Citation Nr: 1127889 Decision Date: 07/26/11 Archive Date: 08/02/11 DOCKET NO. 08-03 303 A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Chicago, Illinois THE ISSUE Entitlement to a rating in excess of 30 percent for post-traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechner, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from March 1967 to December 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2006 rating decision of the Chicago, Illinois RO, which in pertinent part awarded service connection for PTSD, rated 10 percent, effective June 8, 2006. An interim (December 2007) rating decision increased the rating for PTSD to 30 percent, also effective June 8, 2006. In September 2010, a Travel Board hearing was held before the undersigned; a transcript of the hearing is associated with the Veteran's claims file. This matter was previously before the Board in February 2011, when it was remanded for additional development. The matter of entitlement to a total disability rating based on individual unemployability (TDIU) is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if any action on his part is required. FINDINGS OF FACT 1. Prior to April 16, 2009, the Veteran's PTSD was not shown to have been manifested by symptoms productive of impairment greater than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; occupational and social impairment with reduced reliability and productivity due to PTSD symptoms was not shown. 2. From April 16, 2009, but no earlier, the Veteran's PTSD is shown to have been manifested by symptoms productive of occupational and social impairment with reduced reliability and productivity; occupational and social impairment with deficiencies in most areas due to PTSD symptoms is not shown at any time. CONCLUSIONS OF LAW 1. Prior to April 16, 2009 a rating for PTSD in excess of 30 percent is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1-4.7, 4.21, 4.130, Diagnostic Code (Code) 9411 (2010). 2. From April 16, 2009 a 50 percent, but no higher, rating is warranted for the PTSD. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.321, 4.3, 4.130, Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). As the rating decision on appeal granted service connection and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). A December 2007 statement of the case (SOC) provided notice on the "downstream" issue of entitlement to an increased initial rating, and an April 2011 supplemental SOC readjudicated the matter after the Veteran and his representative responded and further development was completed. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). The Veteran has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) ("where a claim has been substantiated after the enactment of the VCAA, the Veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). Significantly, the Veteran's testimony at the September 2010 Travel Board hearing before the undersigned reflects that he is aware of what is needed to substantiate his claim. The Veteran's pertinent treatment records have been secured. He was afforded VA examinations in September 2006, April 2009, and February 2011; those examinations are reported in greater detail below, and cumulatively are adequate for rating purposes, as the reports of the examinations contain the information necessary for consideration of the applicable criteria. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. With the initial rating assigned following a grant of service connection, separate (staged) ratings may be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000)(VA must review the entire record, but does not have to discuss each piece of evidence.) Hence, the Board will summarize the relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claim. PTSD is rated under the General Rating Formula for Mental Disorders. A 30 percent evaluation is warranted when the evidence demonstrates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; 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); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Code 9411. With respect to the rating of his PTSD, the Veteran has been assigned various Global Assessment of Functioning (GAF) scores. Scores ranging from 51 to 60 reflect more 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). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. Lesser scores reflect increasingly severe levels of mental impairment. See 38 C.F.R. § 4.130 [incorporating by reference VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes]. On May 2006 VA treatment, the Veteran reported insomnia due to nightmares, flashbacks often triggered by noises such as helicopters, hypervigilance, hypersensitivity, irritability, anger and outbursts. He reported being estranged from his teenage daughter. He participated in leisure activities including biking and golf. He had no suicidal ideations or potential for violence. On mental status examination, his attitude was cooperative and pleasant. His attention and concentration were mildly impaired. Mood was irritable and affect was in the normal range, congruent with mood and content. He reported sleeping 5 to 9 hours per night with Ambien, and 0 hours without it. Speech was normal in rate and volume. Thought process had normal flow and was logical sequential and relevant. Short-term memory was impaired in that he could not recall what happened the day before. Insight and judgment were adequate. The examiner opined that the Veteran was experiencing many symptoms of PTSD, and noted that the Veteran would soon be retiring at his and his employer's requests. The diagnosis was PTSD, and a GAF score of 61 to 70 was assigned, reflecting very mild symptoms. Trazodone and Citalopram were prescribed. On June 2006 VA treatment, the Veteran reported nightmares of setting up ambushes in Vietnam, flashbacks, sometimes hearing the noises of grenades or gunshots, hypervigilance, hypersensitivity, anxiety attacks, irritability, anger, and outbursts. He reported he was not taking medications as prescribed. He reported fluctuating energy as well as mood swings. His limitations were noted to include poor coping skills, poor impulse control, and poor insight into his illness. On September 2006 VA psychiatric examination, the Veteran denied emotional estrangement from others. He was twice divorced; he reported that his first wife "let herself go" and would not care for herself or the home. He reported that his recent divorce was due to anger, blame, and differences in dealing with a "seriously acting-out" daughter. He had a girlfriend. He reported that he had recently retired after 25 years of working for a chemical manufacturing company; he reported he had a good work record, and he had not missed work due to disability. Business acquaintances at work had developed into good personal friends, and he reported that he still had friends from college and "neighborhood days". He complained of tremors, tenseness, and mild anxiety attacks, which he attributed to six recent major life changes: divorce, losing his home, moving, retirement, vasectomy, and other health concerns. He reported having problems letting go of things, which he attributed to concern over not having what was needed for ammo and medical supplies when going on ambushes at night in service. He reported recurrent distressing and/or intrusive memories, recurrent and distressing dreams that woke him up thrashing and kicking at his wife, difficulty falling or staying asleep, heightened irritability or outbursts of anger, and hypervigilance. He denied any avoidance symptoms, including problems with war-related movies or news reports, and he denied any difficulty with emotional closeness or estrangement from others. He reported having a good network of friends, as he had made and kept friends throughout his life. He denied any impact on his employment or education, as he completed a college degree in 3.5 years and had a 25-year career with one employer. He denied any serious problems due to drinking, though he admitted to being a daily heavy drinker. On mental status examination, the Veteran's appearance and eye contact were normal, and his attitude was cooperative and friendly. He was evasive and denied responsibility for problems in sensitive areas such as divorces or drinking. Speech was normal in rate, flow and volume. Thought processes were coherent, sequential, and relevant. Thought content revealed no hallucinations, delusions, or obsessive behavior. He reported hearing voices calling his code name; on questioning this seemed to happen when he was asleep. Mood was mildly hyper and possibly anxious, and affect was within a normal range and congruent with mood and topic. Memory was unimpaired in all three spheres of immediate, short-term, and long-term. Concentration and attention were within normal limits. Insight and judgment showed little or no awareness of his problems. Impulse control was adequate. There was no current suicidal ideation, intent, or plan. Psychological testing was deemed unnecessary. The diagnoses were PTSD, partially resolved, and adjustment disorder with anxious mood. A GAF score of 76 was assigned, reflecting mild symptoms. The examiner noted that the adjustment disorder was of recent origin and likely due to life changes and concerns. The examiner opined that the Veteran was capable of being employed without significant impairment. Based on the results of this examination, the RO issued the September 2006 rating decision on appeal, granting service connection for PTSD, rated 10 percent, effective June 8, 2006. On March 2007 VA treatment, the Veteran reported that he had retired in June and was upset about it. He denied any acute psychiatric issues other than difficulty sleeping, which he had experienced for many years. He reported volunteering for veterans and keeping himself involved. On mental status examination, mood was "fine" and affect was congruent to mod. Thought process and speech were logical, sequential, and clear. There was no evidence of auditory or visual hallucinations, delusions, or suicidal or homicidal ideations. Cognitive evaluation, insight, and judgment were fair. The assessment was adjustment disorder with anxiety features, a GAF score of 65 was assigned, reflecting mild symptoms. The Veteran reported that he thought he could deal with his insomnia and nightmares without medication as they were not "as bad as you think". On July 2007 VA treatment, the Veteran reported taking only Trazodone to help him sleep. On mental status examination, he was cooperative and alert with intact memory and average intelligence. Thought process was sequential and he denied hallucinations or delusions. Mood was good, though affect was depressed and minimally restricted in range. He denied any suicidal or homicidal ideation, as well as any auditory of visual hallucinations or delusions. He showed judgment and insight. He denied any symptoms of depression such as changes in sleep, interest, guilt, energy, concentration, appetite, or psychomotor agitation. He denied any manic symptoms or psychotic symptoms. The assessment was of adjustment disorder with anxiety features; a GAF score of 65 was assigned. VA treatment records from September through December 2007 show stable symptomatology largely similar to that reflected in the July 2007 treatment record. A December 2007 rating decision increased the initial rating to 30 percent, again effective June 8, 2006. On March 2008 VA treatment, the Veteran reported that he had stopped taking all of his psychiatric medications (Celexa, Risperdal, and Trazodone). He reported hearing voices calling his Vietnam War code name when he was sleeping, which he believed were nightmares; he reported hearing other "voices" saying "mild things he thought he heard in the shower". He denied any symptoms of depression or of a manic episode. He denied any auditory or visual hallucinations, delusions, illusions, thought insertion or withdrawal, thought broadcasting, or paranoid thoughts or ideas of reference. On April 2008 VA treatment, the Veteran reported that he was taking his medications as prescribed. VA treatment records from April 2008 through January 2009 show stable symptomatology largely similar to that reflected in the 2007 treatment records. On April 16, 2009 VA psychiatric examination, the Veteran reported that he was employed for 25 years as a purchasing agent where he had to work alone, lost 9 to 10 work days per month, and was "forced to resign" in 2006 due to increasing PTSD symptoms including isolation, irritability, depression, anxiety, and difficulty working with others. He reported a serious alcohol problem from separation from service until 2007 when he quit drinking alcohol. He reported a first marriage of 5 years and a second marriage of 20 years; he reported that he often argued with his wives and was divorced due to marital problems related to his PTSD symptoms. He reported experiencing repeated flashbacks triggered by loud noises, fireworks, helicopter sounds, and smells of rotting or burning. He reported poor sleep, averaging 2 to 3 hours per night, having trouble going to sleep, and often waking in a cold sweat after which he checks to see if the doors are locked. He reported nightmares of combat and explosions 3 to 4 times per week. He reported that he may attack anyone if awakened suddenly. He reported anhedonia with a loss of most of his past interests and avoiding former friends. He reported being hypervigilant and avoidance of crowds. He reported survivors' guilt and occasional thoughts of suicide though without any attempts. He showed emotional blunting and reporting isolating himself and being irritable to the point of getting into arguments with others. He reported that all of his symptoms had increased in frequency and intensity by the "post-military stressor of unstructured time" and frustration over continuous Iraq war news. On mental status examination, recent and remote memory were good. Concentration was extremely poor, and the Veteran appeared distant with a vacant stare. Affect was sad and anxious. Speech was coherent and relevant but showed some psychomotor slowing. There was some concreteness in his abstracting ability. Judgment was poor. The Veteran admitted to passive suicidal ideation and survivor guilt. He denied any homicidal ideation. He admitted to hypervigilance and anhedonia; he reported nightmares and flashbacks but showed no other delusions or hallucinations. The examiner diagnosed PTSD and alcohol dependence in remission, and assigned a GAF score of 55, reflecting moderate symptoms. The examiner opined that the Veteran's PTSD symptoms were poorly controlled by the structure of his work and "they forced him to resign" in 2006. The examiner opined that not having a work or leisure structure to distract him had caused a marked deterioration in the Veteran's condition, and war news had also increased all symptoms. The examiner found that the Veteran's condition had not improved with treatment and medication, and he remained isolated, hypervigilant, irritable, depressed, and unable to work with others or supervisors as he had poor concentration and very poor social functioning. On January 2010 VA treatment, the Veteran reported lack of satisfaction with his medications to treat his insomnia and anxiety, and concern regarding difficulty maintaining relationships. He reported nightmares and flashbacks of being under attack and seeing others being harmed. He reported being irritable, hypervigilant, and on edge, with difficulty concentrating and poor sleep. He reported occasionally feeling numb and isolating himself from others, especially during the holiday season. He reported feeling depressed for the previous year and a half, with decreased appetite and lack of interest or motivation. He reported suicidal ideations as recent as one week earlier, though he denied any current ideations or history of attempt. He reported that his [second] marriage ended due to his daughter's behavioral problems and his ex-wife's parenting style. He reported using alcohol to help him sleep though he had reduced his intake in the previous few months. He reported seeking treatment because he felt his symptoms had worsened. He reported being close to his older brother, not getting along with his sister, and being estranged from his daughter. He participated in leisure activities. On mental status examination, the Veteran was alert and cooperative though sometimes guarded. Attention and concentration were grossly intact. Mood was "depressed" and affect was within a normal range. Speech was normal in rate and volume. Thought process was circumstantial and talkative. No hallucinations or delusions were noted. Memory was grossly intact. Insight was poor and judgment was fair. The diagnoses included PTSD, anxiety, and depression, and a GAF score of 41 to 50 was assigned to reflect serious symptoms. Zoloft was prescribed to treat depression and PTSD as well as Ambien for sleep, and he was referred to an alcohol treatment program. On July 2010 VA treatment, the Veteran reported that he took the medications prescribed 6 months earlier for only one month and did not refill the prescriptions. He reported that since being off the medications, he had experienced increased nightmares, flashbacks, and irritability, and he continued to experience an exaggerated startle reflex, avoidance, hypervigilance, hyperarousal, emotional distance, and survivor guilt. He reported that his mood was "more down", his sleep had decreased, and his energy level and concentration had decreased as well. He denied any active or passive suicidal ideation, though he admitted to chronic fleeting passive thoughts of suicide. On mental status examination, eye contact was good and he was pleasant and cooperative. Psychomotor activity was within normal limits with no psychomotor agitation or retardation. Speech was fluent at a normal rate, volume, and tone. Mood was "ok but down", though affect tended to be bright and reactive. Thought process was sequential. He denied any hallucinations or delusions. Cognition was grossly intact, and insight and judgment were good. The assessment was PTSD with depressive symptoms, with rule-out assessment of underlying depression. A GAF score of 50 was assigned. Venlafaxine was prescribed and Zolpidem was refilled for insomnia. On September 2010 VA treatment, the Veteran reported that his symptoms had not changed with treatment by Venlafaxine, which caused unpleasant side effects of anxiety. Mental status examination results were identical to those in July 2010; the assessments included PTSD, depression, and a history of alcohol abuse, and a GAF score of 45 was assigned. Bupropion was prescribed in place of Venlafaxine. At the September 2010 Travel Board hearing the Veteran testified that his PTSD began to worsen "about a year and a half ago", or in early 2009. He testified that his social relationships had decreased over time and that he had experienced memory loss with increasing frequency, both of which he attributed to PTSD. He reported two divorces and estrangements from his daughter and his sister, and he was "trying to hang onto" his brother and the friends he had; he believed he had scared people over the years with irrational behavior and outbursts of anger and irritability due to PTSD. He reported spending most of his time by himself at home. He testified that he was seeing a VA psychiatrist on a regular basis and that he continued to have individual therapy every six weeks. On October 2010 VA treatment it was noted that the Veteran had stopped taking Bupropion due to side effects, and because he had not seen any changes in his symptoms. Mental status examination results and assessments were identical to those in September 2010, and a GAF score of 47 was assigned. Mirtazapine was prescribed in place of Bupropion. On February 2011 VA treatment, the Veteran reported that he was sleeping better with Remeron than with Zolpidem, and he was taking medication as needed rather than every night. He reported that he continued to experience ongoing PTSD symptoms without change since the last appointment. His mood continued to be irritable. He reported that he had four arguments since the previous appointment, two of which were with friends who had "broken off" the friendships. He reported that his appetite was fair and his energy level and concentration were down and unchanged. He denied any active or passive suicidal ideation though he reported ongoing fleeting passive suicidal thoughts without plan or intent. On mental status examination, he was well groomed with good eye contact, pleasant, and cooperative. Psychomotor activity was within normal limits with no agitation or retardation. Speech was fluent and at a normal rate, volume, and tone. Mood was "ok but down", and affected tended to be bright and reactive. Thought process was sequential. He denied violent or homicidal ideations, hallucinations, or delusions. Cognitively, he was grossly intact, and insight and judgment were good. The assessments included PTSD, major depression, and history of alcohol abuse, and a GAF score of 47 was assigned. On February 2011 VA psychiatric examination (two days later), the Veteran reported that he was forced to quit his job in 2006 due to increasing PTSD symptoms including isolation, irritability, depression, anxiety and difficulty working with others. He reported having a serious alcohol problem after separation from service until 2007 when he quit drinking. He reported that he often argued with his two ex-wives and was divorced due to marital problems related to his PTSD symptoms. He reported repeated flashbacks triggered by loud noises, fireworks, helicopter sounds, and smells of rotting and burning. He reported poor sleep, averaging 2 to 3 hours per night, with trouble going to sleep. He reported that he wakes up in a cold sweat and checks his home's perimeter. He reported nightmares of combat and explosions 3 to 4 times per week. He reported anhedonia with loss of most past interests. He reported avoiding former friends. He reported hypervigilance, preferring to avoid large crowds and sit with his back to the wall. He showed emotional blunting and reported isolating himself and becoming irritable to the point of getting into arguments. His symptoms were increased in frequency and intensity by the post-military stressors of unstructured time and frustration over continuous Iraq and Afghanistan war news. On mental status examination it was noted that the Veteran was unshaven and unkempt. He was oriented in all spheres. Recent and remote memory were good, though concentration was extremely poor. He appeared quiet and troubled. Affect was sad and anxious. Speech was coherent and relevant but showed some psychomotor slowing. There was some concreteness in his abstracting ability. Judgment was poor. He admitted to passive suicidal ideation and survivor guilt but denied homicidal ideation. He admitted to hypervigilance, anxiety, and anhedonia. He reported nightmares and flashbacks but showed no other delusions or hallucinations. The examiner assessed PTSD and alcohol dependence in remission, and assigned a GAF score of 40, reflecting serious symptoms. The examiner opined that the Veteran's PTSD symptoms were poorly controlled by the structure of his work and "they forced him to quit" in 2006. The examiner noted the Veteran had some deterioration in his symptoms due to a lack of work or leisure structure to distract him, and war news had also increased all of his symptoms. The examiner noted that the Veteran received outpatient treatment and medication, yet his condition had not improved. The examiner opined that, solely as the result of PTSD, the Veteran remained isolated, hypervigilant, irritable, easily angered, and unable to work with others or supervisors, had great difficulty following orders, had become increasingly anxious and depressed, was passively suicidal, had poor concentration, was unable to follow simple instructions, and had very poor social functioning. The examiner found that the Veteran's PTSD symptoms adversely affected his ability to work with others or alone, and opined that the Veteran's PTSD prevents him from performing activities consistent with his work experience and prior education or training. On April 2011 VA treatment, the Veteran reported that he liked the prescribed Mirtazapine better than any previous medication, stating that he knew he would "be a whole lot worse" if he was not taking it. He believed he was getting worse in terms of his "constant level of frustration", reporting that he believed he was "in a downward spiral" and would get "set off" easily. He reported that his anger had worsened, he had no patience, and he had had some altercations recently including one incident at a bar, another incident with the manager at his bank, and a third incident with a neighbor regarding a car blocking his driveway. He reported struggles with motivation. He also reported being "overly involved" with the VFW and taking on "more responsibility than he can handle". On symptom questionnaires, he answered "yes" to every symptom of depression and to every symptom of PTSD. He reported walking the perimeter of his complex and becoming suspicious of a neighbor who questioned his actions. He answered "yes" to all remaining survey questions, which the treating physician noted (if taken at face value) would indicate that he also had an eating disorder, obsessive compulsive disorder, panic disorder, social phobia, generalized anxiety disorder, somatoform disorders, psychosis, mania and alcohol dependence. He reported having two to three alcoholic drinks per day. Regarding employment, he reported that he took an early retirement 5 years earlier but was considering going back to work; meanwhile, he reported being very involved in the local VFW, serving as the Quarter Master and seeking possible election to the "second in the chain below the Commander". On mental status examination, he looked his appropriate age and well-nourished. His posture was comfortable, and eye contact was maintained throughout the interview. Personal hygiene was maintained, and he was dressed neatly and appropriately. His manner was cooperative and pleasant, and he was not irritable, loud or argumentative. He was attentive. There were no motor abnormalities or involuntary movements noted. He was alert and oriented to person, place, date, and situation. Speech was of a normal rate, rhythm, volume, and amount; there was no pressured speech or latency. He was articulate and spontaneous and the conversation flowed smoothly. He had no problems expressing himself or difficulties finding words, though he tended to be circumstantial and had to be re-directed often due to wanting to be complete about relating situations. Mood was "frustrated and irritable but not depressed", and affect was stable and fixed and congruent with mood. He denied suicidal ideation or thoughts of self-harm, as well as cognitive cognitions such as guilt, worthlessness, hopelessness or helplessness. Thought process was organized and goal directed, clear, coherent and logical. There were no perceptual abnormalities and hallucinations were denied. Memory was normal as evidenced by his ability to explain recent and past events within their personal history. Attention and concentration were intact. Insight and reasoning were intact, and judgment was adequate. The treating physician noted that it was unclear if the Veteran over-emphasized his symptoms and his diagnoses would have to be further explored because he endorsed most every psychiatric symptom, and there was only time to explore depression and PTSD symptoms. The diagnoses were nevertheless PTSD and depression, and a GAF score of 63 to 65 was assigned. The examiner noted that the Veteran reported being retired yet "now busier than when he was working". The Board notes that the record reflects that the Veteran has been assigned psychiatric diagnoses other than PTSD (depression, history of alcohol abuse) which are not service connected. While symptoms/impairment due to disability that is not service connected generally may not be considered in rating a psychiatric disability, governing caselaw provides that where it is not possible to distinguish the effects of a nonservice-connected disability from those of the service-connected disability being rated, the reasonable doubt doctrine dictates that all symptoms be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App, 181 (1998). In the instant case, the examiners have generally not distinguished symptoms due to the Veteran's PTSD from those due to co-existing and nonservice-connected psychiatric disability. Therefore, for the limited purposes of this appeal only, the Board will consider all psychiatric symptoms shown as due to the service-connected PTSD. Notably, in assigning the ratings on appeal the RO also did not exclude any symptoms from consideration as due to nonservice-connected disability. The reports of the VA examinations and the VA treatment records, overall, do not show that, prior to April 16, 2009, symptoms of the Veteran's PTSD produced occupational and social impairment with reduced reliability and productivity, so as to meet the criteria for a 50 percent rating. He did not, for example, display flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. While he was not employed due to an early retirement, the impact of the PTSD on his level of functioning, as reflected by his relationships with family and friends, is inconsistent with a disability picture of reduced reliability and productivity. The GAF scores assigned for this period of time, ranging from the mid 50's to 76 reflect moderate or of lesser severity degree symptoms, and do not present a separate basis for the award of an increased rating. However, on longitudinal review of the record, the Board finds that as of the April 16, 2009 VA psychiatric examination, the Veteran's PTSD is shown to have been manifested by symptoms productive of occupational and social impairment with reduced reliability and productivity. He displayed circumstantial thought process, poor concentration and insight, impaired abstracting ability, disturbances of motivation and mood, and difficulty in maintaining social relationships (whereas he had previously held a circle of good friends from several time periods of his life for many years). Significantly, throughout the appeal period the Veteran has been unemployed/retired and under continuous ongoing treatment for his PTSD. While many of the symptoms associated with a 50 percent rating (such as difficulty understanding commands, panic attacks, memory impairment, etc.) are not shown, the Veteran is shown to have had mood (depression) and motivation disturbances since April 16, 2009. The GAF scores assigned since that time (predominantly between 40 and 50) reflect serious symptoms consistent with a finding of occupational and social impairment with reduced reliability and productivity. Consequently, the Board finds that a 50 percent rating for PTSD is warranted from April 16, 2009, but no earlier. The record does not reflect that at any time the Veteran's PTSD was manifested by symptoms productive of occupational impairment with deficiencies in most areas. While deficiencies as to mood and family relations are shown, deficiencies as to work, judgment and thinking are not. Examinations and treatment records during the period of time under consideration do not show any more than fleeting passive suicidal thoughts, or obsessional rituals which interfere with normal activities, speech disturbances, near-continuous panic, spatial disorientation, neglect of appearance or hygiene (he is regularly described as neatly-groomed, with the sole exception of the February 2011 VA examination). It does not escape the Board's attention that when the Veteran was seen for treatment two days prior he was described as well-groomed. It appears from the overall record that his presentation as slovenly and unkempt in February 2011 was compensation-driven, and inconsistent with the overall record. Notably, the Veteran's own descriptions of his functioning throughout the appeal period do not present a disability picture of a gravity consistent with a 70 percent rating. The Board notes the lay statements submitted by the Veteran in support of this claim. Those statements detail the types of problems that result from his PTSD symptoms. They do not reflect a level of impairment associated with a 70 percent rating. The Board notes the GAF score of 40 assigned on the February 2011 VA examination, which would appear to suggest a higher level of psychiatric impairment than is recognized by a 50 percent rating. However, that score is unexplained, is inconsistent with contemporaneous reports of actual symptoms, and in light of the overall evidence may not reasonably be found dispositive. For example, GAF scores of 31-40 reflect some impairment in reality testing or communication; no such symptoms are shown in this case, and the Veteran does not neglect his family - rather, he has stated that he is deliberately estranged from his daughter due to her disturbing behavior, and he remains close to his brother. The overall record shows that the schedular criteria for a 50 percent rating were met or approximated as of, but no earlier than, April 16, 2009; and that the schedular criteria for a 70 percent rating were not met or approximated at any time. Furthermore, inasmuch as the record does not show PTSD symptoms or impairment not encompassed by the schedular criteria, those criteria are not inadequate, and referral of the matter for consideration of an extraschedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111 (2008). The matter of entitlement to a TDIU rating is addressed in the remand below. ORDER A rating in excess of 30 percent for PTSD for the period prior to April 16, 2009 is denied. A 50 percent rating is granted for the Veteran's PTSD from April 16, 2009, but no earlier; a rating in excess of 50 percent for PTSD is denied. REMAND In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims held, in essence, that when the matter of entitlement to a TDIU rating is raised by the record in a claim for increase, such matter becomes part of the increased rating claim. Here, the Board had previously (in February 2011) noted that the Veteran's testimony regarding the circumstances of his employment and early retirement raised a question of possible entitlement to TDIU. On remand, the RO was asked to seek from the Veteran's last employer information regarding his work record and the reason for his early retirement, and the RO was then instructed to make a finding as to whether any TDIU issue was raised by the record. In an April 2011 supplemental SOC, the RO noted the February 2011 VA examiner's opinion regarding the Veteran's employability and found that it "does not support a finding that [the Veteran's] disability precludes [his] ability to secure and maintain gainful employment that, on April 5, 2011, [he was] reported to be considering". However, entitlement to a TDIU rating has now been expressly raised by the Veteran, by virtue of his submission in May 2011 of a VA Form 21-8940, Application for Increased Compensation Based on Unemployability. The Board notes that entitlement to a TDIU rating has not been developed or adjudicated by the RO. Though the Veteran does not currently meet the schedular requirements, 38 C.F.R. § 4.16(b) remains for consideration; the matter of entitlement to TDIU must be developed and adjudicated. Accordingly, the case is REMANDED for the following action: 1. The RO should fully develop the matter of the Veteran's entitlement to a TDIU rating (to specifically include ascertaining the circumstances of the loss of his most recent employment in 2006 and obtaining his vocational rehabilitation file for association with the record). He must co-operate in this matter by providing any necessary releases. 2. The RO should then adjudicate the matter of the Veteran's entitlement to a TDIU rating. If it is denied, the Veteran should be advised of his appellate rights. If he files a notice of disagreement and a substantive appeal after an appropriate SOC is issued, such matter should be returned to the Board, if in order, for further review. The Veteran should be advised that this matter will not be before the Board unless he initiates, and perfects, an appeal as to any negative determination by the RO regarding his entitlement to a TDIU rating. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs