Citation Nr: 1751825 Decision Date: 11/13/17 Archive Date: 11/22/17 DOCKET NO. 09-40 423 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent prior to September 26, 2013, and in excess of 50 percent thereafter for posttraumatic stress disorder (PTSD) and alcohol abuse. 2. Entitlement to service connection for a left elbow disorder, to include epicondylitis or a disorder due to undiagnosed illness. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K. Clark, Associate Counsel INTRODUCTION The Veteran served in the Army National Guard from November 1984 to March 1985 and on active duty from May 1989 to May 1992, including service in the Southwest Asia theater of operations during the Persian Gulf War. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in July 2008 (left elbow) and March 2012 (PTSD) by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2014, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A hearing transcript has been associated with the record. In June 2014 and September 2015, the Board remanded the appeal for additional development and it now returns for further appellate review. As the Veteran is challenging the initial rating assigned for his service-connected PTSD and alcohol abuse, and the record raises the possibility that he is unemployed because of such service-connected disorder, the determination as to whether he is entitled to TDIU is part and parcel of the initial rating claim. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). In this regard, in a March 2017 statement, the Veteran stated that he was recently fired from his job and the evidence of record indicates that he may have been unable to hold a job due to his PTSD. Therefore, the issue of entitlement to a TDIU has been raised by the record and, as such, has been included on the title page of this decision. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C.A. § 7107(a)(2) (West 2014). The issues of entitlement to service connection for a left elbow disorder and entitlement to a 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. For the appeal period prior to September 26, 2013, the Veteran's PTSD and alcohol abuse is manifested by symptomatology resulting in occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 2. For the appeal period since September 26, 2013, the Veteran's PTSD and alcohol abuse is manifested by symptomatology resulting in occupational and social impairment in most areas, without more severe manifestations that more nearly approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. For the appeal period prior to September 26, 2013, the criteria for an initial rating of 50 percent, but no higher, for PTSD and alcohol abuse have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411 (2017). 2. For the appeal period as of September 26, 2013, the criteria for an initial rating of 70 percent, but no higher, for PTSD and alcohol abuse have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, DC 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Further, neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. Analysis Service connection for PTSD was established by a March 2012 rating decision. The AOJ subsequently assigned initial ratings of 30 percent, effective as of May 25, 2007, and 50 percent, effective as of September 26, 2013. The Veteran contends that he is entitled to higher initial ratings because he believes that his PTSD symptoms are more severe than as reflected by the currently assigned ratings. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate for an increased rating claim whenever 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). The Veteran's service-connected PTSD and alcohol abuse is evaluated under the criteria of DC 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. A 30 percent rating contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occasional 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). Id. A 50 percent rating contemplates 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; impairments of short-and long-term memory; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, DC 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a). In Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that the language of the general rating formula "indicates that the presence of suicidal ideation alone...may cause occupational and social impairment with deficiencies in most areas." However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran's service-connected psychiatric disability, and their resulting social and occupational impairment. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders and its adjudication regulations that define the term "psychosis" to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and replace them with references to the recently updated DSM-5. See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014, even if such claims are subsequently remanded to the AOJ. See 80 Fed. Reg. 53, 14308 (March 19, 2015). In the instant case, the Veteran's claim was certified to the Board in August 2013 and, as such, the DSM-IV applies to his claim. In this regard, the Board notes that the DSM-5 removed reference to Global Assessment of Functioning (GAF) scores. However, as the DSM-IV governs the Veteran's claim, such scores are relevant to the evaluation of his PTSD. A GAF score is another component considered to determine the entire disability picture for the Veteran. The GAF scale is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994)). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered, but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). After a review of the record, the Board finds that the Veteran's PTSD and alcohol abuse results in, at most, occupational and social impairment with reduced reliability and productivity for the appeal period prior to September 26, 2013, and occupational and social impairment with deficiencies in most areas for the appeal period since September 26, 2013. In this regard, a June 2007 private treatment record revealed that the Veteran had an anxious mood and that his affect was congruent with such mood. The clinician also noted that the Veteran's speech was normal, his thought process was coherent, and he had no hallucinations, or suicidal or homicidal ideations. The Veteran also submitted a lay statement in June 2007 in which he noted that he had lots of job changes in the past 15 years and that he did not stay at a job for more than one to three years. He also noted that he was abusive to his wife and children, had social behavior changes, depression, panic attacks, nightmares, memory and concentration problems, and avoidance from family and friends. An August 2007 private treatment record indicated that the Veteran had a calm mood with an affect congruent with such mood, his speech was regular, and his thought process was coherent. Such provider also noted that the Veteran had no suicidal or homicidal ideations, and no hallucinations. The Veteran's spouse also submitted a statement in August 2007. In such statement, she noted that the Veteran was a very angry person since his return from military service and that he was very abusive towards her, and their kids witnessed a lot of abuse. She also stated that their kids were very distant from him, she had holes in the walls from him punching them, she signed a warrant for his arrest because of his abuse, he was drinking a lot, and he could not keep a job because he could not handle any kind of duties without getting angry. A November 2007 private treatment record revealed that the Veteran had an anxious mood with an affect congruent with such mood, his speech was normal, and his thought process was logical and coherent. He also had no suicidal or homicidal ideations and no hallucinations. In a February 2009 private treatment record, the treating provider noted that the Veteran was doing fair, had a couple of jobs since June 2008, experienced nightmares, and was having more arguments with his wife. The provider found that the Veteran was alert and oriented, had an anxious mood, and had no suicidal or homicidal ideations. In March 2010, such provider noted that the Veteran had lost his job the prior year and found a new job, but was fired after a guy got in his face. The provider again noted that the Veteran was alert and oriented, had an anxious mood, and that he denied suicidal and homicidal ideations. In September 2010, the same provider noted that the Veteran was still having PTSD-related dreams, his marriage was stable, and that he was only socially close to his family. The provider further noted that the Veteran was again alert and oriented, had an anxious mood and a congruent affect, and that he denied suicidal and homicidal ideations. Thereafter, the Veteran underwent a VA examination in connection with his PTSD claim in August 2011. At such time, he reported that when he had a nightmare, the next day he got very irritable and that he also got into arguments and became hostile. He also reported that he hit his wife a while ago during a bad dream. The examiner noted that the Veteran had been working as an inspector for a manufacturing company for the last two years and worked in isolation. The Veteran reported that he occasionally got into arguments with people and his supervisor. He also reported that he was depressed and lost approximately 10 days from his job. The Veteran further reported that he usually works around the house and has some friends, but does not visit them that often. He also stated that he occasionally went to church and attended church activities. Additionally, the examiner noted that the Veteran had been sleeping better with medication; however, he still had persistent dreams and got very hypervigilant at times. The examiner also noted that the Veteran would get somewhat anxious and depressed at times, but that there was no evidence of any psychotic symptoms at the present time. The examiner further noted that the Veteran was free from delusional thinking, he was oriented to time, place, and person, and his insight was adequate, but he was having some difficulty in concentrating at times during the interview. The examiner also assigned a GAF score of 62. In his April 2012 notice of disagreement, the Veteran stated that he experienced panic attacks more than twice a week, difficulty in understanding complex commands, short and long term memory impairment, impaired judgment and impaired abstract thinking, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, homicidal tendency, thoughts of suicide frequently, alcohol use problems, and depression. Moreover, an August 2013 private treatment indicated that the Veteran was working again, but had difficulty following instructions and got angry often with supervisors. The provider noted that the Veteran had been separated from his wife for 6 months, and he got physical and hit the wall. The provider also noted that the Veteran kept to himself, started back drinking, moved back in with his wife, and had two sons in college. The provider found that the Veteran was alert and oriented, and had an anxious mood with a congruent affect. He also denied suicidal and homicidal ideations. In a statement received September 6, 2013, the Veteran continued to report that he was experiencing symptoms from his PTSD. Specifically, he stated that he was experiencing panic attacks two to three times a day with his supervisors and co-workers; had difficulty understanding complex commands and forgetting to complete his daily tasks; could not establish work relationships with co-workers; had a hard time remembering things both short term and long term; thought about punching co-workers; did not care about hygiene and appearance; had poor judgment; no motivation to do things with family; thought about committing suicide and came close to trying the month prior; and stopped going to church. Moreover, a September 26, 2013 VA treatment record noted the Veteran's reports of having suicidal thoughts all the time since 2010 with no plan, but that he attempted suicide in July 2013 by attempting to jump off a building. He also reported that he had anger and could get violent, and that he went to counseling regularly. The Veteran further reported that he had thoughts of suicide two to three times a week, memory deficit of recent events or where people live, difficulty initiating and maintaining sleep, and had lost 10 jobs due to his anger and arguments. The examiner noted that the Veteran had adequate grooming and hygiene, and was calm and cooperative. The examiner also noted that the Veteran had anger outbursts, irritability, recurrent intrusive thoughts, nightmares, and memory deficit of recent events and could not remember family members' names and conversations. A GAF score of 55 was assigned and the examiner noted that the Veteran's insight and judgment were intact. The Veteran was afforded another VA examination in December 2013 in connection with his PTSD. At such time, the examiner determined that the Veteran had occupational and social impairment with reduced reliability and productivity. In support thereof, the examiner noted that the Veteran remained married to his wife of 23 years, but that they have been separated throughout the past year, and he had no relationship with his two sons. The examiner also noted that the Veteran received several disciplinary write-ups at work due to conflicts with his supervisor and he reported he was convicted of domestic violence associated with his wife in 2008. The examiner further noted that the Veteran possessed the symptoms of anxiety, chronic sleep impairment, flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. At the May 2014 Board hearing, the Veteran testified that his PTSD symptomatology had remained consistent throughout the past five years or so and he experienced problems with sleeping, depression, anxiety, panic attacks, hearing noises, nightmares, memory issues, and rituals of having to place things in a certain way, like his toothbrush and comb. The Veteran also stated that he was staying with his mom and had no hobbies. He further stated that he had prior violent altercations with his wife and on the job, which led to being fired. The Veteran's subsequent VA treatment records indicate that he continued to seek treatment relating to his PTSD symptomatology. Specifically, during 2014-2015, the Veteran continued to report problems with anger outbursts on the job and memory difficulties. See September 11, 2014; January 12, 2015; and April 21, 2015 VA treatment records. The clinicians during such time period also noted that the Veteran had adequate grooming and hygiene, but yet was unkempt in appearance and his insight and judgment were intact or fair. Id. GAF scores of 45, 50, and 55 were also assigned. Id. An August 2015 private treatment record also revealed that he had a lack of concentration at work, memory deficit of recent events, anger irritability, and panic attacks. Additionally, an October 2015 private treatment record indicated that the Veteran had suicidal and homicidal thoughts with no plans and was aware of the difference between physical altercation and a plan to intentionally hurt someone. The clinician also noted that the Veteran experienced irritability or aggression with little or no provocation, anxiety, depression, and slowed thinking, but had no speech difficulty and was oriented to time, place, and person. In January 2016, the Veteran underwent another VA examination. At such time, he reported that he was in the process of divorcing his wife, and was currently staying with friends and occasionally at hotels. He also reported that he talked with his friends and watched television, but did not socialize very much and had no outside activities. The Veteran further reported that he had been working at the Hyundai plant for three and a half years and that he had been using FMLA leave to attend anger management classes as his instances of anger at work led him to enroll in such classes. The examiner determined that the Veteran had occupational and social impairment with reduced reliability and productivity. In support thereof, the examiner noted that the Veteran had symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Based on the foregoing, the Board finds that for the appeal period prior to September 26, 2013, the Veteran is entitled to an initial rating of 50 percent, but no higher, for his service-connected PTSD and alcohol abuse as such disorder had been manifested by symptomatology resulting in occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. In this regard, the evidence of record during the appeal period prior to September 26, 2013, demonstrates that the Veteran had psychiatric symptomatology including depression, anxiety, panic attacks, nightmares, avoidance behavior, memory problems, sleep difficulty, disturbances in mood and motivation, difficulty in establishing and maintaining effective work and social relationships, and forgetting to complete tasks. Furthermore, while the Veteran has stated that he experienced psychiatric symptomatology associated with a higher rating such as suicidal and homicidal thoughts, his contemporaneous medical records suggest otherwise. Specifically, the medical evidence of record reveals the Veteran continued to deny suicidal and homicidal ideations during such time period. Additionally, the Board acknowledges that the Veteran has had problems of violence with his family and on the job during the appeal period prior to September 26, 2013; however, the Board finds that such is not in itself indicative of a 70 percent rating as the objective evidence of record does not demonstrate that his psychiatric symptomatology resulted in other symptoms such as: obsessional rituals which interferes with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; spatial disorientation; and neglect of personal appearance and hygiene. Moreover, the August 2011 VA examiner assigned a GAF score of 62, which reflects some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. However, for the appeal period since September 26, 2013, the Board finds that the Veteran is entitled to an initial rating of 70 percent, but no higher, for his service-connected PTSD and alcohol abuse as such disorder has been manifested by symptomatology resulting in occupational and social impairment with deficiencies in most areas, without more severe manifestations that more nearly approximate total occupational and social impairment. Specifically, the December 2013 and January 2016 VA examinations indicate that the Veteran's psychiatric symptomatology worsened since his August 2011 VA examination. Furthermore, in September 26, 2013, the Veteran sought treatment because he was having daily thoughts of suicide, but with no plan. Additionally, during such period, GAF scores indicative of serious symptoms or any serious impairment in social, occupation, or school functioning, were assigned. Moreover, the Board finds that a 100 percent rating for the Veteran's PTSD and alcohol abuse is not warranted at any time during the appeal period. In this regard, the Veteran's symptoms did not occur at the severity, frequency, or the duration required for a 100 percent rating. The Board acknowledges that the Veteran has experienced serious social and occupational impairment; however such has not been total. Specifically, during the August 2011 VA examination, the Veteran reported that he had some friends, but did not visit them that often, and that he occasionally went to church and attended church activities. Additionally, throughout the appeal period, the Veteran stated that he was staying with his mom or friends. While the Veteran reported that he stopped going to church, he stated that he still talked with friends during the January 2016 VA examination. Moreover, the Veteran was employed during most of the appeal period, albeit such was often problematic due to his symptomatology. Therefore, given the frequency, severity, and duration of the Veteran's symptoms, the Board finds that his PTSD and alcohol abuse has been productive of no more than occupational and social impairment with reduced reliability and productivity prior to September 26, 2013, and no more than occupational and social impairment with deficiencies in most areas as of such date. Accordingly, a 50 percent rating, but no higher, is warranted prior to September 26, 2013, and a 70 percent rating, but no higher, is warranted thereafter for the Veteran's PTSD and alcohol abuse. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PTSD and alcohol abuse, and, as discussed above, has in fact awarded higher initial ratings for each period on appeal. However, the Board finds that his symptomatology has otherwise been stable. Therefore, assigning additional staged ratings for such disability is not warranted. Further, neither the Veteran nor his representative has raised any other issues nor have any other issues been reasonably raised by the record other than entitlement to a TDIU, which will be addressed in the Remand section of this decision. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In sum, the Board finds that the Veteran is entitled to a rating of 50 percent, but no higher, prior to September 26, 2013, and a rating of 70 percent, but no higher, thereafter for PTSD and alcohol abuse. Therefore, to the extent that the Board herein denies the Veteran's claim for a higher rating, the benefit of the doubt doctrine is not applicable and such aspect of his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER For the appeal period prior to September 23, 2016, an initial rating of 50 percent, but no higher, for PTSD and alcohol abuse is granted, subject to the laws and regulations governing the payment of monetary awards. For the appeal period since September 23, 2016, an initial rating of 70 percent, but no higher, for PTSD and alcohol abuse is granted, subject to the laws and regulations governing the payment of monetary awards. REMAND Although the Board regrets the additional delay, another remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Pursuant to the September 2015 remand, the Veteran underwent a VA examination and an addendum opinion was obtained in February 2016 to determine the nature and etiology of his claimed left elbow disorder. Nonetheless, the Board finds that such opinion is inadequate and as such, a remand is necessary to obtain another addendum opinion. Specifically, the examiner found that the Veteran had a diagnosis of left lateral epicondylitis and opined that such disorder was less likely than not incurred in or was caused by the claimed in-service injury, event, or illness. However, the only rationale provided was that there was no documentation in the service treatment records (STRs) of any injury to or complaint regarding the left elbow during service. Thus, an addendum opinion is needed to determine whether the Veteran's left elbow disorder, diagnosed as left lateral epicondylitis, is related to his military service, to include his in-service duties as a truck driver, to include performing maintenance on the vehicles. Furthermore, with regard to the raised claim for a TDIU, the Board finds that additional development is needed to adjudicate such matter. Specifically, in March 2017, the Veteran submitted a statement that he was recently fired from his job, and the medical evidence of record indicates that such firing may have been due to his service-connected disabilities. Specifically, a September 2015 counseling record for the vocational rehabilitation program noted that the Veteran's service-connected disabilities significantly impaired his ability to prepare for, obtain, and/or retain employment, and that his job at the time as an assistant quality manager at Hyundai was not considered suitable due to his impairments. Additionally, a July 2016 medical record for requested FMLA leave indicated that the Veteran was unable to perform his job functions as an assistant manager due to his psychiatric disability as the provider noted that the Veteran was still experiencing depression, lack of concentration at work, memory deficit, anger, irritable behavior, hypervigilance, and insomnia with an inability to function during the day. However, a December 2016 rehabilitation plan indicates that the Veteran's program goal was to secure suitable employment to match his interests, aptitudes, and abilities in the occupational field of network administrator, and that he would complete a Bachelor's in global business/general business form Troy University in May 2020. Thus, on remand, the Veteran should be provided Veterans Claims Assistance Act of 2000 (VCAA) notice regarding the information and evidence necessary to substantiate a TDIU claim and be requested to complete and return VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). The AOJ also should conduct any additional development deemed necessary for the adjudication of such claim. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The Veteran should be provided with proper VCAA notice regarding the evidence and information necessary to substantiate a TDIU claim. He should also be requested to complete and return VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). 2. Return the record to the VA examiner who conducted the February 2016 left elbow examination. The record and a copy of this Remand must be made available to the examiner. The examiner should note in the examination report that the record and the Remand have been reviewed. If the February 2016 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. After a review of the entire record, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran's left elbow disorder, diagnosed as left lateral epicondylitis, had its onset during service or is otherwise etiologically related to service. The examiner should specifically address the Veteran's claim that such disability was caused by his in-service duties as a truck driver, including performing maintenance on the vehicles. The examiner is advised that the sole basis of a negative opinion cannot be the fact that the Veteran's service treatment records are silent as to any left elbow disorder. A complete rationale should be provided for all opinions offered. 2. As relevant to the TDIU claim, the AOJ should review the record and conduct any additionally indicated development, to include obtaining any examinations and/or opinions, deemed necessary for the adjudication of this claim. 3. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed 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). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs