Citation Nr: 1237986 Decision Date: 11/06/12 Archive Date: 11/16/12 DOCKET NO. 06-37 237A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD), evaluated as 30 percent disabling from September 19, 2000 to January 22, 2001, and as 50 percent disabling from January 23, 2001. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD C. Fleming, Counsel INTRODUCTION The Veteran had active service from April 1971 to April 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. During the current appeal, and specifically in March 2009, the agency of original jurisdiction (AOJ) concluded that an increased rating of 50 percent for PTSD was warranted from January 23, 2001. The United States Court of Appeals for Veterans Claims (Court) has held that a claimant will generally be presumed to be seeking the maximum benefits allowed by law and regulations, and it follows that such a claim remains in controversy where less than the maximum available benefit is awarded, or until the veteran withdraws the claim. AB v. Brown, 6 Vet. App. 35, 38 (1992). During the pendency of this appeal, the Veteran was awarded an increased evaluation for his service-connected PTSD. The Veteran has not suggested that the increased evaluation would satisfy his appeal for a higher rating of his PTSD, nor has he otherwise suggested that the maximum rating available for PTSD is not being sought. Thus, the Board concludes that the issue of entitlement to a higher initial rating for PTSD remains in appellate status. In October 2010, the Board remanded the appeal for further notification, evidentiary development, and adjudication. The Board instructed the AOJ to provide the Veteran with VCAA-compliant notice, obtain relevant VA treatment records, provide the Veteran with a psychological examination, and then re-adjudicate the claims. The AOJ sent the Veteran the requisite notice via an October 2010 letter, obtained current VA treatment records, and scheduled him for a VA examination, which was conducted in November 2010. The Veteran was then provided a supplemental statement of the case (SSOC) in December 2011, in which the RO again denied the Veteran's claims. Thus, as to the claim decided herein, there is compliance with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). FINDING OF FACT The Veteran's PTSD has been manifested by reports of disrupted sleep, nightmares, suicidal thoughts, depression, isolating behavior, anger problems, difficulty with social interactions, and a Global Assessment of Functioning score no worse than 45. These manifestations are indicative of occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking, and mood but are not reflective of total impairment in occupational and social functioning. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for an increased schedular evaluation of 70 percent, but not greater, for PTSD have been met for the entire appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2011). REASONS AND BASES FOR FINDING AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his 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). The 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. VCAA notice should be provided to a claimant before the initial unfavorable AOJ decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the Veteran's initial rating claim is a "downstream" issue in that it arose from initial grant of service connection. Prior to the December 2005 rating decision, a letter dated in May 2004 advised the Veteran of the evidence necessary to substantiate his claim for service connection for PTSD and of his and VA's respective obligations with regard to obtaining evidence. Importantly, where, as here, service connection has been granted and the initial rating and effective date have been assigned, the claim for service connection has been more than substantiated. It has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice was intended to serve has been fulfilled. Once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional § 5103(a) notice. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-491 (2006); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Regarding VA's duty to assist, VA obtained the Veteran's post-service medical records and secured examinations in furtherance of his claim. VA has no duty to inform or assist that was unmet. The Veteran has not identified any additional pertinent medical records which have not been obtained and associated with the claims folder. Pertinent VA examinations with respect to the issue on appeal were obtained in September 2005, July 2007, and November 2010. 38 C.F.R. § 3.159(c)(4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examinations obtained in this case are sufficient, as they considered all of the pertinent evidence of record, including the statements of the Veteran, and provided explanations for the opinions stated as well as the medical information necessary to apply the appropriate rating criteria. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issue adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4). Thus, VA has no duty to inform or assist that has not been met. II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4. The Board attempts to determine the extent to which the Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two evaluations should 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. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the Veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Court has indicated that a distinction must be made between a veteran's dissatisfaction with original ratings and dissatisfaction with determinations on later filed claims for increased ratings. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Consequently, the Board will evaluate the Veteran's claim for increase as claims for higher evaluations of the original disability ratings assigned to his service-connected PTSD. Also, when an original rating is appealed, consideration must be given as to whether an increase or decrease is warranted at any time since the award of service connection, a practice known as "staged" ratings. Id. Here, the Veteran contends that he is entitled to initial ratings in excess of 30 percent for the first portion of the appeal period and in excess of 50 percent for the second portion of the appeal period for his service-connected PTSD due to the severity and frequency of his symptomatology. The Veteran's PTSD has been evaluated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, which evaluates impairment from PTSD. Specifically, pursuant to Diagnostic Code 9411, a 100 percent evaluation is warranted if the evidence establishes 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 oneself 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, Diagnostic Code 9411 (2011). A 70 percent evaluation is warranted if the evidence establishes 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 work-like setting); inability to establish and maintain effective relationships. Id. A 50 percent evaluation is warranted if the evidence establishes 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. Id. A 30 percent rating is warranted if the evidence establishes that 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). Id. The list of symptoms in the rating formula is not intended to constitute an exhaustive list, but rather shows examples of the types and degrees of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2011). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. Carpenter v. Brown, 8 Vet. App. 240 (1995). Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV). A GAF score of 61-70 is indicative of 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, has some meaningful interpersonal relationships. A GAF score of 51-60 is indicative of moderate symptoms (e.g., flat effect 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 score of 41-50 is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Here, the Veteran has received ongoing treatment at VA medical facilities in Columbus and Chillicothe, Ohio. In addition, he was afforded VA examinations in September 2005, July 2007, and November 2010. The Veteran's ongoing VA treatment reflects that he was hospitalized from early September to early October 2000 for treatment of alcohol dependence. At his October 2000 discharge evaluation, he was found to have depressive disorder and a GAF score of 50 on admission. He was noted to have been using alcohol and marijuana and to have been experiencing hallucinations due to delirium tremens. He reported his mood as "good" and reported experiencing some nightmares but no psychosis and no suicidal or homicidal ideation. Later treatment notes from October 2000 reflect that the Veteran demonstrated "mild to moderate" PTSD symptomatology. He was again seen in November 2000 for complaints of depression and nightmares of his time in Vietnam. At that time, the Veteran's treating psychiatrist found him to display an appropriate affect with no evidence of hallucinations or delusions and no suicidal or homicidal ideations. The psychiatrist assigned a rule-out diagnosis of PTSD and a GAF score of 85. Report of VA treatment the Veteran received on January 23, 2001, reflects that he reported experiencing occasional nightmares and depression, as well as occasional suicidal thoughts. He reported working as a janitor. His affect was noted to be blunted, but no delusions, hallucinations, or suicidal or homicidal ideations were noted at the time. The psychiatrist diagnosed the Veteran with major depression and assigned a GAF score of 45. Later treatment in October 2001 reflects a diagnosis of major depression and a GAF score of 70; at that time, the Veteran complained of nightmares and flashbacks, as well as intermittent depression. No suicidal or homicidal ideation was noted at the time. At an intake psychosocial evaluation for domiciliary vocational rehabilitation conducted in August 2003, the Veteran reported having completed high school and to have last worked as a card dealer in a casino. He reported that he was divorced and lived alone. The examiner noted complaints of depression and anxiety, but no suicidal or homicidal ideation. During domiciliary treatment in September 2003, the Veteran reported experiencing nightmares three times per week. Similarly, at the October 2003 discharge evaluation, the Veteran was noted to display no problems with thought or orientation, with no delusions or hallucinations and no suicidal or homicidal ideations. His affect was noted to be blunted, and he was noted to isolate and display negative thinking. He reported being unemployed at the time. A GAF score of 50 was assigned. The Veteran was seen for psychiatric intake in November 2006, at which time he complained of nightmares and flashbacks and stated that he was easily startled and irritable. He complained of decreased concentration and stated that he had "no interest" in returning to work following being laid off and that he was a "loner." His GAF score was 60. In an April 2007 treatment note, the Veteran complained of weekly nightmares, with less frequent flashbacks and no psychosis or mania and no suicidal or homicidal ideation. His GAF score was noted to be 60 at that time. He underwent a social work assessment in July 2007, at which time he was noted to be not particularly close to his family, with no close friends. He did acknowledge socializing at the VFW occasionally. No suicidal or homicidal ideation was noted, although the Veteran complained of anger, nightmares, and a desire not to be around people. He was noted to display a depressed mood and flat affect, with diminished ability to focus. His GAF score was assessed at 50. Further treatment records from July 2008 reflect that the Veteran continued to report sleep problems and nightmares, as well as significant financial concerns due to his being "unable to work." He was oriented with intact cognition and no psychoses or suicidal ideation, but was noted to have an anxious affect and mood. His GAF score was 55. Similarly, the Veteran was assigned a GAF score of 60 at an October 2008 treatment visit, at which time he reported a worsening of symptoms, including difficulty sleeping and depression. Mood was noted to be depressed, but no suicidal or homicidal ideation was noted, and the Veteran was oriented to person, place, and time, with no inappropriate appearance, affect, or thought process. Similarly, the Veteran complained of panic attacks and daily nightmares at a December 2008 treatment visit. The Veteran underwent a social work assessment in January 2009, at which time he reported that he was not close to his family and had no close friends, although he maintained contact with his son and grandchild. The Veteran further claimed to experience frequent homicidal ideation as well as nightmares and flashbacks. His support system was noted to be limited, with his family at a distance and friendships limited to an infrequently-seen neighbor. He stated that he experienced nightmares and flashbacks on occasion and was increasingly uncomfortable around people. The evaluator found him to have "clinically significant" impairment in social and occupational functioning and assigned a GAF score of 45. November 2009 treatment notes reflect that the Veteran's symptoms were worsening, including increased irritability and depression. He stated that he continued to experience nightmares and had given his gun to a friend for safekeeping, without any specific homicidal or suicidal ideation noted. He was noted to be depressed and anxious, and a GAF score of 45 was assigned. When the Veteran was seen in January 2010, he reported that his symptoms of depression, nightmares, and irritability were improved and stated that he had no suicidal or homicidal ideation. A GAF score of 45 was assigned at the time. At a September 2010 treatment visit, he was noted to have a blunted affect with no evident psychosis but was noted to be "disgruntled and difficult to engage in goal oriented conversation." He stated that he experienced ongoing problems with sleep and intrusive thoughts and reported minimal support from his friends and family, although some interaction with friends from the VFW was noted. The Veteran stated that he had a 'strained" relationship with his son. He was again noted to complain of decreased motivation, as well as increased fatigue, at a May 2011 treatment visit. At that time, his GAF score was again assessed at 45. At a July 2011 treatment visit, the Veteran reported ongoing nightmares, as well as intrusive thoughts and anti-social behavior. He reported that he would go to the VFW but sit alone and that he declined an invitation to be a VFW officer. He was noted to experienced a distressed mood and was assigned a GAF score of 45. Similarly, at an October 2011 treatment visit, the Veteran complained of ongoing nightmares and exaggerated startle response, although no suicidal or homicidal ideation and no hallucinations were noted. He was again found to have a GAF score of 45. Report of the September 2005 examination reflects that the Veteran complained of experiencing ongoing nightmares of his time in Vietnam. He stated that he had worked many jobs in the years since service and had difficulty socializing and getting along with co-workers. He reported that he had a son and a sister living nearby, both of whom he saw occasionally. He also stated that he had "a couple close friends" and dated on occasion. He was alert and oriented, casually groomed and dressed, with good eye contact. Thought processes were essentially normal. No psychosis or delusions were noted. The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 61, pointing to the Veteran's "minimal reduction of social, vocational, and mental functioning." The examiner specifically found that the Veteran's symptoms would likely cause "low moderate work inefficiency and productivity" and moderately reduced reliability . The Veteran was also afforded a VA examination in July 2007. At that time, the Veteran reported that he had been laid off from work the previous year and had recently been offered his job back but declined due to his "difficulty in controlling his frustration with others." The Veteran stated that he visited with his son and grandchild two to three times per year and that he occasionally socialized with an elderly neighbor who was also a veteran. He reported that he preferred being alone and did not want to socialize, due to his inability to trust others. On examination, the Veteran's affect was restricted, and he complained of problems with memory and irritability. He was oriented to person, time, and place; thought content revealed no suicidal ideation, but the Veteran reported occasional idea of hurting others, without current intent. He had no delusions; and judgment and insight were intact. The Veteran reported experiencing anxiety attacks of mild to moderate severity as often as multiple times per day. He further stated that he experienced intrusive thoughts up to multiple times a day and nightmares several times per month. He was further noted to avoid interacting with others, although he was noted to continue to enjoy hobbies of reading and fishing. The examiner assigned a GAF score of 57, attributing the score to the Veteran's irritability, intrusive thoughts, estrangement from others, and frequent panic attacks. However, the examiner further noted that his irritability "has made it difficult to impossible for him to tolerate perceived workplace inequities" and that he would likely find it challenging to have to deal with authority figures changing his work assignments or otherwise interact with people on a regular basis at work. The examiner further noted that the Veteran displayed a "near total amount of social impairment." The Veteran was afforded a third VA examination in November 2010. At that time, he reported that he experienced nightmares at least once per week, as well as occasional intrusive thoughts. He also reported avoidance, social isolation, and isolation, but stated that he did have some interaction with other veterans at the VFW, where he went every week to play cards. He stated that he avoided social gatherings as a rule but occasionally socialized in small groups and saw his son on occasion. He reported being opposed to going back to work, in particular due to his irritability with other people. He further stated that he believed himself to be "too out of shape" both mentally and physically to return to work. He reported panic attacks at least twice per week. He reported that he had no desire to get to know anyone new and had distanced himself from family and friends. On examination, the Veteran displayed restricted affect, with little eye contact and spontaneous speech. His thought processes were clear and coherent. He acknowledged having transient thoughts of suicide but denied current suicidal ideation. The examiner assigned a GAF score of 55, attributing the score to the Veteran's "moderate to severely moderate difficulties in social and occupational functioning," as well as his depression, irritability, and isolation from others. The examiner found him, however, not to be unable to secure or maintain employment due to PTSD. The Veteran's treating VA psychiatrist and social worker have submitted letters in support of the Veteran's claim. In a letter dated in May 2009, the care providers stated that the Veteran is unable to maintain gainful employment and noted that he is "unpredictable if angered or agitated" and found it difficult to deal with managers and co-workers. The Veteran's psychiatrist submitted a second letter in September 2010 in which he stated that the Veteran continued to be unable to work due to his PTSD symptoms. The Board finds that, in this case, the clinical evidence more closely approximates the level of occupational and social impairment contemplated by a 70 percent rating for the entirety of the appellate period. Specifically, throughout the appeal period, the Veteran has been socially withdrawn and isolated, experiences suicidal thoughts and panic attacks, suffers from nightmares which center around his in-service stressors on multiple occasions per week, and has anger issues, intrusive thoughts, flat affect, and anti-social behavior which results in few to no interpersonal relationships with people, both within and outside of his own family. In addition, the Board notes that the Veteran has not been employed on a full-time basis for a number of years, and his anti-social behavior and extreme irritability have reached such a level that they affect his ability to perform job-related tasks. Further, prior to that, the Veteran's job history involved frequent conflicts with co-workers, job changes, and success primarily in jobs that were solitary in nature. This coupled with the fact that he has been divorced, has few to no friends, and maintains an emotionally distant relationship with his family members, is reflective of criteria enumerated under the 70 percent evaluation for PTSD. Suicidal ideation; panic or depression affecting the ability to function independently, appropriately, and effectively; and difficulty in adapting to stressful circumstances (including work or a work like setting) are listed under the criteria for the evaluation of a 70 percent evaluation for PTSD. However, the Board observes that a rating in excess of the 70 percent assigned herein is not warranted. This is so because the competent evidence of record does not demonstrate that the Veteran's symptomatology most closely approximates a 100 percent evaluation. In this regard, the Board notes that the Veteran's medical records do not contain evidence to support a finding that, at any time during the appellate period, he has displayed gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, or disorientation as to time or place. The Board notes that, while the Veteran reported to have hallucinations at an October 2000 treatment visit, this was attributed not to PTSD but to delirium tremens, which he was being hospitalized to address. In addition, the more recent VA treatment records and VA examination reports are all silent as to any mention or discussion of hallucinations and are therefore better reflective of the Veteran's current symptomatology. Indeed, the record establishes that the Veteran has maintained some relationship with family members, that he socializes on occasion with his neighbor and others at the VFW, and that he continues to perform his activities of daily living independently. He has consistently maintained his personal appearance and hygiene to a socially acceptable level, without any indication of grossly inappropriate behavior. In addition, although some transient suicidal and homicidal ideation has been noted, the Veteran's treatment providers and VA examiners have not deemed him to be a persistent danger to himself or others. Similarly, although some memory loss has been noted, the Veteran has not been shown to be disoriented to time or place or to have memory loss as to the names of his relatives or himself. In addition, VA and private treatment records throughout this appeal have shown that the Veteran's GAF scores have ranged from 45 to 85. From September 19, 2000, to January 22, 2001, the Veteran had GAF scores of 50 in October 2000 and of 85 in November 2000. Since January 23, 2001, he has had scores of 45 in January 2001, January 2008, January 2009, November 2009, January 2010, July 2011, and October 2011; 50 in October 2003 and July 2007; 55 at his November 2010 VA examination; 57 at his July 2007 VA examination; 60 in November 2006, April 2007, and October 2008; 61 at his September 2005 VA examination; and 70 in October 2001. The Board notes that the reported GAF scores ranging of 41 to 50 are indicative of serious symptoms. In this case, the Board concludes that the frequently-assigned score of 45 is most consistent with both the Veteran's identified symptoms and the 70 percent rating assigned herein. In that connection, the Board acknowledges that the Veteran has been assigned a multitude of different GAF scores, ranging as high as 85. However, the Board notes that the most consistent evaluation of the Veteran's GAF score, for the entirety of the appeal period, is the score of 45, indicative of the serious symptoms contemplated by the 70 percent rating assigned herein. Moreover, the Board also notes that, while important, the GAF scores assigned in a case are not dispositive of the evaluation and must be considered in light of the actual symptoms of the Veteran's disorder. See 38 C.F.R. § 4.126(a). Accordingly, and based on this evidentiary posture, the Board concludes that the totality of the evidence of record has shown that the Veteran's PTSD warrants an initial rating of 70 percent, but no higher, for the entirety of the appeal period. Resolving reasonable doubt in the Veteran's favor as to the severity of his service-connected PTSD, the Board concludes that the criteria for an initial 70 percent evaluation are met throughout the appeal period. However, the criteria for a 100 percent schedular evaluation are not met, as the Veteran continues to maintain some basic social relationships. The GAF score assigned reflects severe, but not totally incapacitating, PTSD. Thus, while the criteria for a 70 percent evaluation have been met throughout the appeal period and the appeal is granted to this extent, the criteria for a total schedular evaluation for PTSD are not met. In essence, the preponderance of the evidence is against an evaluation in excess of 70 percent for PTSD. As the evidence is not in equipoise, the provisions of 38 U.S.C.A. § 5107(b) regarding resolution of reasonable doubt are not applicable to warrant an evaluation in excess of 70 percent. The above determinations are based upon application of the pertinent provisions of VA's rating schedule. In denying the claim for a rating higher than that assigned herein, the Board has also considered whether the Veteran is entitled to a greater level of compensation on an extra-schedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57, 60 (1993). The Board finds that the record does not reflect that the Veteran's PTSD is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. 38 C.F.R. § 3.321(b)(1)(2011). The threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extra-schedular referral is required. Id.; VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). In this case, the issue of the Veteran's entitlement to a TDIU is herein remanded for further evidentiary development. Furthermore, the Board finds that the rating criteria to evaluate PTSD reasonably describe the claimant's disability level and symptomatology. Therefore, the Veteran's disability picture is contemplated by the rating schedule, and no extra-schedular referral is required. 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). ORDER An initial increased rating of 70 percent, but no higher, for PTSD is granted for the entire appeal period, subject to laws and regulations governing the award of monetary benefits. REMAND Regrettably, the Board finds that remand is necessary for further evidentiary development for the issue of entitlement to a TDIU. The Board acknowledges that under applicable criteria, a TDIU may be awarded where the schedular rating is less than total and when it is determined that the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2011). Under § 4.16(a), if there is only one service-connected disability, it must be rated at 60 percent or more. If there are two or more disabilities, at least one of those disabilities must be rated at 40 percent or more, and the total combined rating must be 70 percent or more. Disabilities resulting from common etiology or a single accident, disabilities of one or both of the upper extremities or of the lower extremities, disabilities affecting a single body system, multiple injuries incurred in action, or multiple disabilities incurred as a prisoner of war may be considered as one disability in applying the provisions of § 4.16(a). Despite these requirements, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). The Court has stated that, in order for a veteran to prevail on a claim for a TDIU, the record must reflect some factor that takes his case outside of the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In adjudicating a claim for TDIU, the Board may not reject the veteran's claim without producing evidence, as distinguished from mere conjecture. Friscia v. Brown, 7 Vet. App. 294 (1995). In Friscia, the Court stated that VA has a duty to supplement the record by obtaining an examination which includes an opinion on what effect the appellant's service-connected disabilities have on his ability to work. Here, service connection has been granted for PTSD, evaluated as 70 percent disabling, and for coronary artery disease, evaluated as 60 percent disabling. His total combined service-connected evaluation is 90 percent. As such, he meets the criteria for consideration of entitlement to TDIU on a schedular basis because his rating satisfies the percentage requirements of 38 C.F.R. § 4.16(a). He contends that his disabilities, specifically his PTSD, render him unable to secure or follow a substantially gainful occupation. Consequently, VA must determine whether the Veteran's service-connected disabilities, without consideration of any nonservice-connected disabilities, combine to preclude him from engaging in substantially gainful employment (work that is more than marginal, which permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). Here, the Board notes that the relevant evidence includes the Veteran's treatment records from VA treatment providers, as well as VA examinations provided in September 2005, July 2007, and November 2010. At the examinations, conducted to evaluate the Veteran's PTSD disability, the examiners evaluated the Veteran's ability to work as impacted by his PTSD. The Veteran also underwent a VA examination concerning his service-connected coronary artery disease in August 2011. However, the examiners did not make a determination as to whether the Veteran's service-connected disabilities, when considered together, rendered him unable to seek or maintain gainful employment. In addition, the Veteran has stated to VA on multiple occasions that he is unable to work due to his service-connected disabilities, in particular PTSD. To that end, the Veteran has submitted statements from his treating VA psychiatrist and social worker opining that he is unemployable due to PTSD. However, these letters, dated in May 2009 and September 2010, do not offer clear rationale for their conclusion that the Veteran cannot work. The Board notes further that no adequate VA opinion has been obtained that assesses the Veteran's employability, based on both a thorough assessment of all his service-connected disabilities and his educational and occupational history and experience. Accordingly, upon review of the record, the Board finds that a medical examination and opinion are needed to decide the Veteran's claim for TDIU. Thus, on remand the Veteran's file must be provided to a qualified VA medical professional, who must conduct a thorough review of the medical evidence, examine the Veteran, and provide a medical opinion addressing the question of whether the Veteran's service-connected disabilities, when considered together and without consideration of his age or any non-service-connected disabilities, have combined to make him unemployable at any time during the appellate period. 38 U.S.C.A. § 5103A(d); Friscia v. Brown, 7 Vet. App. 294 (1995). Such opinion must be based upon consideration of the Veteran's service-connected medical conditions as well as his documented history and assertions, to include employment history and education, and medical evidence associated with the record. 38 U.S.C.A. § 5103A. In view of the foregoing, the case is REMANDED for the following action: 1. Schedule the Veteran for VA examination with a qualified VA medical professional to determine the effect, if any, of his service-connected PTSD and coronary artery disease on his employability. The Veteran's claims file, including a copy of this Remand, must be made available to the examiner for review in connection with the opinion, and a notation that this review has taken place should be made in the examination report. After thoroughly reviewing the Veteran's claims file and examining the Veteran, the examiner must opine as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that the Veteran's service-connected PTSD and coronary artery disease combine to preclude him from engaging in substantially gainful employment that is consistent with his education and occupational experience. If the examiner finds that the Veteran's service-connected disabilities are of such nature and severity as to prevent him from securing or following substantially gainful employment, he or she must opine as to when the Veteran in fact became "unemployable" and as to which specific service-connected disability(ies) have rendered him unemployable. The examiner must discuss the May 2009 and September 2010 letters from the Veteran's VA treatment providers in the context of any negative opinion. A complete rationale must be given for all opinions and conclusions expressed. If the examiner finds that he/she must resort to speculation to render the requested opinion, he/she must state what reasons, with specificity, that this question is outside the scope of a medical professional conversant in VA practices. 2. Ensure that the examination report complies with (and answers the questions posed in) this Remand. If the report is insufficient, it should be returned to the examiner for corrective action, as appropriate. 3. Then, readjudicate the issue remaining on appeal-entitlement to a TDIU. If this benefit remains denied, the Veteran and his representative must be provided a supplemental statement of the case and given an appropriate opportunity to respond. The case must then be returned to the Board for further consideration, if otherwise in order. No action is required of the Veteran until he is notified; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2011). He has the right to submit additional evidence and argument on the matter that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ____________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs