Citation Nr: 21070083 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 17-16 865A DATE: November 23, 2021 ORDER Effective from August 7, 2008, entitlement to an initial 70 percent disability rating for unspecified anxiety disorder also claimed as posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to an initial disability rating in excess of 10 percent for degenerative joint disease of the right knee is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDING OF FACT For the entire period on appeal, the Veteran's unspecified anxiety disorder also claimed as PTSD has been productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; but not total occupational and social impairment. CONCLUSION OF LAW From August 7, 2008, the criteria for entitlement to an initial disability rating of 70 percent for unspecified anxiety disorder also claimed as PTSD have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.4, 4.7, 4.130, Diagnostic Code 9413. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service in the United States Navy from September 1989 to February 1998. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in April 2016 and August 2017. During the pendency of the Veteran's initial increased rating claims for his right knee and psychiatric disabilities, the Veteran's representative asserted in a June 2019 notice of disagreement related to the evaluations of the Veteran's right and left lower extremity radiculopathy disabilities that the agency of original jurisdiction (AOJ) failed to consider the issue of entitlement to a TDIU. Thus, the Board has taken jurisdiction over this issue. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board acknowledges that the Veteran has been in receipt of a combined evaluation of 100 percent effective from December 12, 2019. However, the Board notes that a 100 percent disability rating does not necessarily render the issue of TDIU moot. In Bradley v. Peake, 22 Vet. App. 280, 293-94 (2008), the United States Court of Appeals for Veterans Claims (Court) determined that a separate TDIU predicated on one disability (although perhaps not ratable at the schedular 100-percent level) when considered together with another disability separately rated at 60 percent or more could warrant SMC under 38 U.S.C. § 1114(s). Thus, the Court reasoned, it might benefit the Veteran to retain or obtain the TDIU even where a 100 percent schedular rating also has been granted. Bradley, 22 Vet. App. at 293-94. Under Bradley, the Department of Veterans Affairs (VA) must consider a TDIU claim despite the existence of a schedular total rating and award SMC under 38 U.S.C. § 1114(s) if VA finds the separate disability supports a TDIU independent of the other 100 percent disability rating. See id. The record reflects that the Board sent a July 10, 2019 docketing letter to the Veteran that was copied to his representative stating that the Veteran's appeal had been placed on the Board's docket, and the Veteran had 90 days from the date of the letter or until the Board issued a decision in his appeal (whichever came first) to request a change in representation or to submit additional argument or evidence. The Veteran's representative later submitted a July 16, 2019 request for a 90-day extension to gather additional evidence and prepare a brief. However, the record shows that the representative later submitted a brief related to the current appeal in October 2019 in which he waived any right to have the AOJ review his argument and requested for the Board to review the case on its merits. In consideration of this statement, the Board finds that the July 2019 extension request was satisfied by the representative's submission of the October 2019 brief. The Board also notes that after the July 2019 statement of the case (SOC) adjudicated the Veteran's increased rating claim for his psychiatric disability, additional VA treatment records dated from January 2010 to November 2019 were associated with the claims file. Although the Veteran has not provided a waiver of the agency of original jurisdiction's (AOJ's) initial review of this additional evidence, and as explained in further detail below, the Board's grant of a 70 percent rating for the entire appeal period for the Veteran's psychiatric disability is a complete grant of the benefits sought with respect to this issue. There is therefore no prejudice to the Veteran in the Board proceeding to adjudicate this claim. The Board notes that a September 16, 2016 letter notified the Veteran that his Veteran Readiness and Employment Program (VR&E) (formerly known as Vocational Rehabilitation and Employment) program had been interrupted. The letter stated that the Veteran could either request an administrative review or file a formal appeal within one year of the date of the letter if he disagreed with the decision. Additional letters sent to the Veteran on October 25, 2016 and November 16, 2016 proposed to end his participation in the VR&E program. The letters stated that if the rehabilitation counselor did not hear from the Veteran within 30 days from the date of the letter or the Veteran did not take one of the provided steps to disagree with the decision to close his case, the decision would become final. The letter again indicated that the Veteran could seek administrative review or appeal the decision to the Board. The Veteran later sent a November 28, 2016 e-mail to his vocational rehabilitation counselor regarding the possible closure of his case and stated that he had sent a notice of disagreement. His counselor responded on November 30, 2016 that she was happy to work with the Veteran to find a resolution. A notice of disagreement was later received in December 2016 that the Veteran indicated was submitted in response to the September 2016 and October 2016 letters. However, the record reflects that the Veteran's VR&E benefits were subsequently resumed as letters dated on May 22, 2017 and October 2, 2017 notified the Veteran that he had been awarded a vocational rehabilitation subsistence allowance. It was not until approximately one year later on November 16, 2018 that the vocational rehabilitation counselor sent a letter that proposed to interrupt the Veteran's VR&E participation. The Veteran's vocational rehabilitation counselor also later reported in a December 11, 2018 e-mail that she would not discontinue his case at that time. Letters dated on March 6, 2019 and April 24, 2019 show that the Veteran's case was later placed in interrupted status in March 2019 before his VR&E benefits were discontinued in April 2019. Both of these letters also included appellate rights under the modernized review system. Based on the foregoing, the Board finds that the issuance of a statement of the case pursuant to Manlincon v. West, 12 Vet. App. 238 (1999) with respect to the December 2016 notice of disagreement is unnecessary. The Board further notes that in an October 2010 statement, the Veteran requested for the agency of original jurisdiction (AOJ) to obtain his Vet Center records from a facility in Jacksonville, Florida. The address provided by the Veteran for the facility is different than the address currently listed for the Jacksonville, Florida Vet Center on VA's website. See Jacksonville, FL Vet Center, Department of Veterans Affairs, https://www.va.gov/directory/guide/facility.asp?ID=379. Moreover, the Veteran later indicated that he had not previously received treatment from a Vet Center. He reported in a subsequent August 2013 VR&E record that although he called the Vet Center a while ago, they informed him that he did not qualify. As such, the Board concludes that there are no outstanding Vet Center records. Neither the Veteran nor his representative has raised any other 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). 1. Entitlement to an initial disability rating in excess of 50 percent for unspecified anxiety disorder also claimed as PTSD. 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. Disability ratings are intended to compensate impairment in earning capacity due to a service connected disorder. 38 U.S.C. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 U.S.C. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. Evidence to be considered in an appeal from an initial disability rating was not limited to that reflecting the then current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). In contrast, for an already established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). For both types of increased rating claims, it is possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See Fenderson, 12 Vet. App. at 126-27; Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). Such separate disability ratings are known as staged ratings. The August 2017 rating decision granted entitlement to service connection for unspecified anxiety disorder also claimed as PTSD and awarded an initial 50 percent disability rating effective from August 7, 2008. The Veteran's psychiatric disability has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9413; however, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. A 50 percent rating is assigned 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned 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 memory loss for names of close relatives, or for the Veteran's own occupation or name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact occupational and social impairment. Vasquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vasquez-Claudio, 713 F.3d at 118. The Board acknowledges that psychiatric examinations frequently include the assignment of a global assessment of functioning (GAF) score. The GAF was 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, Fourth Edition (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). Clinicians dealing with mental health issues currently use the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The Court noted that the DSM-5 eliminated GAF scores because of their conceptual lack of clarity and questionable psychometrics in routine practice, and further stated that an adjudicator is not permitted to rely on evidence that the American Psychiatric Association itself finds lacking in clarity and usefulness. The Court explained symptoms should be the primary focus when assigning a rating for a psychiatric disorder and clarified that the use of numerical GAF scores as a shortcut for gauging psychiatric impairment would be error. Further noted was that the adequacy of medical examinations has never depended upon the use or inclusion of GAF scores. Golden v. Shulkin, 29 Vet. App. 21 (2018). In light of the above discussion, the Board finds any GAF scores assigned in this case to be of no probative value. The Veteran was provided with a VA examination related to psychiatric disorders in March 2009. The examiner noted that the Veteran had been married for 19 years, and the marriage was going alright. He had two children with whom he was very close. The Veteran also reported having 6 to 7 friends and participating in activities such as fishing and spending time with family. The examiner noted that the Veteran had a history of suicide attempts, noting that the Veteran overdosed on sleeping pills in 1999 as he thought that his "family would be better if I was dead." The examiner added that he did not have current suicidal ideation. In addition, the Veteran had a history of violence/assaultiveness that included 10 to 20 fights with the most recent fight occurring one month ago. The examiner indicated that the Veteran was under the influence of alcohol/drugs during approximately 50 percent of these incidents, but the examiner did not provide details regarding the circumstances of the most recent fight. In this regard, the Veteran had a history of alcohol and opiate abuse. He most recently drank alcohol three years ago and used opiates two years ago. The Veteran had received outpatient treatment for a psychiatric disorder in 2004 and 2005 as well as from 2007 to the present. The examiner noted that he was treated by a civilian psychiatrist for depression with Effexor and Paxil. He had also been receiving individual counseling from a private provider for depression, grief issues, the Veteran's history of being "kicked out" of the Navy, and drug counseling. There had not been one or more hospitalizations for a psychiatric disorder. The Veteran's response to psychotherapy had been fair. Regarding the frequency, severity, and duration of non-PTSD psychiatric symptoms, the examiner stated that the Veteran experienced a mildly depressed mood 4 to 5 days last week that lasted for 4 to 5 hours a day with no known precipitating factors. In relation to depression, the Veteran slept 2 to 5 hours a night, experienced decreased appetite, had decreased concentration, and had poor self-esteem. The psychiatric examination showed that the Veteran was clean and dressed appropriately and casually. The examiner stated that he was able to maintain his personal hygiene. His speech was unremarkable, and he had an attentive attitude and constricted affect. In terms of mood, the Veteran reported being alright, but also feeling tired and nervous. He was oriented times three with unremarkable thought processes and content. There were no delusions. The Veteran had average intelligence and understood the outcome of his behavior. He partially understood that he had a problem. The Veteran 's energy was high despite sleeping 2 to 5 hours a night. He did not have inappropriate behavior. In relation to the history of fighting, the examiner noted that the Veteran had poor impulse control with episodes of violence. The Veteran's remote and immediate memory were normal. The examiner stated that the Veteran was capable of managing his financial affairs. The Veteran's usual occupation was as a contractor, and he was currently self-employed. The duration of the current employment was 10 to 20 years. The Axis I diagnosis was depressive disorder not otherwise specified (NOS), opiate abuse in reported remission, alcohol abuse in reported remission. The examiner opined that the Veteran's psychiatric symptoms were not severe enough to interfere with occupational and social functioning. In June 2009, a VA Substance Abuse Treatment Team (SATT) psychiatry assessment noted that the Veteran was referred for an evaluation and possible treatment after receiving disability and being able to access VA care. The record stated that the Veteran's most recent psychiatric diagnoses included attention deficit disorder (ADD) and depression. The Veteran reported overdosing on aspirin at age 10, but he denied any further suicide attempts or current suicidal or homicidal ideation, intent, or plan. The Veteran reported that his mood was sporadic, angry at times, and sad for no reason. He reported visual hallucinations such as flashbacks and sometimes having auditory hallucinations such as the devil talking to him with the most recent event occurring 3 to 4 months ago. The Veteran reported that the devil tried to make him do bad things to people such as beating them up. Regarding the mental status examination, the Veteran did not appear acutely psychotic, he had adequate eye contact, and he showed a fair rapport. He was described as calm, cooperative, and reasonable with normal speech. His mood was euthymic with a congruent affect and logical thought process. His thought content contained paranoia/suspiciousness. The Axis I diagnoses were opioid dependence, ADD, hallucinogen persisting perception disorder, and questionable hallucinogen induced psychotic disorder with delusions. In August 2009, a VA treatment record noted that the Veteran's sleep was reportedly "horrible" due to intrusive memories. He still had auditory/visual hallucinations. The Veteran also denied having suicidal intent or a plan. Although he had homicidal ideation at times towards a past commanding officer who assaulted him, he had no plans or intent and denied current homicidal ideation. He continued to have paranoid ideas. In September 2009, a VA treatment record stated that there were no further hallucinations and infrequent paranoid feelings. The Veteran also did not have current homicidal or suicidal ideation. A subsequent October 2009 VA treatment record stated that the Veteran reported having some problems with memory such as forgetting appointments or other "simple things." He acknowledged feeling more distracted as he had to return to work to help out. He had also been doing a lot of driving. He complained of an increase in his sleep walking and talking/screaming in his sleep. His mood was good, and there was no psychosis. The provider stated that the Veteran had been doing well with regards to his opiod dependence and remained abstinent. There was no suicidal or homicidal ideation. The assessment was opioid dependence, PTSD, and ADD. In a November 2009 VA treatment record, the Veteran reported that holidays were stressful for him due to financial worries. His mood was irritable, and he reported verbally "exploding at little things." He had auditory hallucinations, but not of the command type. There were no visual hallucinations or suicidal or homicidal ideation, intent, or plan. He reported compliance with his medication. In February 2010, a VA treatment record noted that the Veteran had experienced difficulty obtaining his medication since his last visit. He was feeling stressed, could not sleep, had nightmares, and experienced a decreased appetite. The Veteran felt frustrated during the three days he recently went without medication, but he did not feel suicidal. The Axis I diagnoses were opioid dependence - remission, PTSD, and attention deficit hyperactivity disorder (ADHD). In June 2010, a VA treatment record stated that the Veteran reported feeling depressed at times as well as angry and irritable due to pain. Although he sometimes felt hopeless as his doctor told him he had to live with the pain, he denied having suicidal ideation. There was also no psychosis. In July 2010, the Veteran reported he was recently hospitalized for suicidal ideation. He indicated that he had been feeling overwhelmed, and he now felt a lot better. The Veteran still experienced stress related to pain and financial issues. The Veteran denied having current suicidal ideation, intent, or a plan. There was also no homicidal ideation or psychosis. However, his wife reported that the Veteran experienced paranoia, thinking that people were out for him or doing something to him. The Axis I diagnoses were opioid dependence, adjustment disorder - mixed, PTSD, and ADHD. An associated mental health suicide risk assessment detailed that the Veteran was hospitalized for 72 hours in mid-July after having suicidal ideas and providing his wife with instructions on what to do. There were no identified/specific plans. Family stressors included relational conflicts and financial stressors included job loss/change/inability to acquire a job. The Veteran had to return his truck after being unable to make payments and feared losing his house. The record noted that the Veteran had easy access to a weapon/firearm. The Veteran's estimated risk level was moderate. In August 2010, the Veteran reported not having cravings for drugs and remaining abstinent. However, conflicts at home were noted to be a possible trigger for relapse. He was emotionally upset and sad, feeling that he had a lack of support. The provider noted that he seemed overwhelmed and anxious. Another August 2010 entry stated that the Veteran continued to have significant family conflicts and felt overwhelmed and unsupported. Although he denied having suicidal ideation, intent, or plan; there was some homicidal ideation that was not directed to any specific person. He reported "lashing out at everybody basically." While he denied previous physical violence towards others, he sometimes broke objects. There was no homicidal intent or plan, and there was no psychosis. In September 2010, a VA mental health suicide risk assessment noted that the Veteran had experienced suicidal ideation without a plan or intent during the past week when his truck was repossessed. The record noted that he had no access to weapons/firearms, and his estimated risk level was low. In October 2010, a VA treatment record stated that the Veteran had anxious/worried affect and seemed overwhelmed with no acute psychosis. Although homicidal ideation was absent, he was noted to have passive thoughts of suicide without intent or plan; and the record indicated that he contracted for safety. The Axis I diagnoses were opioid dependence - remission, PTSD, ADHD, and adjustment disorder. The Veteran's passive suicidal ideation was also noted to be unchanged in November 2010. In a December 2010 VA treatment record, the Veteran reported having a frustrated mood. Although he stated he was sleeping better, the Veteran's wife reported that he tossed and turned in addition to screaming out. Auditory hallucinations were present. While he denied having suicidal ideation, he sometimes had thoughts about hurting his brother-in-law without intent or plans. In January 2011, the Veteran reported that he felt like "ending it all," but he had no plan or intent to hurt himself. The Veteran's mood had been depressed, and he denied current suicidal or homicidal ideation. He still had auditory hallucinations, but he reported remaining sober. A subsequent January 2011 SATT telephone encounter note stated that the Veteran continued to struggle with emotional lability that was exacerbated by symptoms of PTSD and family/financial concerns. The Veteran had been accepted to the Bay Pines VA healthcare system for inpatient care for PTSD/military sexual trauma (MST), and he was awaiting a shuttle to the facility at the Tampa, Florida airport. A January 2011 case manager discharge planning note from the Jacksonville 1 VA clinic stated that the Veteran was transferring mental health care to the Bay Pines Center for Sexual Trauma Services (CSTS) program for treatment of MST. It was presumed that he would continue treatment for approximately 3 months. The provider summarized that the Veteran had been referred in July 2010 after his discharge from the Orange Park Medical Center for suicidal and homicidal ideation. The Veteran continued to struggle with problems related to a business dispute with his brother-in-law, and he continued to have problems in the areas of his finances, occupation, and primary support. The diagnoses were opioid dependence in full sustained remission, alcohol dependence in full sustained remission, and PTSD (MST). The provider further noted that the Veteran was last seen in December 2010 and early in January 2011, but the providers had been unable to reach the Veteran until the January 2011 telephone encounter. The provider noted that this event was highly unusual, and in hindsight might have been an indication of building anxiety for the Veteran. The provider also stated that as he was writing the current note, the provider received a phone call from a doctor of CSTS who informed the provider that after the Veteran's arrival at CSTS, the Veteran informed the staff that he had significant problems with sleepwalking and worried about his safety. The Veteran also became belligerent with nursing staff to such an extent that they planned to call the police. The CSTS doctor intervened and they decided it was best for the Veteran to return to Jacksonville at that time. In March 2011, a VA treatment record stated that the Veteran's nightmares were intense, but less bothersome. He reported having a fair appetite without hallucinations, paranoia, or homicidal/suicidal ideation. The Veteran's mood was better, and he had been handling stress better in the past few weeks. In an April 2011 VA treatment record, the provider noted that the Veteran did not verbalize any desire to drink or use drugs despite having significant stressors. He was also attending marital therapy at church. Later in April 2011, the Veteran's mood was good, his sleep was better, and he was noted to be attending Alcoholics Anonymous/Narcotics Anonymous (AA/NA). However, the Veteran's wife reported that he was restless, he kicked, and he moaned in his sleep. His appetite was fair, there were no hallucinations/paranoia, and he denied having homicidal or suicidal ideation. Later in April 2011, the Veteran was assessed for possible admission in VA's Present-Centered Therapy (PCT) program. When asked about his current problems, the Veteran reported that his anger was probably the worst in addition to being antisocial. He did not really like people and did not trust anyone. The provider noted that the Veteran reported having occasional thoughts of suicide in response to physical pain or thinking that his family would be better off financially if he were dead. He denied serious consideration of suicide at that time, but he noted that he had been actively suicidal/homicidal 2 months ago in relation to a conflict with his brother-in-law over business. The provider also noted that he had current aggressive ideation in relation to his brother-in-law due to feeling unfairly treated in a business arrangement. He denied having a history of physical fights in the past two years. The Axis I diagnoses were PTSD, opioid dependence in sustained full remission, and alcohol dependence in sustained full remission. In July 2011, a VA suicide screen revealed that the Veteran had experienced thoughts of killing himself in the past 2 weeks. He did not have a plan. The record noted that he did have a history of a suicide attempt in that he planned to shoot and kill himself a little over a year ago. The Veteran reported that his wife intervened and called the police which led to the Veteran being "Baker Acted." The Veteran reported that although he had not pulled the trigger, he had held the gun to his head with the intention of shooting himself. The provider further detailed that the Veteran identified having passive suicidal ideation in the form of sometimes thinking that things would be easier for him and his family if he were not around. The Veteran denied having any specific thoughts, plans, or intentions for self-harm and noted that he had discussed warning signs with his family. The provider also noted that he had a history of impulsive and/or aggressive tendencies as well as feelings of anger and anxiety/agitation. The estimated risk level for suicide was low. Later in July 2011, a VA treatment record noted the Veteran's report of auditory hallucinations of the devil screaming and sometimes telling him to seek revenge on the perpetrator of the MST. However, he had no homicidal or suicidal ideation, intent or plans. He also reported visual hallucinations of shadows. In August 2011, a VA treatment record stated that the Veteran was angry with the provider authoring the note as the Veteran was unable to receive travel reimbursement for an earlier visit in August. He was otherwise doing fair and remaining abstinent of drugs. His mood was angry and irritable, and the Veteran reported having fleeting thoughts of self-harm due to stress from ongoing financial issues. He denied having any intent or plan. There was no homicidal ideation or psychosis. The provider noted that he poor self-esteem and limited coping. The Axis I diagnoses were opioid dependence - remission, adjustment disorder - mixed, PTSD, depression NOS, and ADHD. In September 2011, the Veteran reported in a VA treatment record that the last couple weeks were horrible and he should have gone to the hospital. He had been having increasing stress as his cell phone was cut off as well as his electricity for brief time, and he could not travel for PTSD treatment due to a lack of funds. He had been having suicidal ideation, but there was currently no suicidal ideation, intent, or plan. His daughter had been supportive, and his mom had come to town to help him. The Veteran's mood had been better. The provider noted that there was no acute psychosis. In December 2011, the Veteran reported that things were better than they had been, and he was remaining sober. His sleep/appetite was fair, and he did not have psychosis or suicidal or homicidal ideation. A subsequent December 2011 entry stated that although the Veteran had some recent difficulties with anger/irritability, he had been doing better at managing his anger. He acknowledged some paranoia and noted that cognitive strategies had been helpful in reducing its intensity. He denied suicidal ideation. The Veteran also denied current aggressive ideation, but he noted one incident when he shoved a neighbor during an argument. In September 2012, the Veteran reported that he remained sober and continued to have stress at school. His mood was ok, and his sleep and appetite were fair. There were no hallucinations, paranoia, or homicidal or suicidal intent. The Veteran was noted to be somewhat irritable due to a mix-up with appointments. In November 2012, an additional VA examination related to psychiatric disorders was conducted. The Axis I diagnoses were PTSD; alcohol dependence, in sustained full remission; and opioid dependence, in sustained full remission. ADHD was an additional diagnosis that pertained to the mental health disorders. Although the examiner stated that it was possible to distinguish what symptoms were attributable to each diagnosis, the examiner noted that the symptoms were due to the PTSD and ADHD as the Veteran's alcohol and opioid dependence had been in remission for years. Symptoms of re-experiencing prior traumas and avoiding were due to his PTSD. Symptoms of difficulty concentrating could be due to either his PTSD or ADHD. The examiner opined that the Veteran had 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 similarly stated that the impairment was attributable to his PTSD and ADHD as his alcohol and opioid dependence had been in remission for years. Regarding social relationships, the Veteran continued to be married and described his relationship as "up and down." He reported that he now had no friends whatsoever. The Veteran also reported that he stopped working as a contractor in 2009 due to physical limitations and pain as well as needing to remove himself from the workplace to maintain his sobriety and as a result of mental health concerns. He was a full-time student working towards a degree in civil engineering. The Veteran denied having arrests since being discharged. However, he reported being involved in approximately 30 physical altercations post-discharge. The last altercation occurred that week with his son's wrestling coach. The Veteran indicated that he stopped drinking in 2005 and denied relapsing since that time. He also reported becoming addicted to opiates/pain medication (Vicodin, oxycontin, Lortab) in 2003 and discontinuing these medications in 2007. He continued to attend AA and NA meetings approximately once a week. The Veteran's current symptoms included depressed mood, anxiety, and chronic sleep impairment. The examiner noted that the Veteran experienced a depressed a mood that varied in its severity, describing the symptoms as "up and down" approximately 20 days during the past month. He also reported experienced anxiety for approximately 5 to 7 days, adding that the symptom was "sometimes it is really bad." He denied having any sleep impairment. The Veteran additionally experienced anhedonia approximately 50 percent of the time. He reported having difficulty concentrating and experiencing anger/irritability on a daily basis as well as visual and auditory hallucinations once approximately one month ago. The Veteran denied having suicidal or homicidal ideation or intent. He was deemed capable of managing his financial affairs. In a March 2013 VA treatment record, the Veteran reported that he had been having problems with literature in school, citing his poor focus and attention as well as retention issues. He also reported feeling stressed as he had not been back for his PTSD treatment due to transportation problems. The Veteran denied having homicidal or suicidal ideation. In May 2013, the Veteran reported having increasing depression, anxiety, and irritability. He described financial problems and issues with pain and school. He had been a lot more irritability lately and argued with two of his teachers, a veteran, and classmates. He denied having homicidal or suicidal ideation. The Veteran's VA treatment records subsequently included a June 2013 message from the Veteran in which he reported having serious issues with his VA medical services and his perception that he was being persecuted rather than helped by the system. The message included the Veteran's report that the past couple of months and frustrations from June 2013 had forced him "into a dark corner" and hindered his mental and physical quality of life. This issue had also occurred during the worst time due to final examinations. The Veteran described a recent issue having problems receiving medication from a VA pharmacist. In August 2013, a VR&E record noted that the Veteran presented to a meeting with a vocational counselor requesting a referral for mental health/psychology. He reported having nightmares which resulted in accidentally hurting his wife and throwing his CPAP machine in his sleep. He additionally reported a high stress level with several, recent anger-related situations; including incidents resulting in security being called at the VA pharmacy and involving yelling at a support specialist in the VR&E office. The Veteran also reported an increased pain level as well as attending school full-time that increased his stress and anxiety. A separate August 2013 VR&E record elaborated that the pharmacy incident was caused by the pharmacist not giving the Veteran Lyrica as it was a narcotic. The Veteran responded by knocking on the glass at the pharmacy and "shooting him the rod" before VA security was called. In April 2014, a VR&E record noted that the Veteran was requesting mental health counseling and reported having increased anxiety, increased irritability, and anger management issues. An August 2013 VA administrative note indicated that the Veteran had a conflict with the scheduled appointment and became very agitated, asking why it took so long to schedule the appointment and reporting that he had been asking for help for months. He expressed frustration with the VA system and his feeling of being unable to receive help, adding "this is why so many Veterans kill themselves." He reported feeling disrespected by VA employees. The Veteran denied having current homicidal or suicidal ideation. Later in August 2013, the Veteran reported having feelings of hopelessness and worthlessness. He had passive suicidal thoughts at times, and active thoughts with the last incident occurring in January 2013. The Veteran also reported that he was very easily angered and irritated and struggled to let go of even small things. When he was upset, he would yell, curse, or completely shut down. He also had a history of throwing or breaking things, with the last such event occurring in December 2012. He additionally reported physical altercations as recently as 2 months ago. The Veteran had been sitting at a picnic table at school and saw someone with whom he previously had a falling out. The Veteran responded by grabbing the individual by the throat and pushing him to the ground before stopping himself. The police were called, and they spoke to the Veteran with no further consequences. He denied having homicidal thoughts. In November 2013, a VA treatment record stated that the Veteran denied having prominent mood symptoms, psychosis, or homicidal or suicidal ideation. A similar report was noted in January 2014, March 2014, and April 2014. However, the April 2014 record noted that the Veteran still had symptoms consistent with PTSD, and he was feeling stressed with finals related to his civil engineering degree. A subsequent May 2014 record included a message from the Veteran apologizing for missing an April 2014 appointment. The Veteran reported that he had been struggling for the last couple of months with school, health, and mental issues. He indicated that he had been taking final examinations the week the appointment. In June 2014, a VA treatment record noted that the Veteran was agitated about his care at VA. He was in distress due to being taken off a certain medication without an explanation. Although the Veteran felt that he was being dropped by the PCT clinic, the provider observed that the Veteran no-showed for a recent PCT appointment and the PCT attempted to contact the Veteran on multiple occasions. The Veteran was able to deescalate and planned to return home. The provider noted that he did not have suicidal or homicidal ideation. Later in June 2014, a VA treatment record noted that the Veteran swam on a daily basis to deal with stress. He reported being overwhelmed and overworked lately, and he was trying to cope effectively. A subsequent June 2014 message from the Veteran in his treatment record noted that he apologized for missing an appointment. The Veteran reported that he was "crumbling down with nowhere to go," adding that he was "not sure what do at this point as [he] was being attacked from all angles and falling apart." Later in June 2014, a message from the Veteran in his treatment records noted that he took issue with an instruction he received to stop taking Adderall. The Veteran noted that the medication was treating his ADHD, and he was struggling in school without it. The Veteran reported that he could hardly sleep, and his mind was racing and causing him to think irrationally. In July 2014, a provider noted in a VA treatment record that the Veteran had multiple no-shows and a June 2014 urine drug screen was still positive for stimulants despite being told to stop them earlier in June 2014. It was unclear where the Veteran was obtaining the stimulants, and this was a significant violation of his suboxone contract. The provider noted that the Veteran's increasing anger around controlled substances was concerning for active addiction. A July 2014 e-mail to the Veteran from an SATT Clinic provider in his treatment records noted that the provider had not heard back from the Veteran after several phone messages and written correspondence, and the provider observed that the Veteran did not attend his appointment on that date. The provider instructed the Veteran to contact them as soon as possible if wanted to re-establish care in the clinic. In August 2014, a VA PCT individual psychology note documented the Veteran's report that he was transferring his mental health care and suboxone to community providers. The Veteran indicated that his PCT treatment had been useful, but the frequency of appointments and location were not working for him. The provider noted that his mood appeared to be stable with a congruent affect. There was no evidence of hallucinations or delusions reported or observed. The Veteran also denied suicidal or homicidal ideation or thoughts of harm to himself or others. In September 2014, a private treatment record stated that the Veteran was now following up with a civilian mental health clinic. He was still on suboxone and Adderall, and he was also receiving guanfacine (Tenex) from this provider. In February 2015, Dr. F., MD, completed a Disability Benefits Questionnaire (DBQ) related to PTSD. The Axis I diagnoses were PTSD due to military sexual trauma (MST), chronic, severe; major depressive disorder, recurrent, severe; and ADHD NOS. Dr. F. opined that it was not possible to differentiate what symptoms were attributable to each diagnosis, stating that the Veteran's PTSD and depression were interactive and inseparable. Dr. F. also opined that the Veteran had total occupational and social impairment. He similarly found that it was not possible to differentiate what portion of the impairment was attributable to each diagnosis, noting that the Veteran's major depressive disorder was in response to, and caused by, his PTSD. Regarding social functioning, the Veteran was still married and had positive contact with his mother and stepfather. He did not have any friends. Although he attended church, he was not social there. He also had a strained relationship with an adult daughter and a good relationship with a teenage son. The Veteran completed an Associate of Arts degree in liberal arts in 2014 and was working towards a Bachelor of Science degree in civil engineering. The Veteran was struggling in school and failed a physics and Spanish course the previous semester. Full time attendance was not plausible due to chronic physical and mental health problems. The Veteran began to receive mental health treatment from VA from 2009 to 2013 and transferred to private treatment in June 2013. He currently received individual psychotherapy twice a month. He had been "Baker Acted" three times for suicidal ideation and homicidal ideation. He was currently taking mirtazapine, Effexor, and suboxone. The Veteran's relevant legal and behavioral history included assault and battery in 2003. Dr. F. stated that he also had a recent charge of assault and battery at a college campus before noting that the charges were still pending. He engaged in avoidance of people and places, social isolation, restricted affect, anhedonia, episodes of uncontrolled anger and rage, a depressed mood, and feelings of worthlessness and guilt. Dr. F. stated that the Veteran had tobacco use disorder and smoked 1 pack per day. He denied having any drug or alcohol abuse since 2005 to 2006 and regularly attended AA and NA meetings. His alcohol dependence and opioid dependence were in remission. Dr. F. stated that the Veteran's current symptoms included a depressed mood, anxiety, suspiciousness, and panic attacks more than once a week. He also had near-continuous panic or depression affecting his ability to function independently, appropriately, and effectively, a chronic sleep impairment, mild memory loss, and impairment of short and long-term memory. In addition, symptoms of a flattened affect; circumstantial, circumlocutory, or stereotyped speech; and speech intermittently illogical, obscure, or irrelevant were present. Impaired judgement, impaired abstract thinking, gross impairment of thought processes or communication, and disturbances of motivation or mood were other noted symptoms. Dr. F. also found that the Veteran had disturbances of motivation and mood, difficulty in adapting to stressful circumstances, and both difficulty and the inability to establish and maintain effective work and social relationships. Dr. F. further stated that he had suicidal ideation and impaired impulse control, such as unprovoked irritability with periods of violence. He additionally had grossly inappropriate behavior and was in persistent danger of hurting himself or others. Dr. F. summarized that the Veteran no longer enjoyed things that used to make him happy, he was unable to concentrate, he had a tendency to isolate socially, and he had decreased energy. Dr. F. also remarked that the Veteran had anger as well as irritability with physical aggression, and his anger issues were still at a serious level and had caused his wife to leave him in the past. Dr. F. found that the Veteran was capable of managing his financial affairs. In March 2017, a VA examiner conducted an examination related to the Veteran's psychiatric disability. The examiner opined that the Veteran's symptoms did not meet the diagnostic criteria for PTSD under the DSM-5 criteria. The only psychiatric disorder diagnosis was unspecified anxiety disorder, and the examiner opined that the disability was manifested by 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 Veteran continued to be married and was living with his wife, their teenage son, and their two grandchildren. He reported that he called the Department of Children and Families on his daughter and she left the previous night. The Veteran reported that he had no friends. The Veteran reported that he was hospitalized for a mental health disorder in 2010 or 2009 as he "was going to" kill his brother-in-law after the Veteran discovered he was locked out of the joint checking account they had shared as business partners. The Veteran reported that his brother-in-law "took everything." The Veteran's current treatment for his psychiatric disability included individual psychotherapy and medication in the form of amphetamine/dextroamphetamine, mirtazapine, and Effexor. The Veteran's recent legal and behavioral history included a "breach of the peace" approximately 3 years ago. Regarding substance abuse, the Veteran quit using alcohol in 2006. He denied having any current issues with substance abuse and reported that the last time he smoked marijuana was maybe in 2005. The examiner stated that the Veteran's symptoms included a depressed mood, anxiety, and a chronic sleep impairment. The Veteran reporting sleeping for approximately 5 hours a night and having nightmares. He also described feeling on edge, watchful, or on guard. The Veteran avoided anything related to Catholicism. He additionally reported feeling anger. There were no other relevant symptoms. The Veteran was found to be capable of managing his financial affairs. In July 2019, the Veteran attended a VA examination to evaluate his psychiatric disability. Similar to the March 2017 VA examination, the only diagnosis was unspecified anxiety disorder, and the examiner opined that the disability was manifested by 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 Veteran continued to be married, but he described the relationship as "off and on." The Veteran reported that they had grown in different ways fought about "stupid things." However, he reported having a very close relationship with his 2 sons and 2 grandchildren. The Veteran and his wife also had custody over their 2 grandchildren. The Veteran also reported that he had not had a friend since he quit drinking in 2009. The Veteran had not worked since 2009, and he had been participating in the VR&E since 2014. The provider noted that the Veteran was currently prescribed non-VA medications to treat his psychiatric disability, including suboxone, Adderall, and Effexor. The Veteran reported that the medication helped to reduce opioids and slowed his mind down to the point where he could focus and complete things. The Veteran denied being arrested or involved in a physical altercation since the March 2017 VA examination. He also did not report any current substance abuse. The Veteran was described as well-groomed with appropriate hygiene. There were no behavioral signs of psychosis or mania. He also spoke at an organized rate and volume with organize and relevant speech. The examiner also stated that the Veteran was capable of managing his financial affairs. The Veteran was alert and fully oriented. The examiner stated that the Veteran's current symptoms including a depressed mood and anxiety. Under the remarks section of the report, the examiner noted that the Veteran reported experiencing anxiety 3 or 4 times a week for a time period ranging from 30 minutes to a couple of days. The anxiety was related to worrying about things or situations. The Veteran also reported feeling depressed on average of 4 days a week for a couple of hours to a couple of days. He attributed the depression to his personal thoughts of how he was viewing a situation. The Veteran reported that he enjoyed watching certain television shows and was always trying to find something to do such as swimming in a pool at his house. He reported only eating one big meal a day. He also described experiencing difficulty concentrating and low self-esteem due in part to "failing out" of VR&E and not having a job. Although the Veteran denied having current suicidal or homicidal ideation, he reported trying to shoot himself 18 months ago and the gun jamming. He attributed the suicide attempt to his struggles with VR&E and the death of his grandmother. The examiner summarized that the Veteran's results from a self-administered forced choice screening questionnaire were indeterminate, meaning that they were neither suggestive of feigning symptoms nor honest responding. After reviewing the evidence from the appeal period, the Board finds that an initial 70 percent rating is warranted for the entire appeal period. During this period, the evaluations and treatment records documented symptoms and behavior representative of impaired impulse control (such as unprovoked irritability with periods of violence); difficulty in adapting to stressful circumstances (including work or a worklike setting); and suicidal ideation. As early as the March 2009 VA examination, the examiner noted that the Veteran had poor impulse control with episodes of violence. His history of violence/assaultiveness included 10 to 20 fights, and the most recent fight occurred a month prior to the examination. Although the examiner indicated half the fights had been related to alcohol of drugs, the examiner also noted that the Veteran last drank alcohol and used opiates prior to the appeal period approximately 2 to 3 years ago. A relatively short time later in November 2009, the Veteran reported irritability and verbally exploding at little things at the same time that he reported feeling stressed due to financial worries associated with the holidays. In July 2010, he reported recently being hospitalized for suicidal ideation when he was feeling overwhelmed. Although he denied having current suicidal ideation during his July visit at VA, he was nevertheless found to have a moderate risk level after the mental health suicide risk assessment was conducted. In August 2010, the Veteran reported lashing out at others and breaking things in the same record that he reported feeling overwhelmed. The Veteran was also noted to have recent suicidal ideation in September 2010 in response to his truck being repossessed; and current, passive suicidal ideation was noted in October 2010. The Veteran was additionally so belligerent with the VA nursing staff in January 2011 that they planned to call the police. The Veteran indicated that he continued to have occasional thoughts of suicide in April 2011; current, passive suicidal ideation in July 2011; fleeting thoughts of self-harm in August 2011; and recent suicidal ideation was noted in September 2011. The Veteran further indicated that he recently shoved a neighbor during an argument in December 2011. During the November 2012 VA examination, the Veteran reported being involved in approximately 30 physical altercations following his discharge with the last altercation occurring that week with his son's wrestling coach. He also described having anger/irritability on a daily basis. In May 2013, the Veteran reported irritability and arguing with his teachers when he was experiencing financial, pain, and school related stressors. In June 2013, the Veteran reported being pushed into a dark corner due to frustrations with his VA medical care while also dealing with his final examinations. The August 2013 VR&E note also described the Veteran's interaction with VA security due to his angry reaction to difficulties with a VA pharmacist that included him knocking on the pharmacy window and giving the pharmacist the middle finger. An additional August 2013 VA treatment record noted that the Veteran had been involved in a physical altercation approximately two months ago when the Veteran assaulted another person with whom he previously had a "falling out." Passive suicidal ideation was again noted in August 2013 along with the Veteran's report of active suicidal ideation also being present in December 2012. A subsequent May 2014 record indicated that the Veteran missed his VA appointment while he was struggling with the stress of final examinations at school, and the Veteran similarly indicated in June 2014 that he missed a VA appointment when he was feeling overwhelmed. In the February 2015 DBQ, Dr. F. reported that the Veteran had impaired impulse control, such as unprovoked irritability with periods of violence; episodes of uncontrolled anger and rage; and pending charges related to assault and battery at a college campus. His symptoms also included difficulty in adapting to stressful circumstances and suicidal ideation. Although these specific symptoms were not documented during the March 2017 VA examination, the examiner did note that the Veteran described feeling on edge, and he experienced anxiety and feelings of anger. The Veteran later informed the July 2019 VA examiner that he experienced anxiety 3 or 4 times a week for a time period ranging from 30 minutes to a couple of days. Although the Veteran denied having suicidal or homicidal ideation at the time of the examination, he reported trying to shoot himself 18 months ago and indicated that the attempted suicide was only prevented by the gun jamming. This report suggests that the Veteran continued to have symptoms of suicidal ideation after the March 2017 VA examination. The Veteran displayed some, but not all, of the symptoms listed as examples under the 70 percent rating criteria. Although the Board has considered the examiners' determinations regarding the level of occupational and social impairment experienced by the Veteran, the Board finds that the symptoms reported by the Veteran are of greater severity than those associated with a 50 percent disability rating. Resolving all doubt in favor of the Veteran, the Boards finds that the overall level of impairment during this period is consistent with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. See also Bankhead v. Shulkin, 29 Vet. App. 10, 20 (2017) (the language of the general rating formula indicates that the presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas). The Board also acknowledges that the Veteran has received different psychiatric diagnoses during the appeal period, including for disorders such as PTSD, ADHD, and depression NOS. However, the most recent VA examinations from March 2017 and July 2019 reflect the examiners' determinations that the most appropriate diagnosis under the DSM-5 for the Veteran's symptoms is unspecified anxiety disorder. No other mental disorder was diagnosed during these examinations. Affording the Veteran the benefit of the doubt, the Board finds that the psychiatric symptoms noted during the appeal period were manifestations of his service-connected unspecified anxiety disorder also claimed as PTSD. The Board notes that in the representative's October 2019 brief, the representative specifically stated that the Veteran was seeking a 70 percent disability rating for his psychiatric disability for the entire appeal period, indicating that the Veteran would be satisfied with the grant of a 70 percent rating for his psychiatric disability. Consequently, discussion of whether a rating higher than 70 percent is warranted for the service-connected unspecified anxiety disorder also claimed as PTSD is unnecessary. Cf. AB v. Brown, 6 Vet. App. 35, 39 (1993) (a veteran is presumed to be seeking the maximum possible rating unless he indicates otherwise). In light of the evidence discussed above, and resolving all reasonable doubt in favor of the Veteran, the Board finds that a 70 percent disability rating for the Veteran's service-connected unspecified anxiety disorder also claimed as PTSD, but no higher, is warranted for the entire period on appeal. 38 U.S.C. § 5107(b). REASONS FOR REMAND 1. Entitlement to an initial disability rating in excess of 10 percent for degenerative joint disease of the right knee is remanded. 2. Entitlement to a TDIU is remanded. Regarding the Veteran's increased rating claim for his right knee disability, the Veteran was last provided with a VA examination to evaluate his disability in April 2019. During the examination, muscle strength testing of the right knee extension showed normal strength (5 out of 5). A subsequent December 2019 VA examination related to peripheral nerves conditions also included muscle strength testing findings for the knee extension, noting that the test revealed active movement against some resistance (4 out of 5) in the right knee extension. As this report at least suggests a worsening in the severity of the Veteran's right knee disability since the April 2019 VA examination, the Board finds that a contemporaneous VA examination for this disability should be obtained on remand. See VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997). The Board also finds that any decision with respect to the increased rating claim remanded herein may affect the Veteran's claim for a TDIU. Thus, the claims are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Final appellate review of the Veteran's claim for a TDIU must be deferred until the appropriate actions concerning the Veteran's increased rating claim for his right knee disability are completed and the matter is either resolved or prepared for appellate review. The Board also notes that the Veteran has not yet completed a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. Consequently, the AOJ should request that he do so upon remand. The record also reflects that the Veteran submitted a June 2010 letter from the Social Security Administration (SSA) notifying him that his claim for disability benefits was denied as he had not worked long enough. However, the record does indicate that the AOJ has attempted to obtain his complete SSA records. As these records are potentially relevant to the increased rating claim for the Veteran's right knee disability and his TDIU claim, a remand is necessary for the AOJ to attempt to obtain these records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(2). The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any health care providers who have provided treatment for his right knee disability. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records, to include records dated since November 2019. 2. Provide the Veteran with a VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) and ask him to complete and return this form. 3. Obtain from the Social Security Administration (SSA) the records pertinent to the pertinent to the Veteran's claim for SSA disability benefits as well as the medical records relied upon concerning that claim. If the records are not available, the Veteran should be notified of such. 4. After completing the preceding development in paragraphs 1 through 3, the Veteran should be afforded a VA examination to address the current severity and manifestations of his right knee disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file and to comment on the severity of the Veteran's service-connected disability. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the right knee disability under the rating criteria. In particular, the examiner should provide the range of motion for both knees in degrees and test the range of motion and for pain in (1) active motion, (2) passive motion, (3) weight-bearing, and (4) nonweight-bearing. The examiner is also asked to indicate the point during range of motion testing that motion is limited by pain. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why this is so. The presence of objective evidence of pain, excess fatigability, incoordination, and weakness should also be noted, as should any additional disability (including limitation of motion) due to these factors. In addition, based on examination results and the Veteran's documented history and assertions, the examiner should indicate whether, and to what extent, the Veteran experiences functional loss due to pain and/or any of the other symptoms noted above during flare-ups and/or with repeated use; to the extent possible, the examiner should express any such additional functional loss in terms of additional degrees of limited motion. In this regard, even if the Veteran is not experiencing a flare-up at the time of the examination, the examiner must elicit relevant information as to the Veteran's flares or ask him to describe the additional functional loss, if any, he suffers during flares and then estimate the Veteran's functional loss due to flares based on all the evidence of record-including the Veteran's lay information-or explain why he or she could not do so. 5. After the above development, and any additionally indicated development, has been completed, readjudicate the issues on appeal, to include the inextricably intertwined issue of entitlement to a TDIU. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a supplemental statement of the case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.C. Spragins, 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.