Citation Nr: 1122336 Decision Date: 06/09/11 Archive Date: 06/20/11 DOCKET NO. 07-34 649 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUE Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD), evaluated as 30 percent disabling from July 9, 2001 to October 21, 2004; 70 percent from October 22, 2004 to March 7, 2007; and 50 percent beginning on March 8, 2007. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and Dr. J.S. ATTORNEY FOR THE BOARD Kristy L. Zadora, Associate Counsel INTRODUCTION The Veteran had active duty service from October 1963 to September 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a November 2006 rating decision of the Seattle, Washington Regional Office (RO) of the Department of Veterans Affairs (VA) which granted service connection for PTSD and assigned an initial rating of 30 percent, effective July 9, 2001. A December 2007 Decision Review Officer (DRO) decision assigned an initial 70 percent rating, effective October 22, 2004 and a 50 percent rating beginning on March 8, 2007 for PTSD. The Veteran testified before the undersigned at an April 2011 hearing at the RO (Travel Board hearing). A hearing transcript is associated with the claims file. Additional evidence pertinent to the claim on appeal was submitted in April 2011 and subsequent to the issuance of the December 2009 supplemental statement of the case (SSOC). This evidence was accompanied by a waiver of RO consideration. See 38 C.F.R. § 20.1304 (2010). FINDINGS OF FACT 1. Prior to November 1, 2003, the Veteran's PTSD was manifested by deficiencies in most of the areas of work, school, family relations, judgment, thinking and mood. 2. Beginning on November 1, 2003, the Veteran's PTSD has been manifested by total social and occupational impairment. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 70 percent for PTSD were met from July 9, 2001 to October 31, 2003. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.126, 4.130, Diagnostic Code (DC) 9411 (2010). 2. The criteria for an initial rating of 100 percent for PTSD have been met since November 1, 2003. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.126, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2010). The appeal arises from disagreement with the initial rating following the grant of service connection. The courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required; and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). The United States Court of Appeals for Veterans Claims (Court) has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements are appropriately addressed under the notice provisions of 38 U.S.C. §§ 5104 and 7105. Hartman, supra. Where a claim has been substantiated after the enactment of the VCAA, a veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). There has been no allegation of prejudice in this case with regard to the instant claim. Initial Rating Criteria Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In instances in which a veteran disagrees with the initial rating, the entire evidentiary record from the time of a veteran's claim for service connection to the present is of importance in determining the proper evaluation of disability, and staged ratings are to be considered in order to reflect the changing level of severity of a disability during this period. Fenderson v. West, 12 Vet. App. 119 (1999). Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by a veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. 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. PTSD is evaluated under VA's General Rating Formula for Mental Disorders. Under the formula, a 30 percent rating is assigned where the disorder is manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, DC 9411. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. The criteria for a 70 percent rating for PTSD are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent rating is warranted when 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. 38 C.F.R. § 4.130, DC 9411. The extent of social impairment will also be considered, but an evaluation will not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet App 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Ultimately in Mauerhan, the Court upheld the Board's decision noting that the Board had considered all of the Veteran's psychiatric symptoms, whether listed in the rating criteria or not, and had assigned a rating based on the level of occupational and social impairment. Mauerhan, supra at 444. 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 (4th ed. 1994) (DSM-IV). A GAF of 61 to 70 reflects some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. A GAF of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. A GAF of 41 to 50 signifies 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 of 31 to 40 signifies some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., where a depressed man avoids friends, neglects family, and is not able to work). DSM-IV; 38 C.F.R. §§ 4.125, 4.130. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). Although GAF are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. PTSD Claim An April 2001 private mental health evaluation reflects the Veteran's complaints of long-standing depression, suicidal ideation, low motivation and energy, memory loss and isolating behaviors. He reported a history of alcohol abuse, but had stopped drinking in 1995. Mental status examination showed his behavior, verbal presentation and cognition to be within normal limits but noted little eye contact. He was well-groomed and verbose, with a congruent mood. The provider noted that the Veteran was disinclined to hear anything he had to say and spoke over him on a few occasions. A diagnosis was deferred. At a May 2001 private mental health evaluation it was noted that the Veteran had been criminally charged with brandishing a gun following an altercation with another dog owner. Complaints of hypervigilance and a heightened reactivity to police cars, other dogs and the perpetrator from the past assault were reported in an August 2001 mental health treatment note. A September 2001 private psychiatric evaluation reflects the Veteran's reports of depression, constant panic attacks, difficulty sleeping, anxiety, the inability to leave the house and racing thoughts. His panic attacks included classic panic attacks as well as tremors. Suicidal ideations without intent were reported. Mental status examination found him to be seriously depressed upon direct questioning and diagnostic testing despite his apparent cheerful and self-deprecating demeanor. He was very attached to his dog who accompanied him to this evaluation. Diagnostic impressions were bipolar II disorder, panic disorder with agoraphobia, PTSD and a history of alcohol abuse. A GAF of approximately 70 to 75 was assigned. A September 2001 private mental health treatment note, shows the Veteran reported that his older sister had died a few months ago and that she was his primary caretaker while growing up. He reported fantasies of "suicide by police" during private mental health treatment later in September 2001. An October 2001 private mental health treatment note shows the Veteran reported that he had been working daily. He continued to be depressed without panic attacks or much anxiety. Assessments of a single episode of moderate depression and PTSD were made. An October 2001 private mental health treatment note shows that the Veteran reported that he would commit suicide if his dog died. The Veteran was awarded SSA benefits due to diabetes mellitus and obesity in July 2004, effective November 1, 2003. It was noted that because of his physical disabilities, a psychiatric evaluation was not required. His only prior relevant work was as a welder. In October 2004, the Veteran underwent VA hospitalization for treatment of his psychiatric disability. An emergency service note indicates that the Veteran was referred for evaluation following suicidal ideation, including thoughts of crashing his car. He was feeling very depressed and had a history of two suicide attempts, including an attempted overdose four years ago. His service dog accompanied him to the hospital and a friend would come and get him when admitted. On mental status examination he was fully oriented, with coherent, organized and goal-directed thought processes and reality-based thought content. Insight was fair. A GAF of 25 was assigned. His GAF was noted to be 24 in an October 2004 VA inpatient treatment note. Mental status examination found his affect to be appropriate, his mood to be mildly depressed and his memory and intelligence to be within normal limits. Abstract thinking was not impaired. Speech was normally productive, relevant and coherent. Insight and judgment were fair and concentration was impaired. Memory and intelligence were within normal limits. He was not delusional and auditory and visual hallucinations were denied. A VA hospital discharge summary dated later in October 2004, noted the Veteran's complaints of increased depression and vague suicidal thoughts prior to admission. He reported sitting on a beach five years ago contemplating shooting himself when he met another veteran who suggested that he had PTSD. He lived by himself, was twice divorced and had three grown children. This was the Veteran's first psychiatric hospitalization. Upon discharge, suicidal or homicidal ideation was denied. Discharge diagnoses included depression not otherwise specified (NOS) and PTSD. A GAF of 54 was assigned. The Veteran reported frustration, hopelessness, helplessness, lack of trust of others, avoidance of people, emotional numbness, anxiety, hyper-startle response and nightmares during VA treatment in November 2004. He was alert and oriented with appropriate grooming, dysphoric mood and affect that was congruent with mood. Speech had a normal rate/rhythm and there were no auditory, visual, tactile or olfactory hallucinations. Thought processes were tangential. There were no delusions, obsessions, suicidal ideations or homicidal ideations. Insight and judgment were good. A diagnosis of chronic PTSD was made and a GAF of 55 was assigned. Complaints of depression, nightmares and sleep difficulties were reported in a July 2005 VA treatment note. He reported Intermittent passing thoughts of suicide without current ideation. He lived alone with his service dog and had good friends who helped with the maintenance of his house. He enjoyed going out first thing in the morning with his dog to a nearby coffee shop and drinking coffee with other people, including veterans. He no longer engaged in a lot of volunteer activities as he had in the past due to his physical disabilities. The Veteran attended the session with his service dog. On mental status examination he was polite and pleasant and motor activity was within normal limits. Affect was normal, mood was reported to be depressed and thinking was linear. Hallucinations, delusions or paranoid ideations were denied. The assessment was depression and anxiety. An October 2005 VA treatment note shows the Veteran reported that his mother had died the previous month, his adult daughter had recently been arrested for robbing his home and stealing his car; and a person who was going to give him a ride to the airport died four hours before they were to meet. The Veteran was described as polite and pleasant; motor activity was within normal limits; mood was depressed but thought processes were organized. There were no psychotic symptoms, or suicidal or homicidal ideation. In a March 2006 summary Dr. J. B. indicated that he had treated the Veteran for depression for the past four years. The depressive symptoms had been pervasive. In a March 2006 VA treatment note, the Veteran reported increased depression. His motor activity was within normal limits, mood was depressed and thought processes were organized and goal directed. There were no psychotic symptoms, or suicidal or homicidal ideation. An assessment of depression was made. An October 2006 VA psychiatric examination reflects the Veteran's complaints of sleep difficulties, daily depressed mood, passive thoughts of death with a history of two suicide attempts, anxiety, avoidance of crowds, isolation and nightmares. He relied on his dog for anxiety relief. These symptoms occurred constantly and limited his total daily functioning as he was apathetic, did not work or volunteer, self-isolated, limited his associations to a familiar group and had little to do with his children. After service, he had worked as a welder in a shipyard and in a private machine shop. He described his relationship with his supervisors and co-workers as good and he suffered no work disruption as a result of his increased physical problems, the death of family members, his divorce, his estrangement from his family and a death threat from a dog owner in May 2001. He was divorced, did not have a significant other and described his relationship with his adult children as estranged. He did have a good relationship with his older sister. A persistent exaggerated startle response, difficulty concentrating, hypervigilance, irritability and outbursts of anger were noted. The Veteran attended this session with his dog. The October 2006 VA examiner found the Veteran's orientation to be within normal limits but his appearance and hygiene were inappropriate and showed signs of neglect. His behavior was appropriate and affect and mood were abnormal with disturbance of motivation and mood. A persistent, restricted range of affect was noted. He seemed much more cheerful and loquacious than his appearance and descriptions would indicate. Communication was within normal limits but his speech was intermittently abnormal in that it was circumstantial circumlocutory and pressured. He intermittently responded with much more detail than was requested and he seemed to drift from the topic or question at times. Panic attacks were present and occurred once per week. There was no suspiciousness, delusions, hallucinations, obsessional rituals or homicidal ideations. Thought processes were appropriate, judgment was not impaired, abstract thinking was normal, and memory was impaired to a mild degree in that he forgets names, directions and recent events. Passive thoughts of death in that he continued to contemplate suicide were noted. The diagnoses were depression and PTSD. A GAF of 38 with major impairment was made. The Veteran experienced markedly diminished participation in activities, feelings of detachment or estrangement from others, inability to recall all aspects of the trauma, restricted range of affect and sense of a foreshortened future. He also experienced numerous symptoms of increased arousal. These symptoms caused distress or impairment in social, occupational or other areas of functioning. He was intermittently unable to perform activities of daily living, although he could provide self-care, due to his symptoms. These symptoms also caused occupational and social impairment with occasional decrease in work efficiency and an intermittent inability to perform occupational tasks although he generally was functioning satisfactorily with routine behavior, self-care and conversation. He had difficulty understanding complex commands due to his concentration and focus symptoms and appeared to pose a threat of persistent injury to himself due to two previous suicide attempts and persistent suicidal thoughts. A December 2006 VA treatment note indicates that the Veteran was neat and clean, that his motor activity was within normal limits and that his affect was labile, as he vacillated between irritability, anger and laughing. Mood was elevated and thought process was logical and goal-directed. He displayed no psychotic symptoms, suicidal or homicidal ideation. A November 2007 VA treatment note shows the Veteran reported that some days he felt exhausted and did not have the mental and physical energy to do things. During good days, he took a walk with his service dog, who he described as his best companion. He had a few friends that also assisted him. He reported that his house was a "mess" and that did not clean up after himself. Psychotic symptoms or suicidal ideation were denied. His current medication had helped but he still experienced episodes of depression, low energy, crying and feelings of hopelessness and worthlessness. On examination his affect was dysphoric and tearful. He was dressed appropriately but grooming and hygiene were marginal. A March 2009 VA treatment note reflects the Veteran's reports that he was sometimes panicky when outside his house. Suicidal ideation or plans, delusions or hallucinations were denied. The Veteran's affect was euthymic with his thought process intact and goal-directed. He was cooperative and dressed appropriately. A September 2009 VA treatment note indicates that the Veteran had placed a gun to his head in his therapist's office three weeks earlier and threatened to commit suicide. He was persuaded by his therapist to not do so. The therapist recommended that the Veteran be admitted for in-patient treatment but he refused due to his service dog. The Veteran also reported that he had stopped taking his medication. A September 2009 VA examination reflects the Veteran's reports of depression, feelings of isolation, a lack of motivation, sleep difficulties, nightmares several times per month and concentration difficulties. He felt frustrated at this inability to remember simple things such as his zip code. He avoided conversations about service and avoided talking to other veterans. He reported that he did not really have friends, just acquaintances, and had limited motivation. Irritability, problems with anger management, hypervigilance and an exaggerated startle response were also reported. He had one sister who died, his father died when he was a child, he has been divorced twice and had three adult children that he did not have any contact with. He lived alone with his dog. Mental status examination conducted by the September 2009 VA examiner noted that the Veteran was adequately groomed with adequate hygiene. He tended to speak in a somewhat loud tone or voice throughout the interview and with a run-on pressured fashion. Thoughts were quite digressive but mentally and logically organized. There were no hallucinations or delusional thoughts. Affect was labile and he appeared to be fairly jovial at times but was tearful at other times. Continued ongoing suicidal ideation without intent was noted. He was fully oriented with a somewhat impaired memory. Abstract thinking ability was within normal range. The diagnoses were chronic severe major depression and PTSD. A GAF of 50 was assigned. The examiner opined that the Veteran engaged in suicidal behavior in the past and to some degree used suicidality as a way of communicating his distress to others and these ideations would reemerge when he felt particularly stressed or frustrated. He did not appear to be an imminent danger to himself or others as he did not express any such thoughts or intentions during the interview. In a September 2009 VA treatment note, the Veteran reported that the gun he had brought to this therapist's office was loaded and that his bond with his service dog was what kept him from harming himself. The Veteran was noted to have a "high risk for suicide flag" in an October 2009 VA treatment note. He reported that he always had thoughts of suicide but did not have the intention of killing himself today. In a November 2009 private psychology evaluation Dr. R.S. noted that the Veteran was often personable and friendly, that he loved children and animals and that he liked to help others and lift their spirits. He was well-oriented and displayed no evidence of hallucinations or a major thought disorder. He experienced a wide-range of mood and could be irritable, reactive and impulsive. He was sensitive to signs of mistreatment or disrespect towards himself and had a tendency to make assumptions and misperceive. While depressed, he did not care about anything and can shut down to the point of neglecting basic self-care or lash out. Homicidal ideations while driving were reported. He pulled a gun and pointed it at his head out of frustration, anger and depression during a recent session and had abruptly discontinued his psychotropic medication prior to this incident. Depression immobilized him, caused him to withdraw, procrastinate and isolate. The examiner noted that the Veteran was almost inseparable from his service dog and that he came to all appointments. During the November 2009 evaluation, the Veteran endorsed all 17 symptoms on the "PTSD Checklist" in the moderate to extreme level, scored in the extreme anxiety/panic range on the Burns Anxiety Inventory and scored in the severe depression range on the Burns Depression Checklist. The examiner opined that there was strong evidence of difficulties in multiple areas, i.e. work, family relations, judgment, thinking and mood due to symptoms of PTSD, depression and anxiety. This has had a cumulative deleterious effect on his physical and mental health resulting in the neglect of his personal care, impaired impulse control and the ability to cope with stress and to live and function independently. A GAF of 35 to 45 was assigned. A March 2011 private treatment summary from Dr. J.B. notes that there has been poor compliance, or even discontinuation, of the Veteran's medication. His symptoms included poor interest in self-care, suicidal thoughts on occasion and nearly disabling depressive symptoms where he would stay in his home or bed. He had a very limited life outside of his treatment and his home, finding himself living alone with his dog that was his only comfort. He often noted that if it weren't for his dog he would not want to live. During his April 2011 hearing, the Veteran testified that he had made suicidal gestures with a handgun and often had suicidal ideation. He had occasional thoughts of harming others when the issues of veterans or war came up. He became easily lost in thought and had concentration difficulties. He became disoriented in public and had difficulty controlling his impulses. Most of his family was dead, and he had no relationship with his three adult children. He had acquaintances, particularly because of his dog, but did not have a real friend. His dog had prevented his suicide on several occasions. Dr. R. S. testified during the April 2011 hearing that he treated the Veteran between June 2007 and May 2010, when he retired. He spoke with the Veteran prior to the hearing and his current impressions were consistent with the November 2009 summary. His affect was labile and he had difficulty managing stress. When under stress, his self-care diminished. When he was threatened, felt disrespected or mistreated; he had a very difficult time managing his negative reaction. His anger and depression combined with his impulsiveness led to incidents such as with the gun in his office. His personal hygiene was neglected, in part, due to his physical limitations but he did attempt to appear presentable. He had been quite homicidal and suicidal during treatment. His current estimated GAF would be approximately 40 due to suicidality and isolation. The Veteran's symptoms, particularly his impulsiveness and his inability, would render him unemployable since he walked off his last job following an altercation involving a derogatory remark about veterans. His social support system was very marginal and his judgment was variable as he was aggressive and confrontational under stress. There were no hallucinations or delusions. Analysis Prior to November 1, 2003, the Veteran's PTSD was manifested by depression, suicidal ideation, low motivation and energy, memory loss, self-isolation and constant panic attacks. Treatment notes detail an altercation he had with another individual about his service dog and during which he brandished a weapon, resulting in criminal charges and illustrating his inability to handle stressful circumstances. He was noted to be well-groomed and there was no indication that personal hygiene had been neglected. His older sister passed away in September 2001 and he had described a good relationship with her. Although the Veteran's assigned GAFs of 70 to 75 suggest mild impairment at one point, the totality of the clinical evidence and the Veteran's statements suggests more than mild impairment. Carpenter, supra. He had deficiencies in the area of work as shown by the reports of difficulties with co-workers. There were deficiencies in the area of mood as shown by his depression; in family relationships, as shown by the difficulties with his children; and in the area of judgment as shown by his impulsivity and arrest. Hence the evidence shows deficiencies in most of the areas needed for a 70 percent rating for the period from July 9, 2001 to November 1, 2003. 38 C.F.R. §§ 4.7, 4.130, DC 9411. A rating in excess of 70 percent prior October 31, 2003 is not warranted as the Veteran maintained gainful employment, demonstrating that there was not total occupational impairment. He reported a good relationship with his older sister prior to her death and had relationships with his co-workers, and some friends, showing that there was not total social impairment. Beginning November 1, 2003, the Veteran's PTSD has been manifested by total occupational impairment. He was no longer working and his private psychologist testified that the Veteran's PTSD had rendered him unemployable since he left his last job. At times during this period he was given GAFs suggestive of an ability to work, but these scores do not appear to have been sustained and were interspersed with scores indicative of an inability to keep a job. The record suggests that the Veteran has been able to function only with the assistance of his service dog, and while leading a fairly isolated life. The Veteran has maintained some social contacts as shown by the occasional reports of friendships or acquaintances, but the Veteran has reported no relationship with his adult children, no real friends and a few acquaintances only due to his service dog. Grossly inappropriate behavior was demonstrated in an incident in which he brought a gun to his private psychologist's office and threatened suicide. Suicidal ideation has been regularly noted during this period. He described being unable to maintain his house due, in part, to his lack of motivation. Both the Veteran and his private psychiatrist described his intermittent disorientation to place and his memory difficulties. Given the total occupational impairment and severe social impairment, the Veteran's disability has resulted in symptoms that have most closely approximate total social and occupational impairment since November 1, 2003. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. Extraschedular Consideration Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(1)(b). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the Rating Schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step--a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, supra. Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer, supra. When the Rating Schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. The Veteran's psychiatric had manifested by social and occupational impairment described in detail above. The rating criteria contemplate social and occupational impairment. These symptoms are contemplated by the rating schedule. Hence, further consideration of an extraschedular rating is not warranted. Total Rating for Compensation Based on Individual Unemployability (TDIU) The Court has held that TDIU is an element of all appeals of an initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU is granted where a veteran's service connected disabilities are rated less than total, but they prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16. Consideration of TDIU is not warranted as prior to October 31, 2003 as the Veteran was gainfully employed as a welder. Jackson v. Shinseki, 87 F.3d 1106 (Fed. Cir. 2009) (TDIU is a part of an increased rating or initial rating only when there is evidence of unemployability). A grant of TDIU beginning on November 1, 2003 is precluded as the Veteran has been granted a total rating as of that date. 38 C.F.R. § 4.16. ORDER An initial rating of 70 percent for PTSD is granted from July 9, 2001 to October 31, 2003 is granted. An initial rating of 100 percent for PTSD, effective November 1, 2003, is granted. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs