Citation Nr: 1806294 Decision Date: 01/31/18 Archive Date: 02/07/18 DOCKET NO. 09-14 628 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been submitted to reopen the Veteran's claim of entitlement to service connection for peripheral neuropathy. 2. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to September 18, 2017, and entitlement to a disability rating in excess of 70 percent thereafter. 3. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Colin F. Kemmerly, Attorney ATTORNEY FOR THE BOARD A. N. Nolley, Associate Counsel INTRODUCTION The Veteran had honorable active duty service with the United States Army from August 1969 to March 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2008, March 2011 and February 2014 rating decisions of the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA). In a November 2017 rating decision, the RO increased the assigned disability rating for the Veteran's PTSD from 30 percent to 70 percent on and after September 18, 2017. However, because the increased disability rating assigned is not the maximum rating available throughout the period on appeal, the claim remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The reopened issue of entitlement to service connection for peripheral neuropathy is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). (CONTINUED ON NEXT PAGE) FINDINGS OF FACT 1. A May 2006 rating decision denied the claim of entitlement to service connection for peripheral neuropathy; the Veteran did not appeal the decision or submit any pertinent evidence within the appeal period. Therefore, the decision is final. 2. Evidence received subsequent to the expiration of the appeal period is not cumulative or redundant of the evidence previously of record and relates to an unestablished fact necessary to substantiate the claims for a peripheral neuropathy. 3. During the entire period of the claim, the social and occupational impairment from the Veteran's PTSD has more nearly approximated total impairment rather than impairment in most areas. 4. In light of the assignment of a 100 percent disability rating for the Veteran's service-connected PTSD, his claim for TDIU is rendered moot. CONCLUSIONS OF LAW 1. New and material evidence has been presented to reopen the claim of entitlement to service connection for peripheral neuropathy. 38 U.S.C.A. § 5108 (West 2014); 38 C.F.R. § 3.156 (2017). 2. The Veteran's PTSD warrants a rating of 100 percent throughout the entire period of the claim. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2017). 3. The grant of a 100 percent rating for PTSD renders moot the appeal for a TDIU. 38 U.S.C.A. § 1155(West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Neither the Veteran nor his representative has raised any 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 a duty to assist argument). Burden of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. New and Material Evidence Generally, if a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C.A. § 5108 (West 2014). "New" evidence is defined as existing evidence not previously submitted to agency decision-makers. "Material" evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative, nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156 (a). The threshold to reopen a claim is low. Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The RO initially denied service connection for peripheral neuropathy in September 2003. The denial was confirmed and continued in March 2004 and October 2004 rating decisions. In May 2006, the RO reopened the claim and denied it on the merits, finding that the Veteran was not entitled to service connection because the medical records did not show that the Veteran received a diagnosis of acute or subacute peripheral neuropathy during service or within the presumptive period. He did not appeal the denials or submit any pertinent evidence within the appeal periods. Therefore, the decisions are final. See 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. §§ 20.201, 20.302, 20.1103 (2017). In January 2008, the Veteran filed a claim to reopen the issue of entitlement to service connection for peripheral neuropathy. Evidence received since the May 2006 rating decision, in pertinent part, includes the Veteran's statements during a May 2009 VA environmental examination. At the examination, the Veteran reported that he experienced some minor peripheral neuropathy symptoms during service with continuing symptoms since service. This evidence constitutes new and material evidence. This follows, because the evidence relates to previously unestablished elements that are necessary to grant entitlement to service connection for peripheral neuropathy. As stated previously, the Court has set forth a low threshold to reopen claims and based on the evidence combined with additional VA development, there is a reasonable possibility of substantiating the claim. Shade v. Shinseki, 24 Vet. App. at 110. New and material evidence sufficient to reopen the claim of service connection for peripheral neuropathy has been received. Legal Criteria: Disability Ratings Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2017). The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321 (a), 4.1(2017). In initial rating claims, the Board must discuss whether "staged ratings" are warranted, and if not, why not. Fenderson v. West, 12 Vet. App. 119 (1999). Where a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7 (2017). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2017). In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2017) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to the disability under review. Factual Background and Analysis: PTSD The Veteran contends that he is entitled to an evaluation in excess of 50 percent for his service-connected PTSD. As explained below, the Board finds that the Veteran has met the schedular requirements for a 100 percent disability rating throughout the entire period on appeal. At the outset, the Board notes that it has reviewed all of the evidence of record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, 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 claim. Prior to September 18, 2017, the Veteran's service-connected PTSD was rated 30 percent disabling, pursuant to the criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411, which is included under the General Rating Formula for Rating Mental Disorders. 38 C.F.R. § 4.130. According to the General Rating Formula for Rating Mental Disorders, a 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal, due to such symptoms as: depressed mood, anxiety, suspiciousness, weekly or less often panic attacks, chronic sleep impairment, and mild memory loss, such as forgetting names, directions, and recent events. Id. A 50 percent disability rating is warranted 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted when 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; 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 inability to establish and maintain effective relationships. Id. The maximum 100 percent disability rating is warranted when 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; and memory loss for names of close relatives, own occupation, or own name. Id. The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Accordingly, the evidence considered in determining the level of impairment under Diagnostic Code 9411 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms associated with the Veteran's PTSD that affect the level of occupational and social impairment, including, if applicable, those identified in Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) or the Fifth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-5). In evaluating the evidence, the Board also considers the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). A GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but generally reflects that a person is functioning pretty well, and has some meaningful interpersonal relationships. DSM-IV, at 46. A GAF score of 51-60 indicates moderate symptoms or moderate difficulty in social, occupational or school functioning. Id. A GAF score of 41-50 is assigned where there are serious symptoms, for example, suicidal ideation, severe obsessional rituals, or any serious impairment in social, occupational, or school functioning, for example, no friends, inability to keep a job. Id. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record to this time period and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. 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 of the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2017); VAOPGCREC 10-95, 60 Fed. Reg. 43186 (1995). A July 2003 VA mental health evaluation note indicated that the Veteran was unemployed and raising his son. He had occasional suicidal ideation, but denied homicidal ideation. May 2009 VA treatment records indicated that the Veteran experienced sleep latency problems, nightmares about Vietnam, flashbacks, hypervigilance, concentration problems, and panic attacks. Sometimes he patrolled the perimeter of his home if he awakened at night. The impression was depression and a strong history of PTSD. An October 2010 VA psychology consult noted that the Veteran was haunted by the thoughts of killing an innocent woman in Vietnam. He was concerned that he was going to hell for his involvement in the death of the woman. The Veteran reported that he physically abused his first wife, but felt remorse for his actions. He denied current physical abuse, but was frequently angry and irritable. He verbally snapped at the evaluator during the session. He cried a lot, which made it difficult to drive because he often had to pull over due to his anxiety and crying spells. He thought about the trauma daily. He attended activities, but usually found an excuse to leave early. He stated that he spent time with one friend, but was somewhat disconnected from the friend. He avoided "Oriental people" because he believed they were out to get him. He often awakened at night to check the premises of his home. His symptoms also included guilt, nightmares, tendency to overreact, fighting, and isolation. He reported a good relationship with his sister, daughter, and grandchildren. He was divorced four times. He reported suicidal ideation, but stated that he would never commit suicide. On examination he displayed appropriate grooming; poor eye contact; psychomotor agitation; irritable affect; speech with normal rate, rhythm, and volume; appropriate, relevant, and logical thought process; normal concentration; and impaired attention. The diagnosis was PTSD. A GAF score of 50 was assigned. A December 2010 VA pastoral counseling note indicated that the Veteran presented with a flat affect and mood, was very polite and cooperative, spoke in a normal tone, and seemed to be sad. He shared his feelings of loss and grief related to his combat trauma. The Veteran underwent a VA psychological examination in February 2011. He expressed difficulty maintaining a romantic relationship. He shared that he recently dated a woman six months ago until one day when he awakened in the middle of the night with his fist on top of her because he heard something in the middle of the night. If he heard a noise he would retrieve his weapon and check the perimeters of his home. He experienced constant thoughts about the woman he killed; an inability to function in crowds; irritability; and avoidance of those of Asian descent. His most recent divorce occurred two years prior and the marriage lasted for two years. His ex-wife was scared of him. The Veteran maintained a close relationship with his daughter, but did not communicate with his son. He stated that he physically mishandled his son some years ago because of the Veteran's anger. He was arrested several times for fighting. He had one friend who visited him at his home. He stayed home all day and shopped at night to avoid crowds. He was unemployed for eight years. He quit many jobs due to problems with his supervisors. A mental status examination revealed that the Veteran displayed a cooperative attitude; a mildly to moderately depressed mood; no impairment of thought process or communication; a generally restricted and somewhat blunted affect, as though mildly sedated; and normal attention, memory, and judgment. He denied suicidal or homicidal planning, hallucinations, and delusions. The VA examiner found that his PTSD symptoms resulted in reduced reliability and productivity. A GAF score of 50 to 55 was assigned. A questionnaire completed by the Veteran's treating psychologist in May 2011 indicated that the Veteran's PTSD was mostly described as resulting in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. His GAF scores ranged from 50 to 57 and averaged 53. The Veteran was afforded another VA psychological examination in July 2011. He endorsed symptoms of mild memory loss, such as forgetting names, directions, or recent events; depressed mood; anxiety; suspiciousness; panic attacks that occurred weekly or less often; chronic sleep impairment; 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, for example, retention of only highly learned material, while forgetting to complete tasks; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; suicidal ideation; obsessional rituals which interfere with routine activities; near-continuous panic or depression affective 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; 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 own name. The Veteran's PTSD symptoms impacted his ability to work. The examiner assigned a GAF score of 41-50. In an October 2011 statement, the Veteran reported that he verbally and physically abused his first and second wives. With his third and fourth wives, he reportedly experienced moments of rage and verbally abused them because of his Vietnam experiences. He also stated that he frequently quit jobs. He expressed anger towards coworkers and supervisors and considered physical violence against them. In October 2011, the Veteran stated that he considered part-time employment working at a hardware store, but realized that he would have difficulty helping customers due to his increased anger and irritability. He also reported that his psychiatric medications impaired his memory and his ability to solve problems. VA treatment records dated from May 2012 to August 2012 documented PTSD symptoms such as nightmares, avoidance, numbing, hyperarousal, sleep problems, irritability, and crying spells. Mental status examinations during this period showed that he had full orientation, appropriate grooming, fair eye contact, interactive and responsive behavior, normal speech, anxious mood, linear thought process, fair judgment, intact cognition, and fair insight. He denied hallucinations and suicidal or homicidal ideations. His GAF score during this period was 50. His PTSD was evaluated again in September 2012. His symptoms included anxiety and chronic sleep impairment. His last divorce occurred six or seven years ago. He described a great relationship with his daughter and a poor relationship with his son. He had one friend that he socialized with. With respect to occupational impairment, he was unemployed since 2003. He explained that he quit working when his supervisors upset him. A mental status examination revealed full orientation; pressured speech, normal in tone and syntax; disorganized thought process; moderately labile mood; and full and excessively reactive affect. He denied hallucinations, delusions, and suicidal or homicidal ideation. The examiner concluded that his PTSD was productive of occupational 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 examiner explained that the indicated level of occupational and social impairment was speculative due to the results of the objective testing during the examination and the absence of corroboration of the Veteran's reported functional impairment. A GAF score of 75 was assigned. November 2012 VA treatment records showed that he was not currently dating. He reported a good relationship with his daughter and stated that he was not a good father to his son. His anxiety symptoms made it difficult for him to go to the grocery store. He continued to have nightmares about his combat experience. Even after talking to the VA chaplain and other ministers, he was still unable to forgive himself. He feared going to hell because of his combat activities. His leisure activities included reading and going to the beach when no one was around. He interacted with two friends, one was his neighbor and the other one was a childhood friend. On examination he had full orientation, neat appearance, anxious and mildly agitated behavior, fair eye contact, normal speech, moderately anxious affect, linear thought process, fair insight, fair judgment, intact cognition and memory. There was no suicidal or homicidal ideation. A GAF score of 50 was assigned. A December 2012 statement from the representative indicated that the Veteran was divorced four times and did not have a personal relationship with his son. The Veteran believed that his son hated him. His activities included reading and going to the beach alone when no one was around. He had a friend in his neighborhood and also maintained contact with a childhood friend. The Veteran's medication did not appear to lessen his PTSD symptoms. In his December 2012 substantive appeal he stated that his symptoms included anxiety, irritability, poor sleep, nightmares, flashbacks, intrusive memories, depression, suspiciousness, panic attacks, disturbances of motivation or mood, paranoia, and difficulty establishing and maintaining effective work and social relationships. December 2012 VA treatment records noted that the Veteran's nightmares significantly negatively impacted his sleep, work, relationships, school, mood, sex life, mental health, and leisure activities. As the Board previously found that the July 2011 and September 2012 VA examinations were inadequate, he was afforded another VA examination in December 2013. His PTSD was manifested by anxiety, anger, depressed mood, flashbacks, nightmares, hypervigilance, exaggerated startle response, guilt, and chronic sleep impairment. He could not tolerate being around Asian people. A mental status examination showed that the Veteran had full orientation; speech pressured, though normal in tone and syntax; somewhat disorganized thought process; normal thought content; good eye contact; labile mood with full and reactive affect; and no observable impairment in attention, concentration, or memory. There were no hallucinations, delusions, suicidal ideation, or homicidal ideation. He was cooperative, neatly groomed and dressed, and demonstrated adequate personal hygiene. The Veteran stated that he had no relationship with his daughter. He had one close friend and trusted his VA treatment providers. He enjoyed fishing and riding his bicycle. His post-service employment duties included rolling cable for a cable company, plumbing, working for a telephone company, and truck driving. He changed jobs frequently because of problems getting along with others on the job. He stated that he punched a former supervisor in the face. He was able to work longer periods in positions that allowed him to work alone. His PTSD symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily. The examiner found that his PTSD symptoms were severe and interfered significantly with social and occupational functioning. A GAF score of 55 was assigned. VA treatment records dated in December 2013 noted that he experienced nightmares, avoidance of Asians and neighbors, hypervigilance, concentration problems, sleep problems, and exaggerated startle response. He often could not remember stories and misplaced things in his home. In September 2014, the Veteran reported that he remained in his house with the door locked and the blinds closed, ignoring any knocks on his door. He endorsed feelings of suicide because of the guilt from his Vietnam combat. He snapped at people, did not trust others, misplaced things, and was constantly depressed. He felt that he was a burden to his family. He feared being alone for the rest of his life based on his past four divorces. With his last relationship, he woke up with his legs on her shoulders and his fist in her face during one of his nightmares. He continually walked through the house to ensure that he was home alone and checked his house multiple times if he heard a noise. He kept his weapon nearby because he always felt that someone was in the house with him. Due to his depressed mood, he did not properly care for himself or his house. He paid his bills late and missed appointments. The Veteran submitted a January 2015 email from his uncle assuring him that he was forgiven for his combat action in Vietnam. A February 2015 email showed that the Veteran was rejected for employment due to his PTSD symptoms, including his inability to focus and concentrate, outbursts of anger, and memory issues. A February 2015 statement from his former girlfriend indicated that he was uncomfortable and agitated in crowds. He often screamed and yelled at night. She recalled one incident where she was awakened by the Veteran's fist raised above her face. He punched her in the shoulder and then went back to sleep. She recalled another incident during which she was awakened by the Veteran holding a rifle in her face. He appeared confused and when she informed him who she was, he laughed and went to bed. A February 2015 letter from his aunt, a Catholic nun, showed the Veteran's concerns about going to hell because of his combat duties in Vietnam. She stated that the Veteran needed to be convinced that God was merciful. November 2015 VA treatment records noted that the Veteran was not dating. He had a relationship with his aunt, uncle, and his now deceased brother. He had intrusive memories, nightmares, flashbacks, avoidance, negative beliefs about himself, anxiety, panic attacks, depression, detachment, irritability, hypervigilance, startle, and sleep problems. He recently blew up on one of his friends and had not talked to him since. The psychologist concluded that the Veteran continued to struggle with his psychiatric disorder. He continued to beat himself up and reinforce negative aspects about himself, his life, and his past experiences. He felt isolated, lonely, and was unable to forgive himself for his Vietnam wartime duties. In January 2016, he stated that he experienced problems communicating with people, uncontrollable behavior, anger outbursts, memory loss, nightmares and panic attacks. He explained that his psychiatric medications helped a little. He expressed extreme guilt for his Vietnam combat duties and asked all of his family and friends for forgiveness for the wrongs he committed against them. He found the experience of opening up very embarrassing and made him sick. He felt shame, guilt, embarrassment, and anger. He continued to lock himself in the house because he believed that people stared at him. He expressed loneliness and did not want to be alone, but was scared of hurting another person due to his PTSD symptoms. He recalled getting on a ladder in his garage and tying a rope around his neck because he wanted to end his life. He stopped once he thought about his daughter. He also seriously considered hooking up the exhaust to his truck and falling asleep, as well as going in the woods with his shotgun. He reported that he heard voices during the day because he was usually alone. He responded by screaming or turning the radio up. The Veteran's most recent VA psychological examination was in September 2017. He endorsed symptoms of depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, mild memory loss, difficulty establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, suicidal ideation, and neglect of personal appearance and hygiene. On examination the Veteran was jumpy and shaky when completing his questionnaire. He described his mood as "not good" and his affect was tearful and irritable. He shared that he tried to hang himself and that he put a shotgun in his mouth. The Veteran explained that he wanted to kill himself because he was tired of the panic attacks and nightmares. He also endorsed paranoia symptoms. He heard a woman's voice and saw the Vietnamese woman that he killed, run past him. The Veteran was found to be at an increased risk of harming himself. The examiner concluded that his PTSD caused occupational and social impairment with reduced reliability and productivity. The Veteran had difficulty maintaining or searching for employment due to his PTSD symptoms, however, it was possible that the Veteran was capable of working in a therapeutic environment that understood his limitations. November 2017 VA treatment records noted his symptoms of anxiety, negative obsessions, mood swings, irritability, lack of motivation, social isolation, lack of energy, predominant negative thoughts, lack of concentration, hopeless thoughts, suicidal thoughts occurring at least once per week, disruptive sleep, and nightmares. December 2017 VA treatment records indicated that he had suicidal thoughts twice per week and a severe episode three weeks prior. January 2018 VA treatment records showed that he continued to have the full array of depressive symptoms. He had occasional fleeting suicidal thoughts. He noted some slight improvement in the severity of his nightmares and anxiety. He attended church, but did not like crowds. His granddaughter visited him daily to cook and clean for him. He chased his daughter away due to yelling at her. He still did not have contact with his son. He reported that he occasionally talked to a friend in Virginia Beach. He also kept in contact with his uncle. He moved to North Carolina to be closer to his daughter. He continued to shop at night to avoid people. The Veteran was offered employment as a customer service representative for an airline, but was unable to work because he could not interact with people. He found a job with his friend completing demolition work, but he became upset with his friend and walked away from the job. He desired to work, but was afraid that he would hurt someone. He appeared open to completing volunteer work. The Veteran called the crisis line multiple times. He continued to have problems forgiving himself. Based on the above-noted evidence, the Board finds the Veteran's disability has resulted in occupational and social impairment that more nearly approximates total than deficiencies in most areas. With the exception of the GAF score assigned by a VA examiner in 2012, his GAF scores ranged from 41 to 55, which indicated serious to moderate PTSD symptoms. His PTSD was manifested by anger, irritability, nightmares, chronic sleep impairment, anxiety, avoidance, isolation, hopelessness, suicidal ideation, panic attacks, guilt, crying spells, labile mood, paranoia, suspiciousness, difficulty establishing and maintaining effective relationships, flashbacks, disorganized thought process, memory impairment, and neglect of personal appearance and hygiene. He described hearing a woman's voice and having to scream or turn the radio up loudly in response to hearing the voice. He also described seeing the Vietnamese woman that he killed during service run past him. He had suicidal thoughts throughout this period. He strongly considered suicide by putting a rifle in his mouth, trying to hang himself, and trying to use the exhaust in his truck. He stated that his granddaughter visited him to assist with cooking and cleaning. He stated that he paid his bills late and missed appointments. With respect to social impairment, the Veteran described a good relationship with his daughter for most of the appeal period. However, he had not contact with his son. He physically and verbally abused his former wives as a result of his symptoms and was divorced four times. He described loneliness and a desire for companionship, but was afraid that he would harm any person he dated. He was in a romantic relationship, but put a rifle in her face and punched her in the shoulder in two separate incidents. He disliked crowds, shopped at night, stayed home alone all day, and avoided people. With respect to his occupational impairment, the Veteran was unemployed during this period. The September 2017 VA examiner found that the Veteran could work in a therapeutic environment that understood his limitations. The December 2013 examiner found significantly interfered with his occupational function. The Veteran submitted a rejection letter from a potential employer explaining that the Veteran was not suitable for the position because of his PTSD symptoms. He reported issues with his coworkers and supervisors in the past, including punching a supervisor in the face. He reported quitting several jobs because he was upset with his supervisors. He was unable to work in any position involving interacting with people because of his irritability and anger. Evidence also showed memory issues, concentration problems, and disorganized thought process. In this case, the entirety of the record supports a 100 percent disability rating throughout the appeals period. TDIU A TDIU is provided where the combined schedular rating for service-connected diseases and disabilities is less than total (less than 100 percent). 38 C.F.R. § 4.16 (a) (2017). A TDIU is considered a lesser benefit than the 100 percent rating, and the grant of a 100 percent rating generally renders moot the issue of entitlement to a TDIU for the period when the 100 percent rating is in effect. An exception to this is a separate award at the housebound rate or a TDIU predicated on a single disability (perhaps not ratable at the schedular 100-percent level) when considered together with another disability separately rated at 60 percent or more may warrant payment of special monthly compensation (SMC) under 38 U.S.C.A. § 1114 (s). Bradley v. Peake, 22 Vet. App. 280 (2008). In this case, the Veteran is not seeking special monthly compensation at the housebound rate, and the record does not otherwise reasonably raise that matter. The Veteran has alleged that his service-connected PTSD alone renders him unemployable. Moreover, his only other service-connected disability is tinea versicolor, rated as 10 percent disabling, effective August 1977. The Board points out that a TDIU in this case would only be relevant to a special monthly compensation claim where the PTSD is not considered, meaning that the only disorder that can be considered in addressing whether a TDIU is warranted is the tinea versicolor disability. As already noted, the Veteran does not contend that the tinea versicolor has played a role in employability impairment. Accordingly, the grant of a 100 percent rating for PTSD has rendered his claim for a TDIU moot. ORDER New and material evidence having been presented, reopening of the claim for service connection for peripheral neuropathy is granted. Entitlement to a 100 percent rating for PTSD throughout the period of the claim is granted, subject to the criteria applicable to the payment of monetary benefits. The appeal as to entitlement to a TDIU is dismissed. REMAND The Veteran's VA treatment records contain medical opinions in support of his claim for entitlement to service connection for peripheral neuropathy. In March 2004 a VA medical opined that it was highly probable that the Veteran's sensory neuropathy was due to peripheral neuropathy. This opinion was based on a thorough review of all recent labs searching for an alternative diagnosis to explain peripheral neuropathy, but there was no other likely reason that the Veteran would have developed peripheral neuropathy. In September 2004, a VA neurologist noted a personal history of exposure to Agent Orange and concluded that the dioxin in the herbicide could cause his peripheral neuropathy. The neurologist stated that the Veteran's labs were reviewed and there was no treatable cause for his peripheral neuropathy. During a May 2009 environmental examination, the Veteran reported peripheral neuropathy symptoms since service. The examiner found that his peripheral neuropathy while in Vietnam were symptoms of relatively high doses of dioxin acutely, but were not qualifying diagnoses. The examiner could not rule out subtle primary nerve disease, but the majority of his symptoms seemed to be due to mechanical causes. The conclusion was that the intermittent nature of his symptoms was very favorable and made the likelihood of a primary peripheral neuropathy much lower. The Veteran underwent a VA peripheral nerves examination in April 2010. He reported exposure to Agent Orange during service and thereafter noticed progressive weakness, paresthesia, and burning sensation in his hands and feet. The examiner stated that there was no record of such symptoms in the service treatment records. The diagnosis was chronic inflammatory demyelinating polyneuropathy. The examiner concluded that it was less likely than not caused by or related to Agent Orange based on the medical literature which revealed that there was no cause of the disorder. An Agent Orange Peripheral Neuropathy Review Checklist was added to the claims file in July 2015. The examiner found that his peripheral neuropathy was not early onset and that there was no evidence that his symptoms started within one year of his last exposure to Agent Orange. In light of the Veteran's assertions that he developed symptoms of peripheral neuropathy since service, the medical opinions relating such disorders to in-service Agent Orange exposure, and the medical opinions against the Veteran's claim, the Board finds that a remand is required to obtain another VA medical opinion which addresses all of the medical evidence of record. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. The RO or AMC should undertake appropriate development to obtain any outstanding records pertinent to the above-noted claim on appeal. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. Then, the RO or the AMC should also afford the Veteran a VA examination by a physician with sufficient expertise to address the etiology of the Veteran's peripheral neuropathy. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies must be performed. Following a review of the relevant records and lay statements, the examiner should state an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the disorder originated during the Veteran's period of active service or is otherwise etiologically related to his active service, to specifically include his conceded in-service exposure to herbicides. In doing so, the examiner must consider and discuss the Veteran's statements concerning his in-service symptoms of peripheral neuropathy which continued since service, as well as the March 2004 and September 2004 medical opinions in support of the claim. The examiner must provide a complete rationale for all proffered opinions. If the physician is unable to provide any required opinion, he or she should explain why. If the physician cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the physician should identify the additional information that is needed. 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.A. §§ 5109B, 7112 (West 2014). ______________________________________________ B. MULLINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs