Citation Nr: 1123632 Decision Date: 06/22/11 Archive Date: 06/28/11 DOCKET NO. 09-16 715 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an increased disability rating for service-connected posttraumatic stress disorder (PTSD), in excess of 30 percent prior to October 8, 2009, and in excess of 50 percent from October 8, 2009. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD William Alan Nelson II, Associate Counsel INTRODUCTION The Veteran, who is the appellant, had active service from February 1967 to December 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In October 2007, the Veteran submitted the current claim for increased rating (in excess of 30 percent) for the service-connected PTSD. In the July 2008 rating decision on appeal, the Waco RO continued a 30 percent rating for PTSD. The Veteran entered a notice of disagreement with the 30 percent disability rating assigned by the July 2008 rating decision. An April 2010 Statement of the Case (SOC) reflects that, during the appeal, the Waco RO granted a staged 50 percent rating for PTSD for the rating period beginning October 8, 2009, the date of a VA examination report, thus creating the staged rating on appeal. Although the RO granted a higher 50 percent rating for PTSD for the rating period from October 8, 2009, inasmuch as higher ratings are available during each period, and a veteran is presumed to seek the maximum available benefit for a disability, the claim for a higher disability rating remains viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board determines that the rating issue currently on appeal is entitlement to a higher (staged) disability rating for service-connected PTSD - in excess of 30 percent from October 11, 2007, and in excess of 50 percent from October 8, 2009. One aspect of the increased rating issue on appeal is whether the evidence shows worsening at any time within the one year period prior to receipt of the October 2007 increased rating claim to warrant a higher rating from the date the increase occurred. Because the date that entitlement arose question is part of the increased rating issue on appeal, there remains no separate issue of effective date. In a June 2010 statement, the Veteran urges an "effective date" prior to October 8, 2009, for the 50 percent rating; however, the request was for a 50 percent rating only from the date of the increased rating claim (October 11, 2007). Because the rating period on appeal encompasses the period prior to October 8, 2009, including consideration of the one year prior to receipt of the increased rating claim (received in October 2007), the contention is actually one for increased rating during an earlier period of rating claim rather than for an actual earlier effective date. For these reasons, the issue currently on appeal is one for increased (staged) rating, rather than earlier effective date. As part of the increased rating claim, the Board will consider the entire increased rating period, which includes up to one year prior to receipt of the increased rating claim (received October 11, 2007) to determine if entitlement to a higher rating occurred at any time during the rating period. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. For the rating period prior to October 8, 2009, the Veteran's PTSD was characterized by difficulty with concentration, short-term memory loss, anxiety, nightmares, anger, irritability, social avoidance, hypervigilance, and passive suicidal ideation. 2. The psychiatric symptoms did not worsen in severity during the one year period prior to receipt of increased rating claim on October 11, 2007. 3. For the rating period prior to October 8, 2009, the Veteran's PTSD was not characterized 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 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 inability to establish and maintain effective relationships. 4. For the rating period from October 8, 2009, the Veteran's PTSD has been characterized by nightmares, sleep disturbance, hypervigilance, social avoidance, anger and irritability, visual and auditory hallucinations, poor insight and judgment, and restricted affect. 5. For the rating period from October 8, 2009, the Veteran's PTSD has not been characterized 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 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. CONCLUSIONS OF LAW 1. For the rating period prior to October 8, 2009, resolving reasonable doubt in the Veteran's favor, the criteria for an increased disability rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107, 5110 (West 2002); 38 C.F.R. §§ 3.400(o)(2), 4.3, 4.7, 4.125, 4.130, DC 9411 (2010). 2. For the rating period from October 8, 2009, resolving reasonable doubt in the Veteran's favor, the criteria for an increased disability rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107, 5110 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.125, 4.130, DC 9411(2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). After having carefully reviewed the record on appeal, the Board has concluded that the notice requirements of VCAA have been satisfied with respect to the increased rating issue decided herein. The RO sent the Veteran letters in September 2008 and February 2009 that informed of the requirements needed to establish an increased evaluation for acquired psychiatric disability. The notice letters advised the Veteran that VA used a published schedule for rating disabilities that determined the rating assigned and that evidence considered in determining the disability rating included the nature and symptoms of the condition, the severity and duration of the symptoms, and the impact of the condition and symptoms on employment. In accordance with the requirements of VCAA, the VA letters informed the Veteran what evidence and information he was responsible for obtaining and the evidence that was considered VA's responsibility to obtain. The Board finds that all necessary development has been accomplished, and, therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claims. 38 U.S.C.A. § 5103A. VA has obtained VA and private treatment records and other records identified by the Veteran. The Veteran has been afforded adequate examinations on the issue of an increased rating for service-connected PTSD. VA provided the Veteran with examinations in May 2008 and October 2009. The claims file and treatment records were reviewed, the Veteran's history was taken, and complete examinations with clinical measures were conducted. The conclusions reached and diagnoses given were consistent with the examination reports. For these reasons, the Board finds that the Veteran has been afforded adequate examinations on the issue of an increased rating for service-connected PTSD. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Disability 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 (2010). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where 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. See 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. The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). The schedular criteria, effective as of November 7, 1996, incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. §§ 4.125, 4.130. A rating of 30 percent is warranted for PTSD if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9411. A 50 percent rating is warranted if it is productive of 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 compete 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, may be assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. The criteria for a 70 percent rating 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 schedular evaluation contemplates 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. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). A GAF score of 41-50 indicates "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)." Id. A GAF score of 51-60 indicates "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)." Id. A GAF score of 61-70 indicates "Mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships." Id. 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. If the evidence shows that the 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. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). The U.S. 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). Rating for PTSD The Board finds that the psychiatric symptoms did not worsen in severity during the one year period prior to receipt of increased rating claim on October 11, 2007. The 30 percent rating for PTSD has been in effect from December 14, 1995. VA examination reports as early as 1997 show a history of suicidal thoughts, hypervigilance, discomfort in crowds, and problems sleeping. Because such symptoms had worsened prior to the one year period before receipt of claim for increase (received October 11, 2007), and did not worsen during the one year period prior to receipt of increased rating, a 50 percent disability rating prior to receipt of increased rating claim on October 11, 2007 is not possible. See 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2) (effective date of an increase in disability compensation is the earliest date as of which it is factually ascertainable that an increase in disability had occurred if the claim is received within one year from such date; otherwise, the effective date is the date of receipt of the claim); Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. 2010) (holding "that an increase in a veteran's service-connected disability must have occurred during the one year prior to the date of the veteran's claim in order to receive the benefit of an earlier effective date"). For these reasons, there is no factual or legal basis for assignment of the 50 percent rating prior to October 11, 2007. Rating Period Prior to October 8, 2009 The Veteran is in receipt of a 30 percent rating for service-connected PTSD for the increased rating period from October 11, 2007 to October 7, 2009. After a review of all the evidence, lay and medical, the Board finds that, for the increased rating period from October 11, 2007 to October 8, 2009, the Veteran's PTSD has been characterized by difficulty with concentration, short-term memory loss, anxiety, nightmares, anger, irritability, social avoidance, hypervigilance, and passive suicidal ideation, consistent with the criteria for a 50 percent disability rating under DC 9411. The GAF scores have varied between 45-50, which as described above, indicate serious PTSD symptoms or serious difficulty in social and occupational functioning. The Veteran's psychiatric symptoms have been relatively consistent and a 50 percent rating takes into account social and occupational impairment. 38 C.F.R. § 4.130. The evidence includes a January 2008 VA Mental Health Attending Note that reported low energy, suicidal ideation, nightmares, intrusive thoughts, hypervigilance, and social avoidance. In a May 2008 VA PTSD examination, the VA examiner reported symptoms of nightmares, insomnia, hypervigilance, anger, auditory hallucinations, depression, short-term memory loss, difficulty concentrating, and past suicidal ideation. The VA examiner reported the Veteran was oriented in all three spheres. The VA examiner also reported the Veteran's affect was inappropriate towards the end of the examination, mood was good, reasoning was fair, judgment was poor, and he was clean and casually dressed. The VA examiner reported the Veteran's PTSD had a moderate impact on social and occupational functioning. The VA examiner also reported that the ongoing hallucinations and paranoia were related to the Veteran's (non-service-connected) schizophrenia. Because of this finding by the VA examiner, the Board will attribute the ongoing hallucinations and paranoia symptoms to the non-service-connected schizophrenia. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (the Board is precluded from differentiating between symptomatology attributed to a non-service-connected disorder and a service-connected disability in the absence of medical evidence that does so, but may not disregard such evidence of differentiation in the record). The May 2008 Axis I diagnosis was schizophrenia, paranoid type, and chronic PTSD. The VA examiner assigned a GAF score of 45-50. A July 2008 VA Mental Health Attending Note reported trouble sleeping and that the Veteran had "booby trapped" his house. The Veteran denied suicidal or homicidal ideation. An August 2008 VA Mental Health Attending Note reported suicidal ideation, feelings of hopelessness, hypervigilance, insomnia, and intrusive thoughts. A November 2008 Mental Health Attending Note reported depressed mood, blunted affect, recent and remote memory were intact, thought content was coherent and logical, and no suicidal or homicidal ideation. The Board finds that, for the rating period prior to October 7, 2009, the Veteran's PTSD has not been characterized 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 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 inability to establish and maintain effective relationships, as required for a 70 percent disability rating under DC 9411. 38 C.F.R. § 4.130. The Board concludes that the Veteran's disability picture does not more nearly approximate the next-higher 70 percent rating criteria under DC 9411 for the period from October 11, 2007 to October 8, 2009. The evidence in this case reveals only passive suicidal ideation. In the January 2008 VA Mental Health Attending Note, the Veteran reported suicidal thoughts, but stated that he would never actually do that because his daughter depended upon him. In the July 2008 VA Mental Health Attending Note, the Veteran denied any suicidal or homicidal ideation. In the August 2008 VA Mental Health Attending Note, the Veteran denied any suicidal or homicidal ideation. In the November 2008 VA Mental Health Attending Note, the Veteran denied any suicidal or homicidal ideation. With regard to obsessional rituals, the May 2008 VA examination reported the Veteran was hypervigilant and "booby trapped" his house. The August 2008 VA Mental Health Attending Note reported the Veteran watches the Cambodian man that lives next door to him. The Veteran does not contend, nor does the record reflect, that these rituals interfere with routine activities. The Veteran's speech is not intermittently illogical, obscure, or irrelevant. The May 2008 VA examination reported the Veteran was articulate, verbal, and generally cooperative with the examination. The May 2008 VA examiner also reported that the Veteran had a fairly logical and coherent thought process. The record does not reflect that the Veteran suffers from near-continuous panic or depression affecting the ability to function independently. In the May 2008 VA examination, the Veteran reported feeling depressed all the time; however, it was not quantified, and no further description was given. The November 2008 VA Mental Health Attending Note reported the Veteran's mood was depressed. The record also does not reflect the Veteran suffers from spatial disorientation, and his appearance and hygiene are normal. In the May 2008 VA examination, the Veteran was dressed and well groomed. The May 2008 VA examination reported the Veteran was fully oriented. The record demonstrates that the Veteran's PTSD is characterized by difficulty with concentration, short-term memory loss, anxiety, nightmares, anger, irritability, social avoidance, hypervigilance, and passive suicidal ideation. The Board concludes that the Veteran's disability picture does not more nearly approximate the next-higher 70 percent rating criteria under Diagnostic Code 9411. Even though the Veteran exhibits frequent periods of depression, the Veteran's PTSD symptoms, as a whole, are contemplated by the 50 percent rating. See 38 C.F.R. § 4.7 (the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating, otherwise, the lower rating will be assigned). Rating Period from October 8, 2009 The Veteran is in receipt of a 50 percent rating for service-connected PTSD for the increased rating period from October 8, 2009. After a review of all the evidence, lay and medical, the Board finds that, for the increased rating period from October 8, 2009, the Veteran's PTSD has been characterized by nightmares, sleep disturbance, hypervigilance, social avoidance, anger and irritability, visual and auditory hallucinations, poor insight and judgment, and restricted affect, consistent with the criteria for a 70 percent disability rating under DC 9411, but has not been characterized by total occupational and social impairment, as required for a 100 percent disability rating under DC 9411. 38 C.F.R. § 4.130. The evidence includes an October 2009 VA PTSD examination, where the VA examiner reported symptoms of nightmares, sleep disturbance, hypervigilance, social avoidance, anger and irritability, auditory hallucinations, poor insight and judgment, and restricted affect. During the interview in October 2009, the Veteran's orientation was within normal limits. The VA examiner reported paranoid ideation during the examination as well as delusional thinking and auditory and visual hallucinations. The VA examiner also reported that the Veteran's mood was irritable and affect was restricted. The October 2009 VA examiner reported that the Veteran's current psychiatric impairment severely impacted social and occupational functioning. The VA examiner opined that the Veteran's PTSD symptoms had worsened since the last VA examination. The VA examiner also reported the Veteran's psychiatric symptoms resulted in serious deficiencies in work, family relations, judgment, thinking, and mood. The October 2009 Axis I diagnosis was chronic PTSD and schizophrenia, paranoid type. The VA examiner assigned a GAF score of 41-45. Because the VA examiner did not specifically indicate what symptoms are attributable only to the Veteran's non-service-connected schizophrenia, the Board will attribute all psychiatric signs and symptoms to the service-connected PTSD. See Mittleider, 11 Vet. App. at 182. On review of the evidence, the Board finds that, for the rating period from October 8, 2009, the symptoms of the Veteran's PTSD have been characterized by nightmares, sleep disturbance, hypervigilance, social avoidance, anger, visual and auditory hallucinations, poor insight and judgment, and restricted affect. The GAF scores have varied between 41 and 45. The Veteran's psychiatric symptoms have been relatively consistent, and a 70 percent rating under Diagnostic Code 9411 takes into account occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 38 C.F.R. § 4.130, see also Bowling, 15 Vet. App. at 11-14. The Board also finds that, for the increased rating period from October 8, 2009, the Veteran's PTSD has not been characterized 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 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, as required for a 100 percent disability rating under DC 9411. 38 C.F.R. § 4.130. The evidence in this case does not reveal gross impairment in thought processes or communication. In the October 2009 VA PTSD examination, the Veteran was articulate, verbal, and generally cooperative throughout the examination. The Veteran's speech and communication were grossly intact. With regard to persistent delusions and hallucinations, in the October 2009 VA PTSD examination, the Veteran reported auditory and visual hallucinations. The October 2009 VA examiner also reported that the Veteran had some paranoid ideation during the examination as well as reports of delusional thinking. The Veteran has not evidenced a persistent danger of hurting himself or others. In the October 2009 VA PTSD examination, the Veteran reported a sense of foreshortened future, but did not report any thoughts of harming himself or others. The Veteran has not been disoriented to time or place. In the October 2009 VA PTSD examination, the Veteran was fully oriented in all spheres. The Veteran has not evidenced memory loss for names of close relatives, own occupation, or own name. In the October 2009 VA PTSD examination, the VA examiner did not report any impairment of the Veteran's memory. The record does not reflect memory loss for names of close relatives, own occupation, or own name. The record demonstrates that the Veteran's PTSD is characterized by nightmares, sleep disturbance, hypervigilance, social avoidance, anger and irritability, visual and auditory hallucinations, poor insight and judgment, and restricted affect. The Board concludes that the Veteran's disability picture does not more nearly approximate the next-higher 100 percent rating criteria under DC 9411 for the increased rating period from October 8, 2009. Even though the Veteran exhibits some recurrent auditory and visual hallucinations, the Veteran's PTSD symptoms, as a whole, are contemplated by the 70 percent rating. See 38 C.F.R. § 4.7 (the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating, otherwise, the lower rating will be assigned). For these reasons, the Board finds that the evidence supports a grant of a higher increased disability rating of 50 percent for PTSD for the period prior to October 7, 2009, and the weight of the evidence supports a grant of a higher increased disability rating of 70 percent for PTSD for the period prior from October 8, 2009. To the extent any higher level of compensation is sought, the preponderance of the evidence is against the claims, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has considered whether referral for an extraschedular evaluation is warranted for PTSD. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2010). 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. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DC 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested nightmares, sleep disturbance, hypervigilance, social avoidance, anger, visual and auditory hallucinations, poor insight and judgment, and restricted affect. These symptoms are either explicitly part of the schedular rating criteria under the general formula for rating mental disorders at 38 C.F.R. § 4.130; are analogous to the schedular rating criteria (see 38 C.F.R. §§ 4.20, 4.21), or are "like or similar to" the schedular rating criteria (see Mauerhan at 442-43). The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with PTSD, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An increased disability rating for PTSD of 50 percent, but no more than 50 percent, is granted prior to October 7, 2009; and an increased disability rating of 70 percent, but no more than 70 percent, is granted from October 8, 2009. REMAND The record contains some evidence suggesting the Veteran may be unemployable due to the service-connected PTSD. Such evidence in the record suggesting unemployability constitutes an informal claim for TDIU. Where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim identify the benefit sought has been satisfied and VA must consider whether the Veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (VA to determine all potential claims raised by the evidence, applying all relevant laws and regulations). See also Rice v. Shinseki, 22 Vet. App. 447 (2009) (suggesting, in an effective date appeal, that an appeal for higher rating somehow includes TDIU, or that a TDIU must arise from an increased rating claim, unless it is the veteran who raises the TDIU claim). Based upon the foregoing, the Board finds that the evidence of record has raised a claim of entitlement to TDIU. Accordingly, the issue of TDIU is REMANDED for the following action: 1. The AMC/RO should issue the Veteran notice in accordance with 38 C.F.R. § 3.159 with regard to the inferred claim for TDIU. Said notice should include provision to the Veteran of the appropriate TDIU claim form and requirements to establish inability to obtain or maintain substantially gainful employment due to service-connected disabilities. 2. After completion of the above and any additional development deemed necessary, the AMC/RO should adjudicate the issue of TDIU. If any benefit sought remains denied, the Veteran and his representative should be furnished a Supplemental Statement of the Case, and should be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter or matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs