Citation Nr: 1007143 Decision Date: 02/26/10 Archive Date: 03/05/10 DOCKET NO. 06-37 865 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Wichita, Kansas THE ISSUES 1. Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. 2. Entitlement to total disability based on individual unemployability (TDIU) due to service-connected disability. REPRESENTATION Veteran represented by: Kenneth M. Carpenter, Attorney at Law ATTORNEY FOR THE BOARD Lawrence W. Klute, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1971 to February 1972. This matter comes to the Board of Veterans' Appeals (the Board) on appeal from November 2005 and September 2007 rating decisions by the Department of Veterans Affairs (VA) Regional Office (the RO) in Wichita, Kansas. By its November 2005 rating decision, the RO denied entitlement to TDIU. By its September 2007 rating decision, the RO denied a rating higher than 50 percent for PTSD. Procedural history By a February 2002 rating decision, the Veteran was granted service connection for PTSD with a 30 percent disability rating. He disagreed with that decision, and by an August 2002 rating decision, the RO increased the rating to 50 percent disabling. The Veteran was not satisfied with that decision. He perfected his appeal for a higher rating with a timely filed substantive appeal (VA Form 9). By a March 2006 decision, the Board denied an increased rating higher than 50 percent disabling for PTSD. The Veteran did not appeal the Board's decision. Instead, he filed a new claim of increased rating for PTSD on March 16, 2006. By a March 2007 rating decision, the RO continued the 50 percent disability rating. By a May 5, 2007 claim, the Veteran requested reconsideration of the March 2007 decision in which the RO denied an increased rating for PTSD. By its September 2007 rating decision, the RO continued the 50 percent disability rating for PTSD. The Veteran disagreed with that decision, and perfected the current appeal by filing a timely substantive appeal (VA Form 9). By a December 2009 rating decision, the RO determined that the Veteran's symptoms of depression and sleep disturbance were part and parcel of his service- connected PTSD, and that separate disability ratings were not warranted. By a November 2005 rating decision, the RO denied entitlement to TDIU. The Veteran disagreed with that decision, and perfected the current appeal with a timely filed substantive appeal (VA Form 9). Matters not on appeal By its February 2002 rating decision, the RO denied service connection for peripheral neuropathy due to exposure to herbicides. By a November 2002 rating decision, the RO denied earlier effective dates for PTSD and prurigo nodularia (a skin condition). By a May 2006 rating decision, the RO denied service connection for diabetes mellitus type II due to exposure to herbicides, for glaucoma as secondary to diabetes mellitus type II, and denied an increased rating higher than 30 percent for prurigo nodularia. By a May 2008 rating decision, the RO denied service connection for sleep apnea as secondary to PTSD, and granted service connection for diabetes mellitus type II with a 10 percent disability rating. By a May 2009 rating decision, the RO reduced the rating for prurigo nodularia from 30 percent to 10 percent disabling, effective from August 1, 2009. The Veteran did not disagree with any of the above listed decisions. Therefore, they are not in appellate status. They will be discussed no further herein. See Archbold v. Brown, 9 Vet. App. 124, 130 (1996) [pursuant to 38 U.S.C.A. § 7105(a), the filing of a notice of disagreement initiates appellate review in the VA administrative adjudication process, and the request for appellate review is completed by the claimant's filing of a substantive appeal after a statement of the case is issued by VA]. Matter referred to the RO In a statement received on June 3, 2009, the Veteran filed a new claim of service connection for chloracne, which has not yet been developed by the RO. Therefore, this claim is referred to the RO for such additional action as may be appropriate. (CONTINUED ON NEXT PAGE) FINDINGS OF FACT 1. The Veteran's PTSD is as likely as not manifested by total occupational and social impairment. 2. The Veteran has been unemployable due to his service connected PTSD since September 9, 2003, the last day he worked. He filed his claim of entitlement to TDIU on September 18, 2003. CONCLUSIONS OF LAW 1. The criteria for the assignment of an initial rating of 100 percent for PTSD are met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.7, 4.130, Diagnostic Code 9411 (2009). 2. The Veteran is eligible for TDIU effective September 18, 2003. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.16 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran is seeking an increased disability rating higher than 50 percent for PTSD, and entitlement to TDIU. In the interest of clarity, the Board will first discuss certain preliminary matters. The issue on appeal will then be analyzed and a decision rendered. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA includes an enhanced duty on the part of VA to notify a claimant as to the information and evidence necessary to substantiate claims for VA benefits. The VCAA also redefines the obligations of VA with respect to its statutory duty to assist claimants in the development of their claims. See 38 U.S.C.A. §§ 5103, 5103A (West 2002). The VCAA alters the legal landscape in three distinct ways: standard of review, notice and duty to assist. The Board will now address these concepts within the context of the circumstances presented in this case. Standard of review In general, after the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of 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. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2009). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (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 preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Notice The VCAA requires VA to notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided to VA that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. See 38 U.S.C.A. § 5103 (West 2002); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002) [a letter from VA to an appellant describing evidence potentially helpful to the appellant but not mentioning who is responsible for obtaining such evidence did not meet the standard erected by the VCAA]. After having carefully reviewed the record, the Board has concluded that the notice requirements of the VCAA have been satisfied with respect to the issues on appeal. The Veteran was informed of the evidentiary requirements to substantiate TDIU in March 4, 2004 and July 6, 2007. He was also informed of the evidentiary requirements to substantiate an increased rating in the July 6, 2007 letter from the RO. Crucially, the Veteran was informed of VA's duty to assist him in the development of his claims and advised of the provisions relating to the VCAA in the letters. Specifically, the Veteran was advised that VA is responsible for obtaining relevant records from any Federal agency, including records kept by VA Medical Centers. The letter also informed the Veteran that VA would make reasonable efforts to obtain the Veteran's private medical records, employment records, or records from state or local government agencies. Included with the letters were copies of VA Form 21- 4142, Authorization and Consent to Release Information, and the letter asked that the Veteran complete this release so that VA could obtain records on his behalf. The March 2004 VCAA letter emphasized: "You must give us enough information about your records so that we can request them from the person or agency that has them. If the holder of the records declines to give us the records or asks for a fee to provide them, we'll notify you of the problem. It's your responsibility to make sure we receive all requested records that aren't in the possession of a Federal department or agency" [Emphasis as in original]. The July 2007 VCAA letter further emphasized: "If the evidence is not in your possession, you must give us enough information about the evidence so that we can request it from the person or agency that has it. If the holder of the evidence declines to give it to us, or asks for a fee to provide it, or VA otherwise cannot get the evidence, we will notify you. It is your responsibility to make sure we receive all requested records that are not in the possession of a Federal department or agency. [Emphasis supplied as in original] The March 2004 VCAA notice letter further advised the Veteran: "If there is any other evidence or information that you think will support your claim, please let us know." The July 2007 VCAA notice letter additionally advised: "If there is any other evidence or information that you think will support your claim, please let us know. If you have any evidence in your possession that pertains to your claim, please send it to us." This complies with the "give us everything you've got" provision formerly contained in 38 C.F.R. § 3.159(b) in that it informed the Veteran that he could submit or identify evidence other than what was specifically requested by the RO. [The Board observes that 38 C.F.R. § 3.159 was revised, effective as of May 30, 2008. See 73 Fed. Reg. 23,353-23,356 (April 30, 2008). The final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request the claimant to provide any evidence in the claimant's possession that pertains to the claim.] In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the Court observed that a claim of entitlement to service connection consists of five elements: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date. Because a claim is comprised of five elements, the notice requirements of section 5103(a) apply generally to all five elements of that claim. Therefore, upon receipt of an application for a service connection claim, section 5103(a) and section 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim. This includes notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The Veteran was provided specific notice of the Dingess decision in the July 2007 VCAA notice letter. That letter detailed the evidence considered in determining a disability rating, including "nature and symptoms of the condition; severity and duration of the symptoms; and impact of the condition and symptoms on employment." The Veteran was also advised as to examples of evidence that would be pertinent to a disability rating, such as on-going treatment records, recent Social Security determinations and statements from employers as to job performance and time lost due to service- connected disabilities. With respect to effective date, the July 2007 VCAA letter advised the Veteran as to examples of evidence that would be pertinent to an effective date determination, such as information about continuous treatment or when treatment began, service medical records the Veteran may not have submitted, and reports of treatment while attending training in the Guard or Reserve. The Board is aware of the decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004), in which the United States Court of Appeals for Veterans Claims held, in part, that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must ordinarily be provided to a claimant before the initial unfavorable decision on a claim for VA benefits. Here, as noted above, the Veteran received complete VCAA notice, including Dingess notice, relating to his claim of increased rating for PTSD in the July 2007 VCAA notice letter prior to the RO's September 2007 unfavorable decision. Thus, there is no issue as to timing of the notice as it relates to the claim of increased rating for PTSD. As concerns the claim of entitlement to TDIU, the Veteran did not receive notice required by Dingess until the July 2007 VCAA notice letter, which was after the RO's November 2005 unfavorable decision. However, as further discussed below, inasmuch as the Board is fully granting the Veteran's claim of entitlement to TDIU, there is no prejudice to the Veteran in the timing of the notice. Because there is no indication that there exists any evidence which could be obtained which would have an effect on the outcome of this case, no further VCAA notice is necessary. See Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) [VCAA notice not required where there is no reasonable possibility that additional development will aid the Veteran]. Duty to assist In general, the VCAA provides that VA shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate a claim for VA benefits, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. The law provides that the assistance provided by VA shall include providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2009). The Board finds that reasonable efforts have been made to assist the Veteran in obtaining evidence necessary to substantiate his claim as to the current issues being decided on appeal, and that there is no reasonable possibility that further assistance would aid in substantiating it. In particular, the VA has obtained the Veteran's service treatment records, and his VA treatment records [it does not appear that he has had private treatment]. Additionally, the Veteran was provided with VA examinations in connection with his claim of service connection for PTSD, and his claims for increased rating. These examinations also have relevance to the Veteran's claim of entitlement to TDIU. The reports of these examinations reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted an appropriate psychological examination and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board therefore concludes that the examinations are adequate for rating purposes. See 38 C.F.R. § 4.2 (2009). The Veteran and his representative have not contended otherwise. Moreover, given the favorable outcome of the disposition of the issues on appeal, the Board finds that any question as to the adequacy of the examinations is essentially moot. The Board notes that the record reveals that the Veteran has been receiving Social Security Administration disability benefits, and his last day of employment was September 9, 2003. The underlying SSA records have not been obtained for the file. In deciding the Veteran's claims, the Board has determined that obtaining these records would only add surplus to an already well documented claims folder. Moreover, the Veteran and his representative have not suggested that the SSA records would contain any additional information which would support his claim of increased rating for PTSD. See Brock v. Brown, 10 Vet. App. 155, 161-2 (1997) [VA is not obligated to obtain records which are not pertinent to the issue on appeal]. See also Golz v. Shinseki, No. 09-7039 (Fed. Cir.) (Jan. 4, 2010) (There must be specific reason to believe these records may give rise to pertinent information to conclude that they are relevant). More importantly, and as previously stated, the favorable outcome of this decision (granting a 100 percent schedular from one year prior to date of claim and awarding TDIU from date of when entitlement arose) essentially negates any need to obtain these records. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2009). The Veteran has been ably represented by a service organization representative, and currently his attorney, who has presented argument on his behalf as recently as January 21, 2010. He did not elect to have a personal hearing before a member of the Board. Accordingly, the Board will proceed to a decision. 1. Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently evaluated as 50 percent disabling. Relevant law and regulations Disability evaluations are determined by the application of a schedule of ratings, which is in turn based on the average impairment of earning capacity caused by a given disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2009). Separate diagnostic codes identify the evaluations to be assigned to the various disabilities. If there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2009). PTSD is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.130, Diagnostic Code 9411 (2009). A 50 percent rating is warranted if the disorder is manifested by 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. A 70 percent rating is warranted if the disorder is manifested by 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 that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. The highest available rating, 100 percent, is warranted if the disorder is manifested by 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 oneself or others; an intermittent inability to perform the activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, one's own occupation, or one's own name. Id; see Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002) (the use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran and disorder, and the effect of those symptoms on the claimant's social and work situation). Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a) (2009). Furthermore, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2009). Analysis Following a review of the relevant evidence in this case, and the applicable laws and regulations, it is the Board's conclusion that, with benefit of the doubt given to the Veteran, the assignment of a 100 percent disability rating is warranted for the Veteran's PTSD. Significant in considering its decision, is the fact that the RO in its December 2009 decision, determined that the Veteran's depression and sleep disturbance were part and parcel of the Veteran's service- connected PTSD. The record reveals that the Veteran was first diagnosed with PTSD during 2000, and he has been in VA PTSD Clinic therapy (PCT) since about July 2000. He was granted service connection for PTSD effective August 15, 2000. As noted above, the Veteran has been provided VA examinations relating to his PTSD. A VA psychologist, Dr. S.O., Ph.D., in a March 2005 examination report, and based in part on a Mississippi scale test, diagnosed the Veteran with moderate PTSD, and severe major depression. He gave separate GAF scores: 58 for moderate PTSD problems, and "around" 50 for depression, with a combined score of 43. He commented that the psychological testing was more indicative of the presence of a severe major depression than it is a severe PTSD. The PTSD, being no worse than moderate, was likely to be aggravated in terms of symptomatology by the high level of depression. However, Dr. S.O. essentially deemed the PTSD and depression to be separate entities. He also noted that in March 2005 the Veteran's treating psychiatrist, Dr. C.P., had assigned a GAF score of 40. Dr. S.O. observed that the Veteran showed no impairment of thought processes or communication; he made appropriate eye contact and interacted well during the session, even smiling on occasion; he had frequent suicidal thoughts and was obsessive somewhat about suicide, but had no intention of harming himself. He was oriented in all spheres and easily able to maintain personal hygiene. His speech was logical and goal-directed with normal rate and flow. He has had problems with impulse control in terms of controlling his anger, usually verbal, but he did not appear to act out physically. He engages in mildly self-injurious behavior, picking at the skin of his hands and arms. The Veteran reported no history of panic attacks; he rated his mood at 9 1/2 on a scale of 10, but was usually quite depressed; and he was only able to sleep on and off. He said that he had not worked since September 2003 due to his increasing anger with his supervisors, and had almost engaged in a physical altercation. With regard to PTSD symptoms, Dr. S.O. observed that the Veteran was easily angered; had some sleep problems; occasional nightmares, and was easily startled. He was somewhat demoralized, perhaps due to his depression. When in strange places, he always scans for escape routes, and he checks the doors of his home before he goes to sleep at night. With regard to depressive symptoms, he noted suicidal ideation, the inability to get along with others, and picking at his skin. Another VA psychologist, Dr. R.N., Ph.D., examined the Veteran during August 2007. He administered the Beck Depression Inventory Test, which produced a low score of 41 in the severe range. He had some difficulty with vocabulary, suggesting that his intelligence was probably in the low average range. The Veteran reported that he had suicidal thoughts, but would not carry them out, but he had attempted suicide three times in the past. He felt sad all the time; felt hopeless about his future; felt like crying but could not; and felt as though he was being punished. He sleeps most of the day, and often feels too tired or fatigued to do a lot of the things he used to do. Dr. R.N. noted that the Veteran's PTSD symptoms related to his having flown on 175 combat missions in Vietnam. They included daily intrusive memories; avoidance of reminder such as war movies; becoming jumpy and nervous due to triggers of memories such as helicopters flying overhead; and anger daily over the current war. He did not believe he would live until 60, but expressed love for his wife and family. Dr. R.N. observed that the Veteran was alert and well oriented to person, place, and time. He had good memory, but demonstrated a problem with attention and concentration. He was able to abstract and his social judgment was within normal limits. He reported that he used a CPAP, and that he sleeps well when he uses it. He also reported frequent thoughts of killing people, and he began talking about how he would like to kill the President of the United States. Dr. R.N. diagnosed the Veteran with chronic major depressive disorder, and PTSD, with a GAF score of 45. He commented that he agreed with Dr. S.O. that the depressive disorder was much more severe than the PTSD. He noted that the Veteran had been depressed for many years, and his depressive symptoms, including suicidal thoughts, were severe. The Veteran's wife reported that she believed his symptoms had improved and their relationship had improved. He has few friends, but has a good relationship with her and their children. They were making progress in paying off some substantial bills, but still go to casinos. Dr. R.N. said that he was unable to determine that the Veteran had any physical or psychological condition that would prevent him from working; the Veteran stated that the reason he was not working was because he did not like to be told what to do. Dr. R.N. believed that the Veteran's irritability and hostility toward other people was due to his depression, not his PTSD. The Veteran was afforded another VA PTSD examination in June 2009 by Dr. R.T., a VA psychiatrist. Dr. R.T. diagnosed the Veteran with chronic PTSD and depression not otherwise specified, with a GAF score of 60. He noted that the Veteran's psychiatric symptoms have continued unabated and without remission since the prior VA examination. Because of his long-term marriage and children he has family support, but his social functioning was poor with mainly isolation. He commented that the Veteran's PTSD had caused total occupational and social impairment such that he was not able to function for the last four years in any occupation and had significant social impairment in his contact with society because of an ongoing feeling of hatred and an impulsive feeling to attack other people. These were traceable to his service in Vietnam, and have persisted and, if anything, have increased with time. Dr. R.T. also opined that in view of the Veteran's long clear history of PTSD, the depressive features and his sleep disturbance would be considered part of the PTSD symptomatology picture. In an August 2009 examination report, VA psychologist, Dr. D.R., noted how the Veteran described his anger over what he was made to do in Vietnam, his long history of work instability due to his anger, and his verbally abusive relationship with his wife. He reported that his wife made him go back to PTSD therapy. He said that he was jealous and did not trust his wife over the years; that she understood him, but was possibly afraid of him; and that he never hit her, but was verbally abusive. He discussed how he was always an isolating person; how he didn't want to be around anyone; and how he did not want to go out with his wife, but just be left alone. He said that his wife tells him "you just sit there; you don't take a bath half the time." Dr. D.R. diagnosed the Veteran with chronic severe PTSD, and depression secondary to PTSD. He noted significant PTSD related anger resulting in severely diminished occupational, social, relational, and personal functioning. A GAF score of 50 was assigned (noting it was lower than the GAF score of 60 assigned by Dr. R.T. only two months before in June 2009). The file also contains a documented record since 2000 of the Veteran's PTSD therapy sessions with his treating psychiatrist, Dr. C.P., and the supervisory psychologist, Dr. T.R. In a June 2006 letter, Dr. C.P. stated that she had been treating the Veteran for PTSD for six years. She said that "the symptoms he experiences from this disorder prevent him from ever working again." In a July 2006 evaluation, Dr. C.P. diagnosed the Veteran's depression as having psychotic features because he described a nightmare abut UFO's landing near his house. He reported his struggle with activities of daily living, and how his wife continued to press him to bathe daily and change his clothing. In August 2007 she again diagnosed the Veteran as having major depression with psychotic features. In an August 2003 letter to the Veteran's employer, Dr. T.R., noted that the Veteran had been diagnosed with chronic severe PTSD due to combat experiences. His symptoms included nightmares several times a week, sleep disturbance, difficulty concentrating, intrusive thoughts all day everyday, chronic depression, hypervigilence, and being easily angered with both suicidal and homicidal thoughts. He indicated that it would not surprise him if the Veteran would respond violently at some point on the job. He stated that he believed it would be in the Veteran's best interests if he were to retire. In a January 2006 letter, Dr. T.R. argued that anxiety neurosis and PTSD were one in the same thing insofar as determining the Veteran's unemployability. He stated that the real reason the Veteran was unemployable was due to his chronic homicidal thoughts which interfere with his day on a daily basis. He would not want someone with those thoughts working for him or anyone that he knew. He went on to say that the Veteran is able to control those (homicidal thoughts) with the help of medication, therapy, and isolation from others. The Veteran is easily angered and starts ranting and raving about killing others quite easily. Dr. R.T. asked for a closer look at the merits of his case (for unemployability). In a November 2006 letter, Dr. T.R. reiterated his opinion that the Veteran is chronically homicidal; that he thinks about killing someone every day; that he did not retire, but left work on disability due to the severity of his symptoms; that he had to be restrained from going after a supervisor physically; that he was worried an anxious when he took his family to visit his son who was stationed in Korea; that he isolates himself to the extent that a neighbor inquired whether he had moved; that he sits in the basement in the dark all day; that he can interact with the general public, but lets his wife do the requesting or talking whenever possible; he only goes out where there are crowds when his wife insists, and then he will be nervous and on edge for days. Dr. R.T. criticized the March 2005 VA examiner's report for not finding any psychosis. He noted Dr. C.P.'s diagnosis of major depression with psychotic features. He noted that the Veteran does not trust others. He is transiently psychotic, believing that there is an "evil" side to him which fuels the homicidal thought and other thoughts he has about hurting others. He has seen space ships and believes they have something to do with his "evil" part. Dr. T.R. concluded that, in his opinion, the Veteran is totally disabled due to his PTSD. It affects every aspect of his life every day. The Veteran is not able to work, and he (Dr. T.R.) would not want him working with him or for him. He is too volatile and can be dangerous if the situation were right. In the latest July 2008 letter, Dr. T.R. again stated that the Veteran's PTSD symptoms are so severe and debilitating that they render him unemployable; that it was a chronic ongoing condition that will not likely have remission. He noted symptoms of daily intrusive thoughts about combat; being easily angered by things others would find trivial; being severely depressed and anxious; picking at the skin on his hands to the point of having bloody sores due to anxiety; difficulty concentrating and getting confused if trying to complete a project where there are several steps; avoiding relationships with others except family and he does avoid some family members because they anger him quickly; avoiding groups because he feels closed in and panicky; sitting in a restaurant with his back to the wall; no longer enjoying things that used to be pleasurable to him with no hobbies or activities; difficulty with memory forgetting things he was supposed to do, names he should know; and what he did just a minute before; and trouble with suicidal and homicidal thoughts when angry. Dr. T.R. noted that the Veteran continues to think about killing the boss he had when he was working. He threatened him when he was still working, and still thinks how to kill him. It is the Board's determination that review of the record supports a finding that a 100 percent disability rating for PTSD is warranted, especially in view of the fact that symptoms of depression and sleeplessness have been determined to be part and parcel of the symptoms of PTSD. Dr. R.T. in June 2009 concluded that the Veteran's PTSD had caused total occupational and social impairment. Dr. D.R. in August 2009 noted severely diminished occupational, social, relational, and personal functioning. Dr. T.R.'s series of letters further support such findings. The record does show that the Veteran's PTSD symptoms are manifested by psychotic features in the form of persistent delusions or hallucinations related to his "evil" self; a persistent danger of hurting himself or others with impaired impulse control, anger and irritability, and chronic suicidal and homicidal ideation. The record in particular reveals severe homicidal ideation which Dr. T.R. has stated prohibits employment. While the Veteran is able to present himself at an examination with fair hygiene, the record shows an intermittent inability to perform activities of daily living including maintenance of minimal personal hygiene, as shown by comments that his wife complains about him not bathing or changing his clothing regularly. The record further shows chronic severe depression affecting the ability to function independently, appropriately, and effectively. Dr. T.R.'s description of the Veteran's total isolation from others (sitting all day in his dark basement, unwillingness to go out in groups or crowds) except for interaction with family is indicative of total social impairment. The Veteran also suffers from other multiple PTSD symptoms including nightmares several times a week, sleep disturbance, difficulty concentrating, intrusive thoughts on a daily basis, avoidance syndrome, and hypervigilence. The record also indicates that the Veteran experiences little or no remission from his symptoms. The Board also notes that the GAF scores assigned to the Veteran are consistent with the assignment of a 100 percent evaluation for his service-connected PTSD. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM- IV), a GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." It does not include impairment in functioning due to physical (or environmental) limitations. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). The Veteran's treating psychiatrist, Dr. C.P., assigned a GAF score of 40 in March 2005. The VA examiner in March 2005, Dr. S.O., assigned a GAF score of 43. Dr. R.N. in August 2007 assigned a GAF score of 45. Dr. R.T. in June 2009 assigned a GAF score of 60. Dr. D.R. in August 2009 pointedly disagreed with Dr. R.T. and assigned a lower GAF score of 50. A GAF score of 31 to 40 is indicative of "some impairment in reality testing or communication (e.g. speech at times is illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g. depressed man avoids friends, neglects family, and is unable to work. . . )." A GAF score of 41 to 50 is indicative of "serious symptoms (e.g. 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)." A GAF score of 51 to 60 is indicative of "moderate symptoms (e.g. flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g. few friends, conflicts with peers or co-workers)." The Board finds that Dr. R.T.'s assignment of a GAF score of 60 is inconsistent with his diagnostic comments that the Veteran's PTSD had caused total occupational and social impairment. The other assigned GAF scores (40, 43, 45, and 50) averaged 45, which is indicative of serious symptoms, but being midway between 50 and 40 can be interpreted as involving some major symptomatology. The Board concludes from consideration of all the available evidence that the Veteran as likely as not suffers total occupational and social impairment due to multiple, chronic, and serious PTSD symptoms that are particular to this Veteran and his unique circumstances. Inasmuch as the RO, based on Dr. R.T.'s opinion, determined that the Veteran's depression and sleeplessness were part and parcel of his PTSD symptomatology, the Board's analysis as set forth above contemplates his overall psychiatric impairment. For the foregoing reasons, the Board finds that the Veteran's PTSD has met the criteria for the higher (100 percent) rating. Hart consideration In Hart v. Mansfield, 21 Vet. App. 505 (2007), the Court held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibited symptoms that would warrant different ratings. In reaching its conclusion, the Court observed that when a claim for an increased rating is granted, the effective date assigned may be up to one year prior to the date that the application for increase was received if it is factually ascertainable that an increase in disability had occurred within that time frame. See 38 U.S.C.A. § 5110 (West 2002). Accordingly, the relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. The Veteran's claim for an increased disability rating for PTSD was initially received on March 16, 2006. The RO continued the 50 percent disability rating in a March 2007 rating decision. In May 2007 the Veteran filed a request for reconsideration of the RO's May 2007 decision. By a September 2007 rating decision, and a September 2008 DRO decision in a SOC, the RO continued the 50 percent disability rating. In this case, therefore, the relevant time period for consideration under Hart is from March 16, 2005, to the present. The Board notes that the Board denied an increased rating higher than 50 percent in its March 3, 2006, decision. It is important to note that, notwithstanding the Board's decision in March 2006, all of the evidence of record must be considered in determining the appropriate effective date to be assigned for the Board's decision herein to award a 100 percent disability rating. See Hazan v. Gober, 10 Vet. App. 511 (1997). That is to say, the Board's March 2006 decision does not stand as an absolute bar to the assignment of an effective date earlier than March 16, 2006 if the evidence of record, including evidence procured since the time of the March 2006 decision, otherwise establishes a factually ascertainable increase in disability prior to the date of the Board's decision. Id. The Board has reviewed all the evidence in this case, including all of the evidence that was added to the Veteran's claims file since the time of the Board's March 2006 decision. In this regard, the Board's March 2006 decision, and the subsequent RO decisions and DRO decision, were based on a dichotomy between PTSD and depression. That is to say that, until Dr. R.T.'s June 2009 diagnosis that symptoms of depression were part and parcel of the Veteran's PTSD, the adjudicators had discounted the depressive symptoms as separate and not related to the less severe PTSD symptoms. Now the RO's determination in December 2009 that depression and sleeplessness were part and parcel of PTSD changed the total picture of the Veteran's service connected PTSD for rating purposes. In this regard the RO did not assign an effective date. Based on the Board's discussion above, the Board finds that the record supports a finding that the 100 percent disability rating for PTSD can be made effective March 16, 2005. Dr. S.O.'s March 2005 diagnosis severe major depression can now be viewed as part and parcel of the PTSD, instead of as a separate non-service-connected disability. His combined GAF score of 43 for depression and PTSD can now be given more effect in arriving at a decision. He also noted that Dr. C.P., the Veteran's treating psychiatrist, had assigned a GAF score of 40 during March 2005. As discussed above, such low GAF scores are indicative of serious to major PTSD symptoms. The Board notes that Dr. S.O. also commented that the PTSD, being no worse than moderate, was likely to be aggravated in terms of symptomatology by the high level of depression. Accordingly, a 100 percent disability rating for PTSD is granted effective March 16, 2005. Extraschedular rating consideration The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1). In the case at hand, the Board has granted a 100 percent rating, the maximum rating available. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. Conclusion In summary, for the reasons and bases expressed above, the Board concludes that the criteria for a 100 percent disability rating for the Veteran's service-connected PTSD, effective March 16, 2005, have been met. 2. Entitlement to total disability based on individual unemployability due to service-connected disability (TDIU). Relevant law and regulations It is the established policy of the VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). A total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. A total disability may or may not be permanent. Total ratings will not be assigned, generally, for temporary exacerbations or acute infectious diseases except where specifically prescribed by the schedule. 38 C.F.R. § 3.340(a). A total disability rating for compensation purposes may be assigned where the schedular rating is less than total, where it is found that the disabled person is unable to secure or follow substantially gainful occupation as a result of a service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, providing at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 4.16(a). Disabilities resulting from common etiology or a single accident will be considered one disability for the purpose of one 60 percent disability, or one 40 percent disability in combination. 38 C.F.R. § 4.16(a). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). Analysis The Veteran's September 18, 2003, claim of entitlement to TDIU indicates that he was last employed as of September 9, 2003. He filed a November 2006 statement indicating that he retired due to Social Security disability. Recognition is given to the long-held practices of dismissing claims for TDIU in instances where the Veteran is in receipt of a total schedular rating. Notably, VA's General Counsel determined that if VA has found a veteran to be totally disabled as a result of a particular service-connected disability or combination of disabilities pursuant to a rating schedule, there is no need, and no authority, to otherwise rate that veteran totally disabled on any other basis. VA's General Counsel has determined that, because both a 100 percent disability schedular rating and a total disability rating awarded pursuant to 38 C.F.R. § 4.16(a) reflect unemployability, a determination that that individual is unemployable as a result of service-connected disability under 38 C.F.R. § 4.16(a) is unnecessary to adequately compensate the individual and is superfluous. See VAOPGCPREC 6-99 (June 7, 1999). The Court has since, however, issued Bradley v. Peake, 22 Vet. App. 280 (2008), taking a position contrary to the one reached by VA's General Counsel in the precedent opinion No. 6-99. In response to Bradley, the General Counsel recently took action to withdraw this prior opinion. And although no additional disability compensation may be paid when a total schedular disability rating is already in effect, the Court's decision in Bradley recognizes that a separate award of a TDIU predicated on a single disability may form the basis for an award of special monthly compensation (SMC). Therefore, although granting a higher 100 percent schedular rating in this decision for the PTSD, effective from March 16, 2005, the Board is nonetheless considering the Veteran's claim of entitlement to a TDIU for the entire claims period. In this regard, the Board notes that by an August 2002 rating decision, the RO granted an increased 50 percent rating for PTSD, effective August 15, 2000. At that time he was also service connected for prurigo nodularia, with a 30 percent disability rating since August 1994. His combined rating was 70 percent, effective August 15, 2000. Again, effective from March 16, 2005, the Veteran is in receipt of a total schedular (100 percent) rating. Review of the medical and other evidence of record also reflects that the Veteran has been unable to obtain and/or maintain substantially gainful employment due solely to his service-connected disabilities, specifically his PTSD, since September 18, 2003. As discussed above, in an August 2003 letter to the Veteran's employer, Dr. T.R. noted that the Veteran had been diagnosed with chronic severe PTSD due to combat experiences. His symptoms included nightmares several times a week, sleep disturbance, difficulty concentrating, intrusive thoughts all day everyday, chronic depression, hypervigilence, and being easily angered with both suicidal and homicidal thoughts. He indicated that it would not surprise him if the Veteran would respond violently at some point on the job. He stated that he believed it would be in the Veteran's best interests if he were to retire. The record also contains a note dated September 9, 2003, from a VA social worker at the PTSD Clinic. She stated that Dr. T.R. had brought the Veteran and his wife to see her because it had become clear that the Veteran could not work any longer. He recommended that the Veteran quit work as of that date, and file for Social Security disability benefits. The social worker set up an appointment for a telephone interview with SSA to apply for disability benefits. She discussed lifestyle adjustment changes with the Veteran and his wife, including that his depression might become worse. The Veteran admitted that he had been feeling bad because he could not tolerate his work environment any longer. Applying for TDIU with VA was also discussed. The Veteran did file his claim of entitlement to TDIU on September 18, 2003. Therefore, based on the foregoing analysis, the Board finds that the Veteran is entitled to a grant of TDIU, effective September 18, 2003. ORDER Entitlement to a 100 percent disability rating for service- connected PTSD is granted, effective from March 16, 2005, subject to controlling regulations applicable to the payment of monetary benefits. Entitlement to TDIU is granted, effective September 18, 2003. ____________________________________________ MICHAEL A. HERMAN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs