Citation Nr: 1237497 Decision Date: 11/01/12 Archive Date: 11/09/12 DOCKET NO. 05-15 013 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD), currently rated as 30 percent disabling effective October 9, 2002; and rated as 50 percent disabling effective April 30, 2010. 2. Entitlement to a total disability based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant, spouse ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran served on active duty from June 1969 to December 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an April 2003 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA). This matter was remanded in October 2007, October 2009, and March 2012 for further development. The Veteran presented testimony at Board hearings in August 2006 and July 2012. Transcripts of the hearings are associated with the Veteran's claims folder. The Board notes that the April 2003 rating decision granted service connection for PTSD and assigned a 30 percent rating. The RO issued an October 2011 rating decision in which it increased the rating to 50 percent effective April 30, 2010. Since the increased rating does not date back to the date of receipt of the claim, there are different time periods to consider. Additionally, the Veteran, in his July 2012 Board hearing, stated that he cannot work due to his service connected PTSD. The Court of Appeals for Veterans Claims held that a request for a TDIU, whether expressly raised by the Veteran or reasonably raised by the record, is not a separate 'claim' for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue whether a TDIU is warranted as a result of that disability. Id. As such, the Board has added the issue of entitlement to a TDIU rating. This issue is remanded to the Appeals Management Center (AMC) in Washington, D.C. FINDINGS OF FACT 1. Effective October 9, 2002, the Veteran's PTSD was manifested by 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. 2. The Veteran's PTSD is not manifested by occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. CONCLUSIONS OF LAW Effective October 9, 2002, the criteria for entitlement to a disability evaluation of 50 percent, but no higher, for the Veteran's service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.7 and Code 9411 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Notify Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) Veteran status; 2) existence of a disability; (3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App.112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant pre-adjudication notice by a letter dated October 2002. In any event, in Dingess v. Nicholson, 19 Vet.App. 473, 490-491 (2006), the Court held that in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. 5103(a) (West 2002), notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Also see Hartman v. Nicholson, 483 F.3d 1311, 1314-1315 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet.App. 112, 116-117 (2007). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claims, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See 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, normally falls upon the party attacking the agency's determination.) See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Assist VA has obtained service treatment records; assisted the appellant in obtaining evidence; afforded the Veteran psychiatric examinations in December 2002, August 2006, April 2009, April 2010, and April 2011; obtained medical opinions as to the etiology and severity of disabilities; and afforded the appellant the opportunity to give testimony before the Board. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the appellant has not contended otherwise. Increased Ratings The present appeal involves the Veteran's claim that the severity of his service-connected PTSD warrants a higher disability rating. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected PTSD has been rated by the RO under the provisions of Diagnostic Code 9411. Under this regulatory provision: a 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). a 50 percent is warranted if the Veteran experiences 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. a 70 percent is warranted when the Veteran experiences occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. a 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent 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. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran filed his claim in October 2002; and he underwent a VA examination in December 2002. He reported that on numerous occasions, he saw dead bodies while serving in the Mekong Delta. On one occasion, he saw dead bodies being run over by a truck. He reported that he is able to work; but that he does encounter difficulties due to anxiety, sleep disturbances, and problems related to intrusive memories. He estimated that his ability to perform satisfactorily on the job had decreased by approximately 30-50 percent due to psychological problems. He felt that it was his responsibility to keep working despite the difficulties. He reported that he has never sought treatment for his psychological problems, though he reported that the symptoms have been constant since he returned hom from the military. The Veteran reported anxiety, feelings of sadness, concentration problems, and other depressive symptoms. He also reported symptoms of re-experiencing past traumas, nightmares, intrusive memories, emotional numbing, and avoidance of stimuli that remind him of the trauma. He stated that he remains isolated from others. He had symptoms of agitation and hyperarousal. The examiner stated that the symptoms are not so severe that they would lead to severe interpersonal or occupational impairment; however, they certainly disrupt day-to-day functioning and his ability to work. He did not report symptoms of psychosis; and there was no evidence of thought disorder, hallucinations, delusional thinking, mania, or suicidal or homicidal ideations. Data from the Beck Depression Inventory yielded a score suggesting that the Veteran experiences consistent depression; though it was not apparent that the Veteran met the criteria for a major depressive disorder. The examiner determined that the symptoms were significant and that they affected functioning. The examiner also opined that the Veteran suffered from significant interpersonal and occupational role impairment. When the Veteran became hyperaroused or agitated, he had to withdraw (frequently) from others at his workplace. Consequently, his ability to work effectively has reduced. The examiner assigned a Global Assessment of Functioning (GAF) score of 60. A GAF of 61-70 indicates 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 with some meaningful interpersonal relationships. A GAF of 51-60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 41-50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 31-40 indicates 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). A GAF of 21-30 indicates 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.) American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) (Fourth Edition); see 38 C.F.R. § 4.130 (2011). The Veteran underwent consistent psychiatric treatment with the VA; and in May 2004, he completed the Trauma Recovery Program. In July 2004, the Veteran submitted an undated correspondence from Dr. F.S. (the examiner who conducted the December 2002 VA examination, and one of the VA psychologists from which the Veteran received treatment). Dr. F.S. stated that he assigned the Veteran GAF of 45 because the Veteran's hyperarousal symptoms had increased and made it difficult for him to maintain control of his emotions and behavior. Dr. F.S. stated that it is difficult for the Veteran to be around other people or to cope with sudden increases in stress. The Veteran submitted a November 8, 2005 correspondence from VA Dr. P.E.D. It stated that the Veteran was receiving treatment at the VA Medical Center and that he should be excused from work for a period of 30 days. A December 6, 2005 correspondence continued the excusal from work for another 30 days. Outpatient treatment reports from November 2005 reflect that the Veteran's depression increased. However, they also reflect that the Veteran was in no acute distress. He related well and was fully cooperative. Psychomotor activity was normal (no involuntary movements). His speech was of normal rate and rhythm. His mood was dysthymic, with full range of emotions expressed. His affect was congruent. His thought process was goal oriented and logical. His thought content was normal, with no evidence of auditory or visual hallucinations. There was no evidence of suicidal or homicidal ideations. Intelligence was average; insight and judgment were good. The examiner assigned a GAF score of 55 (indicating moderate symptoms). A March 2006 outpatient treatment report reflects that the Veteran stated that his medical leave will continue, perhaps a maximum of 12 months (until November 2006). The Veteran underwent an Independent Medical Evaluation in August 2006. The examiner noted that the Veteran was married, and that he had been employed as a field supervisor for 35 years. The Veteran reported that his last day of work was in November 2005; and that he has been out on disability secondary to his PTSD. In August 2005, the Veteran and his family had to evacuate to Jackson, Mississippi in the wake of Hurricane Katrina. He had to evacuate for two months. When he returned, his home was flooded and he lost all his personal belongings. He stated that his $200,000 home (whose mortgage had been fully paid) was lost and he was only able to recover $9,600 from his insurance company, and $13,000 from FEMA. He moved in with his brother-in-law until a tree fell on the trailer. Since then, he bought a house in Polarville, Mississippi. He stated that any progress he had made in regards to his PTSD was lost. He reported experiencing flashbacks of places that he had served; and he wondered about the fates of other soldiers with whom he had served. He reported difficulty sleeping. He did not feel comfortable around crowds or other people (he was afraid that he would hurt them). He reported being very irritable, and having several outbursts of anger. He reported difficulty concentrating. The Veteran reported that after evacuating away from Hurricane Katrina, he resumed psychiatric treatment. He stated that he was very moody; and he had passive suicidal ideation (though he never formulated a plan). He reported feeling hopeless; and he stated that after working his whole life, there will never be any retirement for him. He stated that he has spent approximately 2/3 of his savings; and he has had to withdraw from his 401(k). He reported that he returned to work in October 2005, and his symptoms got progressively worse. He reported that he experiences dizziness secondary to the medications he has to take. He cannot drive and he relies on his wife to accompany him. He stopped working in November 2005; and in May 2006, he went on long term disability with half pay. He doubted his possibility of being able to return to work. He noted his potential for violence and he stated that he doesn't want to hurt (or be hurt by) co-workers. The examiner also conducted a phone interview with the Veteran's wife. She stated that the Veteran's worsening symptoms were putting a strain on their marriage. Upon examination, the Veteran was casually dressed and neatly groomed. He maintained good eye contact and did not present with any abnormal movements or mannerisms. His speech was soft, and of normal rate, rhythm, and tone. He described his mood as irritable and frustrated. His affect was appropriate to mood. His thought processes were logical and goal directed. There was no evidence of a formal thought disorder. He denied experiencing any auditory hallucinations, visual hallucinations, or other perceptual disturbances; and he did not present with any overt signs of psychosis. He firmly denied any suicidal/homicidal ideation, plans, or intent. He was oriented to time, place, and person. He had difficulty with memory; but his memory was intact for remote recall. His intellectual capacity was in the average range; and his insight and judgment were fair. The examiner diagnosed the Veteran with: (1) major depression, single episode, mild, without psychotic features, (2) PTSD, and (3) alcohol abuse, in remission. He assigned a GAF score of 55. The examiner noted that the Veteran has reported that he has been incapacitated by PTSD symptoms; and that the symptoms have been corroborated by his wife. After initially responding well to treatment, he regressed following Hurricane Katrina. The examiner was of the opinion that the Veteran is unable to work due to diagnoses of Major Depression and PTSD. He stated that the Veteran's treatment plan should have returning to work as the primary goal. He opined that with treatment, there is no reason why the Veteran could not return to work in the near future. Outpatient treatment reports dated September 2006 and October 2006 reflect that the Veteran's GAF score was 50. The examiner noted that the Veteran suffered severe stress in losing his home to Hurricane Katrina; and that it was unlikely that he would be able to return to his previous work. A January 2007 treatment report reflects that the Veteran received long term disability due to exacerbation of PTSD. The Veteran began going to a support group that met monthly. Outpatient treatment reports reflect that the Veteran's GAF score from November 2006 through April 2008 was 55. An April 2008 treatment reports reflects that the Veteran's mood was "good" and "stable." The Veteran underwent a VA examination in April 2009. The examiner reviewed the claims file in conjunction with the examination. She noted that the Veteran had been on long term disability since November 2005. The Veteran reported that he experiences nightmares approximately once per week. He also complained of irritability all day. He reported intrusive thoughts and suicidal ideation (without plan or intent). He stated that he is isolated and that he stays on his farm and does not go out. He can drive; but he spends most of his day watching television or fishing in a pond. He reported feelings of sadness and anxiety. He reported that he avoids war movies. The examiner saw no evidence of a perceptual disorder; and the Veteran denied any hospitalizations. He stated that he was going to group therapy; but that the program was discontinued due to lack of staff. He reported that venlafaxine decreases his irritability; and that he also takes Depakote. He complained that he only sleeps for four hours per night. He denied any current substance abuse. He reported that he has regular contact with his son, children, and grandchildren. He said that he wished his grandchildren would visit more often. He reported a good reported a good relationship with his wife; but admitted to suffering from irritability towards her as well. Upon examination, the Veteran was alert and attentive, and he tracked the conversation adequately. He was oriented to person, place, time, and situation. There was no abnormality of posture. Psychomotor activity was within normal limits. Speech functions were appropriate for rate, volume, prosody and fluency, with no evidence of paraphasic errors. Intellectual functioning appeared to be within the average range. He reported that his mood was sad, irritable, and anxious. His affect was appropriate to verbal content and context. Memory functions were grossly intact with respect to immediate, remote recall of events and factual information. Thought processes and content were within normal limits. He reported vague chronic suicidal ideation without plan or intent. He reported having thoughts of hurting others if they bothered him enough. He denied symptoms of a perceptual disorder. The examiner noted no abnormal behavior. The Veteran reported that he maintained his own activities of daily living. His judgment appeared intact. There was no evidence of substance abuse. The examiner noted that the Veteran had reported that his PTSD has caused a 30-50 percent interference with work productivity. However, the examiner also noted that the Veteran had risen to the rank of supervisor. The examiner concluded that the Veteran's work function must have at least been adequate. The examiner assigned a GAF of 55. Although the Veteran claims he can no longer work, the examiner opined that there was no evidence that the Veteran's symptoms rise to a level that would prevent him from doing some kind of work. She opined that the symptoms do not appear to fall in the range of severe occupational impairment. A June 2009 outpatient treatment report reflects a GAF score of 40. The examiner noted moderate to severe stress related to PTSD with social isolation. The basis for the low GAF score is unclear. He stated that he was angered by the April 2009 VA examination because the examiner only seemed to be interested in whether or not he wanted to harm himself. He reported that he gets 3-4 hours of sleep per night; and that he has nightmares 2-3 times per week. Upon examination, the Veteran was well groomed and appropriately dressed. No tremors were noted. His speech was clear, and of a normal rate and tone. His mood was neutral. His affect was anxious at times. His thought process was linear and goal oriented. He denied suicidal and homicidal ideations, but admitted occasional suicidal ideations in the past. There was no flight of ideas or looseness of associations. The Veteran was not paranoid or delusional. He denied audio or visual hallucinations. He was oriented to time, place, person, and situation. His judgment and insight were fair. Outpatient treatment reports dated March 2010 and April 2010 reflect GAF scores of 50-55 and 51 respectively. The Veteran underwent another VA examination in April 2010. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that despite completing a four week inpatient program, his PTSD symptoms have not decreased. He stated that when he is agitated, he does not remember his coping strategies. He reported that his wife has rented a home in New Orleans to be close to her business. He has remained in Polarville because he likes being in the country, where it is more isolated. He stated that since his most recent VA examination, he was diagnosed with kidney cancer for which he was to undergo surgery later in the week. He reported that he only sleeps approximately three hours per night, and the diuretics cause him to have to get up every hour to use the bathroom. He also stated that he still has nightmares on occasion. He stated that he is still bothered by crowds, and people in general. He described himself as short-tempered. He stated that at times, he wants to fight; and he recalled an incident in which he got into a confrontation with another man at a grocery store. Police were called; but no one was arrested. He reported that he is hypervigilant. He stated that he becomes jumpy when he hears loud noises, and that he has to sit with his back to the wall. He also reported that he is more forgetful. He stated that he experiences intrusive memories on a daily basis. He reported that a typical day for him involves walking down to his pond to fish. He cooks and picks up after himself. He stated that he rarely talks to friends; but he does feel close to his family. He stated that he enjoys his bow and arrow and cutting the lawn. Upon examination, the Veteran was alert and attentive, and tracked the conversation adequately. He was oriented to person, place, time, and situation. There were no particular abnormalities of posture or behavior noted. Psychomotor activity was mildly agitated in that he would shift in his chair at times. His speech was appropriate for rate, rhythm, volume, and prosody. There was no evidence of paraphasic errors. He appeared to be of average intellectual functioning. He described his mood as irritable for the most part; but stated that he has an "okay" mood when no one is around. He said that his medications help his mood. He reported passive suicidal thoughts on occasion; but he denied any serious plan or intent to harm himself. He described homicidal thoughts; but denied that he had harmed anyone within the past year. He presented with a fairly euthymic mood; and his affect was appropriately variable. Memory functions were grossly intact with respect to recent and remote recall of personal events and factual information. He maintained his own activities of daily living independently. He reported poor sleep. His judgment and insight appeared grossly intact. The examiner was of the opinion that the Veteran was competent to handle his own funds. The examiner found that the Veteran's thought processes were logical and linear. The Veteran denied hallucinations and delusions. The examiner found that the Veteran's overall concentration and attention were within normal limits; and that the Veteran's reported concentration difficulties were age related. The examiner assigned a GAF score of 55. A September 2010 functional assessment reflects that the Veteran's GAF score was deemed to be 55. It was noted that the Veteran was fairly stable with his medication; and that the Veteran's symptoms were moderate when compared to others with a similar diagnosis. He continued to have nightmares, intrusive thoughts, exaggerated startle response, hypervigilance, and nervousness. He also complained of poor concentration and memory. The examiner opined that the Veteran is not ready to return to work. The examiner opined that the Veteran would be moderately impaired when it came to his ability to perform simple and repetitive tasks and to perform work where contact with other is minimal. His ability to comprehend and follow instructions was limited to a moderately severe degree. The examiner opined that the Veteran would experience severe functional limitations when it came to supervising or managing others, performing under stress where working speed and sustained attention are fundamental to the job. A September 2010 outpatient treatment report reflects that the Veteran was assigned a GAF score of 40. The Veteran reported that his mood was fairly stable; but there are times when his mood was down. He reported that two of his "buddies" committed suicide, and he was not sure why. The Veteran denied suicidal thoughts; and he stated that he has a strong support system with his wife. He was told that his kidney cancer is stable. Upon examination, the Veteran was groomed and dressed appropriately. There were no tremors noted. The Veteran's speech was clear, and of a normal rate and tone. His mood was neutral. His affect was appropriate to situation. His thought process was linear and goal directed. He denied suicidal and homicidal ideations. There was no flight or ideas or looseness of associations; and he was not paranoid or delusional. He denied audio or visual hallucinations. His judgment and insight were good. Outpatient treatment reports from December 2010 through May 2011 reflect GAF scores between 52-56 (again, reflecting moderate symptoms). The Veteran underwent another VA examination in April 2011. The examination was conducted by the same psychologist that conducted the April 2009 examination. The examiner reviewed the claims file in conjunction with the examination. She found that the Veteran experienced recurrent and distressing recollections of the traumatic events (including images, thoughts, and perceptions), and recurrent distressing dreams. The Veteran reported: efforts to avoid thoughts, feelings, or conversations about the trauma; efforts to avoid activities, places, or people that arouse recollections of the trauma; and markedly diminished interest or participation in significant activities. He reported irritability and outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. The examiner found that the Veteran's symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning. The examiner found that the Veteran also experienced depressed mood, disturbances in motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation. The Veteran also reported auditory and visual hallucinations (seeing dead bodies, feeling someone stand over him and call his name). He reported that these began 5-6 months ago. However, the examiner stated that there did not appear to be any relationship to the Veteran's PTSD. The examiner found that the Veteran has been diagnosed with PTSD; but that symptoms are not severe enough to interfere with occupational or social functioning, or to require continuous medication. The examiner assigned a GAF score of 55-60 and found that he was capable of managing his own financial affairs. She found that the Veteran's PTSD does not impact the Veteran's ability to work. She noted that Dr. S. provided a list of the Veteran's medications; but an April 2011 outpatient treatment report revealed that the Veteran's mood has been stable and that he has been getting 5-6 hours per night. The examiner noted that the Veteran's Depakote level was subtherapeutic and that the Veteran didn't take it for two weeks because he and his wife were arguing, and she did not order it. Instead, the Veteran was only going to outpatient medication management. The examiner noted that the Veteran remains married; and that he denied substance abuse. Prior to April 30, 2010 The Veteran's PTSD is currently rated as 30 percent disabling prior to April 30, 2010. In order to warrant a rating in excess of 30 percent, the Veteran's PTSD must be manifested by 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 Board notes that the December 2002 VA examiner did not note any of the enumerated symptoms. However, the Veteran estimated that his ability to perform satisfactorily on the job had decreased by approximately 30-50 percent due to psychological problems. Moreover, the December 2002 VA examiner substantiated the Veteran's contention by stating that the Veteran's symptoms were significant; that they affected functioning; and that the Veteran suffered from significant interpersonal and occupational role impairment. The examiner assigned a GAF score of 60 (indicating moderate symptoms). The Veteran's symptoms became more severe, resulting in a GAF score of 45 in July 2004; and an excusal from work from his VA doctor in November 2005. The Board finds that the significant interpersonal and occupational role impairment (noted in the December 2002 VA examination report) more closely approximates to the criteria for a 50 percent rating. Once again, the Board notes that the symptoms listed under the 50 percent rating criteria are not shown; but the level of reduced reliability and productivity indicated that a 50 percent rating is warranted. In giving the Veteran the benefit of the doubt, the Board finds that a 50 percent rating, but no greater, is warranted effective October 9, 2002. In order to warrant a rating in excess of 50 percent, the Veteran's disability must be manifested by occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. The Board notes that the GAF scores at the December 2002, August 2006, and April 2009 VA examinations were 60, 55, and 55 (all indicative of moderate symptoms). The December 2002 VA examiner noted that the Veteran's symptoms were not so severe as to lead to severe interpersonal or occupational impairment. The August 2006 VA examiner noted that the Veteran was married and that he had been employed as a field supervisor for 35 years (until November 2005). The August 2006 examiner also opined that there was no reason that the Veteran could not return to work in the near future. At the Veteran's April 2009 VA examination, he reported that he has regular contact with his son, children, and grandchildren. He also reported a good relationship with his wife; and that he had been going to group therapy before the program was discontinued. The April 2009 VA examiner noted that the Veteran had risen to the job of supervisor at his work; and that there was no evidence that the Veteran's symptoms would prevent him from doing some kind of work. The Board acknowledges that while most of the GAF scores indicate the Veteran's symptoms were moderate, a few GAF scores in the outpatient treatment reports indicate severe symptoms. In particular, a June 2009 GAF score of 40 indicates severe symptoms. However, the findings listed in the report are consistent with the findings associated with his more moderate GAF scores. The outpatient treatment reports reflect that the Veteran was well groomed and appropriately dressed. No tremors were noted. His speech was clear, and of a normal rate and tone. His mood was neutral. His affect was anxious at times. His thought process was linear and goal oriented. He denied suicidal and homicidal ideations, but admitted occasional suicidal ideations in the past. There was no flight of ideas or looseness of associations. The Veteran was not paranoid or delusional. He denied audio or visual hallucinations. He was oriented to time, place, person, and situation. His judgment and insight were fair. The Board finds that with fair insight and judgment, with a good marriage, and with regular contact with his children and grandchildren, the Veteran does not suffer from deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and a rating in excess of 50 percent for PTSD must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). Effective April 30, 2010 The Veteran's GAF score at his April 2010 and April 2011 VA examinations was 55 and 55-60. Once again, the GAF scores indicate moderate symptoms. Moreover, the April 2010 examiner specifically stated that the Veteran's symptoms were fairly stable, and that they were moderate when compared to other with similar diagnoses. The examiner then went on to say that the Veteran is not ready to return to work. The examiner opined that the Veteran would be moderately impaired when it came to his ability to perform simple and repetitive tasks and to perform work where contact with other is minimal. His ability to comprehend and follow instructions was limited to a moderately severe degree. The examiner opined that the Veteran would experience severe functional limitations when it came to supervise or manage others, perform under stress where working speed and sustained attention are fundamental to the job. While the Board once again acknowledges that the Veteran's symptoms would interfere with work, the preponderance of the evidence is against a finding that the Veteran's symptoms result in deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. The Veteran remains married, participates in group therapy, has good family relations, has a good support system, and has grossly intact judgment and thinking. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and a rating in excess of 50 percent for PTSD must be denied. See Gilbert v. Derwinski, 1 Vet. App 49 (1990). The potential application of various provisions of Title 38 of the Code of Federal Regulations have also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1). However, as discussed above, the evidentiary record in this case persuasively shows that the Veteran's symptoms squarely match the type and degree of the examples set forth under the criteria for the current 50 percent schedular rating. Consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) is not appropriate in such a case where the rating criteria reasonably describe the Veteran's disability level and symptomatology. See generally Thun v. Peak, 22 Vet.App. 111 (2008). The Board therefore finds that referral for extraschedular consideration under 38 C.F.R. § 3.321(b)(1) is not warranted in this case. ORDER Effective October 9, 2002, a rating of 50 percent, but no greater, is warranted for the Veteran's PTSD. REMAND TDIU In order to establish service connection for a total rating based upon individual unemployability due to service-connected disability, there must be an impairment so severe that it is impossible to follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. VA regulations establish objective and subjective standards for an award of total rating based on unemployability. When the Veteran's schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned provided that if there is only one service-connected disability, this disability shall be rated at 60 percent or more. When there are two or more disabilities, at least one disability must be ratable at 40 percent or more, and any additional disabilities must result in a combined rating of 70 percent or more, and the disabled person must be unable to secure or follow a substantially gainful occupation. See 38 C.F.R. § 4.16(a). A total disability rating may also be assigned on an extra-schedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for Veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). Thus, the Board must evaluate whether there are circumstances, apart from any non-service-connected conditions and advancing age, which would justify a total rating based on unemployability. A TDIU claim is an alternate way to obtain a total disability rating without recourse to a 100 percent evaluation under the rating schedule. See Parker v. Brown, 7 Vet. App. 116, 118 (1994). Effective November 8, 2005, the Veteran is service connected for PTSD, evaluated as 50 percent disabling; diabetes mellitus, evaluated as 20 percent; coronary artery disease, evaluated as 10 percent disabling; and a right second metacarpal fracture, evaluated as 0 percent disabling. His combined rating is therefore 60 percent. See 38 C.F.R. § 4.25. Thus, the Veteran does not meet the schedular requirements for a total disability rating based on individual unemployability due to service-connected disabilities under 38 C.F.R. § 4.16(a). However, the Board must still determine whether the Veteran's service-connected disabilities result in impairment so severe that it is impossible to follow a substantially gainful occupation. The Board, however, lacks the authority to grant a TDIU on this extraschedular basis, in the first instance. See Bowling v Principi, 15 Vet. App. 1, 10 (2001). Rather, the Board must first refer the claim to the Director of VA's Compensation and Pension Service. See VAOPGCPREC 6-96 (Aug. 16, 1996), discussing the holding in Floyd v. Brown, 9 Vet. App. 88, 96 (1996). See, too, Bagwell v. Brown, 9 Vet. App. 237, 238-9 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995); Sanchez-Benitez v. West, 13 Vet. App. 282, 287 (2000). Following a full and thorough review of the evidence of record, the Board concludes that the preponderance of the evidence supports referring the case to the Director of VA's Compensation and Pension Service to consider whether a TDIU on an extraschedular basis is warranted. This matter is remanded to the Appeals Management Center (AMC) for the following action: 1. The AMC should refer the Veteran's claim to the Under Secretary for Benefits or the Director of VA's Compensation and Pension Service for extraschedular consideration under 38 C.F.R. § 4.16(b) (2011). 2. Then, readjudicate the claim of entitlement to an award of a TDIU due to service-connected disabilities. If the determination is unfavorable to the Veteran, the AMC must issue a supplemental statement of the case and provide the Veteran and his representative a reasonable period of time in which to respond before this case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B , 7112 (West Supp. 2010). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs