Citation Nr: 1136364 Decision Date: 09/27/11 Archive Date: 10/03/11 DOCKET NO. 06-25 198 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES Entitlement to an initial rating for posttraumatic stress disorder (PTSD) in excess of 30 percent prior to July 9, 2007, and in excess of 50 percent from July 9, 2007. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from August 1968 to July 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, in which the RO, in pertinent part, granted service connection and assigned an initial, 30 percent rating for PTSD, effective June 27, 2005. In a December 2008 rating decision, the RO granted a higher, 50 percent rating from July 9, 2007. As a higher rating for this disability is assignable before and after this date, and the Veteran is presumed to seek the maximum available benefit, the Board has characterized the appeal as encompassing both matters as set forth on the title page. See AB v. Brown, 6 Vet. App. 35, 38 (1993). In February 2011, the Veteran testified during a Board hearing before the undersigned Acting Veterans Law Judge at the RO; a transcript of that hearing is of record. In May 2011, the Board remanded the claim to the RO, via the Appeals Management Center (AMC) in Washington, DC, for additional development. As the RO/AMC scheduled the Veteran for a VA examination and obtained the requested medical opinion, the Board finds that the RO/AMC has substantially complied with the prior remand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the claim on appeal have been accomplished. 2. Since the June 27, 2005 effective date of the grant of service connection, the Veteran's PTSD has been manifested by chronic sleep disturbance, nightmares, flashbacks, intrusive thoughts, hypervigilance, exaggerated startle response, anxiety, depression, social isolation, anger, frustration, irritability, anger outbursts, difficulty concentrating, memory impairment, occasional suicidal ideation, crying spells, near-continuous anxiety and depression, occasional auditory and visual hallucinations, and an inability to establish and maintain effective relationships. 3. Collectively, the Veteran's psychiatric symptoms have suggested occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSION OF LAW Affording the Veteran the benefit of the doubt, the criteria for an initial, 70 percent rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.20, 4.126, 4.130, Diagnostic Code (DC) 9411 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2010) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2011). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353- 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this case, November 2007 and June 2009 post-rating letters provided notice to the Veteran regarding the information and evidence needed to substantiate the claim, as well as what information and evidence must be submitted by the Veteran and what information and evidence would be obtained by VA. The letters also provided general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. Hence, the letters meet the content of notice requirements of Pelegrini and Dingess/Hartman. Moreover, after issuance of the November 2007 and June 2009 letters, and opportunity for the Veteran to respond, the July 2011 supplemental statement of the case (SSOC) reflects readjudication of the claim. Hence, the Veteran is not shown to be prejudiced by the timing of the notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter on appeal. Pertinent medical evidence associated with the claims file consists of the Veteran's VA outpatient treatment records; private medical records from Dr. M.P., Counseling Consortium for PTSD, a counselor (W.F.), and Dr. P.M.; and the reports of June 2007, July 2008, June 2009, and June 2011 VA examinations. The Board finds that the examinations were adequate to allow proper adjudication of the issue on appeal. The examiners conducted complete examinations, recorded all findings considered relevant under the applicable diagnostic code, and considered the full history of the disability. Also of record and considered in connection with the appeal are various written statements provided by the Veteran, and his representative, on his behalf. No further RO action on this matter, prior to appellate consideration, is warranted. In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO, the Veteran has been notified and made aware of the evidence needed to substantiate this claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with any claim herein decided. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of these matters, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Law and Regulations Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2011). When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7 (2011). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3 (2011). A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is entitlement to a higher initial rating assigned following the grant of service connection, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson v. West, 12 Vet. App. 119 (1999). In this appeal, because the RO has already granted staged ratings for the Veteran's PTSD, the Board will consider the propriety of the rating for each disability at each stage, as well as whether any further staged rating of each disability, pursuant to Fenderson, is warranted. The Veteran's PTSD has been evaluated under Diagnostic Code 9411. However, the actual criteria for evaluating psychiatric impairment other than eating disorders is set forth in a General Rating Formula. See 38 C.F.R. § 4.130. Pursuant to the General Rating Formula, a rating of 50 percent is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; and difficulty establishing and maintaining effective work and social relationships. A 70 percent rating requires 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); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability 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. The Board notes that in accordance with the General Rating Formula for Mental Disorders, a 100 percent rating is applicable if the manifestations of the service-connected psychiatric disorder result in total occupational and social impairment. Although the Rating Formula lists specific symptoms that are indicative of total impairment, the Court has held that the symptoms listed in the Rating Formula are only examples, and that evidence of those specific symptoms is not required to show that the veteran is totally disabled. In rating a mental disability VA is required to consider all symptoms that affect social and occupational functioning, and not limit consideration to those symptoms listed in the Rating Formula. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In other words, the primary consideration is whether the manifestations of the service-connected psychiatric disorder result in total social and occupational impairment, regardless of whether the veteran demonstrates those symptoms listed in the Rating Formula. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). III. Factual Background A July 2005 VA outpatient treatment record reflects that the Veteran was tearful and distraught and asked to see a psychiatrist. He said he experienced nightmares, altered sleep, hypervigilance, anxiety, lack of interest, and depressed mood. He said he had flashbacks of various events during service. He denied any suicidal ideation. In a September 2005 statement, the Veteran said that he had problems with flashbacks, bad dreams, sleeping, and unexplained anger, and that he was not comfortable in crowds and had imaginary sighting of Vietcong. He also said he had difficulty following through on chores and finishing things. A January 2006 VA mental health record reflects the Veteran was referred from primary care after a positive PTSD screening. He complained of nightmares and flashbacks. On mental status examination, he became teary at times when relating his experiences in Vietnam. He denied suicidal or homicidal ideation. He endorsed paranoia, trouble in crowds, moodiness, increased temper, hearing garbled voices and seeing shadows in his peripheral vision, nightmares 2 to 3 times per week, and disturbed sleep. His affect was labile and his mood was depressed. Cognition was intact and his speech was normal rate and rhythm. Thoughts were goal-directed without delusion or psychotic content. The diagnoses were PTSD and depression with a GAF score of 55. He was given a trial of fluoxetine and Trazodone. An April 2006 VA mental health record reflects that the Veteran was working in his upholstery business. He complained of daytime sleepiness. On mental status examination, he was pleasant and made good eye contact. He became teary when talking about nightmares and military experiences. He said his sleep was only slightly improved and that he still had difficulty with concentration and irritability. His affect was labile and his mood was depressed. His dosage of fluoxetine and Trazodone was increased. An August 2006 letter from Dr. M.P., a private physician, reflects that the Veteran had significant depression over the past several years. He endorsed night sweats, night terrors, obsession, agitation, bizarre thinking, flashbacks, confusion, moodiness, and decreased sleep. A March 2007 VA outpatient treatment record reflects that the Veteran's depression was stable. During a depression screening, the Veteran was asked whether he had little interest or pleasure in doing things or felt down, depressed, or hopeless and he replied "not at all." He also denied suicidal ideation. Later that month, a VA mental health record indicates that the Veteran reported some increased anger and that helicopter noise tended to upset him. He said his sleep was disrupted by nightmares. He denied crying spells and suicidal or homicidal ideation. His affect was full and his mood was dysphoric. During a PTSD screening he endorsed having nightmares, avoidance tendencies, feelings of detachment, but denied hypervigilance or increased startle response. An addendum noted that he would be put on the anger management waiting list. A May 2007 mental health record reflects that the Veteran attended an anger management group counseling session. A May 2007 private medical record from Counseling Consortium for PTSD reflects that the Veteran endorsed similar symptoms as noted above. He said that he felt jumpy, that his nerves were on edge, and he felt "out of it more often than not." It was noted that the Veteran's PTSD symptoms appeared through all aspects of his life and that he should be considered disabled by VA. The report of a June 2007 VA examination reflects that the Veteran endorsed difficulty initiating and maintaining sleep and that he only slept 2 to 3 hours per night. He also reported being anxious and nervous; having nightmares; intrusive thoughts on a daily basis; irritability, feelings of isolation and withdrawal from others; and feelings of guilt. He said the medication was helpful at first, but was not effective any longer. He said that he worked for himself doing upholstery and was also a minister. He said he had been married to his wife for 33 years and had two children. He said he was close to his daughter. On mental status evaluation, the Veteran was appropriately dressed and groomed. His speech was clear, coherent, and goal-directed. He was alert and oriented to time, place, and person. His short-term memory and concentration were somewhat impaired. Long-term memory was within normal limits. He was tearful during the evaluation. His mood was dysphoric and his affect was sad. He reported peripheral hallucinations, but no other thought or perceptual disorder was noted. The diagnosis was PTSD and the GAF score assigned was 50. The examiner noted that the Veteran was currently experiencing a mild to moderate level of impairment in social and occupational functioning. A July 2007 VA mental health record reflects the Veteran's complaints of impulse control problems and blowing up. He said anger management was helpful sometimes. He denied audiovisual hallucinations and paranoia. He said he had anhedonia at times, but denied suicidal or homicidal ideation. He said his sleep was often fragmented because of nightmares. His affect was full and his mood was dysphoric. He was given a trial of Depakote to take at bedtime. In a March 2008 letter from a private mental health counselor (W.F.), it was noted that the Veteran had been attending a support group for 3 months. The counselor noted that the Veteran had dreams of Vietnam about 3 nights per week and terrible night sweats. He also had flashbacks, avoidance symptoms, "blank spots" in his memory, isolation tendencies, moodiness, and angered easily. The counselor indicated that he personally witnessed the Veteran have an exaggerated startle response to a loud noise in the next room. A March 2008 record from the Counseling Consortium for PTSD reflects the Veteran continued to endorse nightmares, difficulty sleeping, flashbacks intrusive thoughts, isolation tendencies, anhedonia, exaggerated startle response, periods of depression, and anxiety. He also said he had difficulty thinking, concentrating, and remaining on task. The psychologist noted that the Veteran continued to show "significant" PTSD symptoms and that his social and industrial processes continued to suffer. An April 2008 VA mental health note reflects that the Veteran had 2 friends recently die and that one was a close Vietnam buddy. On mental status examination, he was teary-eyed and said he was having a difficult time coping. He endorsed continued nightmares and intrusive thoughts. His affect was labile and his mood was dysphoric. The report of a July 2008 VA PTSD examination reflects the Veteran's complaints of difficulty sleeping, nightmares, flashbacks, intrusive thoughts, hypervigilance, exaggerated startle response, difficulty with loud noises, difficulty being in crowds, isolation, problems with anger, agitation, and frustration. He said that he lived with his wife of 35 years and that she had difficulty dealing with his anger and irritability. He denied having any friends or hobbies and said that he had poor motivation to complete his activities of daily living. On mental status examination, he was alert and oriented to person, place, month, year and time. Orientation to date was off by two days. Thought process was linear. Affect was blunted. Insight was demonstrated. Speech was fluent, grammatical, and free of paraphasias. Attention was mildly impaired. He was able to recall 2 out of 3 words after 5 minutes without prompting. He described having auditory and visual hallucinations, which the examiner noted were better described as flashbacks. He denied suicidal ideation, but reported having thoughts of suicide in the past. He reported being depressed at times. The diagnosis was PTSD and the GAF score assigned was 50. The examiner noted that the Veteran was experiencing moderate to severe impairment in functioning. An April 2009 private medical record from Consortium Counseling for PTSD reflects that the Veteran said he had few, if any, close friends. He endorsed symptoms similar to those described above. The report of a June 2009 VA PTSD examination reflects the Veteran stated that he felt like that he was "falling apart", and that he was angry and did not sleep well. He said he had nightmares 2 to 3 times per week and only slept for 4 hours per night, waking up several times. He said that he thrashed around in his sleep and his wife could not sleep with him. He denied frank flashbacks, but did describe seeing things in his peripheral vision. He said he had intrusive thoughts approximately 5 times per week. He said he did not like to be around a lot of people and that restaurants were okay as long as he sat so he could see the entire room. He said he avoided going to stores and did not have any friends. He also reported difficulty with anger management and isolation from his wife. He said he began upholstering furniture on his own because he prefers to be by himself. He also does odd jobs. On mental status examination, the Veteran was alert and oriented to personal information and place. Temporal orientation was normal. Insight was adequate. Affect was blunted and tearful. Response latencies were normal. He demonstrated adequate attention and was not distractible. Spontaneous speech was fluent, grammatical and free of paraphasias. Immediate, recent, and remote memory was all within normal limits. During the interview, he was logical and goal-directed. He reported minimal dysphoria and did not report any other symptoms of depression. He denied suicidal ideation or plan. There was no evidence of thought disorder. There was no pressures speech, grandiosity, irritability or restlessness noted. The diagnosis was PTSD, chronic, moderate, and the GAF score assigned was 50. The VA examiner noted that the Veteran was experiencing moderate to severe impairment in social functioning and a moderate degree of impairment in occupational function. The examiner opined that the Veteran's overall level of disability was moderate. A December 2008 VA mental health note reflects that the Veteran's PTSD was stable. It was noted that he had some marital conflict. He was teary during the interview, but said that crying spells and nightmares were less. He said that his ability to sleep was slightly improved. He denied suicidal ideation. His affect was labile and mood dysphoric. A suicide risk assessment note reflects that the Veteran denied feeling hopeless, and denied engaging in behaviors without thinking things through or considering the consequences. It was noted that his suicide risk was low. In March 2009, a suicide risk screening was negative. An April 2009 VA mental health note reflects that the Veteran continued to have nightmares 2 to 3 times per week. He said the nightmares increased during the first part of 2009 following the deaths of a friend of his son and his pastor. He continued to have flashbacks and was constantly on guard. His speech and thought process/content were normal. His mood was depressed and anxious. Suicidal ideation was present but with no plan or intent. Short-term memory was impaired, but long-term memory was intact. The diagnosis was PTSD and the GAF score assigned was 55. The report of private examinations conducted in June and July 2009 by Dr. P.M. reflects that the Veteran endorsed the PTSD symptoms outlined above. He said that his symptoms had progressively worsened over the years and that his income had steadily declined over the past 4 to 5 years due to the length of time it takes him to complete a job. It was also noted that the Veteran was a part-time minister. On mental status examination, the physician noted that it appeared the Veteran was suppressing his depression and anxiety. The diagnosis was PTSD, chronic, severe, and the GAF score assigned was 50. The physician noted that the only place the Veteran could function without stress was in his church and that the only way he could work was by himself on upholstery, but that this was becoming harder due to the necessity of having to work with clients. The physician stated that the Veteran was close to becoming unemployable. An August 2009 VA primary care note reflects that the Veteran was under a good bit of strain related to marital discord. He reported that his medication for PTSD had been helpful overall. A mental health record dated that same month indicates the Veteran had a positive depression and suicide screen. He said he was feeling down, depressed, and hopeless. He also reported frequent arguments with his wife. Later that month, he reported similar symptoms and he was assigned a GAF score of 55. In a November 2009 supplemental evaluation, Dr. P.M. stated that he strongly disagreed with a 50 percent disability rating assigned. The physician noted that the Veteran was a private man who was reluctant to reveal exactly how much he was suffering emotionally and that he had recently lost two jobs because he had missed appointment dates. It was also noted that the Veteran had suicidal thoughts, difficulty communicating with customers, and difficulty controlling his temper. Dr. P.M. opined that the Veteran's PTSD symptoms were severe and resulted in total occupational and social impairment. A November 2009 VA mental health note reflects that the Veteran was seen in the emergency room with complaints of increased PTSD symptoms following news of a helicopter crash with troops being killed. The emergency room report reflects that he had suicidal intent, panic attacks, and increased audio and visual hallucinations. His medications were adjusted, but it was noted that he needed to be alert while working as an upholsterer. A February 2010 VA mental health note reflects that the Veteran reported having an increase in his PTSD symptoms. He said he was having some marital discord and was very irritable. He denied any suicidal ideation, intent, or plan. During the February 2011 Board hearing, the Veteran testified that he was self-employed as a reupholsterer, but was only doing piecemeal work because of the economy. He said he had to quit a previous job at McDonald's because he could not deal with the stress and aggravation while working with others. He said he had trouble being in crowds, nightmares and flashbacks. He also described having symptoms of hypervigilance, uncontrolled anger, and difficulty with memory (remembering names). The report of a June 2011 VA examination reflects that the Veteran said he owned his own upholstery business and that business was down because of the economy. He said he has probably missed 20 days of work in the past year because of his PTSD symptoms. He said he was less productive because of concentration problems and low energy. He said that he had a very poor relationship with his wife because of his irritability. He said that he has a fairly good relationship with his grandchildren and that he has a close friend that he sees 3 times a week. He also said that he had 2 to 3 casual friends that he sees at church once a week. On mental status examination, the Veteran was alert and oriented. He appeared dysphoric and his affect was anxious and constricted. His speech reflected anxiety. There was some evidence of psychomotor agitation. The Veteran's eye contact was fair. He was cooperative and pleasant. His thought process was logical and coherent and devoid of current auditory or visual hallucinations. He denied current thoughts of hurting himself or others. The last time he was physical aggressive was with somebody 3 years ago. His memory was intact for immediate, recent and remote events. He was not able to concentrate well enough to spell "world" backwards. The diagnosis was PTSD and depressive disorder, not otherwise specified. The GAF score assigned was 53. The examiner indicated that the Veteran was exhibiting moderate to considerable PTSD symptoms and was moderately to considerably impaired in social and occupational functioning. IV. Legal Analysis Considering the pertinent evidence, as outlined above, and resolving all reasonable doubt in the Veteran's favor, the Board finds that a 70 percent rating for PTSD is warranted from the effective date of the grant of service connection. As an initial matter, the Board notes that the Veteran has also been diagnosed with depression in addition to PTSD. Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Here, the medical evidence has not distinguished between the psychiatric symptoms related to PTSD and depression and there is clearly some overlap. Hence, in this case, the Board has considered all of the Veteran's psychiatric symptoms in granting the 70 percent rating. Collectively, the Veteran's PTSD has been manifested by chronic sleep disturbance, nightmares, flashbacks, intrusive thoughts, hypervigilance, exaggerated startle response, anxiety, depression, social isolation, anger, frustration, irritability, anger outbursts, difficulty concentrating, memory impairment, occasional suicidal ideation, crying spells, near-continuous anxiety and depression, occasional auditory and visual hallucinations, and an inability to establish and maintain effective relationships. The Board points out that the medical evidence reflects that the Veteran has had near-constant depression and anxiety since the grant of service connection. During most of the mental health interviews, he became teary when describing his symptoms and has reported frequent crying spells and occasional suicidal ideation. He also has had impaired impulse control as demonstrated by unprovoked irritability and anger outbursts. He has also described difficulty adapting to stressful circumstances, including past work experiences. During the most recent June 2011 examination, his speech reflected anxiety and there was some evidence of psychomotor agitation. Most of his social interaction is with his wife and he has described discord in their marriage and withdrawal from that relationship. Overall, these symptoms are commensurate with a 70 percent rating under DC 9411. In this case, the Veteran has not exhibited obsessional rituals, although he has endorsed hypervigilance. He also has not exhibited spatial disorientation or neglect in his personal appearance. Thus, although not all of the criteria for a 70 percent rating are met in this case, the Board concludes that since the effective date of the grant of service connection, the type and degree of symptomatology contemplated for a 70 percent rating appear to be demonstrated. Furthermore, the VA examiners' have generally opined that the Veteran has moderate to severe or considerable impairment due to his PTSD. Dr. P.M. suggested that the Veteran tended to under report his symptoms and that his symptoms were severe and resulted in total occupational and social impairment. Hence, resolving reasonable doubt in the Veteran's favor, the Board finds that a 70 percent rating is warranted. Likewise, the Board also notes that the multiple GAF scores assigned ranging from 50 to 55 are consistent with either a 50 percent or 70 percent rating. According to DSM-IV, GAF scores ranging from 41 to 50 are indicative of 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 GAF score from 51 to 60 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). The Veteran's GAF scores of 50 are consistent with severe or serious symptoms, which are reflected in the criteria for a 70 percent rating. Although he has received GAF scores of 53 and 55, which reflect more moderate symptomatology consistent with a 50 percent rating, as noted above, reasonable doubt is resolved in the Veteran's favor. 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; or memory loss for the names of close relatives, own occupation, or own name is not demonstrated by the medical evidence of record. The Board notes that Dr. P.M. opined that the Veteran had total occupational and social impairment; however, the Veteran has remained self-employed throughout the appeal period and maintains an effective, if somewhat strained, relationship with his wife, and has reported having friends at times and engaging in church activities. Thus, the Board finds that the most persuasive evidence of record does not reflect total occupational and social impairment. The facts of this case do not present such an extraordinary disability picture such that the Board is required to remand this matter to the RO for the procedural actions outlined in 38 C.F.R. § 3.321(b)(1), which concern the assignment of extra-schedular evaluations in "exceptional" cases. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 94-95 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Thun v. Peake, 22 Vet. App. 111, 115 (2008). Finally, the Board notes that in some instances a claim for increase arguably includes a claim for unemployability benefits. See Rice v. Shinseki, 22 Vet. App. 447 (2009) (finding that a claim of entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service connected disorders is part of an increased rating claim when such claim is raised by the record). However, the evidence reflects that the Veteran has continued to work as an upholsterer during the course of this appeal. While he has alleged that his PTSD symptomatology affects his ability to concentrate at his job and interact with customers, he has not alleged that he is unable to work due to his PTSD. Under these circumstances, the Board does not find that a claim for a TDIU has been raised by the record. ORDER An initial rating of 70 percent from June 27, 2005 for PTSD is granted, subject to the regulations controlling the disbursement of VA monetary benefits. ______________________________________________ MICHAEL MARTIN Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs