Citation Nr: 1124593 Decision Date: 06/29/11 Archive Date: 07/06/11 DOCKET NO. 09-36 367 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Prior to March 25, 2008, entitlement to an increased evaluation for posttraumatic stress disorder, evaluated as 50 percent disabling. 2. On and after March 25, 2008, entitlement to an increased evaluation for posttraumatic stress disorder, currently evaluated as 70 percent disabling. 3. Entitlement to a total disability rating based on individual unemployability. REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs ATTORNEY FOR THE BOARD K. Millikan, Counsel INTRODUCTION The Veteran served on active military duty from June 1968 to February 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision by the Denver, Colorado, Regional Office (RO) of the Department of Veterans Affairs (VA). The issue of entitlement to a total disability rating based on individual unemployability (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. Prior to March 25, 2008, the Veteran's posttraumatic stress disorder (PTSD) was manifested by deficiencies in most areas to include mood, work, and relationships due to such symptoms as severe depression, sleep difficulties, difficulty sustaining employment, difficulty with activities of daily living upon intensification of symptoms or during depressive episodes, irritability, and severe isolation, but not total social and occupational impairment. 2. On and after March 25, 2008, the Veteran's PTSD is manifested by deficiencies in most areas to include mood, work, and relationships, due to such symptoms as difficulty establishing and maintaining effective relationships, irritability, anger, severe isolation, hallucinations, sleep difficulties, suicidal thoughts without plan, severe depression, and difficulty maintaining steady employment, and marked, but not total, social and occupational impairment. CONCLUSIONS OF LAW 1. Prior to March 25, 2008, the criteria for a 70 percent evaluation, but no more, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). 2. On or after March 25, 2008, the criteria for an increased evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Under the Veterans Claims Assistance Act of 2000 (VCAA), 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 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). This notice must be provided prior to an initial RO decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). For increased rating claims, the VCAA requires generic notice of the type of evidence needed to substantiate the claim, i.e., evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1280-81 (Fed. Cir. 2009). Defective timing or content of VCAA notice is not prejudicial to a claimant if the error does not affect the essential fairness of the adjudication, such as where (1) the claimant demonstrates actual knowledge of the content of the required notice; (2) a reasonable person could be expected to understand from the notice what was needed; or (3) a benefit could not have been awarded as a matter of law. Sanders v. Nicholson, 487 F.3d 881, 889 (Fed. Cir. 2007), rev'd on other grounds, Shinseki v. Sanders/Simmons, 556 U.S. __ (2009). Defective timing may be cured by a fully compliant notice letter followed by a readjudication of the claim. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Here, VA's duty to notify has been satisfied. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). June and October 2006 letters that provided the required notice were sent to the Veteran prior to initial adjudication. Additionally, the Veteran was represented by a certified veterans' service organization throughout the claims process. Accordingly, VA's duty to notify has either has been satisfied or any deficiency has caused no prejudice to the Veteran. VA's duty to assist the Veteran has also been satisfied. 38 U.S.C.A. § 5103A(b), (c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran's service treatment records, VA medical records, and identified private medical records have been obtained. VA provided the Veteran with adequate medical examination in October 2006 and August 2009; the examinations addressed the Veteran's relevant symptoms and were based upon a review of the claims file. There is no indication in the record that additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. at 121-22. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537, 542-43 (2006), aff'd, Mayfield v. Nicholson, 499 F.3d 1317 (2007); see also Dingess/Hartman, 19 Vet. App. at 486 Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2010). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2010). In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2010). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are, however, appropriate when the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). By a March 2007 rating decision, the RO assigned a 50 percent evaluation for PTSD, effective April 21, 2006. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). The Veteran appealed that rating decision. In a September 2009 rating decision, the RO assigned a 70 percent evaluation effective March 25, 2008. Additionally, in a February 2010 rating decision, the RO assigned a temporary evaluation of 100% from December 6, 2009 through February 1, 2010. Generally, a Veteran is assumed to be seeking the highest evaluation available and a claim remains in controversy where less than the maximum available benefit is awarded, unless he or she "express[es] a clear intent to so limit the issue on appeal." AB v. Brown, 6 Vet. App. 35, 38-39 (1993). The issues on appeal are thus entitlement to an evaluation in excess of 50% prior to March 25, 2008, and entitlement to an evaluation in excess of 70% on and after March 25, 2008, with the exception of the time period from December 6, 2009 to February 1, 2010. Evaluation prior to March 25, 2008 During this time period, the Veteran was evaluated as 50 percent disabling, which contemplates PTSD manifested by occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders (General Rating Formula), Diagnostic Code 9411. A 70 percent evaluation is assigned for PTSD 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 intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Global Assessment of Function (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness" and is used as a tool to determine the severity of one's disability. See DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, FOURTH ED, American Psychiatric Association (1994) (DSM-IV), p.32; 38 C.F.R. §§ 4.125(a), 4.130 (2010). GAF scores ranging between 61 to 70 reflect some 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, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect 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). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). In a January 2006 lay statement, a friend of the Veteran's, S.F. stated that he has noticed avoidance, isolation, anger and non-socialization. He noted that the Veteran owned weapons. In a February 2006 lay statement, the Veteran's sister stated that her brother was currently moody and kept a messy home. In his April 2006 claim, the Veteran stated that he was always unable to maintain constant or steady employment. He stated that even though he had a degree, he was going to work part time for a golf course that summer. The last job that he had was an engineer lasted for 14 months before he was let go. The Veteran stated that he could not seem to cope with laundry, personal hygiene, and keeping his apartment clean as he didn't have the energy or enthusiasm. He chose a more menial job than what he is qualified for so that he could minimize contact with others. He reported severe anxiety and depression, and suicidal thoughts but no plan. In January and February 2006 VA medical records, the Veteran began group therapy for PTSD. In March 2006 VA records, the Veteran reported sleep trouble and that he was unemployed but had finished his masters degree. In March 2006 Vet Center records, the Veteran reported he was less anxious and had a new job working a golf course. He reported sleep problems. In an April 2006 VA record, the Veteran reported continuing insomnia. In April 2006 Vet Center records, the Veteran reported agitation due to starting a new job at the golf course. In May 2006 VA record, the Veteran reported improved mood. In July 2006 Vet Center records he reported suicidal thoughts, but no intent, and sleep difficulty. An October 2006 VA examination was conducted upon a review of the claims file. The Veteran reported he was laid off in 2003, and then worked for a government contractor with Homeland Security, from October 2004 to December 2005. He states he was let go due to his attitude towards supervisors and his irritability. He has become more symptomatic as he is no longer preoccupied with work. The Veteran reported increased intrusive thoughts, diminished concentration, and increased depression. He worked for a golf course for the summer and then in June 2006 began working in New Orleans with the hurricane recovery. He was able to concentrate reasonably well on that job and did well not having a supervisor to interact with. He reported depressive episodes that tend to occur about twice per month and last from 1 to 7 days. They are characterized by self-isolation, diminished concentration, and suicidal ideations without plan or intent. His sleep was more disturbed with restlessness and nightmares about unsafe situations. The Veteran struggled with lonesomeness. He reported significant intrusive thoughts about his combat experience, negative attitudes towards authority, and some road rage. He was reluctant to try other medications for relief. He was currently looking for employment in his hometown and on the night shift to avoid supervisors. The Veteran's other major concern was relationships with women and with friends. He was only attached to his daughter and his sister. The Veteran stated that his sister helped him care for his apartment due to his lack of focus. He lived alone, although he had a brief marriage shortly after service discharge. Since that time, he's been unable to establish close relationships. Mental status examination indicated the Veteran was casually dressed, neat, and clean, but was mildly vigilant. There was some blunting of his emotional expression, but he was not overtly depressed or anxious and was of good average intelligence. The examiner found that the Veteran was able to maintain activities of daily living, including personal hygiene, but at times of depression, he required help. His symptoms waxed and waned, but were of at least a moderate degree all of the time with intensification every week or two. The Veteran was significantly impaired in his social functioning and remained isolated most of the time, but there were no inappropriate behaviors and his thought processes and communication were unimpaired. He was currently employed although his employment was impaired to some degree due to his difficulty with supervisors. The diagnoses were chronic PTSD and anxiety disorder, mixed depression and anxiety associated with his PTSD. The examiner assigned a GAF score of 50, which signifies serious symptoms, for example suicidal ideation, severe obsessional rituals, and frequent shoplifting; or any serious impairment in social, occupational, or school functioning, for example no friends, unable to keep a job. See DSM-IV at 46-47. In a December 2006 VA medical record, the Veteran reported that he was doing well, but noted depressive feelings on transitions. In a May 2007 Vet Center record, the Veteran stated that he liked his new job because he was working with one other person and at night so he could work alone. He was irritable and very isolated. He was troubled by his difficulty with relationships and making connections with others. In August 2007 Vet Center records, the Veteran reported that he was trying to manage his anger and nerves with people at work. He was especially irritable at work. He reported sleep difficulties and anxiety. In an August 2007 VA record, the Veteran reported that he was coping well, but his episodes of hypervigilance caused gastrointestinal problems. He had been working alone in a small cubicle causing a lot of intrusive thoughts. In November 2007 Vet Center records, the Veteran reported depression and irritability. He had recently lost a friend which triggered thoughts of Vietnam. In an August 2009 VA examination, the Veteran provided a history of his recent employment. In October 2006 he had obtained a bachelors degree in computer science and eventually developed specialized training in 2-way radio function that had been the recent focus of his work. From October 2004 through December 2005 he was employed with a government contractor but was let go because of his irritability and difficulty in working with others. He worked at a golf course in the spring of 2006 and then began working with Homeland Security in New Orleans after Hurricane in June 2006. Then in early 2007 he working in Arizona, which he felt was going well. After a month, he was pulled off the contract due to further investigation into his security, and after having nothing for 3 months and not working, he was let go for reasons he does not know, other than possibly his PTSD diagnosis. He thus had not worked since March 2007. Since that time, he has had 2 job applications not approved. Prior to March 25, 2008, the evidence of record supports a 70 percent evaluation for the Veteran's PTSD. The level of occupational and social impairment due to a psychiatric disorder is the primary consideration in determining the severity of a psychiatric disorder for VA purposes and not all the symptoms listed in the rating criteria must be present in order for a rating to be warranted. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding that the psychiatric symptoms listed in the rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings). First, the veteran's GAF scores must be assessed. The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health - illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quotation omitted). A GAF score is highly probative, as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). Here, the Veteran's GAF score was 50, which contemplates serious symptoms, for example suicidal ideation, severe obsessional rituals, and frequent shoplifting; or any serious impairment in social, occupational, or school functioning, for example no friends, unable to keep a job. See DSM-IV at 46-47. This GAF score does not definitely demonstrate entitlement to either a 50 or a 70 percent evaluation, as both of those evaluations include serious symptoms such as difficulty establishing and maintaining effective relationships, reduced reliability and productivity, and disturbances of motivation and mood (50 percent), and an inability to establish and maintain effective relationships, deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, and difficulty in adapting to stressful circumstances including work or a worklike setting (70 percent). However, the Veteran's reported symptoms and objective findings indicate that the his PTSD is manifested by difficulty maintaining steady employment, although he was generally able to find new employment when let go, difficulty with activities of daily living upon intensification of symptoms or during depressive episodes, consistent sleep trouble, irritability, severe isolation, and intrusive thoughts. Although the evidence does not show any impairment in judgment or thinking, it does show that his periods of depression interfere with his ability to independently function and to conduct personal hygiene. Additionally, the evidence shows that he has deficiencies in work, family relations, and mood. Accordingly, although not all the symptomatology is shown for a 70 percent evaluation, resolving all reasonable doubt in favor of the Veteran, the disability picture more nearly approximates the criteria for a 70 percent evaluation. 38 C.F.R. §§ 4.3, 4.7 (2010). A 100 percent evaluation prior to March 25, 2008, however, is not warranted. The evidence of record does not demonstrate that the Veteran is totally socially and occupationally impaired. The Veteran was currently unemployed, but has been employed the majority of this time period. Although he was severely isolated, he was close to his daughter and sister. Additionally, the evidence showed that there was no impairment in thought process, communication, no inappropriate behavior, and he was fully oriented at all times. 38 C.F.R. § 4.130, Diagnostic Code 9411. Thus, a 70 percent evaluation, but no more, is warranted prior to March 25, 2008. Evaluation on and after March 25, 2008 On and after March 25, 2008, the Veteran's PTSD is assigned a 70 percent evaluation, which contemplates PTSD 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 intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent rating is warranted for 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; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, General Rating Formula. 38 C.F.R. § 4.130, Diagnostic Code 9411. In a May 2008 Vet Center records, the Veteran reported he was enjoying volunteering at a theatre company. In September 2008 Vet Center records, the Veteran reported he was more depressed. In an October 2008 VA record, the Veteran was doing fine at that time with working. In an October 2008 statement, the Veteran stated that his job required extended periods of travel, which increases his anxiety and causes isolation, insomnia, and nightmares for the 3 to 4 weeks of time when he was away from home working. He reported that he began working for the State of Colorado in February 2007 but found it extremely difficult to interact with coworkers. His work area also positioned him with his back to the door, which he found difficult. He eventually quit and took a job in Arizona, but was eventually removed when he did not pass a security clearance after it was discovered he had seen a counselor for PTSD. He has been unemployed since April 2008. He stated that he was too mentally exhausted to look for another job. The Veteran reported that he had no relationships except for his daughter. He had daily suicidal thoughts. The Veteran stated he was unable to clean his house, do his laundry, or other normal daily chores. He stated that his daily personal hygiene habits were hard to accomplish on a regular basis due to lack of focus. In October and November 2008 private psychiatric treatment records, the Veteran reported loneliness. In an October 2008 private evaluation, he reported obsessive thinking, sleep problems, mind racing, and dreams. The examiner found the Veteran well-groomed, cooperative, with psychomotor retardation, a flat affect, a depressed and anxious mood, delayed and soft speech, flashbacks, hallucinations, and violent dreams, but fully oriented without delusions and intact thought process, memory, cognitive function, judgment, and insight. A GAF score of 45 was assigned, which contemplates serious symptoms, for example suicidal ideation, severe obsessional rituals, and frequent shoplifting; or any serious impairment in social, occupational, or school functioning, for example no friends, unable to keep a job. See DSM-IV at 46-47. In October and December 2008 VA medical records, the Veteran was alert and oriented with a normal mood and affect. In an October 2008 private evaluation, the Veteran completed extensive psychiatric questionnaires. The questions and answers that are relevant to this determination are indicated below. The examiner determined there was moderately to highly severe PTSD and severe depression. The Veteran reported that if pushed too far, he was likely to become violent, that it seemed as if he had no feelings, that he was frightened by his urges, that no one understands how he feels, not even his family, that he has a hard time expressing his feelings, that he did not laugh or cry at the same things that other people do, that he loses his cool and explodes over minor everyday things, and that he feels super alert or on guard much of the time. He also reported the following were somewhat or slightly true: that lately he felt like killing himself, that he cries for no reason, that his memory was as good as it ever was, that people who know him best were afraid of him, that he felt like he could not go on, that he was not able to remember some important things that happened while in the military, and that if something happens that reminds him of the military he gets anxious or panicky. It was not at all true that he was able to get emotionally close to others, that he falls asleep and stays asleep, and that he had found it easy to keep a job since leaving the military. He reported that in the past month, he felt distant or cut off from others, felt emotionally numb, and felt irritable and angry. He experienced moderate loss of interest in activities he used to enjoy and difficulty concentrating. There was no trouble remembering important parts of a stressful military experience. The Veteran reported that in the past week he felt different than most people his age, cared less about consequences of his actions than other people, has lost interest in doing things for enjoyment when there is no one to join him, was so afraid of becoming violent that he did not allow himself to show anger, he was more confused about his life, he did not know himself as well as he used to, he knew fewer ways to control or reduce his anger than most people, had more trouble remembering things, and worried that he was going crazy because bad memories keep intruding. Also in that same evaluation, the Veteran reported that he felt sad much of the time, did not expect things to work out for him, received very little pleasure from things he used to enjoy, had thoughts of suicide but wouldn't carry them out, felt like crying but couldn't, was so restless or agitated that it was hard to stay still, had trouble making decisions, was irritable all the time, found it hard to keep his mind on anything, and was too tired or fatigued to do a lot of the things he used to. In a November 2008 evaluation submitted by a private psychologist, the diagnoses were PTSD and major depression. She reported his current symptoms included intrusive memories, recollections, dissociative episodes, hypervigilance, and anxiety. He avoided stimuli that remind him of war. He was severely socially isolated, even feeling detached and alienated from his daughter. There was also depression and isolation. He had been unable to work steadily or maintain a normal social or family life. The Veteran's serious depression caused him to be unable to sustain long-term emotional attachments. There was a flat affect and psychomotor slowing. The private psychologist opined that the Veteran was severely disabled due to marked social disability and an inability to sustain employment. A GAF score of 45 was assigned, which signifies serious symptoms. See DSM-IV at 46-47. In a July 2009 VA medical record, the Veteran was alert and oriented with a normal mood and affect. An August 2009 VA examination was conducted upon review of the claims file. The Veteran reported current sleep difficulties, with nightmares 3 times per week, regarding violent interactions with other people. He reported suicidal thoughts, irritability, avoidance of war news and politics, depressive episodes, an ongoing sense of doom, and that he was tired. He also reported intrusive thoughts about his combat experience. Because of this, he has not ridden a motorcycle for the past year. The Veteran reported his last employment was in March 2007, although he did some volunteer theater work. During that time, he met a woman, and began a relationship, but repeated his usual experience of getting cold feet, becoming numb, and withdrawing from the relationship. He has recently been seeing a private therapist which he felt had been productive. He was currently volunteering in an addiction treatment center and was hopeful that this could be a future career. He sometimes ate lunch with others at the treatment center and could tolerate a restaurant reasonably well. After he develops a friendship he begins to disconnect from that person, and then self-isolates for a long period of time and experiences depression. He noted that he pushes himself to get to the golf course weekly. The Veteran stated that he had been estranged from his daughter and granddaughter since the summer of 2008, due to his irritability. He had some future hope about being able to work in addiction counseling and to eventually establish a personal relationship that he could sustain. Mental status examination showed that the Veteran was neat and clean with solid average intelligence and no evidence of a thought disorder. The examiner found that the Veteran has had difficulty maintaining jobs since service discharge, continued to have difficulties with interpersonal relationships, and had difficulties with irritability in work situations. He had not worked since March 2007 primarily due to PTSD and the unwillingness of others to hire him in a high security government position. The diagnoses included PTSD and anxiety disorder. The examiner determined that PTSD resulted in deficiencies in most of the following areas: works, school, family, relations, judgment, thinking, and mood. The Veteran was able to maintain activities of daily living including personal hygiene. The symptoms were significant and there had been no remissions over the past year. The examiner also noted there was no inappropriate behavior, thought processes and communication are unimpaired, social functioning was superficially not impaired, but he distances himself from people and was unable to establish meaningful relationships due to emotional numbing, which also interfered with his team working experience. The GAF was 45 which signifies serious symptoms. See DSM-IV at 46-47. In an October 2009 VA medical record, the Veteran reported depression. A GAF score of 50 was assigned, which signifies serious symptoms. See DSM-IV at 46-47. In February 2010 VA records, the Veteran reported anger. In March 2010 VA records, the Veteran reported high anxiety about an upcoming trip, intrusive thoughts about Vietnam, sleep disturbance, and nightmares. He stated he did not get a recent job that he was qualified for. On and after March 25, 2008, the evidence of record does not support an evaluation in excess of 70 percent for the Veteran's PTSD. The level of occupational and social impairment due to a psychiatric disorder is the primary consideration in determining the severity of a psychiatric disorder for VA purposes and not all the symptoms listed in the rating criteria must be present in order for a rating to be warranted. See Mauerhan, 16 Vet. App. 436. First, the Veteran's GAF scores must be assessed. The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health - illness." Carpenter, 8 Vet. App. at 242. A GAF score is highly probative, as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey, 7 Vet. App. at 207. Here, the veteran's GAF scores were all in the 41 to 50 range, which signifies serious symptoms, for example suicidal ideation, severe obsessional rituals, and frequent shoplifting; or any serious impairment in social, occupational, or school functioning, for example no friends, unable to keep a job. See DSM-IV at 46-47. As indicated above, these scores demonstrate serious symptoms of PTSD. Here, however, the GAF scores do not appear to demonstrate entitlement to a 100 percent evaluation, which requires total social and occupational impairment, rather than "serious impairment" in those areas. Accordingly, the Veteran's GAF scores tend to support a 70 percent evaluation. Second, however, all the pertinent evidence of record must be considered and the decision must be based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Here, the Veteran's symptoms quite clearly indicate deficiencies in most areas, including difficulty establishing and maintaining effective relationships, irritability, anger, severe isolation, hallucinations, sleep difficulties, suicidal thoughts without plan, severe depression, and difficulty maintaining steady employment. A November 2008 examiner stated there was marked social disability, but not total disability. Although he was unable to sustain long-term relationships, he was able to eat lunch with others, volunteer at a treatment center, sustain a relationship with his sister, and obtain if not sustain employment. The evidence of record thus does not demonstrate total social disability. Additionally, the evidence shows there is no inappropriate behavior, no impaired thought process or communication, no delusions, suicidal thoughts without plan, and that the Veteran was fully oriented. The Veteran has alleged an inability to maintain his activities of daily living, but the August 2009 VA examiner determined he had the ability to do so. The Veteran's PTSD symptomatology is severe; however, a 100 percent evaluation requires total impairment which is not shown. Accordingly, a 70 percent, and not a 100 percent evaluation, is warranted. Extraschedular evaluation Consideration has also been given regarding whether the schedular evaluation is inadequate, thus requiring that the RO refer a claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2010); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this regard, the schedular evaluations in this case are not inadequate. Ratings in excess of 50 and 70 percent are provided for certain manifestations of the service-connected PTSD but the medical evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's symptoms, as the criteria assess occupational and social impairment due to PTSD and address various psychiatric symptomatology. This issue therefore, does not warrant referral for consideration of an extraschedular rating. After review of the evidence, there is no evidence of record that would warrant a rating in excess of 70 percent for PTSD at any time during the period pertinent to this appeal. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2007); see also Hart, 21 Vet. App. 505; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Prior to March 25, 2008, an evaluation of 70 percent, but no more, for service-connected PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. On and after March 25, 2008, an increased evaluation in excess of 70 percent for service-connected PTSD is denied. REMAND Entitlement to TDIU was denied by the RO in a March 2007 rating decision. Since that time, however, the Veteran has alleged that his PTSD causes him to be unemployable. In his September 2009 substantive appeal regarding his increased evaluation claim, he stated that he had previously submitted a TDIU claim, and that give his work difficulties, he was requesting that it "be considered in my case as soon as possible." was not been developed or adjudicated by the RO. Once a veteran submits evidence of a medical disability, makes a claim for the highest rating possible, and submits evidence of unemployability, the issue of entitlement to TDIU is raised. Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001). When TDIU based on a disability is raised in connection with an increased rating claim for that disability, the Board has jurisdiction over the issue of TDIU because it is part of the claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009); VAOPGCPREC 6-96 (August 16, 1996). Accordingly, the issue of entitlement to TDIU has been raised by the record and the Board has determined that it has jurisdiction over the issue as it is part and parcel of the increased rating claim. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran proper VCAA notice as to what is needed to substantiate a claim for entitlement to a TDIU. 2. Undertake any other necessary development and then adjudicate the issue of entitlement to a TDIU rating. If the benefit sought is not granted, the Veteran and his representative should be furnished with a Supplemental Statement of the Case, and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs