Citation Nr: 0001385 Decision Date: 01/18/00 Archive Date: 01/27/00 DOCKET NO. 94-09 086 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to a disability rating in excess of 50 percent for a post-traumatic stress disorder (PTSD). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD R. A. Seaman, Associate Counsel INTRODUCTION The veteran served on active duty from November 1965 to September 1967, including service in Vietnam from September 1966 until August 1967. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 1993 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, which denied the veteran's request for a disability rating in excess of 10 percent for PTSD. The RO initially established service connection by a rating dated in January 1990. By this rating, the veteran's PTSD was rated as 10 percent disabling effective from June 1988. The veteran's claim for an increased rating for PTSD was received on December 29, 1992. The veteran appeared at a personal hearing before the RO in October 1995. A transcript of that hearing is of record. The hearing officer issued a December 1995 decision which increased the evaluation for PTSD from 10 percent to 30 percent effective from December 29, 1992. This case was previously before the Board in May 1996, at which time it was remanded for additional development. After readjudicating the veteran's claim for an increased rating, and with consideration given to the additional development, the RO issued a July 1998 rating decision which increased the evaluation for PTSD from 30 percent to 50 percent effective from December 29, 1992. The claim is now before the Board for further appellate consideration. As a preliminary matter, the Board finds that the RO has complied with the directives of the May 1996 remand. See Wood v. Derwinski, 1 Vet. App. 190 (1991). Accordingly, a new remand is not required to comply with the holding of Stegall v. West, 11 Vet. App. 268 (1998). Service connection has also been established for malaria, which is currently evaluated as zero percent disabling, effective from October 1, 1968. The record indicates that in July 1996, the veteran's local representative raised the issue of entitlement to an increased disability rating based on individual unemployability. In November 1998, the veteran's national service representative requested that the RO send the veteran VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability). The RO mailed VA Form 21-8940 to the veteran on November 9, 1998. However, there is no indication of record that the veteran has submitted a completed VA Form 21-8940. FINDINGS OF FACT 1. The RO has obtained all relevant evidence necessary for an equitable disposition of the veteran's appeal. 2. When the veteran was examined in September 1996, he had been working full time as a technician for about 9 months; the examiner concluded that the veteran's PTSD symptoms were mild to moderate, had not interfered with his ability to work, and warranted a Global Assessment of Functioning (GAF) score of 60 to 65. 3. When the veteran was examined on June 23, 1997, he had been laid off from his job in October 1996 and had been unable to find work since then; the veteran's PTSD was manifested by intrusive thoughts, nightmares, hypervigilance, social isolation, irritability, poor impulse control, depressed mood; the examiner concluded that the PTSD symptoms were productive of serious impairment in his social and occupational functioning and warranted a GAF score of 49. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for PTSD are not met prior to June 23, 1997. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Diagnostic Code 9411 (as in effect prior to and after November 7, 1996). 2. The criteria for a disability rating of 70 percent, but not 100 percent, for PTSD have been met as of June 23, 1997. 38 U.S.C.A. §§ 1155, 5107 (West 1991); 38 C.F.R. Part 4, Diagnostic Code 9411 ( as in effect prior to and after November 7, 1996). REASONS AND BASES FOR FINDINGS AND CONCLUSION Background. Service records show that the veteran served in combat in the Republic of Vietnam. He served as an infantryman and received the Combat Infantryman Badge. The veteran filed a claim of service connection for PTSD in July 1988. He underwent a VA structured clinical interview in September 1989, and presented for VA psychiatric examinations in September and November 1989. During the clinical interview, the veteran reported that his service in Vietnam was exclusively combat in nature. Specific in- service trauma he recalled included witnessing a close friend's death from friendly artillery fire, and participating in a battle where approximately 40 out of the 90 men in his unit were killed. It was noted that the veteran's combat duty was terminated after he contracted severe malaria, and that he was hospitalized for malaria during his last two months in Vietnam. The veteran reported that while he was hospitalized, his entire company was killed with the exception of six survivors. The veteran sobbed openly as he described losing his fellow servicemen. Noted symptoms were infrequent intrusive thoughts (monthly), infrequent combat nightmares (approximately every two months), exacerbation of symptoms by war related stimuli, diminished interest in significant activities, estrangement from others, emotional numbing, irritability, difficulty concentrating, hypervigilance, exaggerated startle response, and survivor guilt. During psychiatric examination in September 1989, the veteran reported the same traumatic events, and the VA examiner noted similar symptoms as those found during the structured clinical interview. The veteran also reported that he had problems with alcohol abuse. Diagnosis was PTSD and probable alcohol abuse. During VA examination in November 1989, it was noted that the veteran presented as alert, oriented, and cooperative. He was casually but neatly dressed. His affect was appropriate although slightly restricted in range. His overall mood was mildly depressed. Testing profiles were noted as strongly suggestive of a high level of distress and tension. Diagnosis was PTSD, with alcohol abuse in partial remission since 1980. In a January 1990 rating decision, the RO granted service connection for PTSD, evaluated as 10 percent disabling, effective June 28, 1988. In December 1992, the veteran applied for an increased disability rating for PTSD, alleging that his PTSD had increased in severity to such a degree that he had a hard time functioning. He noted that he had entered an alcohol detoxification program at a VA Hospital in November 1992. He also reported that he was receiving family counseling at the same facility, and was "a regular" there for individual and psychiatric counseling. The RO obtained all pertinent medical records from the VA Hospital, and the veteran reported for another VA psychiatric examination in March 1993. The veteran reported continuing PTSD symptoms to the VA physician that were simultaneous with alcohol abuse. He stated that he had difficulty relaxing and falling asleep, and continued to have occasional nightmares about combat experiences. He reported continuing hypervigilance and exaggerated startle responses, and stated that he sometimes awakened at night to patrol his home. He also reported problems of irritability and trouble controlling his anger, which resulted in family conflict. It was noted that the veteran had no friends at all and had rarely been close to people since his separation from military service. Mental status evaluation revealed that the veteran appeared somewhat more sullen and depressed than he had during previous VA examinations. Overall, the VA physician reported, the veteran's mood was mildly to moderately depressed. Diagnosis was PTSD, with alcohol abuse in remission for the prior five months. In a July 1993 decision, the RO denied the veteran's request for an increased disability rating for PTSD, holding that the PTSD symptoms and their effects did not produce more than mild social and industrial impairment. The veteran's notice of disagreement with that decision was received in September 1993. At a personal hearing in October 1995, the veteran testified that he had remained sober for the prior two to three years. He stated that he slept with a gun under his bed, with which he nearly killed his wife when he mistook her for an intruder. He reported continuing periodic thoughts and nightmares related to his Vietnam experiences. He testified that he had no social life and no close friends. He basically stayed at home, and considered himself "a loner." He stated that he had been unemployed since he had a work- related accident in 1991. He testified that he had applied for jobs but had not received any employment offers. A letter written by the veteran's spouse was presented to the hearing officer. She stated that the veteran "lives with Vietnam on a daily basis . . . ." She opined that alcohol abuse was his way of hiding feelings concerning his Vietnam experiences. She stated that his anger and despair were constant, and that he could not tolerate people. She reported that the veteran had no friends and had refused to make friends since returning from Vietnam. She described the veteran as an "angry, bitter man . . . ." The RO obtained records reflecting that the veteran received monthly VA outpatient mental health care between March and October 1993. Those medical records noted the veteran's complaints of nightmares, flashbacks, and racing thoughts. Major depression was noted, and the veteran's affect was noted as restricted. Those medical records showed continuing diagnosis of PTSD, along with adjustment disorder with depressed mood. The hearing officer issued a supplemental statement of the case in December 1995, which held that, "while . . . documentation of the veteran's condition is not extensive, with resolution of reasonable doubt, it is felt that definite social and industrial impairment is produced by the disability." Accordingly, the hearing officer granted an increased disability rating for PTSD from 10 percent to 30 percent. On appellate review, the Board concluded that the March 1993 VA examination, in conjunction with all other evidence of record, was inadequate for reaching a decision as to the veteran's claim for an increased rating for PTSD. Accordingly, the veteran's case was remanded for further development, to include a current VA examination, a VA social and industrial survey, and an effort to obtain all pertinent treatment records since October 1995. A VA social and industrial survey was conducted in June 1996. The veteran reported that he had found full-time employment and had been working since January 1996. At the survey, the veteran was initially guarded and defensive. He spoke tersely and avoided discussing his Vietnam experiences. After he relaxed, he recounted his fellow serviceman's death and his own feeling of helplessness, and apologized when he began to cry. When he recalled being told, during his in- service hospitalization for malaria, that only six men from his division came back alive, he seemed to choke back tears, and stated that "my malaria saved me." It was noted that the veteran's memory of Vietnam was clear and vivid, but his memory was very poor and erratic regarding dates and events after his service in Vietnam. The veteran reported that alcohol abuse after service led to a divorce from his first spouse. The veteran remarried, and stated that his relationship with his step-children "came to a test and was lost . . . ," which added more pressure on him. He said that he was "tired of struggling to live." The VA social worker noted that the extensive material in the veteran's claims file showed that he definitely has PTSD, the symptoms of which had "waxed and waned over a period of 25 years." The social worker also reported that: At close view of his industrial adjustment, he functioned best in jobs where he had minimal interaction with people . . . . He appears to be an industrious worker. The PTSD symptoms were successfully submerged while he was drinking and working. Expectedly, alcohol exacted its toll . . . on the veteran's functioning, and exacerbated his avoidant behavior, intrusive reliving of his PTSD symptomatology and explosive acting-out behaviors that the immediate family were drawn into. While maintenance of sobriety is a positive sign of improving maladaptive functioning, the veteran has still to learn to reduce and eliminate the pathological or painful aspects of his war trauma. [The veteran] has moderate to severe impairment in his ability to carry on social relationships. This degree of impairment in this area has far-reaching consequences which affect all the subsystems in which the veteran revolves in, such as the family, his job and social environment. His current functioning level is characterized by lack of desire for advancement, passivity and satisfaction with the minimum for survival. He needs psychotherapy that will assist him confront the emotional issues in his war trauma and to attain some enjoyment in various life activities. The veteran was accorded a VA psychological examination in June 1996, which included administration of a Minnesota Multiphasic Personality Inventory (MMPI). The VA psychologist reported that the validity scale configuration of the MMPI indicated a valid test profile for an individual with significant psychological problems. The veteran's psychological defense mechanisms were noted as "ineffective in dealing with current difficulties, which may leave the veteran feeling vulnerable and feeling defenseless." It was found that the veteran was depressed, and expressed a considerable number of physical complaints. The veteran's test profile was "somewhat similar to the profile associated with combat [PTSD] veterans and his [PTSD] score is very close to meeting the criteria for [PTSD]." The VA psychologist stated that the veteran was depressed, but suicidal behaviors should be ruled out. During VA psychiatric examination in September 1996, the veteran reported continuing symptoms of isolative behavior and hypervigilance. He stated that he "still sees" the faces of friends who were killed" during the war. Mental status evaluation revealed that the veteran's eye contact was excellent, and no speech abnormalities were found. Mild anxiety was noted, and his affect was mood congruent. There were no disorders of thought, form, or content. The veteran was oriented in all spheres, and his memory for recent and remote events appeared intact. The VA examiner opined that "there is no question the veteran suffers from mild to moderate [PTSD]. However, he is currently employed, he has been in a long term stable relationship, and even though he still has clear cut symptoms they have not interfered with his ability to work." Diagnosis was PTSD, with alcohol dependence in remission for several years. The veteran was given a GAF score of 60 to 65. The veteran was again accorded a psychiatric examination for disability evaluation purposes on June 23, 1997. He reported that he had been unemployed since October 1996, and had been unable to find work since then. By history, the VA examiner noted the veteran's difficulties with nightmares relating to Vietnam which occurred at least several times a month. The veteran reported that he was plagued by intrusive thoughts of the war on a daily basis, despite the distressing nature of the thoughts. Environmental cues reminded him of the war, especially loud noises and helicopters. The veteran also stated that he continued to have flashbacks, which occurred about once a month. He reported that his interpersonal difficulties continued, and that his only close personal relationship was with his spouse. The VA physician noted automatic reactivity with an increased startle response, as well as hypervigilance, depression, and difficulty controlling anger. Poor occupation adjustment was noted, as the veteran's depression and difficulty with interpersonal relationships had made finding employment particularly difficult. The VA examiner stated that the veteran was somewhat "anhedoniche," and took part in few activities which he enjoyed. It was reported that the veteran had frequent thoughts of suicide but never developed a plan to commit suicide. Mental status evaluation in June 1997 revealed that the veteran was cooperative and had good eye contact. His speech was of normal rate, rhythm, and volume. Mood was depressed and his affect was appropriate to his mood. No evidence of a thought disorder was found; the veteran was logical and coherent. The veteran denied overt delusions, obsessions, and compulsions, but said that he often feels that "people are outside his house." Cognition and immediate recall were intact, but he did have trouble recalling remote events, especially some events concerning the war. Diagnoses were PTSD, alcohol dependence in remission, and dysthymia (secondary to PTSD). A GAF score of 49 was given, with a high of 60 over the past year. The VA physician concluded the examination report by stating: This is a [veteran] who has a clear history of [PTSD] who has moderate symptoms, [including] flashbacks, nightmares, intrusive thoughts, hypervigilance, poor impulse control[,] and depressed mood. He also has serious impairment in his social (no friends) and occupational (unemployed) functioning which is a direct consequence of his PTSD[,] and therefore has a GAF of 49 currently. His mood disorder does not meet the criteria for a major depression but does meet the criteria for dysthymia. After review of VA medical records generated pursuant to the Board's May 1996 remand, the RO issued a July 1998 decision which held that any reasonable doubt regarding the veteran's claim for an increased disability rating was resolved in his favor. Accordingly, the disability rating assigned for the veteran's PTSD was increased from 30 percent to 50 percent effective December 29, 1992. Legal Criteria. A claim for an increased rating is generally regarded as a new claim and is subject to the well- groundedness requirement. Proscelle v. Derwinski, 2 Vet. App. 629, 631 (1992). In order to present a well-grounded claim for an increased rating of a service-connected disability, the veteran need only submit competent testimony that symptoms, reasonably construed as related to the service-connected disability, have increased in severity since the last evaluation. Id. at 631-632; Jones v. Brown, 7 Vet. App. 134, 138 (1994). The veteran has asserted that his PTSD is has increased in severity to a higher degree than contemplated by the current evaluation, and thus the Board finds that his claim of increasing severity of his service- connected PTSD establishes a well-grounded claim for an increased evaluation. See Proscelle, 2 Vet. App. at 631. The VA has afforded the veteran several examinations in relation to this claim, and obtained medical records pertaining to the treatment the veteran has received for his PTSD. There does not appear to be any pertinent evidence that is not of record. Therefore, the Board finds that VA has fulfilled its duty to assist the veteran in developing the facts pertinent to his claim. No further assistance to the veteran is required to comply with the duty to assist mandated by 38 U.S.C.A. § 5107(a). Under the applicable criteria, disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (1999). Separate diagnostic codes identify the various disabilities. VA has a duty to acknowledge and consider all regulations which are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The requirements set forth in these regulations, mandating an evaluation of the complete medical history of the veteran's claimed disability, operate to protect veterans against adverse decisions based on a single, incomplete or inaccurate report, and to enable VA to make a more precise evaluation of the level of the disability and of any changes in the condition. 38 C.F.R. §§ 4.1, 4.2 (1999); Schafrath, 1 Vet. App. at 593-94. The veteran's disability, however, must be reviewed in relation to its history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3 (1999); where there is a question as to which or two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7 (1999); and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10 (1999); Schafrath, 1 Vet. App. 589. In any case, with particular regard to the veteran's request for an increased schedular evaluation, the Board will only consider the factors as enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. §§ 4.1, 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). The degree of impairment resulting from a disability is a factual determination and the Board's primary focus in such cases is upon the current severity of the disability. Id. at 57-58; Solomon v. Brown, 6 Vet. App. 396, 402 (1994). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (1999). The Board points out that the VA Schedule for Rating Disabilities has been revised with respect to the regulations applicable to evaluating mental disorders. The amendments to the regulations applicable to evaluating mental disorders, including the rating criteria for PTSD, became effective on November 7, 1996. The United States Court of Appeals for Veterans Claims (Court) has held that where the law or regulation changes after a claim has been filed or reopened but before the administrative or judicial process has been concluded, the version most favorable to the veteran will apply. Karnas v. Derwinski, 1 Vet. App. 308 (1991). As noted above, the veteran filed his application for an increased rating for PTSD in December 1992, and amendments to the rating criteria for mental disorders became effective on November 7, 1996. Thus, the Board is obligated under Karnas to evaluate the veteran's claim under both the old and new criteria. Under the criteria for mental disorders in effect prior to November 7, 1996, PTSD warrants a 50 percent evaluation when the veteran's ability to establish or maintain effective or favorable relationships is considerably impaired, and because of the psychoneurotic symptoms, the reliability, flexibility, and efficiency levels are so reduced as to result in considerable industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9411 (1996). A 70 percent evaluation is warranted where the veteran's ability to establish or maintain effective or favorable relationships with people is severely impaired, and the psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. Id. A 100 percent evaluation is warranted when the veteran's attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community and there be totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior. The individual must be demonstrably unable to obtain or retain employment. Id. Prior to November 7, 1996, the Schedule for Rating Disabilities provided that the severity of a mental disorder was based upon actual symptomatology, as it affects social and industrial adaptability. Two of the most important determinants of disability are time lost from gainful work and decrease in work efficiency. VA must not under evaluate the emotionally sick veteran with a good work record, nor must it over evaluate his or her condition on the basis of a poor work record not supported by the psychiatric disability picture. It is for this reason that great emphasis is placed upon the full report of the examiner, descriptive of actual symptomatology. The record of the history and complaints is only preliminary to the examination. The objective findings and the examiner's analysis of the symptomatology are the essentials. The examiner's classification of the disease as "mild," "moderate," or "severe" is not determinative of the degree of disability, but the report and the analysis of the symptomatology and the full consideration of the whole history by the rating agency will be. 38 C.F.R. § 4.130 (1996). Pursuant to the criteria which became effective November 7, 1996, a 50 percent rating is warranted for PTSD where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (1999). A 70 percent rating is warranted for PTSD where there is occupation 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. Id. A 100 percent rating is warranted for PTSD where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). Analysis. The record reflects that the veteran's PTSD is manifested by intrusive thoughts of the war, flashbacks, nightmares, hypervigilance, an exaggerated startle response, difficulty relaxing, irritability, and trouble controlling his anger. He is depressed and has no friends or social life. In 1996 a social worker noted that the veteran's inability to carry on social relationships had far-reaching consequences, including job-related consequences. When the veteran was examined in 1989 it was noted that his overall mood was mildly depressed. When he was examined in 1993, the examiner noted that the veteran appeared somewhat more sullen and depressed that he had during the previous VA examinations. The examiner commented that the veteran mood was mildly to moderately depressed. When the veteran was again examined in September 1996, he had been working full time as a technician for about 9 months. The examiner concluded that the veteran's PTSD symptoms were mild to moderate, had not interfered with his ability to work, and warranted a GAF score of 60 to 65. (GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994). A rating of 60 indicates "moderate symptoms or moderate difficulty in social, occupational, or school functioning" and a rating of 70 indicates "some mild symptoms or some difficulty in social, occupational, or school functioning." Ibid. However, when the veteran was next examined in June 1997, he had been unemployed since October 1996 and the examiner noted that his depression and difficulty with interpersonal relationships had made finding employment particularly difficult for him. The examiner concluded that the veteran's PTSD symptoms warranted a GAF score of 49 and commented that the PTSD was productive of serious impairment in the veteran's social and occupational functioning. Prior to the examination of June 1997, the record clearly reflects that the veteran's PTSD was mildly to moderately disabling. Psychiatric examination in 1989 indicated that the condition was mild. When he was again examined in 1993, his condition had become somewhat worse, and was mildly to moderately disabling. Examination in September 1996 reflects that he was working full time and his PTSD symptoms were mild to moderate. Accordingly, the Board finds that the criteria for a rating in excess of 50 percent are not met prior to the examination in June 1997. VA examination in June 1997 contains the first evidence that the veteran's PTSD is productive of more than moderate impairment. While the report of this examination reflects that the veteran had been unemployed since October 1996, there is no indication as to the reason for the termination of the veteran's employment. Apparently, since his employment was terminated, he is no longer able to distract himself from the PTSD symptoms through work and the symptoms have progressively developed and intensified. At the time of the June 1997 examination, the veteran reported that he was plagued by daily intrusive thoughts of the war. This examination reveals that the veteran's PTSD symptoms result in serious impairment in his social and occupational functioning. In the instant case, the Board finds that the current symptoms of the veteran's PTSD most nearly approximate a 70 percent disability evaluation under both the "old" regulations (severe industrial impairment), and the "new" regulations (suicidal ideation; depression affecting ability to function independently, appropriately and effectively; impaired impulse control; and an inability to establish and maintain effective work and social relationships). The June 1997 examination results and the GAF score of 49 serve to establish sufficient reasonable doubt regarding the increased severity of the veteran's PTSD symptoms such as to warrant the assignment of a 70 percent rating. 38 U.S.C.A. § 5107(b). Accordingly, the Board finds that the record supports a 70 percent disability evaluation for PTSD as of the date of the June 1997 examination. The competent medical evidence does not, however, establish that the veteran's PTSD symptomatology is indicative of a disability evaluation in excess of 70 percent. Under the "old" regulations, a 100 disability evaluation is warranted when the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community. The psychoneurotic symptoms are so incapacitating as to border on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic and explosions of aggressive energy resulting in profound retreat from mature behavior. Symptoms also include demonstrable inability to obtain or retain employment. Under the "new" regulations, a 100 percent evaluation is indicative of total occupational and social impairment due to 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, disorientation to time or place or memory loss for family names, own occupation or own name. The Board notes that although the veteran has difficulty with relationships and has a close personal relationship with only his spouse, there is no evidence to show that he is in virtual isolation. While the veteran's employment was terminated in October 1996, a VA examiner had noted in September 1996 that the veteran's PTSD symptoms did not interfere with his ability to work. The record does not suggest that the PTSD symptoms are so incapacitating as to result in gross repudiation of reality or in profound retreat from mature behavior. While the veteran was not employed at the time of the June 1997 examination, he is not shown to be demonstrably unable to obtain or retain employment. Thus, the Board finds that the criteria for a 100 percent rating as in effect prior to November 7, 1996, are not met. Likewise, the Board finds that the criteria for a 100 percent rating which became effective as of November 7, 1996, are not met. No competent medical evidence tends to show that the veteran manifests symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting himself or others; intermittent inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In summary, the Board concludes that, although the evidence regarding an increase in the veteran's disability from PTSD symptomatology is in sufficient equipoise to afford him a disability evaluation of 70 percent, the preponderance of the evidence is clearly against an increased evaluation of 100 percent under either the "old" or the "new" regulations. ORDER A disability rating in excess of 50 percent for PTSD is denied for the period prior to June 23, 1997. A disability rating of 70 percent for PTSD is granted as of June 23, 1997, subject to the law and regulations governing the payment of monetary benefits. REMAND The record reflects that the veteran was unemployed when he was last examined in June 1997 and the examiner indicated that his PTSD symptoms made finding employment particularly difficult. As noted in the INTRODUCTION, the RO send the veteran a VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Unemployability) in November 1998 and the veteran failed to complete and return this form. At that time he did not meet the percentage requirements set forth in 38 C.F.R. § 4.16(a) for a total disability rating based on individual unemployability (TDIU) due to a service- connected disability. However, in view of the grant of a 70 percent rating for his PTSD, he now meets the percentage requirements of this regulation. The claim for a TDIU concerns entitlement to an increased rating for a service-connected disability on a basis other than the evaluations provided in VA's ratings schedule. As the issue of entitlement to a TDIU rating for PTSD is properly raised in connection with a claim for an increased rating for such disability, the question of entitlement to a TDIU rating is considered a component of an increased-rating claim. The Court has held that the issue of entitlement to a TDIU rating is not "inextricably intertwined" with the issue of entitlement to an increased schedular evaluation. See Parker v. Brown, 7 Vet. App. 116, 118 (1994); Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In Holland v. Brown, 6 Vet. App. 443, 446-47, the Court explained that the question of a TDIU rating is distinct from the question of a higher schedular evaluation. The Board has determined that further action by the RO is necessary with respect to the issue and remands the issue of entitlement to a TDIU rating for PTSD. The Board also notes that the veteran's PTSD is the only disorder for which a compensable evaluation is in effect. Even though 38 C.F.R. § 4.16(c) was deleted by the regulatory changes that became effective on November 7, 1996, nevertheless, in view of Karnas, supra, the veteran is entitled to an analysis under that section. See 38 C.F.R. § 4.16(c) (1996); see also Karnas, 1 Vet. App. at 313 (Court held that the Board erred in failing to consider this provision which compels a 100 percent rating for a claimant whose 70 percent service-connected mental disability prevents him from engaging in substantially gainful employment, even if not raised by appellant). Accordingly, this case is REMANDED to the RO for consideration and full development of the issue of whether the veteran is entitled to a 100 percent evaluation under the provisions of 38 C.F.R. § 4.16, pursuant to which the following development should be accomplished: 1. The RO should take appropriate steps in order to determine whether or not the veteran is currently employed. If the veteran is not employed, or has only marginal employment, the RO should accomplish whatever additional development and adjudication of this matter is deemed appropriate and necessary. 2. If the benefit sought is not granted, the veteran and his representative should be furnished with a Supplemental Statement of the Case, and afforded the applicable time period to respond before the record is returned to the Board for further review. Thereafter, the case should be returned to the Board for further appellate review, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until notified by the RO. The veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded to the regional office. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Veterans Appeals for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1997) (Historical and Statutory Notes). In addition, VBA's ADJUDICATION PROCEDURE MANUAL, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. Gary L. Gick Member, Board of Veterans' Appeals