Citation Nr: 20032013 Decision Date: 05/06/20 Archive Date: 05/06/20 DOCKET NO. 13-28 724A DATE: May 6, 2020 ORDER A rating of 50 percent for the service-connected acquired psychiatric disability to include posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to a rating higher than 50 percent for the service-connected acquired psychiatric disability to include posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. FINDING OF FACT For the entire period on appeal, the Veteran’s symptoms more nearly manifested in occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW For the entire period on appeal, the criteria for a disability rating of 50 percent for the acquired psychiatric disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.126, 4.130. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1968 to April 1972. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from an October 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran waived a hearing before the Board in his February 2019 substantive appeal, via a VA Form 9. New evidence has been associated with the claims file since the January 2019 statement of the case; however, in an April 2020 letter, the Veteran’s attorney waived initial consideration of this evidence by the RO. Thus, the Board will proceed in adjudicating the claim. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Rating Claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran’s service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him or her through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Veteran is current assigned a noncompensable rating prior to September 23, 2013, a 30 percent rating prior to December 6, 2018 and a 50 percent rating thereafter under DC 9411. He contends that a higher rating is warranted for the entire appellate period. DC 9411 is governed by a General Rating Formula for Mental Disorders, which provides a 10 percent rating is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent rating is warranted for 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, panic attacks (weekly or less often), chronic sleep impairment, and/or mild memory loss (such as forgetting names, directions, or recent events). A 50 percent rating is warranted for 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/or difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and/or inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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/or memory loss for names of close relatives, own occupation, or own name. In the process of evaluating a mental disorder, VA is required to consider several pertinent factors, such as the frequency, severity, and duration of a veteran’s psychiatric symptoms. See 38 C.F.R. § 4.126. After consideration of these factors and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely based on social impairment. 38 C.F.R. § 4.126(b). Ratings are assigned according to the manifestation of particular symptoms, but the use of a term “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to 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). 1. For the entire period on appeal, a 50 percent rating for the service-connected acquired psychiatric disability is granted. Turning to the evidence of record, the Veteran was afforded a VA psychiatric examination in November 2012. The examiner, a psychologist, determined the Veteran did not meet the criteria for a PTSD diagnosis because, although he experienced trauma while in Vietnam, the Veteran had only mild reexperiencing of his experiences in service and did not display avoidance or increased arousal symptoms. The Veteran had good relationships with his spouse of 39 years and his four adult children. He socialized with family and friends, including eating out at restaurants and attending family gatherings. He was the pastor of a church and attended church activities. He was less physically active than he used to be due to a non-service connected back disability but enjoyed reading and watching television. The Veteran had recurrent and distressing recollections and dreams of the traumatic event. No other symptoms were noted. The Veteran was alert and oriented. His mood was “pretty good” with a full range of appropriate affect. He reported feeling down at times and feeling frustrated about the VA claims process. He denied anger, anxiety, excessive worry, panic attacks, a history of suicide attempt, suicidal ideations, and audio or visual hallucinations. He slept 6 to 7 hours per night on average, although he woke up some nights. He had occasional dreams related to Vietnam, and his spouse reported that he talked in his sleep and occasionally slept walked. He thought about Vietnam periodically, and characterized it as a time in his life he would never forget. He correctly recalled 3 out of 3 on immediate recall, 2 out of 3 on delayed recall, and 3 out of 3 after being cued. The Veteran denied depression and anxiety and exhibited appropriate mood and affect in a November 2012 VA treatment record. In December 2012, the Veteran submitted a statement in which he reported experiencing “flashbacks during my sleep and am awakened in terror.” His spouse and children also told him that one night that he punched a wall and said, “They are trying to kill me!” while he was asleep. Before that night, he was not aware that he was having PTSD symptoms, but he had been having flashbacks and nightmares for years. The Veteran reported symptoms of flashbacks and nightmares in an August 2013 brief. The Veteran sought treatment with a VA psychiatrist in September 2013. The Veteran had symptoms of depression, anxiety, anger, flashbacks approximately three times a week, and nightmares approximately two times per week. He was easily startled, hypervigilant, and often felt numb and detached. He slept 6 hours a night, and no longer enjoyed shooting pool or being around others. He had low energy, fair concentration, and poor appetite. He was anxious, irritable, tense, and “up tight” most days. He denied suicidal and homicidal ideations, audio and visual hallucinations, and paranoia. The Veteran’s daughter was present at this appointment. She reported that he was often agitated and had frequent nightmares. He frequently checked outside his home. She indicated his symptoms had worsened over the past three years. On mental status examination, the Veteran was dressed and groomed appropriately. He exhibited fair eye contact, appropriate psychomotor activity, and fluent and spontaneous speech with normal rate, volume, and prosody. He was depressed with dysphoric affect. His thought processes were goal directed. He denied audio and visual hallucinations, delusions, suicidal and homicidal ideations, and obsessions. He was alert and oriented times three. His insight and judgement were fair. In October 2013, the Veteran reported he was feeling better on medication. He was less irritable, quick tempered, and depressed. He adamantly denied any suicidal ideations, and he denied feeling hopeless, worthless, or guilty. He had flashbacks three times a week, nightmares two times a week, and startled easily. He was hypervigilant. He avoided watching television about Vietnam and avoided crowds. He distrusted others. He slept 6 hours a night. He denied audio and visual hallucinations and delusions. He lived with his wife. On mental status examination, he was appropriately dressed and cooperative. He had fair eye contact. No psychomotor retardation or agitation, tremor, tic, or other abnormal movement was seen. He had fluent and spontaneous speech with normal rate, volume, and prosody. His mood was “ok,” with reactive and not overly dysphoric affect. His thought process was organized, and thought associations were intact without circumstantial or tangential thoughts, flight of ideas, or loose associations. He denied audio and visual hallucinations, delusions, suicidal and homicidal ideations, and obsessions. He was alert and oriented times three. Insight and judgement were fair. In November 2013, the Veteran indicated the psychiatric medications were helping. He was falling asleep at midnight and sleeping through the night with less frequent nightmares. His mood and irritability had improved. He did not feel hopeless. He continued to avoid the news and to have intrusive memories during the day. On mental status examination, he was appropriately dressed and cooperative. He had fair eye contact. No psychomotor retardation or agitation were seen. He had fluent, spontaneous speech with normal rate, volume, and prosody. His mood was “better,” with much brighter affect. His thought processes were organized and goal-directed. His thought associations were intact without circumstantial or tangential thoughts, flight of ideas, or loose associations. He denied audio and visual hallucinations, delusions, and suicidal and homicidal ideations. He was alert and oriented times three. Insight and judgement were fair. In March 2014, the Veteran indicated he continued to feel well. He was not overly depressed or anxious, had only occasional nightmares, and less frequent flashbacks and intrusive memories since being on medications. He reported difficulty with short-term memory. The clinician did not note a functional deficit on examination. The Veteran was screened using the St. Louis University Mental Status Examination (SLUM) for dementia and Alzheimer’s disease, scoring 24/30. On mental status examination, he was appropriately dressed and cooperative. He had fair eye contact. No tremor or tics were seen. He had fluent and spontaneous speech with normal rate, volume, and prosody. His mood was “well,” with euthymic affect. His thought process was organized and goal directed. He denied audio and visual hallucinations, delusions, and suicidal and homicidal ideations. He was alert and oriented times three. His attention and memory were grossly intact. Insight and judgement were fair. June 2014 VA treatment records continued to report that the Veteran was in good spirits. He was not depressed, only had one nightmare a week, and was sleeping well. He enjoyed watching television, was getting along with his family, and felt much better than he did before starting antidepressants. On mental status examination, he was appropriately dressed and cooperative, had fair eye contact, and had fluent and spontaneous speech with normal rate, volume, and prosody. No psychomotor agitation or retardation were seen. His mood was “good,” with euthymic and pleasant affect. His thought process was organized and goal directed. No flight of ideas or looseness of associations were noted. He denied audio and visual hallucinations, delusions, and suicidal and homicidal ideations. He was alert and oriented times three, and his attention and memory were grossly intact. Insight and judgement were fair. In September 2014, the Veteran was calm and pleasant. His depressed mood and anxiety were controlled with medications. He described his mood as “comfortable.” He had good sleep and appetite, and his energy level was “ok.” The Veteran denied cognitive deficits or changes. He had a new grandchild and was happy about having a big family. On mental status examination, he was appropriately dressed and cooperative, made fair eye contact, and exhibited fluent, spontaneous speech with normal rate, volume, and prosody. No psychomotor agitation or retardation were seen. His mood was good with euthymic, calm, and pleasant affect. His thought processes were organized. His thought associations were intact. He denied audio and visual hallucinations, delusions, suicidal and homicidal ideations, and obsessions. He was alert and oriented times three. His attention and memory were grossly intact. His insight and judgement were fair. A December 2014 mental health treatment note indicated the Veteran was mentally well, but he was in pain. He did not have frequent nightmares, was able to sleep most nights, and denied feeling depressed, anxious, or hopeless. On mental status examination, he was appropriately groomed, cooperative, and exhibited fair eye contact. No psychomotor agitation or retardation were seen. He had fluent and spontaneous speech with normal rate, volume, and prosody. His mood was good with calm and pleasant affect. His thought processes were coherent. His thought associations were intact. He denied audio and visual hallucinations, delusions, suicidal and homicidal ideations, and obsessions. He was alert and oriented times three. His attention, concentration, and memory were grossly intact. Insight and judgement were fair. The Veteran reported he was doing “pretty well” in a March 2015 VA treatment record. He rated his mood as a 5 out of 10 on a 10-point scale, with 10 being his best mood. He was sleeping between six and seven hours a night, and the nightmares were mostly gone. His energy level was ok, and appetite was fair. He was having difficulty with memory and concentration. He read for enjoyment. He experienced flashbacks three to four times per week. He saw shadows at times but denied audio hallucinations. He denied suicidal and homicidal ideations. The Veteran was still married to his spouse for 41 years, and one of his adult daughters lived with them. On mental status examination, he was well groomed, attentive, and cooperative. He had fluent, spontaneous speech with normal rate, volume, prosody, and articulation. He had full range of affect. His thought processes were logical and goal directed. He denied delusions, paranoia, and suicidal and homicidal ideations, plans, or intent. He was alert and oriented times four. His remote and recent memory were grossly intact on examination. He had good attention and concentration. Insight and judgement were fair. The impression was that the Veteran’s psychiatric symptoms were stable. In June 2015, the Veteran was doing “fairly well.” He rated his mood as a 6 out of 10 on a 10-point scale. He slept for 6 hours per night. His nightmares had improved. His energy was good sometimes and sometimes it was not. He had difficulty with memory and concentration. He denied auditory hallucinations but saw shadows. His flashbacks had improved. On mental status examination, he was well groomed, attentive, and cooperative. No involuntary movements, tremors, or tics were seen. His speech was normal in rate, volume, articulation, and prosody. His affect was congruent with is mood. His thought processes were logical and goal directed. He denied audio hallucinations, delusions, and suicidal and homicidal ideations, plan, or intent. He was alert and oriented times four. His attention and memory were grossly intact. Insight and judgement were fair. In September 2015, the Veteran rated his mood as a 4 out of 10 on a 10-point scale. He was sleeping 8 to 10 hours nightly. His nightmares had improved. His energy, memory, and concentration were “pretty good.” He denied auditory hallucinations but had seen shadows. He was having fewer flashbacks. On mental status examination, he was well groomed, cooperative, and attentive. No involuntary movements, tremors, or tics were seen. His speech had normal rate, volume, prosody, and articulation. His mood was “fairly well,” with congruent affect. His thought processes were logical and goal directed. No looseness of association or flight of ideas were noted. He denied delusions, paranoia, and suicidal and homicidal ideations, plans, and intent. He was alert and oriented times four. His attention and memory were grossly intact. He had good attention and concentration. Insight and judgement were fair. In November 2015, the Veteran’s mood was rated was an 8 out of 10 on a 10-point scale. He blew up occasionally but less frequently than before. He felt depressed intermittently. He slept 6 to 7 hours per night, napped during the day, and no longer had nightmares. He worked on puzzles to help his memory. His energy was okay. He had difficulty focusing and with short-term memory. He denied auditory hallucinations. He was seeing shadows far less often than before and having fewer flashbacks. He denied suicidal and homicidal ideations. He was still married. On mental status examination, he was well groomed, attentive, and cooperative. His speech was normal in prosody, rate, volume, and articulation. His mood was “fairly well,” with some constriction of affect. No involuntary movements, tics, or tremors were noted. His thought processes were logical and goal directed. He denied delusions, paranoia, and suicidal and homicidal ideations, plan, and intent. He was alert and oriented times four. His attention and memory were grossly intact, and he had good attention and concentration. Insight and judgement were fair. The diagnostic impression included mild major depressive disorder and chronic PTSD. In February 2016 VA treatment records, the Veteran was angry with his son, and stated that if he had not taken his medications, he would have lost his temper. He rated his mood as a 5 out of 10 on a 10-point scale. He thought his self-control had increased. He was sleeping 8 hours nightly and occasionally napped during the day. He reported his memory “comes and goes.” He was no longer having flashbacks or nightmares, and he no longer saw shadows. His energy was good. He denied auditory hallucinations. He was not having flashbacks. He denied suicidal and homicidal ideations. On mental status examination, the Veteran was well groomed, attentive, and cooperative. His speech was normal in rate, volume, and articulation. No involuntary movements were seen. His mood was “in the middle” with euthymic affect. His thought processes were logical and goal directed without looseness of associations or flight of ideas. No delusions or paranoia were reported. He was alert and oriented times four with remote and recent memory intact. He had good attention and concentration. His insight and judgment were fair. The diagnostic impression was recurrent mild major depressive disorder. In April 2016, the Veteran submitted an affidavit in support of his claim. He reported that he had a long history of being unable to handle any type of stressful situation, tremendous irritability, and severe bouts of rage upon provocation which scared people and greatly affected his personal relationships, especially with his family. When he felt stressed, he was quickly overwhelmed by anxiety and anger. In the past, he had been involved in physical altercations with others. He indicated that once provoked, it also took a long time for him to calm down. He preferred to stay at home, so he could control his environment and avoid confrontations. He had struck doors, walls, and other objects during bouts of rage, and he felt badly about his behavior after he calmed down. His spouse indicated to him that it was difficult to get along with him, and that he was mean. He was extremely hypervigilant. When he was home alone, he retrieved his gun because he felt that he could be attacked at any time. He did not feel comfortable in public settings and rarely left his home, unless for a medical appointment or necessary. He experienced frequent terrifying nightmares despite medications. He also had flashbacks. He was tired during the day and was increasingly irritable. When he was not taking his medications, he had difficulty controlling his thoughts, and he felt hyperactive and paranoid. Loud noises and specific smells triggered intense, vivid flashbacks of Vietnam and left him terrified and afraid. In May 2016 VA treatment records, the Veteran’s mood was “in the middle” and rated his mood as a 5 out of 10 on a 10-point scale. He was sleeping 8 hours nightly without nightmares. He tired easily, and his memory had declined over time. He was no longer having flashbacks, he denied auditory hallucinations, and he no longer saw shadows. He denied suicidal and homicidal ideations. On mental status examination, the Veteran was well groomed, attentive, and cooperative. His speech was normal in rate, volume, and articulation. No involuntary movements were seen. His exhibited euthymic affect. His thought processes were logical and goal directed without looseness of associations or flight of ideas. No delusions or paranoia were reported. He was alert and oriented times four with intact remote and recent memory. He had good attention and concentration. His insight and judgment were fair. The Veteran submitted a June 2016 private psychological evaluation by Dr. J.H.S., a psychologist. The Veteran indicated he was in denial for many years about his PTSD symptoms. According to the Veteran’s spouse, the Veteran tended to minimize the severity of his symptoms or blame the symptoms on aging. Dr. J.H.S. indicated the Veteran’s denial and minimization of PTSD symptoms may have led to the November 2012 VA examiner’s conclusion that he did not meet the criteria for a PTSD diagnosis. Although the Veteran had remained married to his wife since 1974, there had been many past informal separations due to incidents of anger that badly scared his wife. He and his spouse did not go out to dinner often because he did not want to be around other people, and he feared he would become involved in conflict. Dr. J.H.S. found that the Veteran’s social interactions appeared to more limited than what was described in the November 2012 VA examination. For example, although the Veteran attended church and interacted socially with other church members, he was only able to do so because he had known them for approximately 27 years. Dr. J.H.S. noted the Veteran’s psychiatric history showed an increasing pattern of symptom emergence that eventually became more clearly related to PTSD and depression. As early as September 2013, clinical notes indicated he was experiencing nightmares, exaggerated startle response, flashbacks, hypervigilance, and feeling numb and detached. Dr. J.H.S. also noted that major depressive disorder and chronic PTSD symptoms were diagnosed in November 2015 and February 2016 VA treatment notes. More recently, the Veteran’s VA psychiatrist increased his medications to eliminate nightmares. Dr. J.H.S. indicated that if the Veteran stopped taking these medications, the nightmares would return. On mental status examination, Dr. J.H.S. found the Veteran to be depressed with congruent affect but appropriate to content. The Veteran reflected on his anger. The Veteran was oriented to person, place, time and situation; however, the Veteran referred to a home calendar during these questions, and Dr. J.H.S. indicated the Veteran’s orientation may not be as good as it appeared. The Veteran experienced intrusive thoughts, images, and memories of the traumatic experiences in Vietnam. He had consistent flashbacks, which were usually triggered by news coverage or documentaries about Vietnam, and the Veteran avoided watching both. Both short and long-term memory were impaired by depression and anxiety. The Veteran admitted that he had denied PTSD symptoms in the past because he over-rationalized the nature and severity of his disability. He denied current suicidal and homicidal plans or intent, but indicated he had an ideation about one year earlier due to anger at an unnamed person. The Veteran did not have quality sleep, and it was often interrupted by nightmares. His nightmares had increased in frequency and severity until his medications were recently increased. The Veteran slept 6 to 7 hours per night, but it was non-restorative. The Veteran said he had “well-documented record of angry and irritable behavior” despite minimal outside prompting. Difficulty with sustained focus and concentration were also noted to be related to the intrusion of traumatic thoughts and memories. Dr. J.H.S. concluded that the psychiatric symptoms significantly impaired most major areas of the Veteran’s functional ability, including interpersonal, social, vocational, and avocational pursuits. Dr. J.H.S. noted the Veteran’s functioning had been significantly impaired since 2012. The Veteran had few friends, had withdrawn, and was avoidant with his family. His social functioning was largely limited as he stayed in his den at home rather than go out to social events or dinner. The Veteran had only few avocational pursuits, spending most of his time watching television. The examiner noted these symptoms were serious and disruptive to the Veteran’s life. In August 2016, the Veteran was “pretty good.” He rated his mood as a 7 out of 10 on a 10-point scale. He denied recent depression. He took slept 5 to 6 hours a night and napped from 30 minutes to one hour. The Veteran indicated the medications had eliminated his nightmares. He stayed up at night watching television. He endorsed some intrusive thoughts of combat but was able to change them to more positive topics. Loud noises triggered his irritability. His energy was good, and his memory and concentration were fair. He expressed concern over his short-term memory. He denied hopelessness, helplessness, suicidal and homicidal ideations, and audio and visual hallucinations. He continued to be married to his spouse of 41 years. On mental status examination, the Veteran was well groomed, attentive, and cooperative. He had normal speech, including rate, volume, and articulation. No involuntary movements, tics, or tremors were seen. His mood was “good” with full range of affect. His thought processes were logical and goal directed. No looseness of associations or flight of ideas were seen. No delusions, paranoia, or auditory or visual hallucinations were reported. He was alert and oriented times four. Remote and recent memory were grossly intact. He showed good attention and concentration, and fair insight and judgment. November 2016 VA treatment notes indicate the Veteran reported he was “pretty good.” He rated his mood as a 5 out of 10 on a 10-point scale. He was sleeping 8 to 9 hours per night. He denied nightmares, exaggerated startle response, and recent intrusive thoughts. His energy was “pretty good.” He was concerned with his difficulty with short-term memory. He denied hopelessness, helplessness, suicidal or homicidal ideations, and audio and visual hallucinations. On mental status examination, the Veteran was well groomed, attentive, and cooperative. He had normal speech in rate, volume, and articulation. No involuntary movements, tics, or tremors were seen. His mood was “good” with full range of affect. His thought processes were logical and goal directed. No looseness of associations or flight of ideas were seen. No delusions or paranoia were reported. He was not having auditory or visual hallucinations and was alert and oriented times four. Remote and recent memory were grossly intact. He showed good attention, good, concentration, fair insight, and fair judgment. In February 2017, he reported that he was “doing fairly well.” His mood was fair. He rated his mood as a 5 out of 10 on a 10-point scale. He was sleeping 9-10 hours a night and denied nightmares. He rarely experienced intrusive thoughts and was no longer startles by loud noises. He continued to have difficulty with memory and concentration. He stopped reading and doing puzzles. He denied audio and visual hallucinations and denied suicidal and homicidal ideations. On mental status examination, the Veteran was well groomed, attentive, and cooperative. He had normal speech in rate, volume, and articulation. No involuntary movements, tics, or tremors were seen. His affect was constricted. His thought processes were logical and goal directed. No looseness of associations or flight of ideas were seen. No delusions or paranoia were reported. He was alert and oriented times four. Remote and recent memory were grossly intact. He showed good attention and concentration, and fair insight and judgment. In May 2017, it was noted the Veteran had a history or neurocognitive disorder. The Veteran’s mood was “pretty good.” He rated his mood as a 7 out of 10 on a 10-point scale. He denied sadness, irritability, anxiety, hopelessness, or helplessness. His energy was good. He denied difficulty concentrating but was forgetful. He was sleeping about 9 hours per night, denied difficulty falling and staying asleep, and felt rested. He denied nightmares. He had a good relationship with his wife. He denied suicidal and homicidal ideations. He had fallen since his last appointment, and although he did not hit his head, he broke a tooth. On mental status examination, he exhibited adequate grooming and hygiene, good eye contact, and cooperative attitude. No abnormal movements were seen. His speech was fluent with normal rate, volume, and articulation. His mood was good with full range of affect. His thought processes were logical, organized and goal directed. No loose associations or flight of ideas were exhibited. He denied suicidal or homicidal ideations, plans, or intent. He denied delusion and paranoia. No auditory or visual hallucinations were reported. No overt psychosis was seen. His insight and judgment were fair. He was alert and oriented times 4. His remote and recent memory were grossly intact. His attention and concentration were sufficient. In August 2017, the Veteran was doing “fairly well,” and his mood was “pretty good.” He rated his mood as a 7 to 8 on a 10-point scale. He was sleeping 7 ot 9 hours a night and napped during the day. He denied nightmares. He rarely had intrusive thoughts. He was no longer startled by loud noises. He had difficulty with memory, but his concentration was normal. He denied audio and visual hallucinations and suicidal and homicidal ideations. On metal status examination, he was well groomed, attentive, and cooperative. His speech was normal in rate, volume, and articulation. He did not have involuntary movements, tics, or tremors. His affect was congruent with his mood. His thought processes were logical and goal directed. No loose associations or flight of ideas was exhibited. He denied delusions and paranoia. He was alert and oriented times four. His recent and remote memory was grossly intact. His insight and judgment were fair. The clinician noted the Veteran presented at this appointment at his baseline for mood. The clinician also noted that medications had eliminated his nightmares, he denied intrusive thoughts, and his memory issues were likely due to pain medication. In November 2017 VA treatment records, the Veteran indicated his mood was “pretty good.” He denied feeling anxious, irritable, depressed, hopeless, or helpless. He denied having flashbacks and exaggerated startle responses. He had some amotivation and anhedonia. His energy level was good. He did not have panic attacks. He occasionally had intrusive thoughts. He was sleeping 8-9 hours per night and napped for 1-3 hours during the day. He denied any difficulty falling asleep or staying asleep and rarely had nightmares. For leisure, he read the Bible, played on his tablet, and listened to music. He denied suicidal and homicidal ideations and audio and visual hallucinations. He continued to live with his spouse. On mental status examination, he was appropriately dressed and groomed with appropriate eye contact. He had coherent, fluid speech with appropriate rate, volume, and articulation. He had full range of appropriate affect that was congruent to his mood. His thought processes were logical, organized and goal directed. No overt psychosis was seen. He was alert and oriented as to time, place and person. His attention and concentration were sufficient. The clinician noted the Veteran’s mood was stable with no depression or anxiety. The diagnostic impression was that the mild major depressive disorder was in partial remission and chronic PTSD. In March 2018, the Veteran’s mood was “pretty good.” His irritability was “fairly well-controlled.” He denied feeling anxious, depressed, hopeless, or helpless. He was frustrated with his lack of mobility. He denied amotivation or anhedonia. His energy level was “moderate to good”. He denied panic attacks. When he was not busy, he had intrusive thoughts of his time in service. He denied any recent flashbacks, hypervigilance, and an exaggerated startle response. He slept 7-8 hours per night and napped a few times per day for about an hour each time. He denied any recent nightmares but occasionally had night sweats. He read the Bible, played on his tablet, listened to music, spent time with grandchildren, and exercised for leisure. He denied suicidal and homicidal ideations and audio and visual hallucinations. The Veteran was still married to his spouse of 41 years, and he was a minister. On mental status examination, he was appropriately dressed and groomed with appropriate eye contact. His attitude was appropriate, calm, and cooperative. He had coherent, fluid speech with appropriate rate, volume, and articulation. He had full range of affect that was appropriate and congruent to his mood. His thought processes were logical, organized and goal directed. No overt psychosis was seen. He was alert and oriented to time, place and person. His attention and concentration were sufficient. His remote and recent memory were intact. In April 2018, the Veteran attended an initial psychotherapy appointment at VA. The Veteran reported that, aside from his PTSD symptoms and his depression, his life was “peaceful.” He had children and grandchildren that lived nearby. He indicated the psychiatric medications were effective. He had past difficulty with irritability and hypervigilance, and his flashbacks were managed with medications. He read his Bible to manage worry. He tended to oversleep rather than have insomnia. On brief mental status examination, the Veteran was oriented as to time, place, person, and purpose. There were no indications of mental content symptoms, perceptual disturbances, or gross cognitive confusion. His thinking and speech were within normal limits. He denied having current thoughts of suicide and did not have history of suicide attempts. In June 2018, the Veteran’s mood was “good.” He denied recent depression, hopelessness, or helplessness. He was “filled with hope and prosperity.” He denied symptoms of crying spells, difficulty getting out of bed due to low mood, amotivation, anhedonia, recent anxiety, panic attacks, recent flashbacks, recent nightmares, night sweats, hypervigilance, and exaggerated startle response. His energy level was “pretty good.” He continued to have intrusive thoughts of the military, often when he was idle. He had occasional irritability but managed it well. He was sleeping 8 to 9 hours per night and napped between 1 to 4 hours during the day. He denied nighttime awakenings. He read the Bible, played on a tablet, listened to music, played with his grandchildren, and exercised for leisure activities. He denied suicidal and homicidal ideations and audio and visual hallucinations. He continued to live with his spouse of 41 years and to serve as a minister. On mental status examination, he was appropriate dressed and groomed without abnormal movements. His attitude was appropriate, calm, and cooperative. He exhibited appropriate eye contact. His speech was coherent and fluid with appropriate rate, volume and articulation. He showed full range of affect that was congruent with his mood. His thought processes were logical, organized and goal directed. No tangential thoughts, losses association, or flight of ideas was noted. No overt psychosis was seen. His insight and judgment were good. He was alert and oriented to person, place, and time. His attention and concentration were sufficient for this interview, and his remote and recent memory were intact. The diagnostic impression was the Veteran’s psychiatric symptoms were stable. The Veteran submitted a June 2018 affidavit regarding his symptoms. He indicated he did not trust people and felt that everyone was trying to take advantage of him. He was always on edge and hypervigilant. If he heard a loud noise, he would jump. The Veteran indicated no matter what he was doing, his mind would always wander to his experiences in service, which made it difficult to concentrate. He had at least three flashbacks per week, which interfered with his concentration. He had nightmares of service at least twice per week. His sleep was not restful, and after a nightmare, he had difficulty going back to sleep. He had mood swings. He was quick to anger and avoided being around other people. He had punched walls in the past due to his anger. His anger and irritability had strained his relationships with his spouse and daughter. He left stressful situations before he began yelling. In August 2018, the Veteran attended another psychotherapy session. The Veteran’s mood was “real good.” He recently attended a family reunion. He indicated he did not have time to be depressed and was spending time with his grandchildren. He was euthymic and denied anxiety. On brief mental status examination, the Veteran was oriented to time, place, person, and purpose. No indications of mental content symptoms, perceptual disturbances, or gross cognitive confusion were seen. Thinking and speech were within normal limits. The therapist and Veteran decided that he could schedule future therapy sessions when necessary, if he encountered a stressor that worsened his symptoms. In November 2018, the Veteran attended a routine follow up at VA. The Veteran’s mood was “good” with no overt depressive or anxious signs and symptoms. The Veteran thought he slept too much. He slept about 8 hours per night, felt refreshed upon awakening, but frequently took daytime naps. He endorsed intermittent anhedonia in relation to conversations with friends and family. If people did not communicate with him, it upset him. He endorsed baseline ongoing PTSD symptoms, such as hypervigilance, which were successfully treated with medications. He denied memory changes, difficulty with concentration, nightmares, flashbacks, suicidal or homicidal ideations, audio or visual hallucinations, hypomania, mania, and feeling hopeless or helpless. No overt psychosis or paranoia was noted. He continued to participate in enjoyed leisure activities. He was still married to his spouse of 41 years and was a minister. In December 2018, the Veteran was afforded a VA examination. The examiner, a psychologist, found the Veteran’s psychiatric symptoms manifested as occupational and social impairment with reduced reliability and productivity. The Veteran reported that his marital relationship, specifically their communication, had improved since the last VA examination. He denied frequent arguments and domestic violence. He frequently visited with his grandchildren. He was in a wheelchair, which limited his activities, but he went to the YMCA for exercise one to two times per week. The Veteran denied a history of suicidal or homicidal attempts or ideations. He had a history of being easily agitated with others. He did not feel close to his spouse, family or grandchildren, and he was not satisfied in his life. He took medications that had improved his sleep and reduced nightmares. He continued to have daytime sleepiness, low mood 15 out of 30 days a month, and situational anxiety. The Veteran had frequent forgetfulness of things such as the names of his medical providers or where he put something. He understood proverbs and was able to calculate simple mathematics. The Veteran had recurrent, involuntary, and intrusive distressing memories. He avoided distressing memories, thoughts, or feelings about or associated with the trauma/. He showed markedly diminished interest or participation in significant activities and had feelings of detachment or estrangement from others. He had a persistent inability to experience positive emotions. He experienced hypervigilance, exaggerated startle response, difficulty with concentration, depressed mood, anxiety, suspiciousness, mild memory loss, circumstantial, circumlocutory or stereotyped speech, and disturbances in mood or motivation. The Veteran exhibited adequate grooming and good hygiene. His motor activity was within normal limits. His speech was circumstantial with mispronounced words. He was cooperative and engaged. He was oriented times four but with poor recall. Gross memory was intact. Good eye contact was exhibited. He reported stable mood with congruent affect. He denied suicidal and homicidal ideations. There were no signs of panic, mania, or psychotic symptoms. His insight and judgment were good. In February 2019 VA treatment records, the Veteran described his mood as “pretty good.” He endorsed occasional amotivation. His energy level was fair to poor. He denied any recent depression, hopelessness, helplessness, crying spells, significant anxiety, panic attacks, physical or verbal altercations, difficulty staying or falling asleep, sleep paralysis, difficulty cooking, suicidal and homicidal ideations, and audio or visual hallucinations. He worried some about finances and occasionally became aggravated and frustrated. He experienced hypervigilance and exaggerated startle response. He rarely had nightmares. He was forgetful at times. He gave an example that sometimes he forgot whether he had taken his medications. He was distracted easily. He was sleeping 7-10 hours per night, and he napped for about an hour and a half. He continued to participate in leisure activities. He was still married to his spouse of 41 years and was serving as a minister. On mental status examination, he was appropriately dressed and groomed. His attitude was appropriate, calm, and cooperative. He exhibited appropriate eye contact. His speech was coherent with appropriate rate and volume. He showed appropriate affect that was congruent with his mood. His thought processes were logical and goal directed. No obsessions or overt psychosis were seen. His insight and judgment were fair. He was alert and oriented to person, place, and time. His attention and concentration were sufficient for this appointment, and his remote and recent memory were sufficient. The Veteran scored 19/30 on SLUM screening. The diagnostic impression was PTSD, MDD in remission, and neurocognitive disorder needed to be ruled out. The Veteran presented with stable mood, no recent depression, and baseline PTSD symptoms. In May 2019, the Veteran was joined by his spouse for his routine follow up appointment. He reported that since his last appointment, he had been “pretty good;” however, he indicated that anger and “hollering” continued to be a problem. He often lashed out at his spouse but also lashed out at others. There was baseline irritability and low frustration tolerance. The Veteran’s moods continued to be influenced by his mobility limitations. He watched television during the day. He also enjoyed reading the Bible and attended church as often as possible. He slept 4 to 5 hours per night and napped 1 to 2 hours during the day. His primary concern was about his physical health limitations. The Veteran was unable to name his prescribed medications, but he was able to correctly identify the doses and indications for each. The medications helped his moods and nightmares. He reported his nightmares were less frequent and severe but continued to occur. He had night sweats several times per week, as well as episodes of acting out his nightmares. He continued to have difficulty with his memory. He continued to participate in leisure activities. On mental status examination, he was appropriately dressed and groomed. His attitude was appropriate, calm and cooperative. He exhibited appropriate eye contact. His speech was coherent with appropriate rate and volume. He showed appropriate affect that was congruent with his mood. His thought processes were logical and goal directed. He denied suicidal and homicidal ideations, audio and visual hallucinations, delusions, and obsessions. No overt psychosis was seen. His insight and judgment were fair. He was alert and oriented to person, place, and time. His attention and concentration were sufficient for this evaluation. The Veteran scored 19/30 on SLUM screening. The Veteran’s psychiatrist noted that the Veteran’s spouse provided collateral information that conflicted with his self-reported symptoms. His physical limitations continued to have a significant effect on his mood. The Veteran’s psychiatrist increased the prescribed medications to better manage his nightmares, night sweats, and possible episodes of night terrors or paralysis. The Veteran was again treated at VA in August 2019. The Veteran’s mood was irritable, but his irritability was improving. He denied depression, hopelessness, helplessness, crying spells, amotivation, anhedonia, recent panic attacks, hypervigilance, recent nightmares, night sweats, recent episodes of sleep paralysis, suicidal and homicidal ideations, and audio and visual hallucinations. He expressed frustration about his physical limitations. He became anxious about traffic or being late. He had intrusive thoughts of his time in the military several times per week but rarely had flashbacks. He continued to have exaggerated startle response. He slept 9 to 10 hours per night. The severity and frequency of his nightmares had improved since his medications were increased at his last appointment. He had increased difficulty with memory, and he sometimes forgot where he was going or what he was doing. As an example, he told his wife to turn down the wrong street on their way to the VA for this appointment. He continued participating in leisure activities. On mental status examination, he was appropriately dressed and groomed. His attitude was appropriate, calm, and cooperative. He exhibited appropriate eye contact. His speech was coherent with appropriate rate and volume. He showed appropriate affect that was congruent with his mood. His thought processes were logical and goal directed. He denied delusions and obsessions. No overt psychosis was seen. His insight and judgment were fair. He was alert and oriented to person, place, and time. The clinician noted some difficulty with word-finding. The Veteran scored 15/30 on SLUM screening, which was a decline from the February 2019 SLUM screening. The Veteran was again seen in psychiatry in December 2019. The Veteran’s mood was “pretty happy.” He denied depressive symptoms including hopelessness, helplessness, amotivation, and anhedonia. He denied suicidal and homicidal ideations, audio and visual hallucinations, mania, hypomania, paranoia, and delusions. His primary concern was his poor memory. The Veteran was frustrated with his physical limitations. He denied nightmares, night sweats, sleep paralysis, and flashbacks. The Veteran did not have difficulty sleeping, but currently napped throughout the day. No overt psychosis was noted. He continued to participate in previously enjoyed leisure activities. On mental status examination, he was appropriately dressed and groomed with a calm and cooperative attitude. He exhibited appropriate eye contact. His speech was coherent with appropriate rate, and volume. His affect was appropriate and congruent to his mood. His thought processes were logical and goal directed. No tangential thoughts, looseness of associations, blocking, or flight of ideas was noted. His insight and judgment were fair. He was alert and oriented to person, place and time. His attention and concentration were sufficient for this appointment. The diagnostic impression was that the Veteran’s psychiatric symptoms were stable. He was referred to neurology to evaluate his difficulty with memory. In January 2020, the Veteran was evaluated by a VA neurologist. The Veteran indicated that he had difficulty with memory for a year. He had to read things repeatedly to remember what he had read. He also had to recheck the calendar repeatedly, got lost easily, and was easily disoriented when being driven in a car. He also forgot things he used to know, specifically relating to directions. He still cooked for himself but sometimes he had to stop to think about the order of operations. He endorsed chronic back pain and worrying about money but did not feel either significantly affected his thinking or memory. He slept during the day and stayed awake at night. He spent most of his days and nights watching television and slept off and on until 4:00 a.m. Occasionally, he had difficulty thinking of the right word, but he had no trouble understanding. His wife described him as mean, which he related to his PTSD. He denied feeling depressed. On mental status examination, he was alert and oriented to person place, event, month, and year but not to the day of the week. His language was fluent and appropriate with good repeats. On SLUM screening, he got 11/30 correct. The clinician noted that his symptomatology was consistent with an attention deficit, which could be related to poor sleep, PTSD, and poorly controlled back pain. However, the clinician found some executive dysfunction which could not be accounted for by his current diagnoses. He was referred for a neuropsychological evaluation. In March 2020, the Veteran underwent a neuropsychological evaluation. He was referred for progressively worsening cognitive functioning characterized by poor memory and disorientation while driving. The Veteran and his wife reported the symptoms started insidiously in the last 12 to 15 months. Neuropsychological testing revealed mild to moderate diffuse deficits affecting cognitive functions in the front-subcortical brain circuits and posterior cerebral cortex of the right hemisphere. The Veteran’s current deficits reflected a decline from his baseline level of functioning. Alzheimer’s disease could not be ruled out. The Veteran was diagnosed with mild cognitive impairment (MCI) and mild neurocognitive disorder. The clinician found this diagnosis was the most appropriate because the Veteran remained largely independent in his activities of daily living. However, the MCI was considered advanced, and the clinician believed he was on the cusp of the early stages of mild dementia. Exacerbating factors included chronic pain, irregular sleep, and chronic PTSD. The diagnostic impression was MCI due to multiple etiologies and chronic PTSD. Upon review of the evidence of record, both lay and medical, the Board finds that a rating of 50 percent is warranted for the Veteran’s service-connected PTSD disability for the entire period on appeal. The Board finds that the Veteran’s mental health symptoms have remained relatively stable and consistent throughout the appeal period. Specifically, his symptoms have been shown to include depressed mood, anxiety, suspiciousness, irritability and anger, hypervigilance, exaggerated startle response, chronic sleep impairment, mild memory loss, disturbance of motivation and mood, and difficulty in establishing and maintaining effective relationships. VA treatment records also show continued care and effective treatment with medication for his PTSD symptoms of depression, anxiety, nightmares, and difficulty sleeping. Accordingly, the Board finds that a 50 percent rating for the Veteran’s PTSD disability is warranted for the entire period on appeal. The issue of whether the Veteran meets the criteria for a rating higher than 50 percent is discussed in the remand below. Finally, the Board notes that neither the Veteran nor his attorney have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to a rating higher than 50 percent for the acquired psychiatric disability to include PTSD is remanded. The Veteran was recently afforded a January 2020 neurological evaluation and a March 2020 neuropsychological evaluation at VA. The Veteran was diagnosed with “fairly advanced” mild neurocognitive impairment (MCI) based on symptoms of difficulty with short-term memory, having to re-read a text several times before he remembered the content of what he read, and being disoriented in a car. In addition, the clinician also noted that the service-connected PTSD, difficulty sleeping, and non service-connected pain exacerbated the MCI. It appears that the Veteran’s psychiatric symptoms have worsened since the most recent December 2018 VA examination. In addition, the past VA examinations did not adequately discuss or consider the Veteran’s cognitive symptoms, now diagnosed as MCI. The fact that a VA examination is almost a year-and-a-half old is not a valid basis, unto itself, to provide the Veteran with another VA examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-83 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995). However, in this case, the VA treatment records indicate that his symptoms have worsened since the most recent VA examination; therefore, a new VA examination is needed to assist in determining the current severity of the Veteran’s service-connected psychiatric disability. Id., 10 Vet. App. at 400. On remand, the Veteran should be scheduled for another VA examination, to the extent possible, to determine the current severity of the Veteran’s psychiatric symptoms, to include the newly diagnosed MCI. If a VA examination is not possible due to the current pandemic, a medical opinion from an appropriate clinician should be obtained to review the record and assess the current severity of the symptoms of the acquired psychiatric disability. 2. Entitlement to a TDIU, to include on an extraschedular basis, is remanded. The Veteran does not currently meet the schedular criteria for a TDIU as he is service connected for one disability that has not yet been rated at 60 percent or higher at any time during the appellate period. Nevertheless, the Veteran submitted a June 2016 private psychiatric medical opinion that concluded the Veteran was precluded from obtaining or maintaining substantially gainful employment since at least 2012; hence, the issue of unemployability has been raised. Before the claim can be adjudicated however, further development is necessary. The Veteran’s VA treatment records indicate that the Veteran has served as a pastor or minister during the appellate period. See November 2012 to May 2019 VA treatment records. It is unclear whether he was employed by the church or whether he led his church on a volunteer basis and what duties this entailed. On remand, additional development should be undertaken to determine the nature of his role as a pastor and minister. Finally, entitlement to a TDIU is inextricably intertwined with the claim being remanded, as the outcome may impact the TDIU claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Obtain any outstanding pertinent VA treatment records and associate them with the claims file. 2. Request the Veteran submit additional evidence regarding his service or employment as a pastor or minister. See, e.g., November 2012 through May 2019 VA treatment records. Specifically, request the Veteran clarify whether he was employed by the church, what his duties entailed in this role, and identify how much income he may have earned, if any, while serving in that capacity. 3. Schedule the Veteran for a VA psychiatric examination (in-person, telehealth, etc.), if possible, to determine the current severity of the psychiatric symptoms, to include the newly diagnosed mild cognitive disorder. See March 2020 VA treatment records. The claims file, and a copy of this Remand, must be made available to and be reviewed by the examiner. **IF an in-person, telehealth, etc. examination is not feasible given the circumstances surrounding the recent pandemic, refer the case to an appropriate clinician for a thorough review of the record and medical opinion as to nature and severity of the Veteran’s psychiatric symptoms. Specifically, the severity and functional impact on the Veteran’s March 2020 diagnosis of MCI should be addressed. 4. Then, if the Veteran still does not meet the schedular criteria for a TDIU, refer the claim to the Director of Compensation Service to consider whether an extraschedular TDIU is warranted. 5. Readjudicate the claims on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harper, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.