Citation Nr: 1806178 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 03-29 551 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an earlier effective date than December 13, 2001, for a grant of service connection for an acquired psychiatric disability, to include PTSD. 2. Entitlement to an initial rating greater than 70 percent for an acquired psychiatric disability, to include posttraumatic stress disorder (PTSD). 3. Entitlement to an initial rating greater than 10 percent for irritable bowel syndrome. 4. Entitlement to a total disability rating based on individual unemployability (TDIU) due to a service-connected psychiatric disorder. 5. Entitlement to service connection for bilateral extremity numbness (alternatively claimed as joint/knee/shoulder pain), including as a manifestation of an undiagnosed illness or chronic multisymptom illness due to exposure to Gulf War hazards, and to include as secondary to service-connected PTSD. REPRESENTATION Veteran represented by: John F. Cameron, Attorney ATTORNEY FOR THE BOARD Marcus J. Colicelli, Associate Counsel INTRODUCTION The Veteran had active service from July 1985 to August 1992, including in the southwest Asia Theater of operations during the Persian Gulf War. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a 2003 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which granted service connection for irritable bowel syndrome (IBS), assigning a 10 percent rating effective March 1, 2002, and denied service connection for bilateral extremity numbness. In October 2009, the Board denied, in pertinent part, the claim for an initial rating greater than 10 percent for IBS. The Veteran, through his attorney, appealed the Board's October 2009 decision to the United States Court of Appeals for Veterans Claims (Court). In a March 2012 decision, the Court vacated and remanded the Board's denial of the higher initial rating claim for IBS. In January 2013, the Board remanded this case again for additional development. The Veteran also appealed an August 2015 rating decision in which the RO granted service connection for an acquired psychiatric disability, to include PTSD ("acquired psychiatric disability"), assigning a 70 percent rating effective December 13, 2001. The issue of entitlement to a TDIU was not certified for appeal. However, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). In the present case, the issue of entitlement to a TDIU was raised in conjunction with the Veteran's PTSD disability. See August 2017 Veteran statement ("Since January 2002 I have not been able to work at all because of the disabling symptoms of my psychiatric disabilities including posttraumatic stress disorder, irritable bowel syndrome, and painful knees.") Accordingly, in light of the Court's holding in Rice, the issue of entitlement to a TDIU has been raised by the record and is within the jurisdiction of the Board. As previously discussed in the Board's January 2017 decision, counsel for the Veteran has continued to assert that the issue of service connection for a bilateral knee disability remained on appeal. See September 2017 Attorney correspondence. A review of the record does not support this argument, as the Court affirmed in March 2012 the Board's October 2009 denial of the Veteran's service connection claim for a bilateral knee disability, and the decision was not appealed and is now final. Thus, the issue of whether there exists new and material evidence to reopen the issue of entitlement to service connection for a bilateral knee disability has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2017). FINDINGS OF FACT 1. No communication received prior to December 13, 2001 may be interpreted as an informal claim for entitlement to service connection for PTSD. 2. For the entire period on appeal, the evidence of record does not reflect that the Veteran's PTSD was manifested by total occupational and social impairment. 3. The Veteran's irritable bowel syndrome is manifested by, at worst, intermittent diarrhea and abdominal distress, which is not constant. 4. The evidence of record supports a finding that the Veteran's service-connected disabilities, including PTSD, render him unable to secure and follow substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an earlier effective date of December 13, 2001, for the grant of service connection for PTSD, have not been met. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5103A, 5107, 5110, 5126, 7105 (West 2012); 38 C.F.R. §§ 3.102, 3.155, 3.156, 3.157, 3.159, 3.326(a), 3.400 (2017). 2. For the entire period on appeal, the criteria for a rating higher than 70 percent for PTSD have not been met. 38 U.S.C. § 1155 (West 2012); 38 C.F.R. §§ 4.1-4.14, 4.130, Diagnostic Code (DC) 9411 (2017). 3. The criteria for an initial rating greater than 10 percent for irritable bowel syndrome (IBS) have not been met. 38 U.S.C. §§ 1155, 5107 (West 2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.114, DC 7319 (2017). 4. The criteria for TDIU have been met. 38 U.S.C. §§ 5110(a), 5107(b) (2012); 38 C.F.R. §§ 3.400, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist With regard to the specific issues adjudicated below, the Veteran has not raised any concern with the duties to notify or 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). The Board acknowledges that the Veteran has called into question the duty to assist regarding the adequacy of certain existing VA medical opinions and compliance with prior Board remand instructions. The Board finds that these concerns are limited to the issue of entitlement to bilateral extremity numbness, and are wholly addressed in the Remand portion of the decision below. Earlier Effective Date An August 2015 rating decision granted service connection for PTSD, effective from December 13, 2001. The Veteran asserts that the effective date for PTSD should be earlier as "my claim goes back farther than 2002, I filed a claim for my condition in 1994 or sometime near this period." See April 2003 Veteran correspondence. Applicable Law The effective date of an evaluation and award of compensation on an original claim for compensation will be the day following separation from active duty service or the date entitlement arose if the claim is received within one year after separation from service; otherwise, date of receipt of claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (b)(2). For VA compensation purposes, a "claim" is defined as "a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit." 38 C.F.R. § 3.1 (p). An informal claim is "[a]ny communication or action indicating an intent to apply for one or more benefits." It must "identify the benefit sought." 38 C.F.R. § 3.155 (a). Thus, the essential elements for any claim, whether formal or informal, are "(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing." Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009). VA must look to all communications from a claimant that may be interpreted as an application or claim, both formal and informal, for benefits and is required to identify and act on informal claims for benefits. Servello v. Derwinski, 3 Vet. App. 196, 198 (1992). Facts & Analysis In VA Form 21-4138 stamped received by the RO on December 13, 2001, the Veteran raised a new claim for entitlement to service connection for PTSD. The RO subsequently adjudicated the matter in a January 2003 rating decision that began a series of appeals eventually leading to the grant of service connection in August 2015, with an assigned effective date of December 13, 2001. The Veteran separated from active duty in August 1992. The record does reflect that he raised a claim for entitlement to service connection for his knees and hearing loss within a year of discharge, but did not identify any claimed entitlement to an acquired psychiatric disorder. See October 1992 Rating Decision. Moreover, unlike his knees or hearing loss, the Veteran denied any depression or other mental health issue on his 1992 self-report of medical history, and no mental health problem was identified on his discharge examination. See June 1992 Report of Medical Examination. Because the Veteran did not apply for service connection for a psychiatric disorder within one year of separation from service, an effective date back to the day following discharge is not possible. The Board has also considered whether any evidence of record prior to December 2001 could serve as an informal claim. In this regard, any communication or action, indicating intent to apply for one or more benefits under the laws administered by VA, from a claimant, his or her duly authorized representative, a Member of Congress, or some person acting as next friend of a claimant who is not sui juris may be considered an informal claim. Such informal claim must identify the benefit sought. 38 C.F.R. § 3.155. The Board has reviewed the evidence to determine whether any communication submitted by the Veteran indicates an attempt to apply for service connection for a psychiatric disorder. There is no evidence of record that indicates an attempt to apply for service connection for this issue prior to December 2001, to include all documentation associated with the record contemporaneous to 1994 as claimed by the Veteran. While the Board notes the Veteran's arguments that he suffered from symptomatology related to PTSD prior to the current effective date, there is no reference anywhere in the record that he submitted evidence of his symptoms to serve as a claim for compensation benefits, prior to December 13, 2001. Moreover, the Veteran's December 2001 claim temporally coincides with his initial treatment for PTSD/depression with the VA, thus making the propriety of a claim prior to this period unlikely. See December 2001 VA Form 21-4138 ("The doctors at the VA have made a diagnosis of PTSD and have scheduled me for that PTSD class"); see also September 2017 Vocational Evaluation ("It appears that [Veteran] was first diagnosed with PTSD in June 2001"). In sum, the presently assigned effective date of December 13, 2001, is appropriate and there is no basis for an award of service connection for PTSD prior to this date. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Increased Ratings Disability evaluations are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The percentage ratings in VA's Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Staged ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). PTSD PTSD is evaluated under a general rating formula for mental disorders. See 38 C.F.R. § 4.130, DC 9411 (2017). A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, 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); and the inability to establish and maintain effective relationships. A 100 percent rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). On the other hand, if the evidence shows that a Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The United States Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Ultimately in Mauerhan, the Court upheld the Board's decision noting that the Board had considered all of the Veteran's psychiatric symptoms, whether listed in the rating criteria or not, and had assigned a rating based on the level of occupational and social impairment. Mauerhan, supra at 444. In Vasquez-Claudio v. Shinseki, F.3d 112, 117 (Fed. Cir. 2013), the Court also held 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. The Court further held that, in assessing whether a particular disability rating is warranted requires a two-part analysis, including (1) an initial assessment of the symptoms displayed by the Veteran and, if they are of the kind enumerated in the regulation and (2) an assessment of whether those symptoms result in the occupational and social impairment contemplated by that particular rating. See id. at 118. Indeed, considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). It should be noted that prior to August 4, 2014, VA's Rating Schedule that addresses service connected psychiatric disabilities was based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "DSM-IV"). 38 C.F.R. § 4.130. Like this case, diagnoses many times included an Axis V diagnosis, or a Global Assessment of Functioning ("GAF") score (explained in more detail below). The DSM was recently updated with a 5th Edition ("DSM-V"), and VA issued an interim final rule amending certain provisions in the regulations to reflect this update, including the Schedule for Rating Disabilities. 70 Fed. Reg. 45093((Aug. 4, 2014). This updated medical text recommends that GAF scores be dropped due to their "conceptual lack of clarity." See DSM-V, at 16. However, since the Veteran's PTSD claim was originally appealed to the Board prior to the adoption of the DSM-V, the DSM-IV criteria will also be utilized in the analysis set forth below. Regarding the Global Assessment of Functioning (GAF), it is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as indicating 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). See Carpenter v. Brown, 8 Vet. App. 240, 242- 244 (1995). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2017). Facts & Analysis Having carefully considered the Veteran's contentions in light of the medical and lay evidence of record and the applicable law, the Board finds that for the entire period on appeal, the Veteran's PTSD does not more nearly approximate a 100 percent rating for any portion of the period on appeal. As such, the Board finds that the Veteran's symptoms have, throughout the entire period on appeal, caused occupational and social impairment with deficiencies in most areas, such as work, family and social relations, thinking and mood, but have not resulted in total occupational and social impairment. In an August 2015 rating decision, the Veteran was awarded service connection for PTSD and assigned an initial 70 percent disability rating, effective December 13, 2001. The medical evidence of record reflects intermittent mental health treatment beginning in late 2001 including medicinal therapy and group PTSD sessions for moderate symptoms of depression, nightmares, flashbacks, poor concentration and occasional severe symptoms including suicidal ideation, homicidal ideation, and severe anxiety. The symptoms demonstrate an overall GAF score range between 45 and 60 with the average skewing towards the moderate end of the spectrum, which resulted in a determination of disability by the Social Security Administration (SSA) in February 2002 with reaffirmation of the debilitating mental condition in 2006. See i.e. December 2001 VAMC Mental Health note ("Diagnosis: depression...he is a single parent now...severe anxiety, re-experiencing a traumatic event, separation of marriage, suicidal thoughts w/o plan, homicidal thoughts w/o plan, abusiveness, increased startle, irritability, chronic severe joint pain, being hassled by his supervisor at work...impression: PTSD, chronic, severe, MDD severe, chronic pain, job-related issues GAF = 55"); February 2002 VAMC Mental Status note ("meds causing drowsiness, sexual dysf, poor sleep with nightmares, anger, flashbacks...not able to function on job due to drowsiness...intolerant of children which leads to isolation...denies SI/HI...thought of shooting self while hunting friends had to take gun away...speech/demeanor/motor normal...mood dysthymic...cognitive x3...GAF 45"); September 2002 VAMC Dr. McNutt ("problems in his relationships with other people have deteriorated severely in recent years due to PTSD and this has adversely affected his job, family and his ability to socialize with friends...orientated times three, cooperative, restless and distractible, exhibited difficulty in focusing...markedly impaired in responding appropriately to supervision...physical and psychiatric problems impair this veteran"); May 2003 VAMC PTSD Group ("Vet participated well, giving some good ways to deal with conflicts"); March 2004 VAMC Mental Health note ("difficult time with marriage which ended in divorce...appropriately dressed, cooperative, speech normal, mood dysthymic, thoughts normal...appears to be psychiatrically stable but has many physical complaints"); July 2007 VAMC Mental Health consult ("seeks help with management of PTSD related symptoms, nightmares...depression, nervousness, sleep problems, suicidal thoughts, problems controlling anger, difficulty controlling violent behavior...will continue to participate in anger management"); July 2012 VAMC Mental Health note ("last seen in MHC by Dr. Pugh on 8-29-08...reports that mood is better even though he still has flashbacks and chronic pain...been compliant with medications...mood fair, speech normal, cooperative, thought normal, judgment/insight intact"); February 2013 VAMC Mental Health note ("mood has been stable, sleep and appetite are good, denies S/H ideations...GAF 60"); April 2015 VAMC Mental Health note ("denies SI/HI/AVH/SE...sleep is still a problem...increased AH, mood swings, increased depression, feels at times he can't take it and would be better off dead...reports these symptoms returned after he ran out of several meds"); May 2016 VAMC Mental Health note ("followed in MHC with supportive psychotherapy and medication management...reports that mood has been stable...PT has problems taking his medicine which he thinks contribute to his sleep problems...nightmares...denies S/H ideations...marital problems...some auditory hallucinations"). The evidence additionally includes multiple VA psychiatric opinions and statements from the Veteran and his spouse corroborating the treatment record, identifying consistent symptomatology with occasional ebbs and flows as demonstrated by the above noted mental health excerpts. For example, the March 2002 VA examiner noted GAF of 51 and "moderate social and occupational impact" from PTSD symptoms, which included suicidal/homicidal ideation w/o plan, impaired concentration and memory with depressed mood, chronic sleep impairment and full orientation. Similarly, the September 2011 VA examiner opined that the symptoms were "mild to moderate" and included irritability, anger, isolation, depression, impacted social/occupational functioning, and denial of suicidal thoughts. At the most recent examination in August 2015, the Veteran reported "occasional" work as a substitute teacher, refusing jobs that last more than a day or more than one to four weeks so he can avoid field trips and long term planning. He collects SSA disability, and lives with his wife of six years whom he has been with for twelve years total, rearing his step-children but rarely seeing his own daughter. The Veteran also reported that he "he caught his wife cheating" due to his self-imposed isolation, and has a lack of interest in hobbies like basketball. Mental status evaluation demonstrated nearly identical results, noting symptoms including increased drinking to dull leg pain, depression, anxiety, suspiciousness, chronic sleep problems, mild memory loss, mood disturbance, suicidal ideation and difficulty in maintaining and establishing effective work and social relationships, and the examiner opined that the Veteran's symptoms cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning." Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, the Board finds that the current 70 percent rating appropriately reflects the level of severity of the Veteran's PTSD. As noted above, the Veteran has suffered from a consistent litany of symptoms with consistent GAF scores in the 45 to 60 range, stabilized throughout the period on appeal, including anger, depression, occasional suicidal thoughts, irritability, difficulty sleeping, and impairment in occupational and social relationships. A rating higher than 70 percent is not warranted. There is no evidence that the Veteran experiences symptoms of total social and occupational impairment. For example, he did not have symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, or grossly inappropriate behavior. In fact, during the VA examinations, the Veteran was appropriately groomed, cooperative, and oriented to time and place. Furthermore, throughout the course of the appeal, it was noted that the Veteran maintained his relationship of over ten years duration, weathering a divorce and separation, raised children and step-children, and participated in activities including occasional substitute teaching and hunting. As for occupational impairment, while grounds for TDIU has been shown as will be discussed below, along with significant social impairment, the 100 schedular criteria are not shown. The evidence demonstrates that the Veteran is able to communicate with others, albeit with some observed difficulties that are contemplated by the 70 percent rating now in effect. Moreover, as noted above, the Veteran's GAF scores during the appeal period have consistently ranged from 45 to 60, reflecting serious symptoms (in the 40's) to moderate symptoms (in the 50's). Lower GAF scores are available for individuals exhibiting some impairment in reality testing or communication, or any major impairment in several areas (see, e.g., GAF range of 31 to 40), and have not been assigned to this Veteran, indicating that he has not been regarded as exhibiting the most severe categories of functional impairments. The Board realizes that the symptoms noted in the rating criteria are not intended to be an exhaustive list, but are examples of the types and severity of symptoms that indicate a certain level of disability. Thus, the Board believes that based on the overall record, including the Veteran and his spouse's lay statements, the effects of the Veteran's PTSD symptoms were not described to be of a type, frequency, and severity that are in accord with the level of impairment contemplated by the criteria for a 100 percent schedular rating. The Board concludes that the symptomatology noted in the medical and lay evidence has been adequately addressed by the evaluation assigned and do not more nearly approximate the criteria for a higher evaluation at any time during all relevant periods on appeal. See 38 C.F.R. § 4.130, DC 9411. The Board has considered whether any additional Diagnostic Codes would yield an increased rating; however, as the Veteran is diagnosed with PTSD, the most appropriate Diagnostic Code is 9411 for PTSD symptoms. Irritable Bowel Syndrome The Veteran's irritable bowel syndrome (IBS) is currently evaluated as 10 percent disabling effective March 1, 2002, under 38 C.F.R. § 4.114 , DC 7319 (irritable colon syndrome). See 38 C.F.R. § 4.114 , DC 7319 (2017). A 10 percent rating is assigned under DC 7319 for moderate irritable colon syndrome with frequent episodes of bowel disturbance with abdominal distress. A maximum 30 percent rating is assigned for severe irritable colon syndrome with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. Id. Facts & Analysis The Veteran contends that his IBS is severely disabling and results in constant abdominal pain and distress and diarrhea. See September 2017 Attorney correspondence ("[Veteran] is entitled to a rating higher than 10% for his irritable bowel syndrome...April 2008 [VA examiner] stated that his IBS had significant effects on occupation...April 8, 2014 [VA examiner] documented episodes of bowel disturbances with frequent abdominal distress...stated he still has daily unpredictable problems with diarrhea presently in 2017.") For the reasons described below, the Board concludes that an initial rating greater than 10 percent for IBS is not warranted. VA intestines examination in March 2002 documented complaints of stomach pain. A history of dysphagia and epigastric pain was noted. The Veteran reported vomiting, especially at night, with chest discomfort waking him up and making him vomit which happened 3 times a month. He also experienced loose bowels at least 4 times a day and with eating and abdominal cramping. Physical examination showed a soft abdomen. The impressions included irritable bowel, no cause found, and normal bowel x-rays. VA examination in November 2004 noted complaints of episodic diarrhea 3 days a week with symptoms based on food intake as certain foods caused increased symptoms. He took omeprazole 20 mg twice a day for his irritable bowel syndrome which sometimes helped his symptoms and sometimes did not help. Physical examination showed a non-distended abdomen, bowel sounds present in all 4 quadrants, mild tenderness just above the symphysis pubis but otherwise normal to palpation, and no hepatosplenomegaly, ventral hernia, or masses. The impressions included IBS. In a VA examination report dated in April 2008, it was recorded the Veteran had loose bowel movements 2 days out of the week, and on those days has 2 loose bowel movements. Effects on usual occupation (maintenance man) were described as significant, and "Other Effects On Occupational Activities" were indicated as "has frequent vomiting while working. Result in loss job. Also got depressed at the time." Notably, elsewhere in the report, the vomiting was associated with the Veteran's acid reflux, rather than his bowel condition, and his unemployment was associated with leg pain, rather than his bowel condition. Private outpatient treatment in January 2009 included complaints of intermittent diarrhea and abdominal pain and cramping which occurred "every few days." His abdominal pain associated with diarrhea improved after he defecated. A past diagnosis of irritable bowel syndrome was noted. Physical examination showed a soft, non-tender abdomen with minimal tenderness to palpation in the infra umbilical area, normal active bowel sounds, and no hepatosplenomegaly, masses, or ascites. The impressions included intermittent diarrhea "with what sounds like" IBS. VA outpatient treatment in January 2013 included complaints of "a rumbling stomach and diarrhea after arguments." Objective examination showed a soft, non-tender abdomen. The assessment included symptomatic IBS. The Veteran started a trial of Bentyl 10 mg 4 times daily. VA intestinal conditions DBQ in April 2014 showed complaints of cramping and diarrhea due to "nerves in my stomach" after consuming several beers when the Veteran is upset and angry. He drank 3-4 beers a day and was upset most of the time. He also complained of forcing himself to vomit due to a feeling of something stuck in his throat. He complained further of constant soreness in the right upper quadrant. The Veteran took pantoprazole 40 mg twice a day for control of his intestinal condition. He had diarrhea. The VA examiner stated that the Veteran had frequent episodes of bowel disturbance with abdominal distress but not more or less constant abdominal distress and 7 or more exacerbations and/or attacks of the intestinal condition in the previous 12 months. Notably, the Veteran reported his IBS had not worsened and the examiner observed the Veteran's upper GI disabilities, which are not service connected and are alcohol abuse related, far over shadow the Veteran's IBS. The examiner added that the Veteran's "borderline" anemia was most likely due to microscopic blood loss from his upper gastrointestinal/duodenal issues rather than from his IBS diarrhea. VA outpatient treatment in May 2014 showed IBS complaints, but later records are silent in this regard. See i.e. June 2015 Primary Care note ("GI: denies abdominal pain, no nausea, no vomiting, no diarrhea, no constipation"); May 2016 Primary Care note (Listed symptoms do not reflect diarrhea or constipation.) The Board is persuaded by the findings above, that the Veteran's IBS is manifested by, at worst, moderate symptoms with frequent episodes of bowel disturbance with abdominal distress (i.e., a 10 percent rating under DC 7319) throughout the appeal period. See 38 C.F.R. § 4.114, DC 7319. The April 2014 VA examiner specifically found that the Veteran's IBS is manifested by frequent episodes of bowel disturbance with abdominal distress but not more or less constant abdominal distress (as is required for a 30 percent rating under DC 7319). Id. The record evidence also suggests that the Veteran's IBS symptomatology is controlled. Moreover, as noted above, the Veteran's symptomatology has only improved over time without reports of diarrhea/constipation since 2015. In addition, as identified by the 2014 VA examiner, the non-service connected upper GI issues appear to have caused symptomatology that the Veteran appears to have conflated with his IBS that has shown nothing but improvement during the course of the appeal. The Veteran is competent to state what he believes he experiences as a result of his IBS. See Layno, 6 Vet. App. at 470. Nevertheless, the record does not show that the Veteran experiences more than moderate symptoms with frequent episodes of bowel disturbance with abdominal distress (i.e., a 10 percent rating under DC 7319) as to warrant an evaluation in excess of 10 percent at any time during the appeal period. Accordingly, the Board finds that the criteria for an initial rating greater than 10 percent for irritable bowel syndrome is not indicated. See 38 C.F.R. § 4.114 , DC 7319. TDIU Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). The Veteran's currently-assigned disability rating for his psychiatric disorder (i.e. 70 percent) together with his 10 percent rating for IBS yields a combined evaluation of 70 percent. This satisfies the criteria for consideration of TDIU on a schedular basis. VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the veteran is precluded, by reason of his service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. Unlike the analysis for increased rating claims, which are based on average levels of impairment, the analysis for a TDIU claim is based upon the individual. Consideration may be given to a veteran's level of education, special training, and previous work experience, but not to his age or the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Unlike the regular disability rating schedule which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). The ultimate question of whether a Veteran is capable of substantial gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013) ("[A]pplicable regulations place responsibility for the ultimate TDIU determination on the VA, not a medical examiner"). The Veteran has provided multiple statements that his psychiatric symptoms have caused significant negative impacts on his ability to work, including anger and irritability toward supervisors, and isolation with severe anxiety. Although the Veteran has also indicated that he has worked sporadically as a substitute teacher on occasion, the Board does not consider this marginal activity to be gainful employment. The significant effects of the Veteran's psychiatric disorder on his employability are also borne out by his VA treatment records and Vet Center summaries. Moreover, a review of the record shows that the Veteran's contentions have been corroborated by the SSA which found the Veteran to be disabled due to his psychiatric conditions, and multiple examiners including the aforementioned VA psychiatric evaluators and, recently, in a September 2017 Vocational Management Services report submitted by his attorney. As the evidence shows that the Veteran is unable to obtain and maintain gainful employment as a result of his service-connected disability, the assignment of TDIU benefits is warranted. ORDER Entitlement to an effective date earlier than December 13, 2001 for the grant of service connection for PTSD, is denied. Entitlement to an initial evaluation in excess of 70 percent disabling for PTSD, is denied. Entitlement to an initial evaluation in excess of 10 percent disabling for IBS, is denied. Subject to the law and regulations governing payment of monetary benefits, entitlement to TDIU is granted. REMAND A review of the record demonstrates that alternative theories raised regarding the etiology of the Veteran's bilateral extremity numbness/upper and lower joint discomfort have not been sufficiently developed, despite past guidance from both the Board and the Court. See September 2017 Attorney correspondence. The Board is required to consider all issues raised either by the claimant or by the evidence of record. Robinson v. Mansfield, 21 Vet. App. 545, 552 (2008). When determining service connection, all theories of entitlement, direct and secondary, must be considered. Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). Specifically, the Board finds that a medical opinion is needed as to whether the Veteran's claimed signs and symptoms of joint/knee/shoulder pain and discomfort may be considered as due to undiagnosed illness, on a direct basis, or as a medically unexplained chronic multisymptom illness (MUCMI). A medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317(a)(2)(i)(B). A medical opinion should be obtained upon remand that specifically considers whether the claimed signs or symptoms proffered by the Veteran are due to a MUCMI that is defined by a cluster of signs or symptoms, or are individual pathologies which are or are not traceable to active duty service. As articulated in the Board's 2009 Remand decision, to date, he has not been afforded a VA Gulf War examination despite ongoing complaints of joint pain for many years following active duty, particularly in his knees and shoulders upon his return from service in the Persian Gulf region (January to May 1991), and limited medical evidence supporting such a theory including an April 2002 VA treatment note where the doctor stated that the Veteran probably had an element of post-gulf syndrome, but he then added that was unable to state whether there was an internal problem with the Veteran's knee due to the limited examination. Additionally, the Board acknowledges that further clarification is required regarding the proposed correlation between the Veteran's upper/lower extremity difficulties and his mental health. Specifically, an April 2014 VA neurologist did not provide a clinical diagnosis for the Veteran's bilateral extremity condition, but postulated a potential relationship between the ongoing discomfort and a psychiatric diagnosis, stating that further insight into this notion was "beyond my area of expertise." In light of the Veteran's ongoing symptoms and the above, suggestive medical evidence, a possible relationship to service is indicated and the low threshold set forth in McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) is met. Thus, VA Psychiatric and Gulf War examinations are needed to clarify whether any current bilateral extremity numbness/discomfort is related to service as a manifestation of an undiagnosed illness or chronic multisymptom illness due to exposure to Gulf War hazards, or as secondary to service-connected PTSD. Accordingly, the case is REMANDED for the following actions: 1. With any necessary assistance from the Veteran, attempt to obtain updated VA and private medical records of treatment or evaluation of any bilateral upper/lower extremity numbness, pain, discomfort, etc. that is not already on file, and associate them with the electronic claims file. 2. Schedule the Veteran for an appropriate VA examination as to the claimed bilateral upper/lower extremity numbness/pain/discomfort as to whether such complaints are related to military service. The VA examiner should conduct all necessary testing to rule out a diagnosis for the claimed signs and symptoms of bilateral numbness/pain discomfort, primarily of the knees/shoulders. The VA examiner should characterize the Veteran's claimed disabilities as belonging to one of four disability patterns: (1) undiagnosed illness, (2) a diagnosable, but medically unexplained chronic multisymptom illness of unknown etiology, (3) a diagnosable chronic, multisymptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology. With regard to any diagnosed disorder, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current disability is related to service, to include the Veteran's service in the Persian Gulf. Should a diagnosis be found, the examiner is asked to determine: Is it at least as likely as not (50 percent probability or greater) that the Veteran's disorder(s) had its onset in service or is otherwise attributable to service? Is it at least as likely as not that any bilateral upper/lower extremity disorder is caused or aggravated by the service-connected PTSD? The opinion of the April 2014 VA examiner and the Veteran's lay statements in this regard should be considered. Any opinions expressed by the examiner should be accompanied by a complete rationale. 3. Readjudicate the claims on appeal in light of all of the evidence of record, including evidence received since the supplemental statements of the case. If the appeal remains denied, the Veteran should be provided with a supplemental statement of the case as to the issues on appeal, and afforded a reasonable period of time within which to respond. 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. §§ 5109B, 7112 (West 2012). ______________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs