Citation Nr: 1209005 Decision Date: 03/09/12 Archive Date: 03/19/12 DOCKET NO. 07-06 483 A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio THE ISSUE Entitlement to a rating in excess of 50 percent from August 1, 2008, for posttraumatic stress disorder (PTSD) with major depressive disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from July 1965 to July 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision of the Cleveland, Ohio VA Regional Office, which granted service connection for PTSD, rated 30 percent. An interim (February 2010) rating decision granted a 50 percent rating effective July 15, 2008. A March 2011 rating decision found that there was clear and unmistakable error in the February 2010 rating decision in assigning an effective date of July 15, 2008 for the 50 percent rating, noting that the Veteran continued to be entitled to a temporary total evaluation for hospitalization on that date, and amended the effective date for the 50 percent rating to August 1, 2008. In October 2011, a Travel Board hearing was held before the undersigned; a transcript of the hearing is included in the claims file. The most recent (March 2011) supplemental statement of the case (SSOC) identifies the issues on appeal as entitlement to a rating in excess of 30 percent for PTSD prior to July 15, 2008; entitlement to a rating for PTSD in excess of 50 percent from that date; and entitlement to service connection for erectile dysfunction. At the October 2011 Travel Board hearing it was clarified that the only issue the Veteran was pursuing on appeal was the matter of a rating in excess of 50 percent for PTSD with major depressive disorder from August 1, 2008. The matter of entitlement to a total disability rating based on individual unemployability (TDIU) is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action on his part is required. FINDING OF FACT It is reasonably shown that throughout the relevant appeal period (since August 1, 2008), the Veteran's PTSD with major depressive disorder has been manifested by symptoms productive of occupational and social impairment with deficiencies in most areas; at no time is the PTSD with major depressive disorder shown to have been manifested by symptoms productive of total occupational and social impairment. CONCLUSION OF LAW A 70 percent (but no higher) schedular rating is warranted for the Veteran's PTSD with major depressive disorder from August 1, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code (Code) 9411 (2011). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and 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. 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). As the May 2006 rating decision on appeal granted service connection for PTSD and assigned a rating and effective date for the award, statutory notice had served its purpose and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). A January 2007 statement of the case (SOC) provided notice on the "downstream" issue of entitlement to an increased initial rating; and a March 2011 supplemental SOC (SSOC) readjudicated the matter after the Veteran and his representative responded and further development was completed. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). The Veteran has had ample opportunity to respond/supplement the record. He has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) ("where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). At the October 2011 Travel Board hearing before the undersigned, the Veteran was advised of what is still needed to substantiate his claim; his testimony reflects that he is aware of what remains necessary. The Veteran's pertinent treatment records have been secured. His Social Security Administration (SSA) records were secured as well. The RO arranged for VA psychiatric examinations in October 2008 and March 2011, which will be discussed in greater detail below, though the Board finds these examinations to be adequate as each included a review of the Veteran's history and a mental status examination that included all necessary findings. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). He has not identified any pertinent evidence that is outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes which outline the criteria specific for each disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. With the initial rating assigned following a grant of service connection, separate (staged) ratings may be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). PTSD is rated under the General Rating Formula for Mental Disorders (General Formula). A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Code 9411. The Veteran has been assigned various Global Assessment of Functioning (GAF) scores for his PTSD. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). Lesser scores reflect increasingly severe levels of mental impairment. See 38 C.F.R. § 4.130 [incorporating by reference VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes]. The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000)(VA must review the entire record, but does not have to discuss each piece of evidence.) Hence, the Board will summarize the relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claim. The Board notes that during the appeal period (since August 1, 2008), the Veteran was assigned two periods of temporary total evaluation for PTSD with major depressive disorder based on hospitalization (from mid-June through July 2009 and from late June through July 2010), and that such periods are not for consideration herein. On July 2008 VA inpatient discharge (just prior to the start of the relevant period for consideration in this appeal), the diagnosis was PTSD; a GAF score of 32 was assigned. On October 2008 VA examination, the examiner noted that the Veteran had been in treatment with primary care and psychiatry for PTSD groups; he had been resistant to attending VA groups but had been attending Vet Center groups regularly. The examiner noted that the most recent (2006) VA examination had resulted in a GAF score of 50. The Veteran reported that he had been divorced since 1986 (and later had "some girlfriends"). He lived with his younger daughter; he had been living with an older daughter and son-in-law but "was asked to leave because he was not contributing to the household". He reported a stable relationship with both daughters. He had a few friends, but no close friends; he had difficulty trusting others. He reported getting up in the morning to go to McDonald's for coffee then returning home to watch television and surf the internet. His daughter did not want him to do anything in the house; he just had to live there. He went to the mall to walk early in the morning, but never when it was busy because crowds and people troubled him. He went to group meetings at the Vet Center weekly. He reported he was twice (in 2006 and in 2008) admitted to a PTSD recovery unit, and would probably go again because it helped him to better understand himself; he felt the problem was that he was down and having trouble coping; he would leave the unit feeling great, only to worsen again. He reported feeling depressed 5 to 6 days out of the week. He reported feeling lost ever since he left Vietnam. He felt somewhat better when he was working and distracted though he was aware that the depression was still there. He reported feelings of suicidal ideation and plans at times, though he clearly denied intent; he distracted himself from the suicidal feelings by going for a ride, changing the TV channel, surfing the internet, or visiting with a Vietnam veteran who lived across the street to refocus his mind. He reported feelings of suicidal ideation 2 to 3 times per week, particularly on cloudy/rainy days. He denied ever making any suicidal attempt or any history of assaultive behavior. He reported being able to take care of his routine responsibilities of self-care, including doing his own laundry. He reported having a great deal of difficulty socializing with others, and that he found it difficult to hold conversations with others as he was disinterested in what they were saying and had nothing in common [with them]. He reported avoided violence on television. He did not attend church, as he found them hypocritical. He had no feeling of purpose or direction but was trying to find one. He had no interest in socializing. He reported problems with sleep disturbance, endorsing middle insomnia and the need for naps during the day. He reported anhedonia, and did not look forward to holidays or significant events. On mental status examination, the Veteran was casually dressed, neatly groomed, and pleasant and cooperative with good eye contact. He was marked by psychomotor retardation. He displayed a range of affect including becoming tearful several times when recalling Vietnam or discussing his ongoing struggles with depression. His thought process was intellectualized and "a bit plodding"; he was aware of this, stating that he overanalyzed things. His intelligence and fund of knowledge appeared above average. His recent and remote memory was intact; immediate memory was not tested. His cognition was felt to be grossly intact; though he reported difficulty with concentration, focus and distractibility. His mood was depressed and anxious, and his affect was flat. He denied auditory or visual hallucinations or paranoia, but reported general mistrust of others and discomfort with crowds and social engagements. There was no evidence of substance abuse or characterological problems. There was no evidence of any formal thought disorder. He admitted to periodic suicidal thoughts but no attempts, and denied any active suicidal or homicidal ideation, intent, or plan. His thought processes were goal-directed, and his insight and judgment were fair to good. The examiner diagnosis was chronic PTSD as well as moderate recurrent major depressive disorder related to PTSD and ongoing adjustment difficulties. A GAF score of 45 was assigned, reflective of severe persistent psychological symptoms (depression, anxiety, intrusive thoughts, and sleep disturbance) with moderate impairment in social and occupational functioning. The examiner opined that the Veteran's mental health symptoms would likely cause severe discomfort when interacting with other people, and moderate to severe reduced communication effectiveness; the examiner opined that the Veteran's level of frustration, apathy, isolation, and inner turmoil would likely cause moderate to severe work inefficiency and lack of productivity, and his fatigue, frustration, and motivation problems would likely cause difficulty with reliability. The examiner opined that the amount of avoidance of social contact and confrontation shown would likely interfere severely with his ability to interact effectively. The examiner opined that the Veteran had some moderate reduction in ability to adapt to stressful circumstances such as workplace, classroom, or other social environments. The examiner opined that the Veteran was not an immediate danger to himself or others. On April 2009 VA treatment, the Veteran reported attending individual VA therapy and two outpatient groups, in addition to psychiatric care. His medications included Terazosin and Bupropion. He denied any history of suicidal attempts but admitted to ideation in prior months. He reported calling other veterans and talking when he thinks that way, and the ideation goes away; he also reported getting rid of his guns "a long time ago". He denied any current ideation of harming himself. He had been living with his daughter and son-in-law for the previous several years. His PTSD symptoms included re-experiencing, intrusive memories, and flashbacks triggered by helicopters; his nightmares related to war events had increased. He reported trouble falling asleep and staying asleep. His anxiety was very high and he felt unable to go to the store unless nobody else was there shopping. He felt irritable and was having more anger dysregulation. He reported social isolation and depressed mood; he found it hard to be around his veteran friends for coffee at McDonald's and felt forced by his anxiety to leave. He reported wanting not to isolate himself so much. On August 2009 private psychosocial evaluation, psychologist Dr. Tripi reviewed the Veteran's personal, employment, and treatment history. He was noted to be receiving treatment from a VA social worker and a psychiatrist as well as weekly Vet Center group sessions. The Veteran reported difficulty staying asleep, waking after 2 to 3 hours even with medication, and sometimes with physical reactions such as sweating. He reported problems with feeling frightened or confused in the past. He reported that he used to have frequent nightmares but could not recall having any currently. He reported daily intermittent intrusive, involuntary thoughts, and flashbacks regarding his military experiences, which would be triggered by the sight or sound of helicopters or airplanes, loud noises, or news of the war in Iraq. He became very upset around people, places, or events that reminded him of the military. He reported feeling emotionally numb and void of feeling since his separation from service. He reported difficulty trusting others, having no close friends, and having rocky interpersonal relationships. He tried to avoid thinking or talking about traumas over the years, and had difficulty remembering certain aspects of his traumas due to blanks in his memory. He reported feeling alienated from others, and had a sense of doom and negativity, noting that he felt like he had no purpose. He had lost interest in things he previously enjoyed. He reported frequent bouts of irritability and outbursts of anger, not always related to issues at hand. He reported that his concentration was affected, as his mind would wander and he became bored easily. He reported being hypervigilant; he preferred sitting with his back to the wall, checked doors and windows and scanned the environment, and had an exaggerated startle response. Dr. Tripi opined that the Veteran experienced severe social, personal, and occupational impairment due to symptoms including difficulty concentrating and completing tasks in a timely fashion, generalized anxiety with 3 to 4 panic attacks per week, waves of short and long term memory loss, flashbacks and intrusive thoughts, sleep disturbance, overwhelming feelings of anger and sorrow with crying spells, feeling withdrawn and isolative, and bouts of severe depression. The diagnosis was chronic delayed severe PTSD and a GAF score of 42 was assigned. Dr. Tripi opined that, although the Veteran was on medication and in therapy, his symptoms were severe and very active. She opined that, based on his education, training, work history, and level of symptoms, he was not a viable rehabilitation candidate, nor was he capable of sustaining substantial gainful work activity. On January 2010 VA treatment, the Veteran reported difficulty expressing emotions as he had learned to "turn them off" in the military. He reported that it felt weak crying in front of someone else, and he cried when he was alone. He reported war-related nightmares and attempted to process two specific dreams involving feelings of guilt, regret, and helplessness. On mental status examination, the Veteran was appropriately dressed and groomed with good eye contact. His demeanor was talkative and pleasant. His speech was within normal limits. His affect was normal, tearful at times and joking at other times, and his mood was stable. He was fully oriented and his thought process and content were coherent and logical. He denied any suicidal or homicidal ideations, and his insight and judgment were good. On February 2010 VA treatment, the Veteran reported living with his daughter and son-in-law. He continued to have problems and symptoms related to trauma in service. He reported intrusive thoughts, nightmares, exposure distress with physiological reaction, avoidance of thoughts and feelings and related situations, anhedonia at times, emotional numbing, sleep difficulty, irritability, hypervigilance, and an exaggerated startle response. He was receiving psychiatric treatment as well as individual and group therapy. He denied any alcohol or drug use. He denied any history of suicide attempts, and he was not currently suicidal or homicidal. His mood was "mellow" and he was open and cooperative, logical and focused. He reported no hallucinations. Based on these findings, a February 2010 rating decision increased the Veteran's rating for PTSD with major depressive disorder to 50 percent effective July 15, 2008. (A March 2011 rating decision later found that there was clear and unmistakable error in the February 2010 rating decision in assigning an effective date of July 15, 2008 for the 50 percent rating, noting that the Veteran was still entitled to a temporary total evaluation for hospitalization on that date; the March 2011 rating decision corrected the effective date for the 50 percent rating to August 1, 2008, the date following the termination of the temporary total rating.) In an August 2010 statement, the Veteran's treating psychologist Dr. Goran noted that she had been treating the Veteran for PTSD since May 2010. He was clean but ungroomed and poorly dressed, and he was very anxious and intense. He had brought numerous documents with him to validate his history as though he did not expect to be believed. He was polite and cooperative and answered all questions thoughtfully. He reported having more than 20 different jobs from 1969 to 2005, with his longest position as a self-employed computer consultant from 1985 to 1990. He reported that he had been fired from one job after having an altercation with his boss. He reported that he had been unable to find and keep work since October 2005. Regarding treatment, Dr. Goran noted a history of multiple VA hospitalizations for PTSD and treatment at several other VA medical centers and Vet Centers. Dr. Goran noted the Veteran's recent release from another inpatient hospitalization, prior to which he had been living with his daughter and avoiding all other social contact as much as possible. He frequently felt suicidal, slept poorly and had frequent intrusive thoughts, and was hypervigilant and irritable with no sense of connection to anyone but his daughters. The diagnoses were PTSD and recurrent major depressive disorder. Dr. Goran opined that the Veteran was unable to obtain and maintain gainful employment (including sedentary types) and this inability was directly related to his service-connected condition. The opinion was based on the Veteran's symptoms and history and the multiple statements, records, and other opinions examined. On August 2010 discharge from VA inpatient treatment, a GAF score of 31 was assigned for PTSD. The Veteran was noted to be stable for discharge with euthymic mood and no evidence of psychosis, and he was not considered a suicidal or homicidal risk. In a September 2010 summary statement, the Veteran's treating Vet Center therapist noted that the Veteran had been receiving counseling at the Vet Center since March 2007, initially individually and then in group therapy. The therapist noted that the Veteran struggled with nightmares, sleep difficulty, irritability, high stress levels, anxiety, depression, and crying spells, with daily intrusive memories of the war, emotional numbness, and difficulty getting close to others. The therapist noted that the Veteran had difficulty with trust and had very limited social interaction. The therapist noted that the Veteran avoided crowds and calculated the right time to leave home in order to perform necessary obligations without facing crowds. The therapist noted that the Veteran was awarded Social Security disability benefits in August 2007. The therapist opined that the Veteran's chronic PTSD had impaired his ability to function productively. On November 2010 VA treatment for medication management, the Veteran was noted to be taking Bupropion and Prazosin, with no side effects. He reported that he spent most of his time at home but did not elaborate. On mental status examination, he was alert with fairly good grooming and good eye contact. His speech was fluent and spontaneous. His affect was brighter and his thinking was logical. He denied any suicidal or homicidal ideation at that time. The diagnoses were chronic PTSD and recurrent major depressive disorder in partial remission; a GAF score of 45 was assigned. On further November 2010 VA treatment, the Veteran reported his ongoing issues with his PTSD and symptoms of depression. He reported intrusive thoughts, nightmares, avoidance, arousal, and depression. He was attending group therapy regularly and receiving psychiatric care, as well as attending a group at the Vet Center. He was motivated for treatment but understood that he would "never be like [he] was before Vietnam". He denied active suicidal or homicidal ideations or any plan of harm. On mental status examination, he was well groomed, attired appropriately for the weather, pleasant and cooperative. His speech was within normal limits. His mood was stable and his affect was euthymic. He was fully oriented. His thought process and content were coherent, logical, and goal-directed, and his insight and judgment were good. On February 2011 VA treatment, the Veteran reported that he was living with his daughter and her husband after losing his own home several years earlier. He became emotional when discussing his PTSD and his feelings about how much it had cost him. He reported that about two months earlier, he had a "realization" of all that he had lost due to his problems related to his service; he was focused on these problems and struggled with grief and sadness. He denied any active suicidal or homicidal ideations or plan of harm. On mental status examination, he was well groomed and appropriately attired for the weather, and he was pleasant and cooperative. His speech was within normal limits. His affect was euthymic, and his mood was stable though tearful at times. He was fully oriented, and his thought process and content were coherent, logical, and goal-directed. His insight and judgment were good. On later February 2011 VA treatment for medication management, the Veteran was noted to be taking Bupropion and Prazosin. He reported that his nightmares were greatly diminished with these medications and he was sleeping much better with no reported side effects. He reported that he was seeing a new PTSD counselor and it was going well. He reported having flashbacks the previous December about how his life had been for the previous 25 years and he became very emotional; he clarified that he had been thinking intently about his mental illness and viewed these years as a waste due to his PTSD. On mental status examination, the Veteran had fairly good grooming and good eye contact. His speech was fluent and spontaneous. His affect was appropriate and his thinking was logical. He denied any suicidal or homicidal ideation. The diagnoses were chronic PTSD and recurrent moderate major depressive disorder in partial remission; a GAF score of 45 was assigned. On March 2011 VA examination, it was noted that the Veteran had been treated in an intensive in-patient PTSD program in 2006, 2008, 2009, and 2010, noting that his GAF score at the time of his last discharge was 31. The examiner noted that the Veteran continued to receive treatment for PTSD and depression and his most recent GAF score of 45 on February 2011 treatment. The examiner reviewed the history of diagnoses and treatment for depression, then dysthymia, then PTSD and major depression. The Veteran denied any history of assault, violence, or suicide attempt since his previous [2008] VA examination; however, he did report recurrent frequent suicidal ideation. There was no history of substance abuse; the Veteran reported a history of alcohol abuse, and that he had cut back drinking on his own when he realized it was "not taking him to good places"; he had not had a drink since 2006. The examiner noted that the Veteran was being seen by the VA clinic psychiatrist approximately every three months, and attended monthly VA individual therapy and weekly PTSD and smoking cessation group therapy, in addition to a PTSD group at the Vet Center. The Veteran reported that each PTSD hospitalization reduced his symptoms but the reduction was short-lived and the symptoms increased again within a month or two. The Veteran reported improved sleep initiation and maintenance, getting 8 hours of restful sleep per night, and improved anxiety on his current medications of Wellbutrin and Prozac, with no side effects. He reported chronic symptoms of depression, anxiety, and PTSD, ranking his depression at 5 to 6 out of 10 in severity and his anxiety at 5 out of 10. He reported having panic attacks 2 to 3 times per week, brought on by stress and traumatic cues; he reported severe panic attacks once per month. He reported chronic difficulties with irritability and poor frustration tolerance, and he tended to become quiet when angry; on rare occasions, he would take his anger out on inanimate objects. He reported periodic road rage. He denied impulsivity but reported chronic serious difficulties with hypervigilance; he reported that he needed to sit with his back to the wall, repeatedly checked doors and windows, and did perimeter checks when up at night. He reported increased startle response, frequent crying spells, and chronic difficulties with motivation and apathy. He reported serious difficulty with discomfort when exposed to crowds, and no longer went to malls, sporting events, movie theaters, or crowded stores or restaurants; he would go to less crowded restaurants or stores with moderate to severe discomfort. He reported difficulty with mistrust and suspiciousness as well as social withdrawal and periods of social isolation. He reported that he had no friends, and that he kept to himself in his own part of the house despite living with his daughter and son-in-law. He denied any difficulty with energy but reported chronic difficulties with interests and chronic serious difficulties with hopelessness, helplessness, excessive guilt, concentration, focused attention, and distractibility. He reported that he was no longer able to read on a regular basis due to poor concentration, and that he had some difficulty with word processing programs even though he had worked in programming for much of his career. He denied any appetite problems. He reported daily suicidal thoughts but denied any current active suicidal or homicidal ideation, intent or plan. He was divorced with two adult daughters, with whom he had good relationships and regular contact. He had no close friends and did not socialize with neighbors; his socializing was limited to his children and veterans in his PTSD group. He reported being able to attend to activities of daily living, such as shopping, cooking, cleaning, or laundry without difficulty. He reported being neglectful of personal hygiene, showering twice per week and shaving only once per week. He reported that he had withdrawn from activities he previously enjoyed such as reading or going to the mall to walk. He spent much of his time watching movies and surfing the internet. He had been unemployed since 2005. On mental status examination, the Veteran was timely, pleasant, and cooperative with good eye contact. He was periodically tearful, especially when discussing his traumas and the impact of his PTSD on his life. His speech was regular in rate and rhythm, relevant, spontaneous, articulate, and coherent. He appeared able to advocate well for himself, presenting the examiner with many organized documents chronicling his work history, where he had lived, and accounting for his symptoms, traumatic cues, and medications. He was noted to have a tendency to be over-inclusive, and he was difficult to disengage at the end of the interview, as he continued to list additional symptoms and difficulties he was having. His hygiene was adequate; he was unshaven, and his clothing was clean and weather-appropriate. He was alert and oriented to all spheres. His memory was intact for recent and remote; immediate memory was not tested. His cognition was felt to be grossly intact without noticeable difficulties in concentration, focused attention, or distractibility. His intelligence and fund of knowledge appeared average. His mood was depressed and anxious; his affect was blunted but easy to engage in that he was initially guarded but was able to establish rapport with the examiner. He reported mistrust and suspiciousness. He denied auditory or visual hallucinations, delusions, or paranoia, and there was no evidence of any formal thought disorder. He denied any symptoms of mania, hypermania, or obsessive compulsive disorder. He reported chronic difficulties with discomfort in crowds as well as frequent panic attacks but denied impulsivity. He reported irritability, poor frustration tolerance, and outbursts of anger but denied any assaults or violence. He reported hypervigilance, crying spells, and difficulties with motivation, apathy, depression, anxiety, interests, hopelessness, helplessness, guilt, and concentration. His thought processes were goal-directed with some tendencies toward over-inclusiveness and tangentiality. He reported daily distressing recollections and feeling as if the event were recurring with intense psychological distress and physiological reactivity on exposure to cues. He reported avoidance symptoms, marked diminished interests in participating in significant activities, feelings of detachment and estrangement form others, a restricted range of affect, and a sense of a short future. There was no evidence of any substance abuse or underlying personality disorder. Insight and judgment were good. The March 2011 examination diagnosis was PTSD and severe recurrent major depression; a GAF score of 35 was assigned. The examiner explained that the Veteran presented with serious symptomatology and his depression was felt to be due to his chronic PTSD symptoms and psychosocial functioning difficulties due to PTSD, noting that the PTSD and depressive symptoms could be considered collectively as there was such an overlap between the two that it would be speculative to try to differentiate which symptoms would be due to any one condition. The examiner opined that the Veteran had serious difficulties with interpersonal functioning, as evidenced by his lack of friends, social withdrawal, social isolation, chronic difficulties with mistrust, and withdrawal from activities which he previously enjoyed. The examiner noted that the Veteran had moderate difficulty interacting socially and serious discomfort in crowds, and presented as someone who would have moderate difficulty adapting to stressful situations in a work, classroom, or social setting. The examiner noted moderate difficulty establishing and maintaining effective work relationships and serious difficulty maintaining social relationships. The examiner noted that the Veteran's thinking processes were logical and would not adversely affect his social or vocational functioning, though his communication was somewhat reduced due to circumstantiality, over-inclusiveness and emotional detachment. The examiner noted chronic difficulties with concentration, focused attention, distractibility, inner turmoil, apathy, and motivation which would as likely as not lead to periodic missed days from work and moderate to serious reduction in occupational productivity, reliability, efficiency, or work performance. The examiner noted that, despite therapeutic and pharmacological interventions, the Veteran's symptoms remained quite severe and would likely remain chronic with some periodic worsening in response to additional stressors or losses. On March 2011 VA treatment, the Veteran denied any thoughts of suicide or homicide. He reported that he wanted to be less concerned about getting "ticked off" and angry, and his anger was still a significant problem for him; he reported being afraid of going places that might set him off. His insight was fair in that he was aware of his illness and expressed a desire and motivation for change. He reported having a supportive family and/or friends; he reported that he lived with family but was not necessarily happy with his living situation, though he was wary of getting his own place because he knew how much he isolates himself from others. His treatment plan priorities included reducing the frequency and intensity of his irritability and outbursts of anger, and establishing the skills needed for building trust and managing emotions in relationships to reduce his feelings of detachment from others. The treatment plan included monthly individual therapy for six months and weekly PTSD group therapy for six months. The diagnoses included PTSD and major depression; a GAF score of 45 was assigned. The Veteran has also submitted lay statements chronicling his symptoms. VA and Vet Center treatment records through March 2011 reflect findings largely similar to those noted above. At the October 2011 Travel Board hearing the Veteran's representative noted that from 2008 to the present the Veteran's GAF scores have ranged from 31 to 45, and no higher. The Veteran testified that he frequently becomes irritable to the point where he cannot work. He testified to having impulse control problems such as angry outbursts that would affect his ability to be employed. He testified that he is not able to maintain effective relationships. He is able to go out to public places such as the grocery store, but testified that he goes at times when there are no crowds. He had been told by Dr. Goran that he was not employable due to his PTSD symptoms; the Veteran's representative referred to Dr. Goran's statement as well as vocational rehabilitation documents indicating that the Veteran's occupational functioning is impacted by his PTSD to the point that employment is not feasible. The Veteran testified that he is able to communicate with people to a certain extent, but not very well; he is able to write only short emails. He denied having any persistent hallucinations or delusions, though he testified that he used to have them. He testified that he has felt like he is a danger to himself or others, so he isolates himself "so not to get into trouble" or harm people. He had not had any homicidal ideation, but often had suicidal ideation (though with no attempts). He testified that he has had outbursts in public, such as when he believes someone is not telling the truth and he argues and screams in response. He testified that he neglects his personal hygiene because he just does not care, but is able to perform activities of daily living including maintenance of minimal personal hygiene if he wishes to do so. He testified that he is oriented to place, time, and day, and knows his immediate family. The Board finds that the Veteran, his treating VA, Vet Center and private mental health personnel, and VA examiners have reported symptoms associated with PTSD that reflect occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. The symptoms have included frequently recurring suicidal ideation (with no attempt); some obsessional rituals which interfere with routine activities (checking the doors and windows upon waking up in the middle of the night); speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively (frequent panic attacks); impaired impulse control (such as unprovoked irritability with periods of violence); neglect of personal appearance and hygiene (as noted in his hearing testimony); difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships (having no close friends and relating only to his two daughters and fellow veterans from his support group), throughout the appeal period. The Board finds no reason to question the credibility of the Veteran's own accounts; they are consistent with reports by his treating mental health personnel and VA examiners. As the symptoms described meet the schedular criteria for a 70 percent rating under Code 9411, the Board finds that such rating is warranted throughout since August 1, 2008. The evidence of record does not show that symptoms that meet (or approximate) the above-listed criteria for a 100 percent rating were manifest at any time during the evaluation period. At no time during the appeal period is it shown that the Veteran had total occupational and social impairment, due to such PTSD symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting himself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name, or other symptoms of similar gravity; no such symptoms have been shown. Consequently, the Board finds that criteria for a schedular 100 percent rating are not met or approximated for any period of time under consideration. The Board finds that the GAF scores assigned do not provide a separate basis for an award of a rating in excess of 70 percent. The symptoms and level of impairment represented by the GAF scores of 31 to 45 reflect moderate to serious disability, not warranting a rating in excess of 70 percent. The Board notes the GAF scores of 31 and 32 on discharge from inpatient PTSD treatment; however, symptoms of a gravity consistent with such scores (such as behavior considerably influenced by delusions or hallucinations, serious impairment in communication or judgment, or inability to function in almost all areas) have not been reported. Notably, GAF scores of 31 and 32, while reflecting symptoms of significant severity, still do reflect represent a psychiatric disability picture of total occupational and social impairment. Furthermore, the Board finds that the evidentiary record presents no reason to refer the case to the Compensation and Pension Service for consideration of an extra-schedular evaluation under 38 C.F.R. § 3.321(b). There is no evidence of symptoms or impairment not encompassed by the schedular criteria, so as to render those criteria inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). The matter of entitlement to a TDIU rating is addressed in the remand below. ORDER A 70 percent rating is granted for the Veteran's PTSD with major depressive disorder effective August 1, 2008, subject to the regulations governing payment of monetary awards. REMAND In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims held, in essence, that when the matter of entitlement to a TDIU rating is raised by the record in a claim for increase, such matter becomes part of the increased rating claim. Here, entitlement to a TDIU rating has been expressly raised by the Veteran, by virtue of his submission of a VA Form 21-8940, Application for Increased Compensation Based on Unemployability, in July 2011. Additionally, on numerous VA treatment records and examinations, he has reported that he has not worked since 2005. He has stated that he believes his PTSD and major depressive disorder have contributed to his inability to get and keep a job, and he has submitted medical opinion letters in support of this contention. See, e.g., August 2009 psychosocial evaluation by Dr. Tripi. The matter of entitlement to a TDIU rating has not been developed or adjudicated by the RO; therefore, it must be remanded for such action. Accordingly, the case is REMANDED for the following action: The RO should fully develop and adjudicate the matter of the Veteran's entitlement to a TDIU rating. If it is denied, the Veteran should be so advised, and advised of his appellate rights. If he files a notice of disagreement and a substantive appeal after an SOC is issued, such matter should be returned to the Board, if in order, for appellate review. He should be advised that this matter will not be before the Board unless he initiates, and perfects, an appeal as to any negative determination by the RO regarding his entitlement to a TDIU rating. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs