Citation Nr: 1802520 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 12-21 087 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Lincoln, Nebraska THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD) with depression. 2. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities. 3. Entitlement to service connection for a seizure disorder, claimed as secondary to service-connected PTSD with depression. REPRESENTATION Veteran represented by: Penelope Gronbeck, Attorney-at-law WITNESSES AT HEARING ON APPEAL Veteran and his spouse ATTORNEY FOR THE BOARD K. K. Buckley, Counsel INTRODUCTION The Veteran served on active duty from November 1975 to March 1976 and May 1980 to June 1985. He also had "other than honorable" service from June 1985 to October 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated July 2011 and April 2015 of the Department of Veterans Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. In April 2013, the Veteran presented sworn testimony during a Board hearing. In October 2016, the matters on appeal were remanded in order to afford the Veteran another hearing as to the later-appealed issue of entitlement to service connection for seizure disorder. Accordingly, in March 2017, he presented sworn testimony during a Board videoconference hearing. Transcripts of both hearings have been associated with the Veteran's VA claims file. The issue of entitlement to service connection for a seizure disorder is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). The Veteran will be notified if further action on his part is required. FINDINGS OF FACT 1. From the date of service connection, the Veteran's service-connected PTSD with depression has been manifested by occupational and social impairment, with deficiencies in most areas, but has not more nearly approximated total occupational and social impairment. 2. The evidence of record shows that the Veteran was unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for an initial disability rating of 70 percent, but no higher, for PTSD with depression, are met from the date of service connection. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.130, Diagnostic Codes (DC) 9411 (2017). 2. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to a TDIU are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As a preliminary matter, the Board finds that VA has satisfied its duties under the Veteran's Claims Assistance Act of 2000 (VCAA) to notify and assist. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2017). Neither the Veteran nor his attorney has raised any issues with regard to 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 a duty to assist argument). II. Schedular analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claim. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) (2012) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C.A. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. PTSD is evaluated pursuant to DC 9411. Under this diagnostic code, a 50 percent evaluation is for assignment when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory, e.g., retention of only highly learned material, forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty establishing effective work and social relationships. Id. A 70 percent evaluation is contemplated for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. A 100 percent evaluation is warranted when there is evidence of 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 and place; memory loss for names of close relatives, own occupation or name. Id. The GAF is a scale reflecting psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). As will be discussed below, the Veteran has been assigned GAF scores ranging from 45 to 65 as determined by VA and private treatment providers, as well as VA and private examiners. These scores are indicative of moderate to severe impairment. Scores ranging from 41 to 50 reflect serious symptoms, e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social, occupational, or school functioning, e.g., no friends, unable to keep a job. A GAF score ranging from 51 to 60 reflect more moderate symptoms, e.g., flat affect and circumstantial speech, occasional panic attacks, or moderate difficulty in social, occupational, or school functioning, e.g., few friends, conflicts with peers or co-workers. GAF scores ranging between 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. In this matter, the Veteran was granted service connection for PTSD with depression in a July 2011 rating decision; a 50 percent rating was assigned effective July 30, 2010. The Veteran disagreed with the assigned rating and this appeal followed. For the following reasons, the Board finds that a rating of 70 percent is warranted under the schedular criteria from the date of service connection. The Veteran filed a claim of entitlement to service connection for PTSD with depression in July 2010. VA treatment records dated in July 2010 describe the Veteran's irritability, which included "nearly going to jail for almost running his neighbor over whom he believed robbed him." Diagnoses of PTSD and major depressive disorder (MDD) without psychotic features were indicated. A GAF of 60 was assigned. VA treatment records dated in October 2010 noted that the Veteran continued to be irritable and threatened his neighbor with a baseball bat after yelling obscenities. The Veteran reported that his irritability is short-lived, and does not last for more than one to two hours. A GAF of 65 was assigned. In December 2010, the Veteran reported nightmares, severe flashbacks, increased startle response, emotional numbness, difficulty getting close to others, avoidance of reminders, and severe irritability. A GAF of 50 was indicated. In a December 2010 Mental Residual Functional Capacity Assessment, Dr. D.D. reported that the Veteran "continues to struggle with severe PTSD, including nightmares, flashbacks, hyperarousal, avoidance of reminds of his trauma, and problems with his memory." The Veteran endorsed short periods of blind rages, which are characterized by severe anger. Dr. D.D. reported that the Veteran's ability to remember locations and work-like procedures is markedly limited. His ability to understand and remember very short and simple instructions is also moderately limited. His ability to understand and remember detailed instructions is markedly limited. The Veteran is markedly limited in his ability to interact appropriately with the general public. He is also markedly limited in his ability to accept instructions and respond appropriately to criticism from supervisors, including loss of temper. In addition, the Veteran's ability to get along with co-workers or peers without distracting them or exhibiting behavioral extremes is markedly limited. In pertinent part, Dr. D.D. stated, "[d]espite adherence to adequate follow-up, [the Veteran] continues to struggle with severe PTSD, including nightmares, flashbacks, hyperarousal, avoidance of reminders of his trauma, and problems with his memory." Dr. D.D. noted that the Veteran "has had short periods of 'blind rages' which are characterized by severe anger." Dr. D.D. stated that, although the Veteran's symptoms have significantly improved on medication, "he has a limited ability to interact with co-workers, respond appropriately to constructive criticism and function in the workplace without exhibiting behavioral extremes." Dr. D.D. continued, "[i]n the past, these behaviors have gotten him fired." Dr. D.D. further opined that the Veteran's "limited ability to carry out simple or complex detailed instructions create problems for him in the workplace. In my professional opinion, [the Veteran] has significant impairment in his social interactions due to long-standing PTSD. He would not do well in a structured work setting with others." VA treatment records dated in February 2011 noted the Veteran's depressed mood, low energy, nightmares, irritability, impaired concentration, and emotional avoidance except for anger. The Veteran stated that he feels somewhat hopeless, but not suicidal. A GAF of 48 was assigned. The Veteran was afforded a VA psychological examination in June 2011, at which time he reported that he is unable to work due to his black-outs. The Veteran endorsed nightmares two to three times per week and low energy. The examiner indicated that the Veteran exhibited good concentration. He did not demonstrate psychomotor agitation. He denied suicidal ideation. The Veteran is divorced and lives with his fiancé. He denied violence/assaultiveness. He reported that he maintains social relationships with his fiancé and a few friends. During his leisure time, he plays computer games. The Veteran's speech was spontaneous, clear, and coherent. His affect was appropriate and his mood was dysphoric. He was well-oriented. The Veteran's thought processes and content were unremarkable. His insight was intact. He does not have panic attacks or homicidal thoughts. The Veteran is able to maintain minimum personal hygiene. He denied problems with activities of daily living. He reported difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. The examiner concluded that the Veteran's PTSD and depressive symptoms are in the mild range and would not cause unemployability. A GAF of 65 was assigned. The Veteran was afforded a VA examination in June 2012 to address the severity of his PTSD with depression. The examiner indicated that the Veteran's PTSD and depressive disorder, not otherwise specified (NOS), manifest in "[o]ccupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication." The Veteran was formerly employed as a vehicle transporter, but his not currently employed. He last worked in March 2010, but stopped working due to black-outs and depression. The examiner stated that the Veteran's PTSD and depressive symptoms would not cause unemployability. The examiner noted some constriction in the Veteran's interpersonal relationships and recreational activity. The Veteran reported that in the last year, he was arrested for disorderly conduct. He endorsed recurrent distressing dreams, avoidance, feelings of detachment or estrangement from others, difficulty falling or staying asleep, and irritability/outbursts of anger. He stated that he punches his wife in his sleep due to nightmares. A GAF of 62 was assigned. In a May 2013 psychological evaluation, the Veteran reported that he has little contact with his adult son. He has been in a relationship with his girlfriend for 16 years. He reported that he was fired for disorderly conduct in 2012. The examiner indicated that the Veteran was fairly well-groomed. He interacted with the examiner in a serious cooperative manner, but his eye contact was poor. He was well-oriented, and his thought content was coherent and logical. He exhibited no phobias or compulsive behaviors. The Veteran's affect was blunted, and he seemed lethargic. The Veteran denied panic attacks, but did endorse flashbacks. He stated that he continues to experience nightmares and hits his fiancé in his sleep. He reported a poor libido and feelings of hopelessness. He denied suicidal ideation. His judgment was fair. The examiner noted that the Veteran lacks insight into emotional functions. Diagnoses of MDD and PTSD were indicated and a GAF range of 45 to 50 was noted. The Veteran was treated at the emergency department in July 2014 for generalized weakness and altered mental state. It was determined that his medication required adjustment. The Veteran was most recently afforded a VA psychological examination in March 2015. The examiner confirmed continuing diagnose of PTSD and depressive disorder. He reported that the Veteran's psychological symptoms manifest in "[o]ccupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication." A GAF of 62 was assigned. The Veteran has been married since May 2014. He lives with his wife and a friend of his wife's. He has an adult son, with whom he does not maintain contact. He does report contact with his brothers. He stated that he sometimes goes out to eat with his spouse, or speaks to a neighbor. He has not worked for the past three to four years. He reports that he spends his time, playing on the computer. Upon examination, the Veteran was appropriately dressed and groomed. He was well-oriented. His attention and concentration were intact. He described his mood as worried, scared, and upset. His insight and judgment were intact. The Veteran reported impaired sleep; specifically, frequent awakenings. His memory was intact. The Veteran endorsed nightmares and continues to punch his spouse during nightmares. He stated that he avoids places, people, or things that might stress him out. He reported that he was arrested and jailed once for resisting arrest since the June 2012 VA examination. The Veteran endorsed depressed mood, anxiety, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, and irritable behavior and angry outbursts with little or no provocation typically expressed as verbal or physical aggression toward people or objects. The Veteran's spouse described a recent incident in which the Veteran went to Sears for a new battery, "and then flew off the handle right away" at the salesperson and overreacted. In support of his claim, the Veteran submitted a September 2015 assessment by a vocational rehabilitation counselor, who determined that the Veteran has barriers to employment due to his service-connected PTSD including "those symptoms which contribute to emotional inertia and lack of energy as well as unpredictable angry outburst." VA treatment records dated September 2015 document the Veteran's persistent irritability. Specifically, the Veteran described an argument with the friend of his spouse who is living with them. He ended up hitting her with a door when she entered his room. Based on the above, the Board finds that the impact of the Veteran's PTSD symptoms on his social and industrial functioning is sufficient to approximate the degree of impairment contemplated by a 70 percent rating from the date of service connection. As detailed above, the record includes diagnoses of PTSD and MDD. Significantly, multiple VA examiners have repeatedly described the overlapping symptoms of his psychiatric diagnoses. As such, the evidence is in equipoise as to whether the Veteran's psychiatric symptoms are attributable to his service-connected PTSD with depression or at least not consistently clearly separable from his service-connected disability. Mittleider v. West, 11 Vet. App. 181 (1998). Thus, all psychiatric symptoms are considered part of the service-connected diagnoses. Id. Moreover, although the Veteran's GAF scores have generally reflected levels of moderate impairment, neither GAF scores nor an examiner's characterization of the degree of the disability are dispositive of the legal questions involved in determining the appropriate rating for PTSD with depression. The symptomatology associated with the Veteran's service-connected PTSD, to include that indicated by the lay statements and treatment records, supports the assignment of a 70 percent rating because this disability has been shown to result in occupational and social impairment, with deficiencies in most areas, such as work, family relations, and mood, due to such symptoms as near-continuous depression; impaired impulse control, with periods of unprovoked irritability with outbursts of anger; and difficulty in adapting to stressful circumstances. 38 C.F.R. § 4.130, DC 9411. Specifically, these symptoms have been endorsed by the Veteran, as corroborated by VA examiners, private examiners, and treatment providers. Given the overall severity of the Veteran's psychological symptoms, the Board finds that the criteria for a 70 percent evaluation are met. However, the symptoms have not more nearly approximated total occupational and social impairment at any point from the date of service connection. 38 C.F.R. § 4.7 (2017). Symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time and place; memory loss for names of close relatives, own occupation or name, have not been shown. The evidence documents the Veteran's recurrent problems at work, including suspiciousness, hypervigilance, depression, decreased concentration, and anxiety. He is, however, married and maintains contact with some family members. Critically, the evidence does not show total occupational and social impairment due to PTSD. Again, the record establishes that the Veteran is able to maintain social relationships, including with friends and family members. Thus, neither the symptoms nor overall level of impairment meet the criteria for a 100 percent rating under the Rating Schedule, and a rating in excess of the 70 percent assigned herein is therefore not warranted for the Veteran's PTSD with depression. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD with depression, the evidence shows no distinct periods of time during the appeal period, when the Veteran's service-connected disability varied to such an extent that a rating greater or less than 70 percent assigned herein would be warranted. Hart, supra. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). III. Entitlement to a TDIU Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Rating Schedule provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341(a). If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. The existence or degree of nonservice-connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran's service-connected disabilities render him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). 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). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19 (2017); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Veteran has raised a claim of entitlement to a TDIU based primarily on his psychological symptomatology. As detailed above, the Board has herein found that the Veteran's PTSD with depression symptoms more nearly approximate a 70 percent rating from the date of service connection, July 30, 2010. The Board notes that the Veteran is also service-connected for small scar, right hand, at zero percent. As his combined rating is 70 percent, he therefore meets the schedular criteria. Thus, the question is whether the Veteran's service-connected disabilities preclude gainful employment for which his education and occupational experience would otherwise qualify him. As detailed above, the Veteran's service-connected PTSD with depression has interfered with his ability to maintain gainful employment. Specifically, although the Veteran reported that he stopped working due to black-out episodes, he has indicated that he was fired from several jobs due to his irritability. See, e.g.,. VA treatment records dated April 2010, VA examination reports dated June 2011, and private psychological evaluation dated May 2013. Moreover, in the December 2010 Mental Residual Functional Capacity Assessment, Dr. D.D. stated that the Veteran "has a limited ability to interact with co-workers, respond appropriately to constructive criticism and function in the workplace without exhibiting behavioral extremes." Dr. D.D. continued, "[i]n the past, these behaviors have gotten him fired." Dr. D.D. further opined that the Veteran's "limited ability to carry out simple or complex detailed instructions create problems for him in the workplace. In my professional opinion, [the Veteran] has significant impairment in his social interactions due to long-standing PTSD. He would not do well in a structured work setting with others." Additionally, the September 2015 vocational rehabilitation counselor stated that the Veteran "has several barriers to employment, most of which are related to his service-connected disability. Of particular importance are those symptoms which contribute to emotional inertia and lack of energy as well as unpredictable angry outbursts." The Veteran was afforded a VA medical opinion as to the question of entitlement to a TDIU in April 2015. The examiner stated that the Veteran's "ability to work and be productive would be decreased due to his PTSD during elevated levels of stress. However, this issue did not seem to completely prevent employment." The above evidence thus reflects that the Veteran's PTSD with depression has a significant impact on his ability to work. Although some health care professionals, including the June 2011, June 2012, and April 2015 VA examiners, have opined that the Veteran's psychological symptoms do not render him unemployable, the "applicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner." Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). Whether a veteran could perform the physical and mental acts required by employment at a given time is an issue about which a lay person may provide competent evidence. Id. at 1354. Given the significant effects of the Veteran's psychiatric abilities and his documented difficulty maintaining gainful employment, as indicated by the lay and medical evidence, the evidence is approximately evenly balanced as to whether his service connected disabilities render him unable to secure and follow substantially gainful employment. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to a TDIU is warranted from July 30, 2010. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER A 70 disability rating for service-connected PTSD is granted from the date of service connection, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a TDIU is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND The Veteran asserts entitlement to service connection for a seizure disorder, which he contends is secondary to service-connected PTSD. For the reasons set forth below, the Board finds that this matter must be remanded for additional evidentiary development. VA treatment records dated in July 2010 document the Veteran's report of syncopal episodes ("black-outs"), which began earlier in the year. It was noted that the Veteran's syncope is "most likely vasovagal." See the VA treatment record dated July 2010. In February 2011, the Veteran's treating physician stated "[e]tiology of episodes possibly seizures versus cardiogenic syncope." A prolonged multi-day electroencephalogram (EEG) conducted in February 2011 yielded results within normal limits. It was noted that the Veteran experienced "multiple coughing episodes with associated symptoms, and these spells were nonepileptic in nature." See the EEG report dated February 2011. However, treatment records show that the Veteran continues to suffer from episodes of syncope. See, e.g., the VA treatment records dated July 2012 and November 2015. As noted above, the Veteran has contended that he suffers from these episodes due to his service-connected PTSD. He has not yet been afforded a VA examination as to his claimed seizure disorder. The Veteran has not been afforded a VA examination with respect to claim of entitlement to service connection for seizure disorder. As such, the Board finds that this matter must be remanded in order to afford the Veteran a VA examination as to the diagnosis and etiology of the claimed disability. See Charles v. Principi, 16 Vet. App. 270 (2002); see also 38 C.F.R. § 3.159(c)(4) (2017) (a medical examination or opinion is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim). Prior to arranging for the Veteran to undergo further VA examination, to ensure that all due process requirements are met, and that the record is complete, the AOJ should undertake appropriate action to obtain all pertinent, outstanding records. Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding records of VA evaluation and/or treatment of the Veteran. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with respect to requesting records from Federal facilities. All records/responses received should be associated with the claims file. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his claimed seizure disorder. All indicated tests and studies should be conducted. The contents of the electronic claims file must be made available to the examiner for review in connection with the examination. The examiner should either diagnose or rule out a seizure disorder or disability manifested by syncopal episodes. With respect to any diagnosed seizure/syncopal disability, the examiner should render an opinion, with supporting rationale, addressing: (a). whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the disability had its onset in service or is otherwise medically related to in-service injury or disease. (b). whether it is at least as likely as not that any diagnosed seizure disorder or disability manifested by syncopal episodes was caused by a service-connected disability, to specifically include PTSD? (c). whether it is at least as likely as not that the Veteran's diagnosed seizure disorder or disability manifested by syncopal episodes is aggravated (made worse as shown by comparing the current disability to medical evidence created prior to any aggravation) by a service-connected disability, to specifically include PTSD? If the Veteran's diagnosed seizure disorder or disability manifested by syncopal episodes is aggravated by a service-connected disability, the examiner should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. In addressing the above, the examiner must consider and discuss all pertinent medical, periodical, and other objective in- and post-service evidence, and all lay assertions. In this regard, the examiner should note that the absence of evidence of treatment for a claimed disability in the Veteran's service treatment records should not serve as the sole basis for a negative opinion. The examiner is also advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. All examination findings/testing results (if any), along with complete, clearly-stated rationale for the conclusions reached, must be provided. 3. Thereafter, readjudicate the claim remaining on appeal. If a benefit sought remains denied, the Veteran and his attorney should be provided a supplemental statement of the case and given an opportunity to respond before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter or 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 remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2012). ______________________________________________ JAMES L. MARCH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs