Citation Nr: 1140407 Decision Date: 11/01/11 Archive Date: 11/16/11 DOCKET NO. 10-14 971 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to an increased initial rating for posttraumatic stress disorder (PTSD), rated 10 percent from August 17, 2004, to February 1, 2010, and higher than 30 percent, effective February 1, 2010. 2. Entitlement to a total disability rating for compensation based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Aires Robinson, Agent WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran served on active duty from January 1949 to January 1953, and from December 1954 to January 1963. This matter comes before the Board of Veterans' Appeals (Board) from an August 2007 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection for PTSD and assigned an initial disability rating of 10 percent, effective August 17, 2004. The Veteran appealed for a higher rating. In a rating decision in February 2011, the RO increased the Veteran's PTSD disability rating to 30 percent, effective February 1, 2010. However, as that grant does not represent a total grant of benefits sought on appeal, this claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The Veteran testified before the Board in September 2011. Additional evidence was received after the September 2011 hearing without a waiver of the right to have the additional evidence reviewed by the RO. As the additional evidence is duplicative of evidence already of record, the Board finds that remand to RO for initial consideration is not warranted. 38 C.F.R. § 20.1304(c) (2011). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). The issue of entitlement to a TDIU is REMANDED to the RO via the Appeals Management Center, in Washington, D.C. FINDINGS OF FACT 1. From August 17, 2004, to February 1, 2010, the Veteran's PTSD was not shown to be productive of a disability picture that equated to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 2. From August 17, 2004, to February 1, 2010, PTSD is shown to be productive of occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for an initial rating higher than 10 percent for PTSD from August 17, 2004, to February 1, 2010, have not been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2011); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2011). 2. For the period after February 1, 2010, the criteria for a 50 percent rating, but not higher, for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2011); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to notify and to assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. § 3.159 (2010); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claims with an adjudication of the claims by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in a letter dated in December 2004. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the September 2011 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. VA has obtained an examination with respect to the claim. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). General Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2011). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2011). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). After careful consideration of all of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2011). VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Veteran's PTSD is rated under Diagnostic Code 9411 under the General Rating Formula for Mental Disorders. The criteria for a 10 percent rating are occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. The criteria for a 30 percent rating are occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). The criteria for 50 percent rating are occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships. The criteria for a 100 percent rating are 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411, General Rating Formula for Mental Disorders (2011). The Global Assessment of Functioning is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266 (1996); Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). GAF scores from 61 to 70 indicate some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores from 51 to 60 indicate more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores from 41 to 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals) or any serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job). GAF scores from 31 to 40 indicate some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family and was unable to work). GAF scores from 21 to 30 indicate that behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). 38 C.F.R. § 4.125 (2011); Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). In a rating decision in August 2007, the RO granted service connection for PTSD due to in-service dental treatment involving extraction of multiple teeth. The RO assigned an initial 10 percent disability rating, effective August 17, 2004, the date the claim for service connection was received by the RO. The Veteran appealed for a higher rating. On VA psychological evaluation in July 2004, the Veteran reported nightmares, irritability, difficulty sleeping, avoidance of stressor-related stimuli, exaggerated startle response, problems concentrating, intrusive thoughts, and periodic low mood. Although the Veteran had a legal history of a criminal conviction for manslaughter in 1963, the clinician noted no evidence of suicidal or homicidal ideation on examination. He related loss of interest in typically enjoyable activities. A May 2005 VA treatment report shows complaints of nightmares and intrusive recollections of the in-service dental extractions. He endorsed hyperarousal and easy exaggerated startle response. Reportedly, he was withdrawn and avoided situations that reminded him of the dental procedures, such as smells in public restrooms. He reported irritability, feeling mistrustful of others, and difficulty getting close to people. Similarly, a VA clinical treatment note in June 2005, shows complaints of intrusive memories related to the in-service dental extractions. The Veteran was described as appropriately dressed and groomed. Speech was fluent and coherent with no abnormalities exhibited. Affect and mood were congruent. Thought process was linear and thought content appropriate. There were no signs of a formal thought disorder or cognitive impairment. There was no evidence of threat of harm to self or others. The assessment was anxiety disorder, not otherwise specified. In August 2006, the Veteran reportedly became tearful as he recounted his in-service stressor. He reported vivid memories of the incident, nightmares, distressed awakenings, and hypervigilence. The Veteran stated that with medications, his sleep had improved. He stated that when he had nightmares or poor sleep, he had difficulty concentrating the following day, which concerned him as it interfered with his ability to perform as a volunteer in a number of community service projects. The Veteran reported having meaningful relationships with friends. On mental health evaluation, there were no abnormalities noted; speech was normal in pace and volume, thought content was well organized and coherent, mood was normal, affect was appropriate, and he exhibited no psychotic symptoms. In October 2006, the Veteran denied depression, anhedonia, feelings of hopelessness, psychosis, or suicidal or homicidal ideation. He reported sleeping eight hours a night, occasionally disturbed by nightmares. The Veteran endorsed problems concentrating. Insight and judgment were fair. Thought process was linear, logical and goal oriented. Speech was normal. Cognitively, he was awake and alert. The clinician diagnosed PTSD with mild cognitive impairment. In October 2006, an acquaintance of the Veteran, reported that he and the Veteran had held a mutual membership in the same social club for 20 years and shared many friends in common. The acquaintance stated that the Veteran had told him that he suffered from flashbacks related to the in-service stressor. Additionally, the Veteran had problems sleeping and concentrating, as well as irritability. A VA treatment note in March 2007 shows a diagnosis of PTSD. The Veteran reported that his medication was effectively treating his PTSD symptoms, to include anxiety, and intrusive memories. The Veteran was well-groomed with no psychomotor abnormality evident. Affect was cautious, withdrawn, and cooperative. Thoughts were linear and logical. There was no suicidal or homicidal ideation present. There were no hallucinations or delusions present. In June 2007, the Veteran reported stress in his relationship due to the fact that his girlfriend learned that he slept with a gun or knife under his pillow. The Veteran was well-groomed with no psychomotor abnormality evident. Affect was cautious with drawn and cooperative. Thoughts were linear and logical. There was no suicidal or homicidal ideation present. In July 2007, the Veteran reported having several friends and being romantically involved with two partners. He also related having a relationship with his two adult children whom he raised. The Veteran was well-groomed. Speech was coherent with no abnormalities noted. Affect was pleasant and mood congruent. Judgment and insight were fair. Thoughts were linear and logical. There was no suicidal or homicidal ideation present. On VA examination in July 2007, the Veteran complained of difficulty sleeping, vivid nightmares three to four times a week, problems concentrating, intrusive memories triggered by stressor-related stimuli, flashbacks, anxiety, and exaggerated startle response. He denied panic attacks, ritualistic behaviors, and obsessions. On examination, his concentration was normal. There were no delusions or hallucinations present. His thought processes were normal. Judgment and abstract thinking were intact. Memory was fair and he denied suicidal or homicidal thoughts. The Veteran reported an occupational work history that included working for a mapping company for three to four years. He stated he experienced problems getting along with other at this employment. Thereafter, the Veteran worked for two different law firms as an investigator/photographer, for more than 25 years, until he retired in 1994. He stated that he retired in 1994 because his PTSD symptoms were interfering with his employment. Thereafter, the Veteran spent his time volunteering at the Vet Center and for a homeless food assistance program. He also worked as a receptionist. He had a fair relationship with his girlfriend of 15 years, and seemed to be getting along with his peers. The Veteran reported being very close to his two children. There was no history of psychiatric hospitalizations. He related loss of interest in typically enjoyable activities. The examiner diagnosed PTSD and assigned a GAF score of 65 to 70. The examiner determined that the Veteran's psychiatric symptoms had caused significant problems with social and occupational functioning for many years as his condition had been chronic. The examiner further found no difficulties with activities of daily living and determined that the Veteran's psychiatric symptoms were mild or transient but could cause social and psychological impairment with decrease in work or occupational tasks only during periods of significant stress. In a statement in July 2007, the Veteran reported that his symptoms had worsened and he was no longer able to continue working as a volunteer. He related increased frequency in nightmares. Reportedly his medication dosage had been increased which affected his thinking. VA treatment notes in January 2008 note that the Veteran's report that his current medications were working well, especially in the evening. However in the morning, he complained of increased anxiety, flashbacks, irritability, and difficulty relating with others. The Veteran was described as well groomed with no changes in psychomotor activity. Thoughts were linear and logical. Affect was blunted, cautious, euthymic, and cooperative. Mood was okay. There were no delusions or hallucinations present. He denied suicidal or homicidal thoughts. VA treatment notes in 2008 and 2009 show complaints of intrusive thoughts, anxiety, irritability, heightened startle response, nightmares, difficulty interacting with others, and difficulty sleeping. Reportedly, medication helped control his symptoms. A February 2010 private evaluation report form a mental health counselor shows complaints of traumatic memories, problems sleeping, problems with concentration and distractibility, avoidance of stimuli, and daily flashbacks. The clinician noted that the Veteran had been a PTSD and Readjustment Program Counselor since May 1992. Reportedly he requested a leave of absence from his position in July 2007 because his psychiatric symptoms were interfering with his ability to perform his duties and properly assist other Veterans. The Veteran denied a history of legal troubles. The Veteran reported getting along very well with his two adult children and visiting them on a regular basis. He stated that he had been bonding with his grandchildren. The Veteran also related bonding on a regular basis with three extended families in his geographical area. He also sponsored two children. The Veteran reported being psychiatrically treated since 2005. The Veteran related past homicidal thoughts directed at the dentist who had treated him in service. He stated that he no longer slept with a weapon as it became a source of problems with his partner. Since he stopped that behavior, he felt more confident in his personal, social, and sexual life, and his relationship with his girlfriend improved. However, he continued to be paranoid. The Veteran avoided attending social activities. He felt that his concentration problems and distractibility prevented him from being as involved in volunteer activities as he once had been. The clinician opined that the Veteran had developed a lack of concentration in group involvement and his daily activities, and a lack of interest in engaging in activities he one thought enjoyable. As a result of his psychiatric symptoms, he had decreased involvement with others and the general public. The clinician indicated that the Veteran was paranoid and easily startled. The clinician opined that the Veteran's PTSD had worsened since October 24, 2007, and recommended that the Veteran's VA benefits be increased, consistent with worsening symptoms. The clinician assigned a GAF score of 25. On VA examination in November 2010, the Veteran reported flashbacks triggered by certain smells and noises, anger outbursts, insomnia, difficulty maintaining social relationships, panic attacks, nightmares, irritability, emotional shutdown three to four times a week, suspiciousness, depression, hypervigilence, intrusive thoughts, anxiety, hopelessness, social isolation, and inability to trust others. The severity of the symptoms was described as moderate and episodic. The Veteran stated that the symptoms affected total daily functioning which resulted in difficulty establishing and maintaining effective social relationships. The Veteran denied a history of violent behavior or suicide attempts. He was being treated with medication and psychotherapy as much as twice a month. There was no history of psychiatric hospitalizations. The Veteran reported that he was currently divorced and not in a relationship. He stated that he had two sons with whom he had a good relationship. He related keeping weapons under his bed for fear of being attacked. On examination, there was no history of delusions, hallucination, or obsessive behavior. Thought processes were appropriate. The Veteran was able to understand directions. Judgment was not impaired. Abstract thinking was normal. The Veteran had no difficulty understanding commands. Memory was within normal limits. Suicidal and homicidal ideation was absent. The examiner diagnosed PTSD and dysthymic disorder and assigned a GAF score of 55. The examiner opined that the Veteran's psychiatric symptoms were productive of difficulty forming effective social and work relationships, decreased work productivity, and loss of interests in recreational activities. Occupationally, the Veteran experienced difficulty working with others due to mistrust and anger. Despite symptoms of hypervigilence and avoidance, the Veteran was capable of performing basic activities of daily living. The examiner described the Veteran's psychiatric symptoms as productive of occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks, although generally functioning satisfactorily with routine behavior, self-care and normal conversation. At hearings in March and September 2011, the Veteran testified that he had changed his telephone number in an effort to isolate himself from friends and family. He stated that he was no longer doing volunteer work due to inability to concentrate. He also related being easily startled. He endorsed suicidal ideation, depressed mood, irritability, panic attacks, and memory problems. He described getting lost while driving after he experienced a flashback triggered by a smell similar to antiseptic, which reminded him of dentists. Seeing dentists or medical white coats would also result in flashbacks. Although he reported having a few very close friends, he stated that his psychiatric symptoms had negatively impacted his social relationships, to include his relationship with his sons. He explained that he had not retired from his previous employment in 1995, rather he was no longer able to work given the severity of his psychiatric symptoms. In a subsequent statement, the Veteran described include lack of motivation, flashbacks and memory problems that resulted in his home becoming cluttered. The medical evidence for the period from August 17, 2004, to February 1, 2010, contained complaints of nightmares three to four times a week, irritability, difficulty sleeping, avoidance of stressor-related stimuli, exaggerated startle response, problems concentrating, intrusive thoughts, periodic low depressed mood, distressed awakenings, loss of interest in typically enjoyable activities, vivid memories, hyperarousal, difficulties interacting with others, social isolation, suspiciousness, and anxiety. In August 2006, the Veteran reportedly became tearful as he recounted dental treatment in service. While the Veteran complained of problems sleeping, in October 2006 he reported sleeping eight hours a night, occasionally disturbed by nightmares. In June 2007, the Veteran reported that he slept with a gun or knife under his pillow for protection. However, the Veteran consistently denied delusions and hallucinations, panic attacks, paranoid ideation, psychosis, or obsessive ritualistic behaviors. There was no evidence of threat of harm to self or others. There was no history of psychiatric hospitalizations and the Veteran's treatment consisted of medication and outpatient treatment. While the treatment notes show that the Veteran's disability prior to February 1, 2010, at times improved and worsened, thus requiring adjustment of medication, the Veteran generally reported that medications were effectively treating his symptoms. The VA examiner in July 2007 opined that the Veteran was mentally capable of performing activities of daily living. The examiner characterized the severity of the Veteran's psychiatric symptoms as mild or transient, but stated that they could cause social and psychological impairment with decrease in work or occupational tasks only during periods of significant stress. Prior to February 1, 2010, the Veteran's GAF scores ranged from 65 to 70. GAF scores ranging between 61 and 70 indicate some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Neither the number of symptoms, nor the type of symptoms, nor the GAF score controls in determining whether the criteria for a 30 percent rating have been met. It is the effect of the symptoms, rather that the presence of symptoms, that is the most important consideration. The Board finds that the Veteran's symptoms prior to February 1, 2010, did not meet the criteria for a 30 percent rating of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. As for the effect of the Veteran's symptoms on work or family relations, on VA examination in July 2007, the Veteran reported an occupational work history that included working for a mapping company for three to four years. He stated he experienced problems getting along with other at this employment. Thereafter, the Veteran worked for two different law firms as an investigator/photographer, for more than 25 years. He claimed he stopped working because his PTSD symptoms were interfering with his employment. Nonetheless, the Veteran remained actively involved in his community doing volunteer work. The evidence shows that the Veteran had been a PTSD and Readjustment Program Counselor since May 1992 at a VA center, until he requested a leave of absence from his position in July 2007 because of his psychiatric symptoms. He also reported volunteering for a homeless food assistance program, and as a receptionist. Socially, the Veteran reported having meaningful relationships with friends. In a witness statement a friend of the Veteran's reported that he and the Veteran had been members of a social club for approximately 20 years and shared many friends in common. The evidence shows the Veteran had been in a relationship with his girlfriend for at least 15 years, and described the relationship as fair. He also related having a very close relationship with his two adult children. The VA examiner in July 2007 noted no difficulties with activities of daily living and determined that the Veteran's psychiatric symptoms were mild or transient but could cause social and psychological impairment with decrease in work or occupational tasks only during periods of significant stress. As for the effect of the Veteran's symptoms on judgment, thinking, or mood, the Veteran's affect was described as appropriate, blunted, cautious, withdrawn, and cooperative. His mood was good. Speech was coherent, and normal in pace and volume. Thought content was well organized and coherent. Insight, judgment and abstract thinking, were fair or intact. Thought process was linear, logical and goal oriented. Cognitively, he was awake and alert. His concentration was normal. The Veteran was consistently described as well-groomed with no psychomotor abnormality evident. Based on the evidence of record, the Board finds that from August 17, 2004, to February 1, 2010, the symptoms manifested did not result in occupational and social impairment that was equivalent to the symptoms listed in the criteria for a 30 percent rating: occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, panic attacks (weekly or less often), mild memory loss (such as forgetting names, directions, recent events). Nor did the Veteran's actual symptoms approximate such manifestations. The Board finds that the Veteran's symptomatology more nearly approximated the criteria for a 10 percent rating of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. As the preponderance of the evidence is against the Veteran's claim for a rating higher than 10 percent for PTSD from August 17, 2004, to February 1, 2010, that claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The medical evidence after February 1, 2010, shows complaints of traumatic memories, irritability, difficulty sleeping, avoidance of stressor-related stimuli, lack of motivation, exaggerated startle response, problems concentrating, intrusive thoughts, loss of interest in typically enjoyable activities, vivid memories, memory problems, hyperarousal, increased social isolation, suspiciousness, anxiety, past homicidal thoughts, paranoia, anger outbursts, insomnia, panic attacks, nightmares, irritability, emotional shutdown three to four times a week, depression, hypervigilence, anxiety, feelings of hopelessness, and inability to trust others. The Veteran reported that his symptoms affected his total daily functioning which resulted in difficulty establishing and maintaining effective social relationships. At hearings, the Veteran testified that he had changed his telephone number in an effort to further isolate himself from friends and family. The Veteran complained of daily flashbacks. He described getting lost while driving after he experienced a flashback triggered by a smell similar to antiseptic in the air. He also testified that seeing dentists or medical white coats would also result in flashbacks. The Veteran endorsed suicidal ideation. The evidence shows that the Veteran has continued to be treated with medication and psychotherapy twice a month. There was no history of psychiatric hospitalizations. The examiner described the Veteran's psychiatric symptoms as moderate and productive of occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks, although generally functioning satisfactorily with routine behavior, self-care and normal conversation. In February 2010, a private mental health counselor noted a GAF score of 25, while on VA examination in November 2010, the Veteran was assigned a GAF score of 55. As further discussed below, the Board finds that the February 2010 GAF score of 25 is inconsistent with the Veteran's symptomatology as described in that report, and other evidence of record to include VA treatment notes, the VA examination report, and the Veteran's hearing testimony and statements. In this regard, the Board notes that a score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas, which have not been shown at any time during the period on appeal. By contrast, the VA examination report contained a GAF score of 55, which is consistent with the evidence of record, as GAF scores ranging between 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). In any event, as previously noted it is the effect of the symptoms, rather that the presence of symptoms, that is the most important consideration. As for the effect of the Veteran's symptoms on work or family relations, after February 2010 the evidence shows that the Veteran denied continued involvement in volunteer work due to his psychiatric symptoms. The VA examiner in November 2010, opined that the Veteran experienced difficulty working with others due to mistrust and anger. Socially, in February 2010, Veteran reported getting along very well with his two adult children and visiting them on a regular basis. He stated that he had been bonding with his grandchildren. The Veteran also related bonding on a regular basis with three extended families in his geographical area. He also sponsored two children. He continued to be in a relationship with his girlfriend, and related that his relationship was better after he stopped sleeping with weapons under his bed. Otherwise he avoided attending social activities. The clinician opined that as a result of his psychiatric symptoms, the Veteran had decreased involvement with others. Similarly, on VA examination in November 2010, the Veteran reported difficulty establishing and maintaining effective social relationships. He stated that he was divorced and no longer in a relationship. Although on examination he reported that he continued to have a good relationship with his children, at hearings he testified that he had been increasingly isolated and had changed his telephone number in an effort to isolate himself from friends and family. He did confirm having a few very close friends. The examiner opined that the Veteran's psychiatric symptoms were productive of difficulty forming effective social and work relationships, decreased work productivity, and loss of interests in recreational activities. The examiner further stated that the Veteran's psychiatric symptoms were productive of occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks, although generally functioning satisfactorily with routine behavior, self-care, and normal conversation. As for the effect of the Veteran's symptoms on judgment, thinking, or mood, the evidence of record, to include VA treatment notes and the November 2010 VA examination report, show no history of delusions, hallucination, or obsessive behavior. Thought processes were appropriate. The Veteran was able to understand directions. Judgment was not impaired. Abstract thinking was normal. The Veteran had no difficulty understanding commands. Memory was within normal limits. In view of the foregoing, the Board concludes that the evidence is in relative equipoise as to the level of psychiatric disability, and as to whether it is reasonable to conclude that the disability picture is comparable to a 50 percent rating after February 1, 2010. However, in absence of evidence of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships, the criteria for the next higher rating, 70 percent, have not demonstrated. With the exception of some suicidal ideation, the symptoms indicative of a 70 percent rating have not been shown by the evidence of record. Accordingly, the Board resolves reasonable doubt in favor of the Veteran and finds that the criteria for a 50 percent schedular rating, but not higher, are met for PTSD effective February 1, 2010. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although the Board is precluded by regulation from assigning an extraschedular rating in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for consideration of an extraschedular rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disabilities are inadequate. That is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. 38 C.F.R. § 3.321(b)(1) (2011). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is adequate; and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111 (2008). Here, the rating criteria for the Veteran's service-connected PTSD reasonably describe the Veteran's disability level and symptomatology, and provided for higher ratings for additional or more severe symptoms, which have not been shown. The evidence does not show that the disorder causes unusual factors such as marked interference in employment or frequent hospitalizations. Therefore, the disability picture is contemplated by the Rating Schedule, and the Board finds that the assigned schedular ratings are adequate. Consequently, the Board finds that referral for consideration of an extraschedular rating is not required. 38 C.F.R. § 3.321(b)(1) (2011). The Board has considered the entire period since the Veteran filed his claim to determine if staged ratings are warranted for periods other than those discussed above. The Board finds that the evidence does not support assignment of higher ratings during any portion of this appeal. ORDER An initial rating higher than 10 percent for posttraumatic stress disorder from August 17, 2004, to February 1, 2010, is denied. An initial rating of 50 percent, but not higher, for posttraumatic stress disorder, effective February 1, 2010, is granted. REMAND VA has a duty to assist claimants in the development of facts pertinent to claims and VA must accomplish additional development of the evidence if the record before it is inadequate. 38 U.S.C.A. § 5103A (West 2002). The Board regrets the additional delay that will result from this remand. Nevertheless, the Board is constrained by the fact that proper adjudication of the claim requires additional development. The Veteran contends that he is unable to obtain or secure employment due to his service-connected PTSD. Specifically, the Veteran reported that he stopped working in 1994 due to his psychiatric symptoms. Additionally, the Veteran reported that he stopped doing volunteer work in 2007 as of result of increased PTSD symptomatology. A TDIU claim is part of an increased rating claim when a TDIU claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, the issue of entitlement to a TDIU rating has been raised by the record and is within the jurisdiction of the Board. Total disability will be considered to exist where there is impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (2011). Total disability ratings for compensation may be assigned where the schedular rating is less than total when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and if there are two or more 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 (2011). If the schedular rating is less than 100 percent, the issue of unemployability must be determined without regard to the advancing age of the Veteran. 38 C.F.R. §§ 3.341(a), 4.19 (2011). Factors to be considered are the Veteran's education, employment history, and vocational attainment. Ferraro v. Derwinski, 1 Vet. App. 326 (1991). The Veteran has been granted a 40 percent disability rating for recurrent dislocation of the left shoulder, and a 0 percent disability rating for hemorrhoidectomy. In addition, the above decision granted an increased rating of 50 percent for PTSD effective February 1, 2010, thus bringing the combined disability rating to 70 percent. 38 C.F.R. § 4.25 , Table I, Combined Ratings Table (2011). Therefore, effective February 1, 2010, the Veteran meets the minimum schedular percentage criteria for a TDIU. 38 C.F.R. § 4.16(a) (2011). The remaining question before the Board therefore is whether the Veteran's service-connected disabilities prohibit him from sustaining gainful employment, such that a TDIU rating may be assigned. The Board finds that an opinion is needed as to whether the Veteran, solely as a result of his service-connected disabilities, is no longer able to be employed or whether he is more generally unemployable. It does not appear that an examiner has yet been asked to render an opinion as to the overall effect of the Veteran's service-connected disabilities alone on his ability to obtain and retain employment. Therefore, the prudent and thorough course of action is to afford the Veteran an examination to ascertain the impact of his service-connected disabilities on his unemployability. It appears to the Board that additional treatment records may be outstanding. A review of the Veteran's VA medical records reflects that the most recent VA medical records are dated in June 2011. To aid in adjudication, any subsequent VA medical records should be obtained. Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). Expedited handling is requested. 1. Obtain the Veteran's VA treatment records dated since June 2011. 2. Schedule a VA examination to ascertain the impact of his service-connected disabilities on his employability. The claims folder should be reviewed and that review should be indicated in the examination report. The examiner must evaluate and discuss the effect of all of the Veteran's service-connected disabilities on the Veteran's employability. The examiner should opine as to whether it is at least as likely as not (50 percent or more probability) that the Veteran's service-connected disabilities (PTSD, left shoulder disability, and hemorrhoidectomy), without consideration of nonservice-connected disabilities, render him unable to secure or follow a substantially gainful occupation. In making the employability determination, the examiner should also consider the Veteran's level of education, other special training, and work experience. The VA examination report must include a complete rationale for all opinions and conclusions expressed, and the examiner must discuss the rationale of the opinion, whether favorable or unfavorable. 3. Then, readjudicate the claim. If the decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs