Citation Nr: 1002322 Decision Date: 01/14/10 Archive Date: 01/22/10 DOCKET NO. 07-05 177 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an initial evaluation in excess of 30 percent for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Tresa M. Schlecht, Counsel INTRODUCTION The Veteran had active service from August 1967 to August 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2004 rating decision, which denied the Veteran's claim for service connection for PTSD, and an April 2006 rating decision of the St. Petersburg, Florida, Regional Office (RO) of the Department of Veterans Affairs (VA) which granted service connection for PTSD and assigned an initial 30 percent evaluation. During the pendency of the appeal, after the transfer of the file to the Board, the Veteran submitted additional evidence pertinent to the severity of his PTSD after the last VA psychiatric examination was conducted in September 2007. VA regulations require that pertinent evidence submitted by the appellant must be referred to the agency of original jurisdiction for review and preparation of a SSOC unless this procedural right is waived in writing by the appellant. 38 C.F.R. §§ 19.37, 20.1304 (2009). The appellant has not provided a written waiver of review by the agency of original jurisdiction. Therefore, Remand is required to review the additional relevant evidence. That evidence applies to the period from September 23, 2007, the day following the last VA psychiatric examination, to the present. The Veteran's treating VA providers have indicated that it is unsafe for the Veteran to work, even though he is actually working. The clinical evidence does not constitute a claim, but does suggest that the Veteran should be asked to clarify whether he wishes to submit a claim for individual unemployability. This evidence, including the December 2006 VA outpatient treatment note, is REFERRED to the RO for appropriate action. The issue of the appropriate initial evaluation(s) for the Veteran's service-connected PTSD from September 23, 2007 to the present is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to July 6, 2006, the Veteran's service-connected PTSD was manifested by numerous symptoms, including flashbacks, nightmares, detachment, irritability, hypervigilance, and depressed mood, and Global Assessment of Function (GAF) scores ranging from 45 to 55, despite use of medications to treat the PTSD, but was not manifested by more than moderate industrial impairment, and the Veteran continued to work full-time as a crane operator. 2. From July 6, 2006 through September 22, 2007, the Veteran's PTSD was manifested by daily intrusive thoughts and flashbacks, panic attacks, an episode of violence related to a flashback, the need for increased medication requirements, the need for group and individual psychotherapy in addition to medications, GAF scores ranging from 48 to 52 despite intensive medication and psychotherapy, and providers opined that PTSD symptoms and side effects of medications resulted in severe industrial impairment, but the Veteran continued to work full-time as a crane operator. CONCLUSIONS OF LAW 1. Criteria for an increase in the Veteran's initial disability evaluation from 30 percent to 50 percent for PTSD, but no higher evaluation, are met prior to July 6, 2006. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2009); 38 C.F.R. §§ 4.125, 4.130, Diagnostic Code 9411 (2009). 2. Criteria for an increase in the Veteran's initial disability evaluation from 50 percent to 70 percent for PTSD, but no higher evaluation, are met from July 6, 2006 through September 22, 2007. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2002 & Supp. 2009); 38 C.F.R. §§ 4.125, 4.130, Diagnostic Code 9411 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran contends that he is entitled to an increased initial evaluation for his service-connected PTSD. Before assessing the merits of the appeal, VA's duties to the claimant must be examined. VA's duties to the claimant The Veterans Claims Assistance Act of 2000 (VCAA) specifies VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2009). Duty to notify Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2008); 38 C.F.R. § 3.159(b) (2009); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F. 3d 1328 (Fed. Cir. 2006). Here, the Veteran is challenging an initial evaluation assigned following the grant of service connection for PTSD. In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court of Appeals for Veterans Claims held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. Thus, because the notice that was provided before these claims for service connection were granted was legally sufficient, VA's duty to notify in this case has been satisfied. Additionally, the Board notes that, in his February 2007 substantive appeal, the Veteran requested a 70 percent evaluation for PTSD. To the extent that a 70 percent evaluation has been granted, for the period form July 6, 2006 though September 22, 2006, the decision below represents a full grant of benefits, so any action to provide further notice rather than grant the benefit requested would be adverse to the Veteran's interests. Duty to assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the Veteran has been afforded several VA examinations. In addition, he has provided statements from his private treating provider from the Vet Center. The Board notes that the Vet Center records consist of several medical statements, but those medical statements make it clear that the Veteran received ongoing Vet Center treatment. Thus, it appears that there are additional Vet Center records which are not associated with the claims file. However, it is not necessary to obtain the complete Vet Center records, since the medical statements submitted on the Veteran's behalf summarize the Vet Center treatment. VA may fairly assume that the additional records would not be more favorable to the Veteran than the summaries. Since medical statements from the Vet Center have been submitted periodically throughout the pendency of this appeal, the Board finds that no additional development of records from the Vet Center is required. The Board notes that the Veteran's representative contends, in a July 2007 statement that there are additional records which should be sought. In particular, the representative contends that VA has not obtained the complete treatment record represented by a one-page excerpt submitted by the Veteran with a December 2006 statement. The representative contends that, until the complete record associated with that treatment note, which reflects that a GAF of 48 was assigned, further development is required. In particular, the representative notes that the excerpt does not disclose what provider assigned the GAF score of 48. VA outpatient treatment records dated from July 2005 through December 2006 include the complete text of the partial treatment note attached to the Veteran's December 2006 statement. The discussion of the Veteran's symptoms referenced by the representative as incomplete is at page 5 of a printout of 28 pages of the Veteran's VA outpatient treatment record obtained by the RO in January 2007. The complete treatment note, which begins at page 2 of the printout, reflects that the provider who assigned the GAF score of 48 was one of the Veteran's treating VA providers. The partial treatment note discussed by the representative is duplicated at pages 34 to 37 of medical records printed out for association with the Veteran's claim file in July 2007. The Board finds that the Veteran's VA outpatient clinical records are complete though September 22, 2007, the period addressed in this decision. The Board agrees that the records from September 23, 2007 to the present may be incomplete, and further development of the records for that period is addressed in the Remand, below. However, the duty to assist has been fulfilled as to the initial evaluation period addressed in this decision. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Appellate review may proceed. Claim for increased disability evaluation The law provides that disability ratings are intended to compensate reductions in earning capacity as a result of the specific disorder. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify various disabilities. See 38 C.F.R. Part 4. Disability evaluations are determined by the application of a schedule of ratings based on average impairment in earning capacity. 38 U.S.C.A. § 1155. Requests for increased disability ratings require consideration of the medical evidence of record compared to the criteria in the VA Schedule for Rating Disabilities. See 38 C.F.R., Part 4. If the evidence for and against a claim is in equipoise, the claim will be granted. A rating that is assigned with a grant of service connection, such as the case in this appeal, must take into account all evidence of the nature and severity of the disability from the effective date of service connection. Thus, the rating might be a "staged" rating, that is, one comprised of successive ratings reflecting variations in the disability's severity since the date of service connection. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran's appeal for a higher initial evaluation for the disability at issue requires consideration of staged ratings. Criteria for evaluating PTSD PTSD is evaluated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411. Under The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130, a 30 percent rating is warranted where the evidence discloses 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, mild memory loss (such as forgetting names, directions, 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. To demonstrate entitlement to a 70 percent evaluation, the evidence must show deficiencies in most areas and such symptoms as suicidal ideation; obsessional rituals; speech intermittently illogical, obscure, or irrelevant; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene. Entitlement to a 100 percent schedular evaluation is warranted where there are such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; gross inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The Court has noted that Global Assessment of Functioning (GAF) scores are scaled ratings reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders 32 (4th ed.) (DSM-IV). VA's Rating Schedule employs nomenclature based upon the DSM-IV, which includes the GAF scale. See 38 C.F.R. § 4.130. A GAF score from 61 to 70 reflects some mild symptoms, or some difficulty in social, occupational, or school functioning. In such cases, the Veteran is generally functioning pretty well, with some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect moderate symptoms. Scores from 41 to 50 reflect serious symptoms (suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). While important in assessing the level of impairment caused by psychiatric illness, the GAF score is not dispositive of the level of impairment cause by such illness. Rather, it is considered in light of all of the evidence of record. See Brambley v. Principi, 17 Vet. App. 20, 26 (2003); Bowling v. Principi, 15 Vet. App. 1, 14 (2001). Facts The Veteran sought service connection for PTSD, among other disorders, by a claim submitted in February 2004. April 2004 VA outpatient treatment records disclose that the Veteran reported he was attending a PTSD support group in Lakeland, Florida. He was working full-time as a crane operator. He reported that he was quite isolated and detached from others, but was able to work as a crane operator because that job is performed alone. The Veteran reported that his unit frequently came under mortar and small arms fire. The Veteran's mother died while he was in Vietnam, and he did not return to Vietnam after her funeral prior to his discharge. The examiner concluded that the Veteran met the criteria for PTSD, and assigned a GAF score of 50. A statement from a Vet Center provider dated in November 2004 stated that the Veteran was regularly attending a PTSD group. The Vet Center provider assigned a GAF score of 45, noting that the Veteran's GAF score reflected exacerbation of PTSD with recent health problems. In early November 2004, the Veteran underwent cardiac bypass grafting. The Veteran's treating VA provider assigned a GAF score of 46 in November 2004. In January 2005, VA providers assigned a GAF score of 48. On VA examination in March 2006, the Veteran reported avoidance of stressors with significant detachment from relationships. The examiner noted that the Veteran was undergoing aggressive outpatient therapy, with antidepressants, benzodiazepines, and antipsychotic medications, as well an anti-andrenergic medication. The Veteran reported a 30 to 40 percent reduction in symptoms. The Veteran continued to be employed full-time as a crane operator, a position that required "little human contact." The examiner noted that the Veteran's wife had sustained a traumatic brain injury which left her handicapped and that the Veteran and his wife had a handicapped child. The examiner opined that 10 to 20 percent of the Veteran's current PTSD symptoms were caused by post-military stressors. The examiner assigned a GAF of 55. In April 2006, the Veteran's regular VA treating provider assigned a GAF score of 55. In July 2006, the assigned GAF score was 53. The Veteran reported episodes of racing heart rate. He reported being able to sleep from about 10 p.m. to 4 a.m. most nights. The examiner noted that the Veteran had gained weight while on gabapentin and that celexa and paxil had contributed to the Veteran's erectile dysfunction. The provider increased the Veteran's dosage of celexa from 20 mgs to 40 mgs daily. The provider increased the dosage of clonezepam from 0.5mgs to 0.75 mgs. The Veteran again agreed that he would not operate heavy machinery if drowsy. The provider also noted that the Veteran had been started on amitriptyline (Elavil) by the neurologist for peripheral neuropathy. The Veteran was also prescribed ariprazole (Abilify) to decrease nightmares and irritability. In a September 2006 statement, the Veteran's treating Vet Center provider reported that the Veteran was getting less than 4 hours of sleep a night because of frequent nightmares. The Vet Center provider noted that the Veteran was having panic attacks in public places and felt unsafe and insecure. The Veteran had been "written up" at work for not being able to focus on his job and was in danger of losing his job. The provider stated that the dosages of the Veteran's medications had been raised "considerably" "in the past month." Intrusive thoughts and flashbacks occupy his mind daily. December 2006 VA outpatient treatment notes reflect that the Veteran reported that he had a flashback while in a convenience store and grabbed a person he though was Vietnamese. The woman's companion hit the Veteran, the Veteran reported, but did not call the police. The Veteran increased his dosage of Abilify to 10 mg three times a day. The provider prescribed the increased dosage. The provider who treated the Veteran in December 2006 stated that the Veteran's PTSD symptoms resulted in functional deficits of such an extent and severity as to produce total social and industrial inadaptability. The psychiatrist opined that the Veteran was a significant danger to himself and others. Nevertheless, the claims file reflects that the Veteran continued to work full-time as a crane operator. The provider assigned a GAF of 48 in December 2006, and again in February 2007. In May 2007, a GAF score of 52 was assigned. On VA examination conducted in September 2007, the examiner assigned a GAF score of 50. The Veteran reported that he continued full-time employment as a crane operator. He reported side effects of drowsiness and dizziness due to medications. He reported increased withdrawal. He had dried blood on his arms, was dirty, and had poor grooming. He was restless during the examination. He was irritable, and his affect was blunted. He appeared anxious. He was not able to do serial 7's. His thought processes were described as "rambling." He interpreted a proverb inappropriately. He reported that he had no homicidal thoughts, but had daily suicidal thoughts. The examiner noted that the Veteran had a worsening of PTSD symptoms, especially during the past year, despite aggressive therapy. Analysis The examiner who conducted the March 2006 VA examination opined that 10 to 20 percent of the Veteran's symptoms of PTSD were due to post-service stresses. The examiner did not identify any specific symptoms that were due solely to the postservice stresses, nor did the examiner opine that the post-service stresses alone would have been sufficient to cause PTSD. No other examiner or provider indicated that a percentage of the Veteran's symptoms of PTSD were due to post-service stresses. The Board finds that reasonable doubt about the severity of the service-connected PTSD must be decided in the Veteran's favor. 38 C.F.R. § 3.102; cf. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (when it is not possible to separate the effects of a service-connected condition and a non-service-connected condition, VA regulations dictate that such signs and symptoms be attributed to the service-connected condition) (quoting 61 Fed. Reg. 52,698 (Oct. 8, 1996)). A. Rating prior to July 6, 2006 The medication regimen prescribed for the Veteran at the time he submitted his claim for service connection for PTSD demonstrates that the treating providers determined that aggressive medication therapy was required. As the examiner who conducted the March 2006 VA examination noted, the medications prescribed for the Veteran included antidepressants, benzodiazepines, and antipsychotic medications, as well an anti-andrenergic medication. The GAF scores assigned by the Veteran's treating VA and Vet Center providers since the Veteran submitted the claim for service connection for PTSD range generally from 45 to 55. The Board notes in particular that the GAF scores assigned by the Vet Center providers have been very consistent with the GAF scores assigned by the Veteran's VA providers. For example, in November 2004, the Vet Center provider assigned a GAF score of 45; the VA provider assigned a GAF score of 46. The VA provider who treated the Veteran in July 2006 concluded that the Veteran's symptoms had become worse; the Vet Center provider who submitted a September 2006 stated that the Veteran's symptoms had recently increased. The medications prescribed and GAF scores assigned demonstrate that the providers considered the Veteran's reports of his symptoms credible. The Board finds no basis for disagreeing with those medical conclusions. While the highest GAF scores assigned prior to July 6, 2006 reflect moderate impairment due to PTSD symptoms, GAF scores below 55 were generally assigned. The Board finds that the Veteran's symptoms and impairments due to PTSD, including adverse side effects of medications, more closely approximate the criteria for an initial 50 percent evaluation prior to July 6, 2006, although the Veteran did not meet all criteria for a 50 percent evaluation. The Board has considered whether referral for extraschedular consideration is warranted for this period. See Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds that the schedular rating criteria reasonably describes the veteran's disability level and symptomatology during this period. Id. at 115. In particular, the Veteran continued to function independently, and continued to care for his handicapped wife and handicapped child, and continued to work full-time. The Board finds no symptoms of the Veteran's impairment during this period which is not encompassed within the schedular criteria. Since the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, and referral for extraschedular consideration is not required. Id. B. Evaluation from July 6, 2006 At the time of the July 6, 2006, the treating VA provider, who had treated the Veteran for more than 18 months, determined that the Veteran's report of additional symptoms, including racing heart, required additional medications. The provider increased the dosages of the medications used to treat the Veteran's PTSD, even though the provider noted that the Veteran was already having significant side effects of some medications, especially weight gain and erectile dysfunction. The Veteran's Vet Center provider noted in September 2006 that the Veteran continued to have intrusive thoughts and flashbacks daily and that it was becoming more difficult for the Veteran to work. In December 2006, the Veteran reported that he acted on a flashback by grabbing a woman he initially thought was Vietnamese. The VA provider who continued the Veteran's treatment in December 2006 concluded that the Veteran's symptoms and medications made it unsafe for the Veteran to work. The report of the September 2007 VA examination disclosed that the Veteran had daily suicidal thoughts. His speech was rambling. The Veteran manifested an episode of violence in December 2006. At the time of the September 2007 VA examination, the Veteran's personal hygiene and grooming were poor. He was unable to do serial 7's or adequately interpret abstract ideas. The symptoms during this period most closely approximate the criteria for a 70 percent evaluation. The Board finds that the Veteran's symptoms as factually ascertainable form July 6, 2006 though September 22, 2007 are of greater severity than the symptoms factually ascertainable prior to July 6, 2006. The symptoms from July 6, 2006 as whole approximate the criteria for a 70 percent disability evaluation, and staging of this initial evaluation to grant a 70 percent evaluation during this period is warranted. As further discussed in the Remand, below, the evidence after September 22, 2007, may be incomplete, and further development is required to determine the appropriate staged rating from September 23, 2007. In his February 2007 substantive appeal, the Veteran specifically stated that he felt he was entitled to a 70 percent disability rating. Therefore, the 70 percent evaluation assigned in this decision for the period from July 6, 2006 through September 22, 2007, is a complete grant of the benefit sought, for this portion of the appeal period. Again, the Board has considered whether referral for extraschedular consideration is warranted for this period of the initial evaluation. See Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds that the schedular rating criteria reasonably describes the veteran's disability level and symptomatology during this period. Id. at 115. In particular, the Veteran continued to care for his handicapped wife and handicapped child, although describing detachment from these relationships. He continued to work full-time, although he required absences from work for medical treatment, including treatment for PTSD. The Board finds no evidence of symptoms of the Veteran's impairment during this period which are not encompassed within the schedular criteria. Since the schedular rating criteria do reasonably describe the veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, and referral for extraschedular consideration is not required. Id. The Board notes that, even though the Veteran's providers documented their conclusion that it was not safe for the Veteran to continue to work, the Veteran did continue to work fulltime. The fact that the Veteran actually worked establishes that a total disability evaluation is not appropriate. The Veteran does not meet the criteria for individual unemployability, since he actually worked. The factual evidence that the Veteran was able to report to work each day and did perform his job establishes that he did not manifest gross impairment in thought processes or communication, grossly inappropriate behavior, disorientation to time or place, memory loss such as for his own occupation or own name, and that he continued to be capable of independent functioning. The providers' determinations that the Veteran's work was a danger to himself or others meets one criterion for an evaluation in excess of 70 percent, and meeting that criterion alone does not establish entitlement to the 100 percent schedular evaluation. The Board notes that the Veteran himself has requested a 70 percent evaluation for PTSD, and he has avoided any contention that he is individually unemployable as a result of his PTSD. See February 2007 substantive appeal. The Veteran's representative has not raised a contention that the Veteran is individually unemployable. The Board has considered whether a claim for a total disability rating based on individual unemployability (TDIU) as a result of service-connected PTSD has been raised, and has, as noted in the Introduction, above, asked the RO to clarify this issue with the Veteran. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). However, as the Veteran remained employed, although against the medical advice of his providers, further consideration of a claim for TDIU during the periods for which staged evaluations are considered in this decision is not required. Reasonable doubt as to the severity of service-connected PTSD during the period from July 6, 2006 through September 22, 2007 has been resolved in the Veteran's favor to grant a 70 percent initial rating during this staged period. The preponderance of the evidence is against a total schedular rating. The claim for an increase in the initial rating in excess of 30 percent is granted to the extent that a 70 percent evaluation is warranted during the period from July 6, 2006 through September 22, 2007. ORDER Prior to July 6, 2006, an initial evaluation increased from 30 percent to 50 percent is granted, subject to law and regulations governing the effective date of an award of monetary compensation; the appeal is granted to this extent only for this period. From July 6, 2006, through September 22, 2007, an initial evaluation increased to 70 percent is granted, subject to law and regulations governing the effective date of an award of monetary compensation; the appeal is granted to this extent only for this period. REMAND Following the Veteran's September 2007 VA examination, no additional VA outpatient treatment records are associated with the claims file until February 2008. February 2008 records reflect a GAF score of 47 for current functioning, but note that the Veteran had had a GAF score of 28 a month earlier. No record reflecting treatment at the time of a GAF score of 28 is associated with the claims file. The February 2008 VA outpatient record noting this information was added to the file after the last Supplemental Statement of the Case (SSOC) was issued in October 2007. Further development of evidence beginning on September 23, 2007, the day following the Veteran's September 2007 VA examination, is required. Thereafter, an SSOC that discusses all evidence dated after September 22, 2007, should be issued. 38 C.F.R. § 20.1304 (2009). Additionally, the Veteran's Vet Center provider submitted a January 2008 letter after the last SSOC was issued. As the Veteran continues to obtain Vet Center Treatment, current records from the Vet Center, from September 23, 2007 to the present, should be requested, and the additional evidence considered. Accordingly, the case is REMANDED for the following action: 1. The Veteran's VA clinical records from September 23, 2007 to the present should be associated with the claims file. 2. The Veteran's Vet Center clinical records from September 23, 2007 to the present should be requested. 3. The Veteran should be afforded the opportunity to identify any other relevant non-VA clinical records, in additional to the Vet Center records described in paragraph #2, from September 23, 2007 to the present. In particular, the Veteran should be advised that employment records, a statement from the employer as to the Veteran's attendance at work, records of applications for retirement or disability benefits, would assist in substantiating his claim for an increased initial evaluation in excess of 30 percent from September 23, 2007. 4. The Veteran should be afforded VA psychiatric examination. The Veteran's claims files must be made available to, and reviewed by, the examiner, including evidence obtained on Remand. The examiner should review the relevant evidence of record, including all clinical records following the September 2007 VA examination. The examiner should elicit information as to the frequency, duration, and severity of any symptomatology of service- connected PTSD. The examiner should describe any impairment of occupational and social functioning in the veteran's daily activities, including work and social activity. Then, the examiner should address the following: (a) Assign an appropriate GAF score for the Veteran's level of functioning at the afforded VA examination. Provide an explanation for each score assigned. (b) Assign an appropriate GAF score or scores for any periods during which the Veteran's functioning was different than the functional level during the afforded VA examination. Indicate and identify each period during which the Veteran manifested increased or decreased functional impairment. Describe the Veteran's functional abilities and impairments from September 23, 2007 through the date of the VA examination. Assign an appropriate GAF score for each separately-identifiable period of increased or decreased severity of PTSD. Provide an explanation for each score assigned. 5. After determining whether any additional evidentiary development is necessary and accomplishing such, a supplemental statement of the case (SSOC) should be issued addressing the Veteran's claim for an initial evaluation in excess of 30 percent from September 23, 2007. If the benefit sought is not granted, the issue should be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2008). ____________________________________________ L.M. Barnard Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs