Citation Nr: 1135792 Decision Date: 09/23/11 Archive Date: 10/03/11 DOCKET NO. 08-23 135A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an increased evaluation for posttraumatic stress disorder, currently evaluated as 50 percent disabling. 2. Entitlement to a total disability rating based upon individual unemployability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1969 to February 1972. This matter comes properly before the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office in Philadelphia, Pennsylvania (RO). FINDINGS OF FACT 1. The Veteran's posttraumatic stress disorder (PTSD) is manifested by chronic depression, survivor's guilt, recurrent intrusive thoughts of Vietnam, sleeping disturbance with very frequent nightmares, flashbacks, anxiety, panic attacks, irritability, anger, hypervigilance, hyperarousal, exaggerated startle response, difficulty with concentration and attention, social isolation, inability to relate to others or express intimate feelings, lack of interest and motivation, and avoidance behaviors. Objectively, the Veteran was appropriately groomed, alert, fully oriented, cooperative, and not grossly psychotic. He exhibited depressed mood, restricted and blunted affect, normal speech and motor behavior, coherent and goal-directed thought process, fair judgment and insight, transient suicidal ideation, and thought content without any thought disorder, delusion, or hallucination. 2. The evidence of record demonstrates that the Veteran's service-connected PTSD alone renders him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an increased evaluation of 70 percent, but no more, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). 2. The criteria for a total disability rating based on individual unemployability (TDIU) have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (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). The RO's September 2006, December 2007, May 2008, and March 2011 letters advised the Veteran of the necessary elements of the notice requirements. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (noting that a VCAA defect may be cured by issuance of a fully compliant notification followed by a re-adjudication of the claim); see also Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Specifically, the RO's May 2008 letter informed the Veteran of what evidence was required to substantiate his claim for increased disability ratings and of his and VA's respective duties for obtaining evidence. The Veteran was also asked to submit evidence or information in his possession to the RO. See Vazquez-Flores v. Shinseki, 580 F. 3d 1270 (Fed. Cir. 2009). Further, the purpose behind the notice requirement has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claim, including the opportunity to present pertinent evidence. Thus, the Board finds that the content requirements of the notice VA is to provide have been met. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In addition, the duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records, as well as his VA and private medical records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The RO has also obtained multiple VA psychiatric examinations to determine the severity of the Veteran's PTSD. 38 C.F.R § 3.159(c)(4). The VA examinations were based upon a review of the Veteran's claims file, clinical examination of the Veteran, and consideration of the Veteran's statements. The VA examiners discussed the history of the Veteran's condition, conducted an examination of the Veteran, and elicited information from the Veteran concerning the functional aspects of his disability. As they provide sufficient detail to determine the current severity of the Veteran's service-connected PTSD, the Board finds that the VA examinations obtained in this case were adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran has neither advanced an argument that any of the VA examinations of record was deficient in any respect, nor that he was prejudiced thereby. Barr, 21 Vet. App. at 312. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this issue, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (finding that the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (holding that the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2010). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2010). In 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; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Veteran was afforded a VA examination in October 2006. The Veteran reported that overall his marital relationship was supportive and loving. He reported working as a forklift driver and having difficulty at work due to language barrier and fear of losing his job. He stated that he got along fine with his family but had no real close friends and tended to keep to himself. He rarely went outside because he did not like crowds and described hypervigilant symptoms. The Veteran reported continuing to struggle with PTSD symptoms, such as intrusive thoughts and recurring dreams about Vietnam, moderate but occasionally intense psychological distress, anxiety, panic-like symptoms during which he experienced shortness of breath and chest tightness, sleeping difficulty, irritability, hyper startle response, hypervigilance, avoidance behaviors, inability to relate to others or express intimate feeling, and diminished ability to enjoy things. No psychotic symptoms were shown. Objectively, the Veteran was casually dressed and groomed, and appeared to be in no acute distress. He was alert, oriented, and was felt to be a reliable historian. His overall affect was euthymic, however somewhat restricted at the same time. He exhibited good eye contact; normal speech; clear, coherent, goal directed and logical thought process; and through content free of any obsessions, compulsions, delusions, or hallucinations. He denied suicidal or homicidal thoughts. There was no evidence of major concentration or memory disturbances, and his judgment and insight were "pretty good." The examiner found that the Veteran was able to manage his financial affairs. The diagnosis was PTSD, and a global assessment functioning (GAF) score was listed as 51 to 60. See QUICK REFERENCE TO THE DIAGNOSTIC CRITERIA FROM THE DSM-IV, 46-47 (1994) (DSM-IV). In an October 2006 VA psychiatry note, the Veteran reported sleep interrupted by nightmares and intrusive thoughts about his experience in Vietnam. He felt that these symptoms were worse after he talked on the phone with friends who were in combat with him. He was socially withdrawn and stated that he had no social life. He did not like to be around people and always wanted to keep his back covered. The Veteran had flashbacks; kept checking his windows and doors at home; and got easily angered. On mental status examination, the Veteran was casually groomed and dressed, and fully oriented. He exhibited cooperative attitude; intense affect; chronic depressed mood; no involuntary movements; coherent, rational and goal directed speech; and intact associations. He reported nightly flashbacks, with no auditory or visual hallucinations and chronic suspiciousness, but no paranoid delusions. He showed intelligence of above average, intact attention and concentration, no gross memory deficits, and fair judgment and insight. The Veteran reported transient thoughts of suicide by shooting himself with a shotgun, but denied any current active plan or intent to harm himself. The diagnoses were PTSD and depression, not otherwise specified. The examiner noted that the Veteran's chronic PTSD symptoms were moderate and that he was socially isolated. VA psychiatry counseling therapy notes, dated from October 2006 to August 2007 show that the Veteran participated in therapy sessions for PTSD symptoms, to include nightmares of traumatic events, hypervigilance, and sleep disturbances. The Veteran complained of impairment in social functioning secondary to his PTSD and inability to handle interpersonal relationships. The record reflects that the Veteran underwent a VA PTSD research study from November to December 2006. The Veteran reported he graduated high school before enlisting in the Army. He reported working at a manufacturing plant for the previous 29 years, making bricks, but that he lost the job when the plant closed down. He stated that in the 1990s he attended a community college but did not finish his degree due to financial difficulties. The Veteran reported currently working in a warehouse where he had been employed for the past five years. He had difficulty at this job and had problem getting along well with his supervisor. He stated that he frequently got angry and frustrated, and engaged in verbal altercations with his boss fearing that it might lead to his potential termination. The Veteran complained of feelings of depression and pervasive and persistent PTSD symptoms that affected his current life and daily activities. He reported avoidance behaviors on a daily basis, which had become "second nature" to him. He experienced feelings of guilt; pervasive thoughts about Vietnam, occurring several times a week; and nightmares related to his combat experience that interrupted his nightly sleep patterns. He had lost interest in most activities and had suicidal ideation. The Veteran reported staying away from almost all people except for his wife and sons. Objectively, the Veteran was appropriately dressed, with good hygiene. His speech was clear, coherent, and goal directed, but was lacking in content. There were no unusual movements. The Veteran was overall still and attentive during the session and was alert and fully oriented. He denied any hallucinations or delusions. His judgment was intact. It was noted that the Veteran had difficulty maintaining eye contact and continually looked downward when talking. The Veteran's affect was restricted and somewhat blunted but overall appropriate. He described his mood as dysthymic. He denied suicidal or homicidal ideation. The examiner noted that the Veteran appeared to be of average intelligence and organized thought process. The examiner found the current PTSD symptomatology included frequent intrusive thoughts about Vietnam, sleep difficulty with severe and distressing nightmares and night sweating, avoiding crowds and "Oriental" people, social isolation, loss of interest, and exaggerated startle reaction. It was noted that the Veteran's PTSD symptoms tended to affect his work life in that he reported difficulty being around others at work, more specifically "Oriental" people. Although the Veteran maintained a full time job he reported frequently getting angry and engaging in verbal altercations with his supervisor. The diagnoses were PTSD and major depressive disorder, and a GAF score of 42 was assigned. A November 2006 VA consultation report stated that the Veteran had ongoing symptoms associated with his PTSD, to include depression and anxiety. He was currently working in a warehouse and he felt angry and frustrated due to the language barrier at work place. He continued to be troubled by rage and anger towards people at work and towards the government for the recent war situation. He reported trouble sleeping and feeling guarded in crowded situations. He also reported recent suicidal ideation with plans. On mental status examination, the Veteran was alert and fully oriented, and casually groomed and dressed. He exhibited fair eye contact; slow but normal speech; goal-directed thought process; and thought content filled with concern about his employment and current family situation. He denied suicidal or homicidal thoughts. There were no evidence of psychotic symptoms and the Veteran's insight and judgment were limited. The assessments were PTSD and depression, not otherwise specified. In a November 2006 VA psychiatry note, the Veteran reported that he continued to feel rage and did not notice much improvement from taking medication. The Veteran's PTSD symptoms included chronic anger, rage, and frustration. He stated that he tried to stay away from everybody at work because they irritated him. He also reported suicidal ideation with no active plan or intent. His speech was coherent, rational and goal directed. The assessments were PTSD and depression, not otherwise specified. In a February 2007 VA mental health note, the Veteran was pleasant and cooperative, and alert and oriented, with good eye contact. He reported "scary dreams of fallen comrades," occurring two to three times per week. He described his sleep as fair but aroused during his nightmares. He reported living with his wife for 34 years and currently working as a forklift driver in a warehouse. He graduated from high school and attended college for a while. The diagnoses were PTSD and depression, not otherwise specified. The examiner noted that the Veteran's chronic PTSD symptoms were moderate and that he was socially isolated. In a March 2007 VA mental health note, the Veteran was pleasant, cooperative, and appropriately groomed and dressed. He was alert and oriented, and maintained good eye contact. He reported significant improvement in his mood and that his nightmares were significantly improved. No abnormal movements were noted. He exhibited pleasant affect, acceptable insight and judgment, and intact memory. He continued to work in a warehouse and reported less frustration with fellow employees. The diagnoses were PTSD and depression, not otherwise specified; and a GAF score of 52 was listed. The examiner noted that the Veteran's chronic PTSD symptoms were moderate and that he was socially isolated. In a June 2007 VA mental health note, the Veteran was pleasant, cooperative, and appropriately groomed and dressed. He was and alert and oriented, and maintained good eye contact. He continued to report frustration with management at his work and that he missed two days of work in the previous week due to his frustration. He denied suicidal, homicidal, or violent ideation. His speech was clear, coherent, spontaneous, and goal directed. He exhibited flat and a "little depressed" mood, and pleasant affect. He stated that his nightmares were significantly improved. The diagnoses were PTSD and depression, not otherwise specified; and a GAF score of 52 was listed. The examiner noted that the Veteran's chronic PTSD symptoms were moderate and that he was socially isolated. In an August 2007 VA mental health note, the Veteran was alert, oriented, and appropriately groomed and dressed. He denied suicidal, homicidal, or violent ideation; or hallucinations or delusions. There was no evidence of paranoia. His affect was pleasant. The Veteran reported that nightmares were significantly improved. He continued to work in a warehouse job, which he found frustrating. The Veteran's insight and judgment were acceptable, and memories to recent and remote events were intact. The diagnoses were PTSD and depression, not otherwise specified; and a GAF score of 52 was listed. The examiner noted that the Veteran's chronic PTSD symptoms were moderate and that he was socially isolated. In an October 2007 VA psychology note, the Veteran was alert, oriented, and appropriately groomed and dressed. He denied suicidal, homicidal, or violent ideation; or hallucinations or delusions. There was no evidence of paranoia. His affect was pleasant. The Veteran reported that nightmares were significantly improved. He complained low energy level and lethargy. He continued to work in a warehouse but he found the job frustrating lately as he was offended by other workers' Muslim prayers during break time. The Veteran's insight and judgment were acceptable and memories to recent and remote events were intact. The diagnoses were PTSD and depression, not otherwise specified; and a GAF score of 52 was listed. The examiner noted that the Veteran's chronic PTSD symptoms were moderate and that he was socially isolated. In a November 2007 VA psychology note, the Veteran was alert, oriented, and appropriately groomed and dressed. He denied suicidal, homicidal, or violent ideation; or hallucinations or delusions. There was no evidence of paranoia. His affect was pleasant. The Veteran reported that nightmares were significantly reduced in both intensity and frequency and that his energy level was improved. The Veteran's insight and judgment were acceptable and memories to recent and remote events were intact. The diagnoses were PTSD and depression, not otherwise specified; and a GAF score of 52 was listed. The examiner noted that the Veteran's chronic PTSD symptoms were moderate and that he was socially isolated. In November 2007, the Veteran's son submitted a written statement wherein he reported that growing up he did not see his father much as the Veteran always worked. The son reported that the Veteran did not talk to anyone but the people he worked with and never discussed his Vietnam experience. The Veteran woke out of nightmares fighting and in cold sweat. The son also stated that the Veteran distanced himself from everyone and never opened up or showed affection to anybody close to him. A November 2007 statement from a comrade documents the Veteran's courageous and heroic service during his tour of duty in Vietnam. The Veteran underwent a December 2007 VA examination. The Veteran reported that he completed high school and had a fairly supportive marriage with two children. He had worked at the brickyard for 30 years but stated that it reached a point where he could not take the stress of work. He was currently unemployed. He used to work with a lot of foreign-born workers who did not speak English who reminded him of his experience in Vietnam. It was noted that his condition worsened over the years and since he had been unemployed he had lost self esteem. The Veteran reported that in the past five years his isolating tendencies and chronic avoidance symptoms worsened. He was progressively more irritable and tense and his restricted affect and poor interpersonal skills adversely affected his family life and employment. He had difficulty making small talk or relating to his coworkers. It was noted that the Veteran's children indicated that the Veteran's problems with authority contributed to loss of his job. The examiner noted that a VA PTSD research program report gave evidence of the Veteran's decompensation and worsening condition. The Veteran reported a survivor's guilt, and frequent recurring distressing flashbacks and nightmares. As for avoidance symptoms, the Veteran reported that he could not remember the names of friends that he lost and that he had constant sense of angst and alarm so that he had to go check out everything around the house. It was noted that this state of alarm came with racing thoughts, sweat, and panic. The Veteran kept an unloaded gun next to his bed with ammunition and a clip readily available. He had exaggerated startle response to the sound of balloon or fireworks. He ducked down to the ground when he perceived that the surrounding situation was life threatening. There was evidence of hyperarousal, sleep disturbance, hypervigilance towards Asians, and exaggerated response to sudden noise or unexpected surprises. On mental status examination, the Veteran was alert, fully oriented, and appropriately dressed with good hygiene. His speech was clear, coherent, and goal directed although he was sparing in terms of personal disclosure. There was no unusual or idiosyncratic thought process. The examiner stated that the Veteran was not delusional and his judgment was fair enough to allow him to sustain his employment until the company folded. The Veteran had difficulty maintaining eye contact and tended to look away from the examiner, but he was civil and able to comply with instructions. He exhibited restricted and somewhat blunted affect and dysthymic mood. He denied suicidal or homicidal ideation. The examiner noted that the Veteran appeared to have average intelligence and organized thought process. The Veteran had problems with attention and concentration, which the examiner regarded to be a function of PTSD anxiety rather than due to cognitive deficits of an organic nature. It was also noted that the Veteran was apprehensive and guarded all the time and could not take time to relax and finish a project that he started to do. He was quick to lose temper and anger, and it made him angry when people gave him advice. He let people know what he thought of them and he was sensitive when people told him what they thought of him. The examiner stated that this emotional dullness, along with restriction of affect, were signs of severe PTSD. The Veteran had hard time making decisions and was bothered by compulsive and repetitive thoughts. The examiner also stated that the Veteran was not psychotic but he had serious PTSD impairments which rendered him unlikely to sustain any disciplined work although he was competent to handle his finances. The diagnoses were severe chronic PTSD and major depressive disorder, and a GAF score of 42 was listed. In a December 2007 VA psychology note, the Veteran was alert, oriented, and appropriately groomed and dressed. He denied suicidal, homicidal, or violent ideation; or hallucinations or delusions. There was no evidence of paranoia. His affect was pleasant. The Veteran reported that nightmares were significantly reduced in both intensity and frequency and energy level was improved. His insight and judgment were acceptable and memories to recent and remote events were intact. The diagnoses were PTSD and depression, not otherwise specified; and a GAF score of 52 was listed. The examiner noted that the Veteran's chronic PTSD symptoms were moderate and that he was socially isolated. A June 2009 VA examination was conducted. The Veteran reported a history of near death incidents while serving in Vietnam. He reported that he was married and had 12 years of education. He contended that there were vocational and social impairment as a result of his Vietnam experience. Specifically, he stated that he lost his job; his family relationships were always restricted; and he experienced severe depression. On mental status examination, the Veteran was alert, fully oriented, coherent, and able to provide appropriate responses to questions. He exhibited dysthymic affect and depressed mood. He denied suicidal, homicidal, violent ideation. The Veteran reported that he used to work in a warehouse but he had to quit a couple of months previously owing to a frustrating job. He was offended by other workers who did not speak English and was bothered by watching Muslim prayers during breaks. There were no signs of delusional thinking or cognitive deficits. The Veteran had two grown sons and four grandchildren but did not socialize with them or anyone. The examiner found that the Veteran was competent to handle his financial affairs. The diagnoses were severe chronic PTSD and major depressive disorder and a GAF score of 40 was assigned. VA psychiatry group counseling therapy notes, dated from November 2009 to January 2011, show that the Veteran participated in PTSD group therapy sessions for continued PTSD signs and symptoms. The Veteran complained of distress from intrusive memories of his military experience that affected his sleep. He struggled with strong efforts to avoid activities and social situations. In a December 2009 VA psychology note, the Veteran was alert, responsive, fully oriented, cooperative, and with adequate eye contact. He showed constricted affect; sad mood; fluent, spontaneous, and goal directed speech, with normal rate, rhythm, and volume; coherent thought process; adequate attention and concentration; abstract thinking; and adequate judgment and insight. He denied any perceptual disturbances, or suicidal or homicidal ideation. It was noted that the Veteran was not getting out and avoiding things more than he had been. He stated that he had not been seen for three months because he was unable to get in sooner. In a January 2010 VA psychology note, the Veteran was alert, responsive, fully oriented, cooperative, and with adequate eye contact. He showed constricted affect; euthymic mood; fluent, spontaneous, and goal directed speech, with normal rate, rhythm, and volume; coherent thought process; adequate attention and concentration; abstract thinking; and adequate judgment and insight. He denied any perceptual disturbances, or suicidal or homicidal ideation. It was noted that the Veteran was doing moderately well with the PTSD symptoms and had been having bad dreams lately about fighting with people. In a February 2010 VA psychology note, the Veteran was alert, responsive, fully oriented, cooperative, and with adequate eye contact. He showed constricted affect; sad mood; fluent, spontaneous, and goal directed speech, with normal rate, rhythm, and volume; coherent thought process; adequate attention and concentration; abstract thinking; and adequate judgment and insight. He denied any perceptual disturbances, or suicidal or homicidal ideation. The Veteran was still symptomatic and was having nightmares. On a March 2010 VA mental health note, the Veteran was alert, fully oriented, and appropriately groomed and dressed. He showed pleasant affect and positive mood. He denied suicidal, homicidal, or violent ideation; or hallucinations or delusions. His insight and judgment were acceptable, and his memory to recent and remote events was intact. The diagnoses were PTSD and depression, not otherwise specified; and a GAF score of 52 was listed. In an addendum, the examiner stated "[i]n my opinion, [the Veteran's] PTSD symptoms prohibit him from gainful employment." In an April 2010 VA psychology note, the Veteran was alert, responsive, fully oriented, cooperative, and with adequate eye contact. He showed constricted affect; euthymic mood; fluent, spontaneous, and goal directed speech, with normal rate, rhythm, and volume; coherent thought process; adequate attention and concentration; abstract thinking; and adequate judgment and insight. He denied any perceptual disturbances, or suicidal or homicidal ideation. The Veteran related that he had been feeling better emotionally as his family were doing better. He stated that he continued attend his PTSD group and continued to use his grounding skills, and that his symptoms had lessened. On a May 2010 VA mental health note, the Veteran was alert, fully oriented, and appropriately groomed and dressed. He showed pleasant affect and neutral mood. He denied suicidal, homicidal, or violent ideation; or hallucinations or delusions. His insight and judgment were acceptable and his memory to recent and remote events was intact. No abnormal movements were found. The diagnoses were PTSD and depression, not otherwise specified; and a GAF score of 52 was listed. In a June 2010 VA psychology note, the Veteran was alert, responsive, fully oriented, cooperative, and with adequate eye contact. He showed constricted affect; euthymic mood; fluent, spontaneous, and goal directed speech, with normal rate, rhythm, and volume; coherent thought process; adequate attention and concentration; abstract thinking; and adequate judgment and insight. He denied any perceptual disturbances, or suicidal or homicidal ideation. The Veteran related that he had been up and down and had a lot of family problems. He had not been sleeping well although the nightmares were more infrequent. In a July 2010 VA psychology note, the Veteran was alert, responsive, fully oriented, cooperative, and with adequate eye contact. He showed broad affect; euthymic mood; fluent, spontaneous, and goal directed speech, with normal rate, rhythm, and volume; coherent thought process; adequate attention and concentration; abstract thinking; and adequate judgment and insight. He denied any perceptual disturbances, or suicidal or homicidal ideation. He related that he had been feeling pretty good because his son visited recently. He had been trying to get out more and had been able to go out in public and tolerate situations even when he was not comfortable. On an August 2010 VA mental health note, the Veteran was alert, fully oriented, and appropriately groomed and dressed. He showed pleasant affect and "sober" mood. He reported a "very good" visit with his son and family who were visiting from another state in the previous month. He stated that nightmares were improved generally. He denied suicidal, homicidal, or violent ideation; or hallucinations or delusions. His insight and judgment were acceptable and his memory to recent and remote events was intact. The diagnoses were PTSD and depression, not otherwise specified; and a GAF score of 52 was listed. In a September 2010 VA psychology note, the Veteran reported that he had no motivation. He was adequately groomed and casually dressed. He was alert, responsive, fully oriented, cooperative, and with adequate eye contact. He showed constricted affect; sad mood; fluent, spontaneous, and goal directed speech, with normal rate, rhythm, and volume; coherent thought process; adequate attention and concentration; abstract thinking; and adequate judgment and insight. He denied any perceptual disturbances, or suicidal or homicidal ideation. He related that he had been feeling "down in the dumps" and that his motivation was poor. In an October 2010 VA psychology note, the Veteran was adequately groomed and casually dressed. He was alert, responsive, fully oriented, cooperative, and with adequate eye contact. He showed constricted affect; sad mood; fluent, spontaneous, and goal directed speech, with normal rate, rhythm, and volume; coherent thought process; adequate attention and concentration; abstract thinking; and adequate judgment and insight. He denied any perceptual disturbances, or suicidal or homicidal ideation. He stated that he was stressed out by family situations. On a November 2010 VA mental health note, the Veteran was alert, fully oriented, and appropriately groomed and dressed. He showed pleasant affect and "fair" mood. He stated that nightmares continued to be moderate in terms of intensity and frequency. He denied suicidal, homicidal, or violent ideation; or hallucinations or delusions. His insight and judgment were acceptable and his memory to recent and remote events was intact. The diagnoses were PTSD and depression, not otherwise specified; and a GAF score of 52 was listed. The examiner noted that the Veteran's chronic PTSD symptoms were moderate and that he was socially isolated. In December 2010 and January 2011 VA psychology notes, the Veteran reported that he was "stressed out." Objectively, the Veteran was adequately groomed and casually dressed. He was alert, responsive, fully oriented, cooperative, and with adequate eye contact. He showed constricted affect; sad mood; fluent, spontaneous, and goal directed speech, with normal rate, rhythm, and volume; coherent thought process; adequate attention and concentration; abstract thinking; and adequate judgment and insight. He denied any perceptual disturbances or suicidal or homicidal ideation. He stated that he was stressed out by some family situations. Most recently, the Veteran was accorded a VA examination in May 2011. The VA examiner stated that the claims file was reviewed. The Veteran reported that he had been unable to continue working as a forklift operator or any other job for two years. He stated that his marriage was shaky now that he was unemployed because of financial problems. He reported that he was quick to anger and unable to control anger. The examiner noted signs of depression marked with anhedonia, loss of pleasure, which affected the Veteran's daily living and relations with others. The Veteran reported that he could not tolerate foreigners who spoke in their native tongue, the monsoon rain, fireworks, and the sight of toy balloon popping as these stressors seemed to bring flashbacks of his war experience in Vietnam. The examiner stated that the Veteran did not want to disclose many traumatic stressors, probably due to severe guilt or psychogenetic amnesia. The Veteran reported that his marriage was "pretty good," but that his wife did not think that he showed affection toward their sons. He also reported suicidal ideation without intent. On mental status examination, the Veteran was alert and fully oriented. He was appropriately groomed and dressed and looked reserved and distant but was able to show eye-to-eye contact. He reported nightmares, hyperstartle response, hypervigilance, suicidal ideation, anhedonia, and lack of impulse control. He denied hallucination or delusions. It was noted that the Veteran's insight and judgment were acceptable; memory to recent or remote events were intact; and that there was no signs of cognitive deficits on clinical examination. The examiner found that the Veteran was competent to handle activities of daily living and finances; had no abnormal movements; but was not likely to be gainfully employed with the way he presented himself. The Veteran admitted to financial and family problems. The examiner concluded that there was sufficient clinical and psychometric evidence to suggest that the Veteran's PTSD symptoms were sufficient severe to cause mental, social and vocational impairments related to the Veteran's combat experience in Vietnam. The diagnosis was severe PTSD with depression, and a GAF score of 42 was assigned. At his July 2011 hearing before the Board, the Veteran testified that he experienced sleep impairment with daily nightmares, concentration and memory problems, irritability, anger issues, intrusive thoughts about his military experience, and panic attacks. His wife testified that the Veteran could not tolerate being in public places and avoided crowds. PTSD The Rating Schedule establishes a general rating formula for mental disorders. 38 C.F.R. § 4.130 (2010). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. Service connection for the Veteran's PTSD was granted by an August 1999 rating decision, and an initial evaluation of 30 percent was assigned, effective December 4, 1998, under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411. In August 2006, the Veteran filed the present claim for an increased evaluation for his PTSD and in an October 2006 rating decision, the RO granted an increased evaluation of 50 percent for the Veteran's PTSD effective August 14, 2006. The Veteran filed an April 2007 notice of disagreement as to the currently assigned evaluation for his PTSD and perfected his appeal in August 2008. PTSD is rated as 50 percent disabling 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, such as 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or 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 for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. In evaluating the evidence, the Board has noted the various GAF scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See DSM-IV; Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a GAF score of 51-60 indicates moderate symptoms, such as flat affect, circumstantial speech, occasional panic attacks, or moderate difficulty in social or occupational functioning, such as having few friends or having conflicts with peers or co-workers. DSM-IV at 46-47. A GAF score of 41 to 50 is assigned where there are serious symptoms, such as suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social or occupational functioning, such as no friends, unable to keep a job. DSM-IV at 46-47. A GAF of 31-40 is defined as exhibiting some impairment in reality testing or communication, such as speech is at times illogical, obscure, or irrelevant, or any major impairment in several areas, such as work, family relations, judgment, thinking or mood, such as a depressed man that avoids friends, neglects family, and is unable to work. DSM-IV at 46-47. The evidence of record supports a 70 percent evaluation for the Veteran's PTSD. The GAF scores noted during the period on appeal ranged from 40 to 60, with an average of 50, which contemplates serious symptoms, such as suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social or occupational functioning, such as no friends, unable to keep a job. Id. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. The evidence of record demonstrates that the Veteran had chronic depression, survivor's guilt, recurrent intrusive thoughts of Vietnam, sleeping disturbance with very frequent nightmares, flashbacks, anxiety, panic attacks, irritability, anger, hypervigilance, hyperarousal, exaggerated startle response, difficulty with concentration and attention, social isolation, inability to relate to others or express intimate feelings, lack of interest and motivation, and avoidance behaviors. The Board finds that the evidence demonstrates significant impairment in social and occupational functioning, with deficiencies in most areas, such as work, family relations, judgment, or mood. As to the Veteran's social functioning, social isolation and withdrawal, even from family members, have been consistently shown. Although the Veteran has remained married for a long period of time, the November 2007 letter from his son indicated that the Veteran distanced himself from everyone, and never opened up or showed affection to anybody close to him. Throughout record, the evidence demonstrates that the Veteran was unable to handle interpersonal relationships, avoided most social situations, and was socially isolated with no close friends. On the December 2007 VA examination, the Veteran reported that he had difficulty making small talk or relating to others and the VA examiner found that the Veteran was progressively more irritable and tense and that his restricted affect and poor interpersonal skills adversely affected his family life. Moreover, the May 2011 VA examiner concluded that the Veteran's PTSD symptoms were sufficiently severe to cause mental and social impairments related to his combat experience in Vietnam. As for the occupational functioning, the Veteran reported having worked for approximately 29 years for a manufacturing company prior to the shutdown of the business. Thereafter, the Veteran worked as a forklift driver in a warehouse approximately seven years before he stopped working in 2009. However, the Veteran repeatedly reported that he had difficulty being around coworkers from different cultural backgrounds, and had problems following instructions, which often resulted in verbal altercations with his supervisor. At the July 2011 hearing before the Board, the Veteran testified that he had to stop working as he could not take the stress of work and was having homicidal ideations. Based on the foregoing evidence, the Board finds severe occupational functioning due to PTSD symptoms despite the Veteran's long history of employment. To that effect, the December 2007 VA examiner stated that the Veteran had serious PTSD impairments which rendered him "unlikely to sustain any disciplined work." The May 2011 VA examiner also concluded that the Veteran was "unlikely to be gainfully employed with the way [the Veteran] presented himself." Overall, the objective evidence of record shows that the Veteran's level of disability to be in the severe range for his service-connected PTSD. This disability picture more closely approximates a 70 percent evaluation. 38 C.F.R. § 4.7 (2010) (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 for that rating). Accordingly, in considering the evidence of record under the laws and regulations as set forth above, the Board concludes that an increased rating of 70 percent is warranted for the Veteran's service-connected PTSD. See 38 C.F.R. § 4.130, Diagnostic Code 9411. A 100 percent evaluation for the Veteran's service-connected PTSD is not for assignment because the medical evidence does not demonstrate delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; the intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; or memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Although significant impairment has been shown adapting to stressful circumstances, to include at work, as well as the inability to establish and maintain effective relationships, total social and occupational impairment has not been shown. Accordingly, the Board finds that the objective medical evidence of record does not support an evaluation in excess of 70 percent at any time during the appeal. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence shows no distinct period of time, during which the Veteran's PTSD has varied to such an extent that a rating lesser or greater than 70 percent would be warranted. Thus, staged ratings are not in order, and a 70 percent rating for PTSD is warranted. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2010). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual Veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2010). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria under the Rating Schedule reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate, and no referral is required. The Board finds that the Veteran's service-connected PTSD disability picture was not so unusual or exceptional in nature as to render his 70 percent rating inadequate. The Veteran's service-connected PTSD is evaluated as a mental disorder pursuant to 38 C.F.R. § 4.130, the criteria of which is found by the Board to specifically contemplate the level of disability and symptomatology exhibited. The Veteran's service-connected PTSD is manifested by chronic depression, survivor's guilt, recurrent intrusive thoughts of Vietnam, sleeping disturbance with very frequent nightmares, flashbacks, anxiety, panic attacks, irritability, anger, hypervigilance, hyperarousal, exaggerated startle response, difficulty with concentration and attention, social isolation, inability to relate to others or express intimate feelings, lack of interest and motivation, and avoidance behaviors. Objectively, the Veteran was appropriately groomed, alert, fully oriented, cooperative, and not grossly psychotic. He exhibited depressed mood, restricted and blunted affect, normal speech and motor behavior, coherent and goal-directed thought process, fair judgment and insight, transient suicidal ideation, and thought content without any thought disorder, delusion, or hallucination. When comparing the disability picture of the Veteran's PTSD with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's symptoms are more than adequately contemplated by the 70 percent disability rating assigned herein for his service-connected PTSD. See 38 C.F.R. § 4.130, Diagnostic Code 9411. A rating in excess thereof is provided for certain manifestations of the service-connected PTSD but the evidence of record did not demonstrate that such manifestations were present in this case. The evidence does not show the Veteran's service-connected PTSD to be manifested by symptoms such 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 criteria for a 70 percent disability rating reasonably describe the Veteran's disability level and symptomatology of his service-connected PTSD and, therefore, the schedular evaluation is adequate and no referral is required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOPGCPREC 6-96; 61 Fed. Reg. 66749 (1996). In reaching this decision the Board considered the doctrine of reasonable doubt, and finds that the preponderance of the evidence warrants an increased rating of 70 percent, but no more, for his service-connected PTSD. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU The evidence of record raises the issue of entitlement to a TDIU. The record reflects that the Veteran has been unemployed for approximately two years. He reported that he had worked as a forklift driver in a warehouse for about 7 years before he retired due to his PTSD symptoms. Accordingly, the issue of TDIU is part and parcel of the determination of the initial evaluation for the Veteran's PTSD and is properly before the Board. See Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009) (holding that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities; if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability as a result of that disability is warranted). TDIU is warranted when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2010). TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for TDIU benefits; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Service connection is in effect for PTSD, and by this decision has been assigned a 70 percent disability rating. As such, the Veteran meets the minimum schedular criteria for TDIU. 38 C.F.R. § 4.16(a). The record reflects that the Veteran finished high school before he joined the Army in 1969. After military discharge, he worked in physical labor for approximately 34 years making bricks and driving a forklift. However, on the VA PTSD research study conducted during November and December 2006, the Veteran indicated that he had problems at work due to difficulty getting along with others. He frequently got angry and frustrated, and engaged in verbal altercations with his supervisor. He could not tolerate coworkers from different cultural backgrounds, especially "the Orientals" because they triggered his memory of Vietnam. Additionally, the December 2007 VA examiner noted that the Veteran's children reported the Veteran's problems with authority which contributed to loss of his job. At his July 2011 Board hearing, the Veteran testified that he had to stop working because he could not take the stress of work and was having homicidal ideations. As noted above, a TDIU is warranted if the Veteran is unable to follow a substantially gainful occupation due his service-connected disabilities. 38 C.F.R. § 3.340(a)(1). In this case, applying the doctrine of reasonable doubt, the Board finds that the evidence of record is at least in equipoise as to whether the Veteran is unable to follow a substantially gainful occupation due to his service-connected disabilities. To that effect, the December 2007 VA examiner found that the Veteran had serious PTSD impairments which rendered him "unlikely to sustain any disciplined work." On the March 2010 VA mental health note, the health provider who have seen the Veteran on a regular basis for an extended period of time also stated that the Veteran's PTSD symptoms "prohibit him from gainful employment." Further, the May 2011 VA examiner concluded that there was sufficient clinical and psychometric evidence to suggest that the Veteran's PTSD symptoms were sufficiently severe to cause mental, social, and vocational impairments related to his combat experience in Vietnam. The examiner specifically stated that the Veteran was not likely to be gainfully employed based on the way he presented himself at the May 2011 VA examination. Considering the lay statements, as well as the medical evidence of record regarding the severe functional impairments exhibited by his service-connected PTSD, as well as his educational and employment history, the Board finds that the Veteran was unable to follow a substantially gainful occupation due to his service-connected PTSD. Accordingly, a TDIU is warranted. Gilbert, 1 Vet. App. at 54. ORDER An increased evaluation of 70 percent for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. A TDIU is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs