remand this issue for an adequate examination to all injured muscle groups and for AOJ consideration for separate ratings for each affected muscle group. The Court in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. The Veteran has been afforded VA examinations pertaining to the left hip and thigh in 2008 and more recently in December 2013. Review of these examination reports reveals that range of motion testing in passive motion, weight-bearing, and nonweight-bearing situations were not conducted. In light of Correia, these VA examinations are insufficient, and the Veteran must be provided new VA examinations with respect to the hip, which provides range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing. Accordingly, the case is REMANDED for the following action: 1. Undertake appropriate development to obtain any outstanding, pertinent treatment records. 2. Then, afford the Veteran additional examination to ascertain the current severity of his residuals of gunshot wound, left thigh. In so doing, the examiner should carefully identify all muscle groups affected between the entry and exit wounds including review of the February 2010 VA examination identifying an entry wound injury to MG VIII as well as an exit wound injury involving MG XV - the gracilis muscle. 3. Afford the Veteran a VA examination to ascertain the current severity and manifestations of his service-connected left hip disability. All pertinent evidence of record should be made available to and reviewed by the examiner. The examiner must include range of motion testing in the following areas: • Active motion; • Passive motion; • Weight-bearing; and • Nonweight-bearing. The examiner must also conduct these studies for the right hip as well. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner must provide a complete rationale for all the findings and opinions. 4. Then, the issue on appeal should be readjudicated. In so doing, the AOJ should specifically identify all muscle groups involved in the gunshot wound injury and give consideration of entitlement to separate ratings for each affected muscle group, if appropriate. If the benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be furnished with a supplemental statement of the case and afforded the requisite opportunity for response. 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). ______________________________________________ T. MAINELLI Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs