Citation Nr: 1804803 Decision Date: 01/25/18 Archive Date: 02/05/18 DOCKET NO. 14-24 671 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Evaluation of posttraumatic stress disorder, currently evaluated as 70 percent disabling. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1968 to January 1970. This matter is before the Board of Veterans Appeals (Board) on appeal from a March 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi, that granted a 70 percent rating for PTSD, effective November 2, 2011, and that denied a TDIU. The Veteran testified before the undersigned Veterans Law Judge (VLJ) in May 2017. A copy of the hearing transcript has been associated with the claims file. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND A remand is necessary for additional development. The Veteran's two separate Applications for Increased Compensation Based on Unemployability forms and a disability report submitted to the Social Security Administration (SSA) show that he reported last working full time in August 1997, August 1999, and July 2001 respectively. Social Security Administration (SSA) records show that the Veteran has been permanently disabled due to affective/mood disorders and secondarily due to mental retardation since May 2004. SSA in part cited a mental health assessment by a physician in August 2004 that is of record. In a January 2011 VA examination, a VA physician noted the Veteran's reports of insomnia, nightmares and combat content that occurred several times per month. He reported depression, intrusive thoughts of combat, exaggerated startle response, a foreshortened sense of future, and occasional suicidal thoughts in the past, but no longer has them. He was noted to have a restricted affect and he reported that he felt numb a lot. H reported that he tended to be hypervigilant and sensitive to his environment with significantly impaired concentration. The Veteran indicated that he preferred to be by himself and stays in his room most of the day. Upon a mental status examination, the VA examiner noted that the Veteran was pleasant and cooperative, alert and oriented to person, place, date, and situation. His mood was described as tense and his affect was restricted. He denied any suicidal or homicidal ideation. The VA examiner rendered a diagnosis of posttraumatic stress disorder with a Global Assessment of Functioning score of 55. The VA examiner indicated that the Veteran's symptoms were of moderate severity. The VA examiner opined that the Veteran was competent to manage his affairs in his own best interest. The Veteran was afforded another VA examination in February 2012. The VA examiner found that the Veteran had experienced, witnessed, or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. His response involved fear, helplessness, or horror. He had recurrent distressing dreams of the event. He had efforts to avoid thoughts, feelings or conversations associated with trauma. He had efforts to avoid activities places or people that arouse recollections of the trauma. He had a feeling of detachment or estrangement from others. He had difficulty falling or staying asleep. He had irritability or outbursts of anger. He had exaggerated startled response. The VA examiner found that the symptoms described cause clinically significant stress or impairment in social, occupational, or other areas of functioning. They included depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relations, and difficulty adapting to stressful circumstances, including a work like setting. The examiner found that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. The Veteran and his spouse testified in May 2017 regarding his PTSD. He testified that he experienced paranoia and hallucinations. He thought about Vietnam and has been talking about it more on a daily basis. He had related bad dreams, and difficulty sleeping. He experienced concentration and memory deficits and misplaces things. He had trouble because he did not like authority. The Veteran's spouse testified that the Veteran has been getting worse since the last time he was examined. She has to keep track of his medicine to make sure he has enough and takes it. She handles the money. The Veteran sometimes drives a vehicle but no longer does much shopping. While a new examination is not required simply because of the time which has passed since the last examination, VA's General Counsel has indicated that a new examination is appropriate when there is evidence of an increase in severity since the last examination. VAOPGCPREC 11-95 (1995). Accordingly, the Board finds that a new VA examination is necessary to determine the current severity of the Veteran's service-connected PTSD. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995); see also 38 C.F.R. § 3.327 (a reexamination will be requested whenever there is a need to verify the current severity of a disability). Regarding the claim for a TDIU, consideration of entitlement to TDIU is dependent upon the impact of service-connected disabilities on a Veteran's ability to obtain or retain substantially gainful employment. The matter of TDIU is therefore inextricably intertwined with the currently open claims for an increased rating for PTSD. Harris v. Derwinski, 1 Vet. App. 180 (1991). Remand of the inextricably intertwined TDIU claim is therefore required as well. Finally, as these matters are being remanded, updated VA treatment records may be obtained and associated with the claims file. Accordingly, the case is REMANDED for the following actions: 1. Obtain updated copies of the Veteran's VA treatment records, and associate them with the claims file. 2. After obtaining all outstanding records, the Veteran should be afforded an appropriate VA examination to determine the current nature and severity of his PTSD. The entire claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The examiner should identify the nature and severity of all current manifestations of the Veteran's service-connected PTSD. The examiner must also comment on the impact such disability has on the Veteran's social and occupational functioning by addressing the particular occupational skills, function, and cognition that do or do not impair or preclude employment consistent with the Veteran's education and previous experience. 3. After the development requested above has been completed to the extent possible, the RO should again review the record. If any benefit sought on appeal, for which a notice of disagreement has been filed, remains denied, the Veteran and his representative should be furnished a supplemental statement of the case (SSOC) and given the opportunity to respond thereto. The appellant 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 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. §§ 5109B, 7112 (2012). _________________________________________________ J. W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2017).