Citation Nr: 18141478 Decision Date: 10/11/18 Archive Date: 10/10/18 DOCKET NO. 16-19 175A DATE: October 11, 2018 ISSUES 1. Entitlement to an evaluation in excess of 70 percent for post traumatic stress disorder (PTSD) with mood disorder, aggravated attention deficit hyperactivity disorder, and depression with traumatic brain injury. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REMANDED Entitlement to an evaluation in excess of 70 percent for post traumatic stress disorder (PTSD) with mood disorder, aggravated attention deficit hyperactivity disorder, and depression with traumatic brain injury is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from May 2004 to November 2008. This matter is before the Board of Veterans Appeals (Board) on appeal from a June 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. In a letter dated December 13, 2016, the Veteran through his attorney withdrew his hearing request. 1. Entitlement to an evaluation in excess of 70 percent for PTSD with mood disorder, aggravated attention deficit hyperactivity disorder, and depression with traumatic brain injury is remanded. 2. Entitlement to a TDIU is remanded. A remand is necessary for additional development. In Statement in Support of Claim received by VA in March 2014, the Veteran asserted in part, “In recent months, my symptoms and medical disabilities have worsened. I was involuntary hospitalized for behavioral health concerns.” The Veteran was most recently afforded a March 2016 VA examination. The VA examiner found that PTSD results in reduced reliability and productivity. The VA examiner endorsed the symptoms of depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, impairment of short-term and long-term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective relationships. Additionally, it was noted that the Veteran did not have a diagnosis of traumatic brain injury. The Veteran’s substantive appeal was received by VA in May 2016. The Veteran described several circumstances in which PTSD impaired his functioning, and he described his symptoms. In part, he noted that he has, “almost complete intolerance of other people. My anxiety shoots through the roof.” He reported that he attempted suicide in June 2015. He has verbal outbursts, stutters, is constantly depressed, neglects personal hygiene, and has trouble attending VA appointments. He contends that PTSD should be rated closer to 100 percent, and that he is unemployable. 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 Caffrey v. Brown, 6 Vet. App. 377, 381 (1994), see also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997) (holding that a Veteran is entitled to a new examination after a two year period between the last VA examination and the Veteran’s contention that the pertinent disability had increased in severity); 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). Next, the Veteran’s VA 21-8940 Veteran’s Application for Increased Compensation Based on Unemployability shows that he has had no employment since discharge. The Application is from 2011. Any updated employment and educational information should also be obtained on remand. Therefore, the claim for a total disability rating based on individual unemployability (TDIU) is also remanded as it is inextricably intertwined with the claim for an increased rating for PTSD. Hunt v. Nicholson, 20 Vet. App. 519, 525 (2005); Harris v. Derwinski, 1 Vet. App. 180, 183-4 (1991), overruled on other grounds; see Tyrues v. Shinseki, 23 Vet. App. 166 (2009). The matters are REMANDED for the following action: 1. Send the Veteran another VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, to be fully completed and returned to VA. Request that he indicate whether he has had any form of employment, no matter how brief, since 2011. 2. If the Veteran identifies other evidence, obtain updated copies of the Veteran’s VA treatment records, and associate them with the Veteran’s claims folder. 3. Schedule the Veteran for a VA examination by an appropriate examiner to determine the current degree of severity of his service-connected PTSD with mood disorder, aggravated attention deficit hyperactivity disorder, and depression with traumatic brain injury. To the extent possible, the examiner should identify any symptoms and functional impairments due to PTSD alone and discuss the effect of the Veteran’s PTSD on any occupational functioning and activities of daily living. A complete rationale should be provided for all opinions expressed. (Continued on the next page.) 4. After completing the above, and any other necessary development, the claims remaining on appeal must be readjudicated in light of all pertinent evidence and legal authority. If any benefits sought are not granted, issue the Veteran and his attorney an appropriate supplemental statement of the case (SSOC). MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel