Citation Nr: 1135704 Decision Date: 09/22/11 Archive Date: 10/03/11 DOCKET NO. 06-11 644 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD A. Lindio, Counsel INTRODUCTION The Veteran had active duty service from August 1988 until March 1996. This matter originally came before the Board of Veterans' Appeals (BVA or Board) on appeal from a January 2005 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. This case was previously before the Board in May 2010 and was remanded for additional development. As noted in the previous decision, the Veteran was initially granted service connection for PTSD by the January 2005 rating decision. The notice letter associated with the January 2005 rating decision indicates that the decision was mailed in February 2005. The Veteran subsequently, in a June 2005 statement requested that his service-connected PTSD be reevaluated. A September 2005 rating decision subsequently denied an increased rating for PTSD. The Veteran submitted a Notice of Disagreement in January 2006, within one year of the January 2005 rating decision. As such, the Board has taken that January 2006 Notice of Disagreement to apply to the original January 2005 rating decision. A review of the file reflects that the Veteran filed an informal claim of entitlement to TDIU in September 2005; he claimed that he was unemployed due to his mood swings, which he attributed to his service-connected PTSD. The issue of TDIU is considered part and parcel of the Veteran's PTSD increased rating claim. Rice v. Shinseki, 22 Vet. App. 447 (2009). The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to May 27, 2011, the Veteran's PTSD is not manifested by occupational and social impairment with reduced reliability and productivity. 2. From May 27, 2011, The Veteran's PTSD is manifested by occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. Prior to May 27, 2011, the criteria for an initial evaluation in excess of 30 percent for PTSD have not been met,. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2010). 2. From May 27, 2011, the criteria for an initial evaluation of 50 percent, and no higher, for PTSD have been met,. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This appeal arises from disagreement with the initial evaluation following the grant of service connection for PTSD. Courts 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). As to VA's duty to assist, the Board notes that pertinent records from all relevant sources identified by him, and for which he authorized VA to request, have been obtained. 38 U.S.C.A. § 5103A. VA has associated with the claims folder the service medical records and reports of his post-service treatment. He was also afforded formal VA examinations, most recently in May 2011. Furthermore, the development directed in the May 2010 Board remand has substantively been complied with; additional VA medical records have been associated with the claims file, a new VA examination was provided to the Veteran and the RO/AMC considered the Veteran's employability in relation to his PTSD. As such, further development is not indicated. Applicable Law Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian life. Generally, the degree of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity to the several grades of disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Separate Diagnostic Codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. While the Veteran's entire history is reviewed when making a disability determination, 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 a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, at the time of an initial rating, as is the situation in this case, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). A recent decision of the United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Under the relevant rating criteria, a 30 percent disability rating is assigned for a mental disorder (including PTSD) when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is applicable 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; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation will be assigned where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; 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 the inability to establish and maintain effective relationships. Id. 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; and memory loss for names of close relatives, own occupation, or own name. Id. In evaluating psychiatric disabilities, the Board has adopted the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., American Psychiatric Association (DMS-IV). That manual includes a Global Assessment of Functioning (GAF) scale reflecting psychological, social and occupational functioning on a hypothetical continuum of mental illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996)(citing DSM-IV). A score of 41-50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g. no friends, unable to keep a job). A score of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or coworkers). A score of 61 to 70 indicates some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well with some meaningful interpersonal relationships. See Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, DC, American Psychiatric Association, 1994. Merits of the Claim The Veteran contends that his service-connected PTSD is more severe than indicated by the 30 percent disability rating previously granted him. In the August 2011 Written Brief Presentation, his representative claimed that the Veteran's signs and symptoms consisted of occupational and social impairment with reduced reliability and productivity warranting a higher disability rating. VA medical records generally indicated continued treatment for a psychiatric disorder. An April 21, 2004 VA medical record noted daily depression and trouble falling asleep and staying asleep. The examiner found the Veteran to be neatly dressed and groomed; he was oriented to time, person, place, and situation; he had a normal rate and volume of speech. The examiner reported an appropriate/moderately depressed affect/mood and a logical and goal directed thought process. The examiner found no delusions and no suicidal ideation/homicidal ideation; there were no obsession/compulsions, hallucinations/illusions, or anxiety. The examiner also found him able to perform tasks concerning concentration and memory, and to have good judgment/insight. The examiner determined that he had moderate major depression, single episode, and probable PTSD with a GAF score of 50. An April 30, 2004 VA medical record noted that the Veteran reported that he could not hold down a job, as he cannot tolerate people; he lost his temper easily. The examiner found him to be neatly groomed, with clear speech, clear and logical thoughts, and sober mood, but otherwise alright. A May 21, 2004 VA medical record found the Veteran to be neatly dressed in a casual manner, with good eye contact, ability to communicate, grooming, and hygiene. The examiner also found him to be independent with activities of daily living; he was oriented, alert, with good through process, depressed/flat mood/affect; and fair judgment and insight. The examiner found no psychotic symptoms. A July 30, 2004 VA medical record noted that the Veteran reported "mood swings," "anger", and self-hatred. The examiner noted that the Veteran reported that he started drinking in his teens and continued drinking heavily in the army; at that time he also had numerous drug-related offenses. The examiner noted no history of suicidal acts or self harm, but that he did have a history of violence, including when not on drugs. The examiner found him to be neatly groomed and dressed, with normal eye contact; he was fully alert and oriented, with normal and logical speech and thought process. The examiner found him to have alcohol and cocaine dependence in remission, major depressive disorder in early remission, and delayed combat related PTSD. In a December 22, 2004 VA medical record, he reported increased vivid dreams with medications and mood swings. The examiner found him to be casually dressed, with good eye contact, spontaneous and appropriate speech, mood congruent with affect, and intact judgment and insight without suicidal ideation/homicidal ideation/audio verbal hallucination. A June 9, 2005 VA medical record noted that the Veteran had no major conflicts at work the past week; there were minor aggravations he was able to handle. A June 30, 2005 record noted improved perspective due in part to medication change and confidence in vocalizing opinions to those frustrated with him. The Veteran received a VA examination in August 2005. The Veteran reported that he last worked in 2001 as a deck hand, for a 3 month period. He reported PTSD symptoms of dreams of Iraq 2-3 times a month, which is less frequent than previously. He also reported anger outbursts 2-3 times a week and flashbacks 1-2 times a month, the last of which was 2 months previously. He further reported startle symptoms, anger problems, and irregular sleep. The August 2005 VA examiner noted a complicated, intense history of substance abuse that was likely still active. The Veteran reported that he was unable to keep a job; his attitude was a barrier to maintaining steady employment. He indicated that since discharge he had been divorced, unable to keep a job, and that his children have adjusted to his condition. The August 2005 VA examiner found him able to engage in a normal range and variety of activities of daily living, with no restriction of his typical routine. The examiner found him to have no signs or symptoms of emotional distress; thought processes were logical, coherent, and relevant. The examiner noted that he was articulate, attractive, well dressed and groomed, mentally intact, and cooperative with good social skills, intelligence, and understandable speech. The examiner indicated that he was oriented to time, place, person, and situation; affect was within normal limits. The examiner also found good reasoning and a good fund of general information; there was no psychomotor slurring or agitation and verbal comprehension was excellent. The examiner also noted that concentration was within normal limits, though the Veteran may have withheld his best efforts and complained of short term memory problems. The August 2005 VA examiner endorsed the symptoms of anxiety, panic attacks, depression, insomnia, appetite disturbance, anhedonia, nightmares, temper tantrums, and paranoia, though the Veteran denied auditory or visual hallucinations, as well as homicidal and suicidal ideation. The August 2005 VA examiner found the Veteran's main symptoms to deal with his continued alcohol abuse and intolerance to supervision. The examiner opined that the Veteran's condition has not worsened over time and that the examiner was skeptical as to the Veteran's report of cardinal symptoms of PTSD, believing that the Veteran may be exaggerating reports of symptoms, especially given his disciplinary problems while in service and because his Minnesota Multiphasic Personality Inventory was totally invalid because of probable exaggeration. The examiner found PTSD with a GAF of 70 related to it. The examiner opined that the Veteran's condition had not worsened and that per a VA medical record from June 2, 2005 it had improved in a variety of patterns. The examiner found that the Veteran's chief issues dealt with his substance abuse. An August 10, 2008 VA medical record found the Veteran to be well groomed without psychomotor retardation or agitation. The examiner found his mood to be distressed and angry and affect congruent with mood; speech was of normal rate, tone and volume and fluent; thought process was logical and goal directed. A December 8, 2008 VA medical record noted that the Veteran was appropriately attired, neat, and well groomed. The examiner found him to be alert and oriented, with conversational and conversation relevant to experiences, problems and concerns. The examiner noted that affect was dull/flat and mood anxious; however, eye contact was good and recent/long-term memory appeared intact. The Veteran denied suicidal/homicidal ideation and appeared in no acute emotional distress. A February 18, 2009 VA medical record noted that the Veteran reported depression his whole life, with a serious bout in 1992-1993. The Veteran denied suicidal ideation due to his strong religious beliefs. He complained of poor motivation and tended to isolate; the reported minor problems sleeping off and on. The examiner found him to be alert, oriented, neatly dressed, well groomed, calm, and affable; he spoke clearly and coherently and had no gross cognitive defects. A GAF score of 56 was assessed. An April 14, 2009 VA medical record noted that the Veteran informed his medical provider, via a letter, that he was serving time in jail due to drug related charges. A February 19, 2010 VA medical record found him to appear neat, alert, and oriented; he was able to converse relative to experiences and his affect was dull/flat and mood anxious. The examiner found his recent/long-term memory to appear basically intact. He denied suicidal ideation/homicidal ideation and was active and cooperative; he did not appear to be in acute emotional distress. The examiner provided a GAF of 55. The Veteran received another VA examination in May 2011, which included a claims file review. The Veteran reported that he sleeps 2 to 3 hours, and that he has not had nightmares for a while. He also reported being irritable and lashing out verbally, flashbacks, that he disliked being around crowds or noise, and felt paranoid and on guard. He further claimed that he could not get along with co-workers and that he experienced symptoms weekly to daily. He claimed that he last worked in 2008 as an electrician, but that the use of impact guns, gunpowder in construction set him off. He also indicated that he had no relationship and only saw one of his 3 children with whom he got along pretty well; he had a distant relationship with his family. He further reported socializing sometimes with others in the neighborhood, but mostly he just read. The May 2011 VA examiner found no apparent impairment of thought process or communication or impairments of activities of daily living due to PTSD. The examiner found him to be fully oriented to person, place, time, and situation. The examiner also found him to be well groomed, friendly, and cooperative, with a somber mood with appropriate, congruent affect. The Veteran denied suicidal ideation or planning and homicidal ideation or intent; he also denied hallucinations and delusions. The examiner determined attention, memory and judgment to appear to be within normal limits. The examiner diagnosed him with PTSD and a GAF score of 55, based on subjectively reported PTSD symptomatology and functioning in the current examination. The May 2011 VA examiner found no total occupational and social impairment due to PTSD and no deficiencies in judgment, thinking, family relations, work, mood, or school. The examiner did note reduced reliability and productivity due to PTSD symptoms, including suspiciousness, disturbances of motivation, ongoing anxiety, difficulty with maintaining effective work and social relationships, and that they have affected interpersonal and occupational performance. The examiner found no subjective or objective evidence to suggest that the Veteran is incompetent to manage his finances. The Veteran has reported numerous PTSD symptoms via lay statements. In September 2005, he claimed sporadic mood swings and recurring dreams. He also reported limited communication with his children and extreme anxiety in unfamiliar terrain. In February 2006, he reported recurrent dreams that make sleeping almost non-existent. In September 2008 he reported detachment from others and paranoia with strangers. In September 2008, the Veteran's ex-wife reported that the Veteran became detached emotionally and introverted. She claimed that he was paranoid, forgetful, and quickly agitated; he had mood swings. PTSD Disability Rating prior to May 27, 2011 As previously noted, the Veteran was originally assigned a 30 percent disability rating for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, and mild memory loss. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran's representative has argued that the Veteran had reduced reliability and productivity, as well as some difficulty with interpersonal functioning and nightmares. The Veteran and his ex-wife similarly provided lay statements, as to being introverted, paranoid, forgetful, quickly agitated, and mood swings. However, even when considering such statements, the record indicates that the Veteran's PTSD is more indicative of his current 30 percent disability rating than a higher one. Consistent with a 30 percent disability rating, the Veteran has been found by multiple VA medical records and the VA examinations to have anxiety, depressed mood, chronic sleep impairment, suspiciousness, and panic attacks. All such symptoms are consistent with a 30 percent disability rating. Furthermore, a 30 percent disability rating is indicated by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, but generally functioning satisfactorily with routine behavior, self-care, and normal conversation. The record does indicate occasional decrease in work efficiency and intermittent inability to perform occupational tasks. However, although the Veteran claims that his last continuous employment occurred in 2001, the VA medical records are peppered with various reports of intermittent employment and an ability to perform occupational tasks. For example, the June 9, 2005 VA medical record noted that the Veteran had no major conflicts at work the past week; there were minor aggravations he was able to handle. Additionally, the record clearly indicates that prior to May 27, 2011, the Veteran was generally functioning satisfactorily, with routine behavior, self-care, and normal conversation indicative of a 30 percent disability rating. His VA medical records and August 2005 VA examination repeatedly found him able to perform activities of daily living, to be neatly groomed, and to have clear, normal, and/or logical speech. Although the Veteran does have some symptomatology associated with the criteria for the next higher rating of a 50 percent, the record, overall, indicates that his disability picture is more indicative of a 30 percent disability rating. As pointed out by the Veteran's representative, the Veteran has been found to have a flattened affect at times; however, the majority of the VA medical records found his affect to be congruent with his mood, as in the August 2005 VA examination. Similarly, although the Veteran's representative indicated that the Veteran's panic attacks were indicated by his nightmares 1 to 2 times a week, as indicated in an April 30, 2004 VA medical record, subsequent VA medical records indicate that his nightmares do not occur that often. In the August 2005 VA examination the Veteran reported that the PTSD symptoms of dreams of Iraq 2-3 times a month, which is less frequent than the more than once a week indicated by a 50 percent disability rating. Additionally, as previously indicated, his speech was consistently reported as clear, normal, and/or logical by VA medical providers; it was not circumulatory or stereotyped as indicated by a 50 percent disability rating. The record also does not show other indications of a 50 percent disability rating, like difficulty in understanding complex commands, impairment of short and long term memory, impaired judgment, or impaired abstract thinking. VA medical records repeatedly found his thought process to be logical, coherent, and relevant, as well as mentally intact, as indicated by the August 2005 VA examiner. VA medical records, such as the December 8, 2008 and February 19, 2010 ones, found recent/long-term memory to appear intact. An April 30, 2004 VA medical record noted clear and logical thoughts and a May 21, 2004 one noted good thought process and fair judgment and insight. The record prior to May 27, 2011, thus indicates that although the Veteran's PTSD symptoms include some symptoms consistent with a 50 percent disability rating, overall they more closely resemble his current 30 percent disability rating. As was previously discussed, the majority of the Veteran's symptoms are encompassed by those indicated by a 30 percent disability rating and while there are some symptoms indicated by the 50 percent rating criteria the overall evidence indicates only occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Additionally, the Veteran clearly generally is functioning satisfactorily with routine behavior, self-care, and normal conversation. His PTSD symptoms also do not encompass the majority of those indicative of a 50 percent disability rating such as circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short or long term memory; impaired judgment; or impaired abstract thinking. Furthermore, the Veteran's GAF scores have ranged from 50 to 70. The GAF score of 70 is consistent with only some mild symptoms or some difficulty in social or occupational functioning, but generally functioning pretty well with some meaningful interpersonal relationships. On the other end of the scale, a GAF of 51-60 indicates moderate symptoms and 50 indicates serious symptoms. The Veteran's PTSD symptoms do not rise to the level of a 50 percent evaluation prior to May 27, 2011. Although the Veteran's GAF scores at times reflect some serious symptoms, the Court has held that a GAF score is only one factor in determining a veteran's disability rating. See Brambley v. Principi, 17 Vet. App. 20, 26 (2003); Bowling v. Principi, 15 Vet. App. 1, 14 (2001). The majority of the Veteran's symptoms do not reflect such a severity to warrant a 50 percent evaluation. The Board must base its decision on the evidence of record, as it is applicable to the rating code. Based on the evidence, the Veteran's symptoms are not indicative of the type of severity warranting a 50 percent rating at this time, prior to May 27, 2011. Additionally, the Board has considered the statements of the Veteran as to the extent of his current PTSD. He is certainly competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, in evaluating a claim for an increased schedular rating, VA must only consider the factors as enumerated in the rating criteria discussed above, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204, 208 (1994). To the extent that the Veteran argues or suggests that the clinical data supports an increased disability rating or that the rating criteria should not be employed, he is not competent to make such an assertion. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). In evaluating the evidence and rendering a decision on the merits, the Board is required to assess the credibility, and therefore the probative value, of proffered evidence in the context of the record as a whole. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The Board finds that the post-service medical treatment records to carry far more weight of credibility and probative value that the recent lay statements. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran). Such records are more reliable, in the Board's view, than the unsupported assertions of events now over half a century past, made in connection with his claim for monetary benefits from the government. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the Veteran is an interested party; personal interest may, however, affect the credibility of the evidence). Furthermore, in regards to the lay evidence provided by the Veteran, the Board finds such evidence to not be completely credible given the multiple conflicting statements he has provided over the course of his appeal, as indicated in his VA medical records. In his August 2005 VA examination, he reported that he last worked in 2001 as a deck hand; however, in a June 9, 2005 VA medical record he reported that he had not had major conflicts at work the past week. Additionally, in a December 22, 2004 VA medical record, the record indicated that the Veteran was planning to start nursing school the following January. He has also repeatedly alternated in his reports of his relationship with his children. In the August 2005 VA examination he reported that his children had adjusted to his PTSD. However, in an October 7, 2005 VA medical record indicated that his children reported that his family environment was tense, though they desired more of a relationship with him. PTSD disability rating from May 27, 2011 Although the record does not support an increased rating prior to May 27, 2011, the findings of the May 27, 2011 VA examination are supportive of a rating increase, to a 50 percent disability rating, but no higher. The May 27, 2011 VA examiner specifically found the Veteran to have occupational and social impairment with reduced reliability and productivity. The examiner also noted disturbances of motivation and mood and difficulty establishing and maintaining effective work and social relationships. Such findings are supportive of a 50 percent disability rating. Although the May 27, 2011 VA examination continued to find symptoms indicative of a 30 percent disability rating, such as continued findings of no apparent impairment of thought process or communication, and an appropriate and congruent affect, giving the Veteran the benefit of the doubt the Board finds that sufficient evidence is of record to find him to have occupational and social impairment with reduced reliability and productivity indicative of a 50 percent disability rating, from the date of the examination. Such findings are not evident prior to that date, as his VA medical records prior to the examination do not support such a finding, as indicated in the previous section concerning the time period prior to May 27, 2011. However, a rating in excess of 50 percent is not indicated by the record. The record does not demonstrate a 70 percent evaluation for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Symptoms indicative of a 70 percent disability rating are not of record. The Veteran has repeatedly and consistently denied suicidal ideation. An April 21, 2004 VA medical record found no delusions and obsession/compulsions; subsequent VA medical records also found no delusions and did not indicate that he had obsessions or compulsions. Additionally, as previously indicated, the Veteran was repeatedly found by examiners to have logical and coherent speech, not speech intermittently illogical, obscure, or irrelevant, which would be indicative of a 70 percent disability rating. Additionally, the record does not indicate near-continuous panic or depression affecting the ability to function independently, appropriately and effectively or impaired impulse control (such as unprovoked irritability with periods of violence). The May 2011 VA examiner found no total occupational and social impairment due to PTSD and no deficiencies in judgment, thinking, family relations, work, mood, or school. The examiner also found no subjective or objective evidence to suggest that the Veteran is incompetent to manage his finances. To the extent the Veteran has claimed his nightmares to be panic attacks, the May 2011 VA examiner noted that the Veteran had reported not having nightmares for a while. Additionally, although the Veteran reported irritability and lashing out verbally during the May 2011 VA examination, the record did not indicate unprovoked irritability with periods of violence. In regards to spatial disorientation or neglect of personal appearance and hygiene indicative of a 70 percent disability rating, the record has continuously found him to be neatly groomed and dressed and to have no impairment of thought process. The May 2011 VA examiner found his attention, memory, and judgment to be within normal limits. Similarly, to the extent he may claim an inability to establish and maintain effective relationships; the record does indicate that he reported socializing at times with other in his neighborhood. Although the Veteran may show symptoms that could be indicative of a 70 percent disability rating, such as his claim difficulty in adapting to stressful circumstances (including work or a work-like setting) or his reports of an inability to have relationships, overall the record does not indicate that his disability picture from May 27, 2011 to be more indicative of a rating in excess of 50 percent. Rather, the disability picture is better encompassed by the 50 percent disability rating granted him, from May 27, 2011. Additionally, although GAF scores are not dispositive on the matter, the GAF score of 55 found on the May 2011 VA examination is indicative of a moderate disability, which could be characterized by a 50 percent disability rating. Extraschedular Rating In view of the Board's remand below concerning the matter of TDIU being part and parcel of the Veteran's increased rating claims on appeal (See Rice v. Shinseki, 22 Vet. App. 447 (2009)), the matter of consideration of an extra-schedular evaluation is deemed inextricably intertwined with the TDIU claim on Remand ORDER An initial evaluation in excess of 30 percent for PTSD is denied, prior to May 27, 2011. From May 27, 2011, a 50 percent evaluation, and no higher, for PTSD is granted, subject to the provisions governing the award of monetary benefits,. REMAND As previously noted, the Veteran has repeatedly stated that his PTSD makes him unemployable. The issue of TDIU is considered part and parcel of the Veteran's PTSD increased rating claim. Rice v. Shinseki, 22 Vet. App. 447 (2009). As noted in the August 2011 Written Brief Presentation, the development directed by the Board in its last remand was not accomplished. The law mandates that where the remand orders of the Board or the Courts are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, the May 2010 Board remand directed the RO/AMC to consider the Veteran's TDIU claim. It noted that the evidence of record indicates that the Veteran has been partially employed during this time period, though possibly in a marginal employment type of unemployment. As the RO/AMC has not considered the TDIU aspect of this claim under 38 C.F.R. § 4.16, the matter was remanded to the RO/AMC for consideration thereof in the first instance. The Board also noted that, the RO/AMC may decide to pursue further development of the Veteran's employment history, or to obtain additional medical evidence or medical opinion, as is deemed necessary. No further consideration of the Veteran's TDIU claim was performed by the RO/AMC after the case was remanded. Accordingly, the case is REMANDED for the following actions: 1. The RO/AMC shall consider whether the Veteran is entitled to TDIU under the provisions of 38 C.F.R. § 4.16 on the basis of his service-connected PTSD. The RO/AMC may further develop the Veteran's history of employment, or obtain additional medical evidence or a medical opinion, as is deemed necessary. 2. When the development requested has been completed, the case should again be reviewed by the RO/AMC on the basis of the additional evidence. If the benefit sought is not granted, the Veteran should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 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). 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). ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs