Citation Nr: 1127304 Decision Date: 07/21/11 Archive Date: 07/29/11 DOCKET NO. 07-38 581 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD), for the period prior to June 16, 2006. 2. Entitlement to a rating in excess of 50 percent for PTSD, for the period from June 16, 2006 to August 3, 2010. 3. Entitlement to a rating in excess of 70 percent for PTSD from August 4, 2010. 4. Entitlement to an effective date prior to August 4, 2010, for the award of Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Donna D. Ebaugh, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1968 to August 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. In March 2010, the Board remanded this case to the RO via the Appeals Management Center (AMC) in Washington, DC, for additional development. The Board also ordered consideration of the issue of entitlement to a total disability rating due to individual unemployability (TDIU) in the March 2010 Remand. Thereafter, a TDIU was granted by VA in March 2011. As the grant of the TDIU was a grant of the full benefit on appeal, the Board no longer has jurisdiction over that issue. The issue of entitlement to an effective date prior to August 4, 2010, for the award of a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC. FINDINGS OF FACT 1. For the period prior to June 16, 2006, the Veteran's PTSD has resulted in disturbed mood, disturbed sleep pattern, short temper, and passive suicidal thoughts without deficiencies in the areas of family relations; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or an inability to establish and maintain effective relationships. 2. For the period from June 16, 2006 to August 3, 2010, the Veteran's PTSD has resulted in disturbed mood, disturbed sleep pattern, short temper, and passive suicidal thoughts without deficiencies in the areas of family relations; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or an inability to establish and maintain effective relationships. 3. For the period from August 4, 2010, the evidence demonstrated PTSD resulting in disturbed mood, disturbed sleep pattern, short temper, and passive suicidal thoughts, as well as neglect of personal appearance and hygiene without evidence of 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; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 50 percent, but no higher, for PTSD have been met for the period prior to June 16, 2006. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for a rating in excess of 50 percent for PTSD, for the period from June 16, 2006 to August 3, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130, Diagnostic Code 9411 (2010). 3. The criteria for a rating in excess of 70 percent for PTSD, for the period from August 4, 2010, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA VA has specified duties to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The Board has considered whether further development and notice under the Veterans Claims Assistance Act of 2000 (VCAA) or other law should be undertaken. 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 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. The Veteran's claim arises from his disagreement with the initial evaluation following the grant of service connection for PTSD. The Federal Circuit and the U.S. Court of Appeals for Veterans Claims have held that, once service connection is granted, the claim is substantiated, additional 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). Therefore, no further notice is needed under VCAA regarding the claim for a higher initial rating. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). First, the RO obtained the Veteran's service treatment records as well as all pertinent VA outpatient treatment reports. The Veteran has also submitted personal statements and other evidence in pursuit of his claims. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Next, the Veteran was afforded VA examinations in June 2006, January 2007, and August 2010. Notably, the March 2010 Board Remand ordered the August 2010 VA examination. The Board finds that the VA examiner substantially complied with the Remand. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's PTSD disability since the August 2010 VA examination. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. The Board finds that the June 2006, January 2007, and August 2010 VA examinations are adequate reports upon which to base a decision. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information necessary to evaluate the Veteran's disability under the applicable rating criteria. Further, the Board acknowledges that Social Security Administration (SSA) records regarding SSA disability have not been obtained. However, as the Veteran has clearly indicated that he is receiving SSA benefits due to a nonservice-connected cardiac disorder, they are not relevant to his claims for increased ratings for his service-connected PTSD. Murincsak v. Derwinski, 2 Vet. App. 363, 372 (1992); Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010) (there is no duty to get SSA records when there is no evidence that they are relevant). Based on the foregoing, the Board finds that no additional assistance is required to fulfill VA's duty to assist. 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). Initial Rating Claims for PTSD Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. Id. It is necessary to evaluate the disability from the point of view of the veteran working or seeking work, 38 C.F.R. § 4.2 (2010), and to resolve any reasonable doubt regarding the extent of the disability in the veteran's favor. 38 C.F.R. § 4.3 (2010). If there is a question as to which evaluation to apply to the veteran's disability, 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. 38 C.F.R. § 4.7 (2010). 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 disability present. 38 C.F.R. § 4.2 (2010); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has also held that, in a claim of disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). The Board further acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following matters is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In the present case, entitlement to service connection for PTSD was granted in a January 2007 rating decision. The RO assigned an initial 30 percent rating, effective May 31, 2006, the date of the Veteran's claim. The Veteran appealed the decision indicating that a higher rating should have been awarded. As noted above, the Board considered the issue in March 2010 and remanded the matter for a VA examination. Following a VA examination, in March 2011, the RO reevaluated the claim and determined that it should be increased to 50 percent disabling from June 16, 2006, the date of an outpatient treatment record where objective evidence of applicable symptomatology was noted. A 70 percent rating was assigned for PTSD from August 4, 2010, the date of the VA examination. As these staged ratings were not increased to 100 percent disabling, the Veteran is presumed to be seeking the maximum benefit allowed by law and regulation. AB v. Brown, 6 Vet. App. 35, (1993). For all periods on appeal, the Veteran's PTSD disability has been rated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational task (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, recent events). Id. A 50 percent rating is warranted when there is occupational and social impairment, but with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting 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 maximum rating of 100 percent requires 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. Id. The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, the analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In Mauerhan, the Court rejected the argument "that the DSM-IV criteria should be the exclusive basis in the schedule governing ratings for PTSD." See Mauerhan, 16 Vet. App. at 443. Rather, distinctive PTSD symptoms in the DSM-IV are used to diagnose PTSD rather than evaluate the degree of disability resulting from the condition. Although certain symptoms must be present in order to establish the diagnosis of PTSD, as with other conditions, it is not the symptoms but their effects that determines the level of impairment. Id. 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 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). I. For the Time Period Prior to June 16, 2006 As an initial matter, the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998). In this case, the Board will attribute all the Veteran's psychiatric symptoms to his service-connected PTSD residuals. For the period prior to June 16, 2006, the Veteran contends that his PTSD is of such severity so as to warrant a disability rating in excess of 30 percent. For the following reasons, the Board finds that the Veteran's PTSD should be increased to 50 percent, but no higher, for the period prior to June 16, 2006. Prior to June 16, 2006, VA group therapy notes indicate that in May 2006, the Veteran reported that he had had three heart attacks, which he attributed to stress; he had difficulty with two past marriage relationships; he has had trouble with communication with his family for years; he had not been able to sleep more than two to four hours at a time; had frequently gotten into verbal altercations, including some leading to fights; he was not able to participate in family gatherings for very long at a time, and sometimes not at all; he was unable to participate in 4th of July activities; he had nightmares several times per month; he was angered easily; depressed often; had no motivation to do normal daily activities; sometimes did not leave his home for days; and lived in a small town because he could not stand city life. Also in June 2006, an individual therapy note indicated that the Veteran became noticeably uncomfortable when the therapist inquired about his service experiences. Notably, the Veteran had been married for 25 years during the period in question, and remains married. The Board has considered statements from the Veteran's wife in a December 2009 statement. Some of her observations were undated but indicated that the children (who are now in their 30's) were party to them. Therefore, the Board will give the benefit of the doubt to the Veteran that these incidents occurred when the children were in fact children, prior to June 16, 2006. Specifically, the Veteran's wife reported that for years, in the grocery store, or other public places, if the Veteran saw Asian people and heard them speaking in a foreign language, he would approach them and "cuss them out" and have a fit of anger. The Veteran's wife and children would attempt to help him but he would become so angry with them that she felt the need to take their children to sleep somewhere else. She also reported that for at least five years, off and on, the Veteran would wake her in the night with a hand over her mouth and a gun in his other hand. He would tell her to "get down and be quiet or they'll hear you and kill us." She reported that he did not seem to realize what he was doing until she would shake him and then he would stare into space for a long time. The Board acknowledges that she is competent to report her observations as they come to her through her senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds her statements to be credible and probative. Regarding employment, the Veteran reported that he had not been employed for 10 years prior to June 2006, due to a heart disability, not PTSD. After a thorough review of all of the evidence of record, the Board finds that the Veteran's symptoms more nearly approximate the rating criteria for the 50 percent evaluation, but no higher for the period prior to June 16, 2006. In this regard, the Board finds it significant that the Veteran has demonstrated disturbances of motivation and mood and difficulty in establishing and maintaining effective work relationships, as well as nightmares and/or hallucinations affecting his ability to function independently, appropriately and effectively. However, evidence of record does not show that the Veteran's service-connected PTSD caused social and occupational impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood during this time period. Notably, although the evidence indicates that he was quick to anger, the evidence does not suggest that he displayed impaired impulse control. Further, the evidence does not demonstrate difficulties with family relations - indeed, he was able maintain one marriage for 11 years and his current marriage for 25 years, as of the period in question. Likewise, the evidence does not reveal findings of obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression, spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a worklike setting), or an inability to establish and maintain effective relationships. Further, although the Veteran indicated in a June 2006 statement to the VA examiner that he had experienced suicidal thoughts for years, he never acted on the suicidal thoughts. In fact, he specifically reported that he could not do that to his wife and kids. As will be discussed below regarding the period from June 16, 2006, to August 3, 2010, the Board does not find that a 70 percent disability rating is warranted at any point prior to August 4, 2010. II. For the Time Period Prior to August 4, 2010 Regarding the period prior to August 4, 2010, the Board finds that the Veteran's PTSD disability symptomatology continues to meet or more nearly approximate the severity of occupational and social impairment contemplated for a 50 percent rating under the criteria in 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). 38 C.F.R. § 4.7 (2010). In June 2006 VA PTSD examination report, the Veteran complained of suicidal ideations accompanied by a loosely constructed plan but indicated that he could never do that to his wife and kids. He also reported that he has typically awoken from sleep every two hours since service, usually by what he thinks is the sound of a radio. He was indicated that he was a radio operator in service and now hears the radio frequently during the day as well as reports that no one else can hear it. He also complained of intrusive thoughts, nightmares related to combat, avoidance of war movies, sense of foreshortened future, and an exaggerated startle response. He reported frequent angry outbursts and said he had been real heard on his wife and kids but denied any domestic violence. He reported having had an intense fear during his tour in service. He related feeling depressed all day most days and that since he returned from Vietnam, if he doesn't preoccupy himself, he sits and cries. He denied any current suicidal or homicidal ideation but reported that he had suicidal ideations in the past. He also reported thoughts of hurting other people if they start fights with him. He related racing thoughts with episodes of a mildly elevated mood lasting for four days with increased energy and a decreased need for sleep, increased interest in sex, and history of buying sprees. He reported that his mood elevations are accompanied by irritability and are often noticed by his wife who tells him he needs to calm down. He scored 6 out of 13 on the mood disorder questionnaire. He denied auditory or visual hallucinations as well as thought blocking and thought insertion. The Veteran also denied paranoia but noted that sometimes people give him a hard time. He reported that he prefers to be alone but is able to go to group meetings without difficulty, indicating that he voluntarily joined a PTSD support group two months prior. He denied any other psychiatric treatment. Regarding anger, he reported that he has an anger problem. He reported that he has a long fuse but if someone gets him mad, he'll stew on it for months and then may strike out at them from nowhere the next time he sees them. He denied any charges of violent behavior being filed against him. Regarding family relationships, the Veteran indicated that has been married three times. His first marriage lasted one year, ending when he was 18 and in service. The second marriage lasted 11 years, and the third and current marriage has lasted for approximately 30 years. Regarding employment and leisure time activities, as noted above, he had been unemployed for 10 years prior to the June 2006 VA examination, due to a cardiac condition. Prior to that time, he had been employed as a truck driver for 11 years and as well as a manager of three trucking terminals. He left that job due to his cardiac condition and became employed with another company for three and a half years, until he was unable to perform his duties due to his cardiac condition. At the time of the June 2006 VA examination, he reported that he enjoyed managing his three mules, two dogs, fishing, and camping. At the June 2006 VA examination, the examiner noted that the Veteran appeared on time for his appointment, was dressed in jeans and a clean shirt, had average grooming, and was alert as well as fully oriented. He did not hear a radio playing on the day of the examination. His thoughts were coherent, organized, and goal directed while his speech was of a regular rate, rhythm, and tone. There was no evidence of circumstantial or tangential thinking. He was able to repeat 3 of 3 objects immediately and remember 3 of 3 after 5 minutes. He knew the month, day, date, and year. He was able to do serial 7's correctly, counting on his finger from 100 down to 65. He was able to spell "world" and spell it backward correctly. He reported a depressed mood and his affect was indicated to be congruent with the assessment. However, the VA examiner noted that his affect brightened somewhat during the evaluation. He maintained good eye contact and was cooperative and pleasant through the interview. In addition to PTSD, the VA examiner diagnosed rule out major depressive disorder and rule out mood cycling disorder. The VA examiner also assessed an Axis IV diagnosis of relationship difficulties due to poor anger management. Approximately one week after his June 2006 VA examination, the Veteran reported to the outpatient treatment clinic requesting help with his mental health. He indicated a follow up for psychotropic medications. He reported flashbacks, nightmares, staying detached, anger outbursts, easy startle response, and that he avoided news reports. He reported sleep disturbance with frequent middle of the night awakenings. He also developed depression with sadness/irritability, fatigue, feelings of hopelessness, and suicidal ideations with no plans to act. He was diagnosed with moderate major depressive disorder in addition to chronic PTSD. The Board has also reviewed Vet Center group therapy and individual therapy notes of record. In July 2006, the Veteran described his marriage as a good relationship. An August 2006 note indicated that the Veteran reported that the news about the war in Iraq was triggering his nightmares. Another August 2006 note indicated that he reported he liked the group therapy. In December 2006, it was noted that he provided support to another veteran whose wife was dying as well as encouraged new members to continue coming to the group. A January 2007 note indicated that he reported he preferred being by himself and was suspicious of most people. He also had an explosive temper and saw that as part of the problem with his grown children. A February 2007 note indicated that he had an anger problem that he downplayed. He also observed his past behavior regarding his anger and drinking, wondered why his wife put up with him, and admitted that he understood why kids did not like being around him. Another February 2007 note detailed that he had difficulty with abstract thinking, gets fairly angry quickly, and does not respond well to authority. He reported however that he valued group therapy because he liked the support and being with other veterans. The Veteran underwent a periodic VA PTSD examination in January 2007. At that time, he reported that he took antidepressant medication and that it helped him with sleep, although he still reported difficulty sleeping every night. Regarding his family, he reported that he has little contact with his brothers because they have different beliefs than he does. He reported that his relationship with his wife was very good and had improved since their children left home. Regarding leisure activities, he reported that when the weather is cold, he remains in the home watching TV. If the weather is good, he enjoys working in his shop, where he repairs old tractors. He also reported that he enjoyed riding his three mules. He also indicated that he has one good friend with whom he visits at Vet Center counseling and with whom he has lunch weekly. He also indicated that he has other friends who are all Vietnam veterans and people he went to school with. He reported that he had been attending counseling for 8 or 9 months and that he believed it was helping him. He reported that he drinks a pint of whiskey each weekend and smokes five cigarettes a day. He indicated that he had an exaggerated startle reaction to loud noises, difficulty sleeping every night, has nightmares with content related to combat experiences two to three times per week, and finds himself breaking down and crying several times per week (especially when he sees a news show on TV which shows soldiers in Iraq). When asked about his ability to take care of himself and his responsibilities, he reported that it was about a 6 or 7 on a 1-10 scale. He also commented that he usually awakes after two hours of sleep each night, listening carefully for strange noises before returning to sleep. He complained of bad dreams a couple of times per week and reported feeling tired all the time as well as feeling sad much of the time. He reiterated that he breaks down and cries a couple of times per week but feels that has improved since he began taking antidepressant medications. He repotted infrequent sexual activities, partially due to his heart problems. The January 2007 VA examiner indicated that the Veteran was alert, well oriented to person, place and time, well-groomed, made good eye contact, and had fluent and coherent speech with no evidence of excessive tangentiality. He was noted to demonstrate good ability to attend and concentrate but to experience problems with his memory. He was able to abstract, and his social judgment was good. He reported having no problems with racing thoughts. He also reported daily intrusive thoughts about his combat experience, being hypervigilant, and keeping a loaded pistol beside his bed. He avoided crowded places, being unable to go shopping for groceries or needed items. The examiner determined that he had hyperarousal as demonstrated by his difficulty sleeping daily with a sleep pattern that he had since being in combat - sleeping for two hours, awakening, checking the environment, and returning to sleep. He was noted to become tearful while discussing his combat experiences. The examiner administered the Beck Depression inventory on which he obtained a score of 33. He also reported passive suicidal thinking daily and said that he would not act on those feelings because it would leave his wife alone. He was indicated to be generally calm and pleasant. The January 2007 examiner noted that the Veteran's affect did not agree with his self-reported symptoms of depression. In sum, the examiner noted that the Veteran had good friends and a good relationship with his family as well as had hobbies and activities that he enjoyed. The examiner also noted that he may be experiencing vascular dementia and that he should have a neuropsychological evaluation to determine his cognitive disability, if any. A March 2009 VA outpatient treatment record noted that the Veteran reported his anger control was good but that he still had road rage. His nightmares were okay but he still hears the combat radio at night. He still gets up every two hours to look around and goes back to sleep. He continued to have thoughts about being dead on a regular basis but does not act on them because of his wife. The examiner noted that the Veteran was alert, dressed casually, well groomed, and exhibited clear and free-flowing speech as well as calm motor functions. Mood was not well and affect was euthymic. The VA physician increased the Veteran's Zoloft medication. A June 2009 VA outpatient treatment record indicated that the Veteran was alert and oriented, had good grooming and hygiene, was cooperative with good eye contact. Speech was at the normal rate and amount and motor activity was calm. His mood was not good and his affect was somewhat downcast with no delusions, hallucinations, or reported suicidal or homicidal ideation. His thoughts were listed as goal directed without tangentiality, circumstantiality, or loosening of associations. His memory seemed grossly intact. The Veteran also reported that it had been a hard month with a death in the family and that traveling out of state to the funeral was frustrating for him. He also reported that he felt depressed and like a burden to his wife and that he continued to feel things would be better if he were dead but did not have suicidal ideations. A September 2009 VA outpatient treatment record indicated that the Veteran was dealing with the recent deaths of two close friends. He reported that he still had periods of severe depression but didn't feel too bad now. He felt like a burden on society and tried to stay busy to prevent worsening depression. The examiner noted that he was dressed casually, exhibited good grooming, had speech that was clear and free-flowing, had a pleasant but downcast affect, and discussed no suicidal ideations. A November 2009 VA outpatient treatment record indicated that the Veteran reported he was helping his daughter repair her house so that she could move into it. He indicated that it was stressful having his daughter and granddaughter in his house, that his depression was not better, that he still felt down in the dumps, and that he was a burden to people. The examiner noted that he was alert and oriented, had good grooming and hygiene, was cooperative with good eye contact, exhibited speech at a normal rate and amount. He was noted to have goal directed thoughts, grossly intact memory, calm motor activity, depressed mood, and restricted affect but no delusions, hallucinations, suicidal ideation, or homicidal ideation. A January 2010 VA outpatient treatment record indicated that the Veteran reported he was less depressed and the frequency of his nightmares improved. The examiner noted that he was alert and oriented, had good grooming and hygiene, was cooperative with good eye contact. The examiner further indicated that his memory was grossly intact, his speech was at the normal rate and amount, his motor activity was calm, his mood was good, and his affect was pleasant and at ease. He had no delusions or hallucinations as well as no suicidal or homicidal ideations. After a thorough review of all of the evidence of record, the Board finds that the Veteran's symptoms continue more nearly approximate the rating criteria for the currently assigned 50 percent evaluation for the period prior to August 4, 2010. The Veteran's service-connected PTSD is manifested by nightmares, depressed mood, sleep impairment, memory impairment, and hypervigilance, which equates to occupational and social impairment with reduced reliability and productivity. Overall, due to the absence of more serious symptomatology and notwithstanding his intermittent complaints of passive suicidal ideation and hypervigilance, the Board finds that the Veteran's PTSD symptoms do not demonstrate a disability picture more nearly approximating the next-higher 70 percent evaluation under Diagnostic Code 9411, for the period prior to August 4, 2010. In this regard, the Board emphasizes that although the Veteran had a downcast affect at times during the period, his affect improved towards the end of the period. Further, although he continued to have sleep disturbances and report that he was depressed, he was still able to interact with others in group therapy, encourage his group members, help his daughter repair her home, maintain a good relationship with his wife, and enjoy leisure activities such as riding his three mules and working on old tractors. Although the Veteran reported intermittent passive suicidal thoughts, at no time did he express intent to act on those thoughts. In reaching its decision, the Board has also considered the Veteran's Global Assessment of Functioning (GAF) scores. The Veteran was assigned GAF scores ranging from 45-50 at different times during this time period. The GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." See the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) (DSM-IV); see also Carpenter v. Brown, 8 Vet. App. 240 (1995). A GAF score of 41-50 is assigned where there are, "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. These scores fall in the moderate to severe range, which corresponds to the Veteran's symptomatology falling in the criteria for a 50 percent rating according to Diagnostic Code 9411. In addition, throughout this entire period, evidence of record does not show that the Veteran's service-connected PTSD caused social and occupational impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In fact, the Veteran was noted to exhibit normal thought processes, full orientation, normal speech, calm motor functions, good hygiene, and good judgment. Findings of speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; spatial disorientation; or neglect of personal appearance and hygiene were also not shown in the evidence of record during this time period. Based on the foregoing discussion, the Board finds that Veteran's PTSD symptoms continue to more nearly approximate the rating criteria for 50 percent rating during the time period prior to August 4, 2010. III. For the Time Period from August 4, 2010 The Veteran's PTSD has been rated as 70 percent disabling since August 4, 2010, the date of his most recent VA examination. For the reasons that follow, the Board finds that the assignment of a rating in excess of 70 percent for the Veteran's service-connected psychiatric disability is not warranted during this time period. As noted above, a 100 percent rating for PTSD 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. At the August 2010 VA examination, the Veteran reported at times he neglects to bathe or engage in other self-care activities. He reported that he is distant from his family. He is not able to meet the emotional needs of his wife, siblings, or children, reporting that many family members have disowned him. He indicated that his problems with sleep prevent him from physical contact with his wife, that he does not leave the house often, has only one or two distant friends, and does not participate in social activities. He commented that he does not leave the house due to his PTSD symptoms where he might have the opportunity to interact with others. Regarding leisure activities, he detailed that his only recreation is watching television and gardening on occasion. He also reported that if it was not for the presence of his wife, he would prefer to not be alive any longer. He complaining of trauma re-experiencing symptoms, particularly at night, that prevented him from getting a good night's rest. He further claimed that the re-experiencing symptoms also caused him to be in a constant state of hyperarousal, reflecting that he was not able to go out in regular society during the period of hyperarousal. In the past, when he has attempted to do so, he angered quickly and had little ability to control his aggressive behavior. He reported that he avoids contact with others. After a thorough review of all of the evidence of record, the Board finds that the Veteran's symptoms continue to more nearly approximate the rating criteria for the 70 percent evaluation during this time period. In this regard, the Board finds it significant that the Veteran has demonstrated disturbances of motivation and mood, passive suicidal and homicidal ideation with no episodes of violence, fair impulse control, isolative and obsessive behaviors, monthly panic attacks, depression, and neglect of personal appearance and hygiene. As stated above, in order to be entitled to the next-higher 100 percent rating, the evidence must show 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, Diagnostic Code 9411 (2010). Here, however, the Board finds that the Veteran's PTSD symptoms do not more nearly approximate the criteria for the next-higher 100 percent evaluation. Evidence of record clearly does not indicate that the Veteran's psychiatric symptomatology is productive of total social and occupational impairment. The Board acknowledges that the August 2010 VA examination report reflected that the Veteran is as likely as not unemployable due to his PTSD and that he has in fact, been granted entitlement to a TDIU. However, evidence of record during this time period is reflective of significant but not total social impairment. The Veteran has been married to the same spouse for over 30 years with self-reported improvement in the relationship over the last couple of years. It was indicated that he does not leave the house due to his physical disabilities, leaving him moody and irritable. He also described his relationship with his oldest son in positive terms, noted maintaining contact with a few distant friends (with multiple phone calls and visits each month), and discussed participation in leisure activities, including watching television and gardening occasionally. He was further noted to attend and participate in a weekly VA PTSD therapy group since 2006. Notwithstanding the notation by the August 2010 VA examiner that he at times will neglect to bathe or engage in other self care activities as well as the Veteran's complaints of daily, passive suicidal ideation, evidence of record during this time period does not indicate that the Veteran has exhibited grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. As noted above, the Board has also considered the Veteran's assigned GAF scores. The Veteran was assigned a GAF score of 42 at the August 2010 VA examination that contemplates serious symptomatology and substantial but not total impairment in social and occupational functioning. Thus, in addition to the specific symptomatology discussed above, the Board finds that the reported GAF score does not support the assignment of a 100 percent rating during this time period. Based on the foregoing discussion, the Board finds that Veteran's PTSD symptoms continue to more nearly approximate the rating criteria for 70 percent rating during the time period from August 4, 2010. IV. Additional Considerations for All Periods Regarding all periods on appeal, in considering whether the Veteran is entitled to a higher disability rating, the Board has also carefully considered his statements asserting that his disability is more severe than currently characterized. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Moreover, the Board acknowledges his belief that his symptoms are of such severity as to warrant a higher rating; however, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity. Therefore, the Board finds the medical findings, which directly address the criteria under which the service-connected disability is evaluated, to be more probative than the Veteran's lay assessment of the severity of his PTSD. An initial disability rating of 50 percent for PTSD for the period prior to June 16, 2006, is granted. However, for all the foregoing reasons, the Veteran's claims for entitlement to a rating in excess of 50 percent for PTSD for the period from June 16, 2006, to August 3, 2010, and a rating in excess of 70 percent for PTSD for the period from August 4, 2010, must be denied. Both medical and lay evidence fail to support the assignment of higher ratings. The Board has considered additional staged ratings, under Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, 21 Vet. App. 505 (2007), but concludes that they are not warranted. Since the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Finally, the disability does not warrant referral for extraschedular consideration. In exceptional cases where schedular ratings are found to be inadequate, consideration of an extraschedular rating is made. 38 C.F.R. § 3.321(b)(1) (2010). There is a three-step analysis for determining whether an extraschedular rating is appropriate. Thun v. Peake, 22 Vet. App. 111 (2008). First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. Id. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as governing norms. Id.; see also 38 C.F.R. § 3.321(b)(1) (governing norms include marked interference with employment and frequent periods of hospitalization). If the factors of step two are present, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, there has been no showing that the Veteran's disability picture for his PTSD could not be contemplated adequately by the applicable schedular rating criteria discussed above. The criteria provide for higher ratings, but as has been explained thoroughly herein, the currently assigned ratings adequately describe the severity of the Veteran's symptoms for this disability during the periods of appeal. Given that the applicable schedular rating criteria are adequate, the Board need not consider whether the Veteran's disability picture includes such exceptional factors as periods of hospitalization and interference with employment. Referral for consideration of the assignment of a disability rating on an extraschedular basis is not warranted. See Thun, 22 Vet. App. at 111. ORDER An initial disability rating of 50 percent for PTSD for the period prior to June 16, 2006, is granted, subject to governing criteria applicable to the payment of monetary benefits. A rating in excess of 50 percent for PTSD for the period from June 16, 2006, to August 3, 2010, is denied. A rating in excess of 70 percent for PTSD for the period from August 4, 2010, is denied. REMAND The Board's review of the claims file reveals that further development on the matter of entitlement to an effective date prior to August 4, 2010, for the award of a TDIU is warranted. In a March 2011 rating decision, the RO granted entitlement to a TDIU, effective August 4, 2010. In a May 2011 Informal Hearing Presentation, the Veteran's representative indicated disagreement with the assigned effective date of the award for TDIU. In Manlincon v. West, 12 Vet. App. 238 (1999), the Court held that when an appellant files a timely notice of disagreement (NOD) and there is no statement of the case (SOC) issued, the Board should remand, rather than refer, the issues to the RO for the issuance of a SOC. As the May 2011 statement from the Veteran's representative is accepted as a timely NOD with the March 2011 rating decision, this matter will be remanded for the issuance of a SOC. 38 C.F.R. §§ 20.201, 20.302(a) (2010). Accordingly, the case is REMANDED for the following action: The AMC should issue to the Veteran and his representative a SOC addressing the claim of entitlement to an effective date prior to August 4, 2010, for the award of a TDIU. The Veteran is hereby informed that he must submit a timely and adequate substantive appeal as to this issue for the issue to be before the Board on appeal. The appellant 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). (Continued on next page) 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. D. DEANE Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2010). Department of Veterans Affairs