Citation Nr: 1300141 Decision Date: 01/03/13 Archive Date: 01/11/13 DOCKET NO. 09-32 963 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased initial rating for posttraumatic stress disorder (PTSD), currently rated as 30 percent disabling. 2. Entitlement to a total disability rating for compensation purposes based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Macko, Counsel INTRODUCTION The Veteran served on active duty from August 1965 to August 1968 and from July 1970 to July 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2008 and May 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The decision below addresses the rating claim for PTSD. The issue of entitlement to TDIU is addressed in the remand that follows the Board's decision. FINDING OF FACT Since the award of service connection, the Veteran's PTSD has been productive of a disability picture generally characterized by 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), but has not generally been characterized by occupational and social impairment with reduced reliability and productivity and is not manifested by flattened affect; circumstantial, circumlocutory, or stereotyped speech; 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; or impaired abstract thinking. CONCLUSION OF LAW The criteria for entitlement to an initial disability rating in excess of 30 percent for the Veteran's service connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126 (West 2002 & Supp. 2012); see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a) (2012, VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Duty to Notify The record shows that in December 2006 and April 2007 VCAA letters, the Veteran was informed of the information and evidence necessary to warrant entitlement to the benefit sought on appeal. The Veteran was also advised of the types of evidence VA would assist in obtaining as well as her own responsibilities with regard to identifying relevant evidence. See Quartuccio, 16 Vet. App. at 183; Charles v. Principi, 16 Vet. App. 370 (2002). The United States Court of Appeals for Veterans Claims (Court) decision in Pelegrini v. Principi, 18 Vet. App. 112 (2004) held, in part, that a VCAA notice as required by 38 U.S.C. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim for VA benefits. In this case, the RO provided VCAA notice to the Veteran in December 2006 and April 2007, which was prior to the February 2008 rating decision. Accordingly, the requirements the Court set out in Pelegrini have been satisfied. Further, 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). In the present appeal, the Veteran was provided with notice of what type of information and evidence was needed to substantiate the underlying claim of service connection for PTSD. Further, the April 2007 letter also gave notice of the types of evidence necessary to establish a disability rating and effective date for the disability on appeal. The Board also stresses that since the issue in this case (entitlement to assignment of a higher initial rating) is a downstream issue from that of service connection (for which a VCAA letter was duly sent in November 2006 and in April 2007), another VCAA notice letter is not required. VAOPGCPREC 8-2003 (Dec. 22, 2003). The Court has also determined that the statutory scheme does not require another VCAA notice letter in a case such as this where the veteran was furnished proper VCAA notice with regard to the claim of service connection itself. See Dingess, 19 Vet. App. at 491. Thus, VA's duty to notify has been met. Duty to Assist Furthermore, the Board finds that there has been compliance with the assistance provisions set forth in the law and regulations. The record in this case includes all identified medical records, including VA treatment records and the Veteran's records from the Social Security Administration (SSA). The Veteran was afforded VA examinations in February 2008 and February 2010. The examination reports provide sufficient evidence for evaluating the Veteran's PTSD in the context of the rating criteria. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination, it must provide an adequate one). The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case and no further action is necessary. See generally 38 C.F.R. § 3.159(c)(4). No additional pertinent evidence has been identified by the claimant. Legal Criteria The present appeal involves the Veteran's claim that the severity of her service-connected PTSD pathology warrants a higher initial 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 (West 2002); 38 C.F.R. Part 4 (2012). 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 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). 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). At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as 'staged' ratings. Id. at 126. The Veteran's service-connected PTSD has been initially rated as 30 percent disabling by the RO under the provisions of Diagnostic Code 9411, which refer to the rating criteria for mental disorder as set forth at 38 C.F.R. § 4.130 (2012). Under this regulatory provision, a rating of 30 percent is warranted where the disorder is manifested by occupational and social impairment with an 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, and recent events). A 50 percent rating is warranted where the disorder is 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted where the disorder is manifested by 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 that is 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. The highest available rating, 100 percent, is warranted where the disorder is manifested by 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; an intermittent inability to perform the activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, one's own occupation, or one's own name. The Board recognizes that the Court, in Mauerhan v. Principi, 16 Vet. App. 436 (2002), stated that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. However, the Court further indicated that without those examples, differentiating a 30 percent evaluation from a 50 percent evaluation would be extremely ambiguous. Id. at 442. 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) (2012). 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 Global Assessment of Functioning (GAF) scale reflects the psychological, social and occupational functioning under a hypothetical continuum of mental illness. See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown, 8 Vet. App. 240, 243 (1995); 38 C.F.R. § 4.130. According to the DSM-IV, a GAF score 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 score 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). Analysis The Veteran appeals for assignment to a disability rating in excess of the initially assigned 30 percent throughout the period since the effective date of the grant of service connection for PTSD. In October 2006, the Veteran initiated psychiatric treatment with VA. She reported to the primary care clinicians that she had difficulty sleeping, had vivid dreams about Vietnam, and had had thoughts of suicide, but no plan. She had recently lost her job, which she did not attribute to the PTSD but to other aspects of her life. In the initial psychiatry evaluation, the psychiatrist noted the Veteran had good judgment, though a depressed affect. She was assessed as depressed, but not suicidal. She was alert, articulate and appropriate; the mood was sad. Recent and remote memory was intact with a good fund of information, no hallucinations or delusions. Thinking was abstract and judgment was intact. The Veteran was initially assessed with dysthymia and medication was prescribed. Still in October 2006 the Veteran underwent a mental health evaluation with a psychologist (Dr. C). The Veteran reported working up until the previous week, only to be fired for a reason other than PTSD (gender issues, for which the Veteran attributed in-patient treatment in 2000 and a recent divorce after many years of marriage). She had two roommates with whom she got along well. She discussed her stressor of combat during her tour in Vietnam. The Veteran reported three children and being on good terms with the ex-spouse. The clinician noted a serious affect and goal directed speech. The assessment included recurrent major depression, chronic PTSD with a GAF of 55. The Veteran attended treatment regularly. In December 2006 she reported still being unemployed and while she had gone fishing, she still felt down and was sleeping excessively. Affect remained controlled and speech was goal-directed; appearance was well-dressed. In February 2007 the Veteran continued to report bad dreams and nightmares about Vietnam, trouble sleeping, and anxiety. During the February 2007 evaluation with Dr. C., the Veteran reported remaining unemployed, and having dreams and nightmares, some of which were intense about combat. The Veteran recently spent the holiday with her children, which helped her. Affect remained serious and controlled and speech remained articulate and goal directed. GAF was 50. In March 2007 the Veteran reported to Dr. C that she had run out of Paxil, and so the nightmares, about combat, had become more intense. The Veteran remained well-dressed, affect controlled and speech was goal-directed. GAF was 55. In February 2008 the Veteran was afforded a VA psychiatric examination that included a claims file review. The Veteran reported the divorce after a long-term marriage and again did not attribute it to PTSD. Her relationship with her three adult children was excellent. She discussed the stressor incident, a combat event in Vietnam involving the rescue of a helicopter crew. This event figured in her nightmares which she still experienced. Following her retirement from service, she held a civil service job until 2000 when she was fired, which she did not attribute to PTSD. She obtained employment as a stocker in grocery stores for years until her recent firing in 2006, which she also did not attribute to PTSD. Her one hospitalization in 2000 she also attributed to the stress and circumstances surrounding her loss of federal employment, not PTSD. She initiated treatment with VA to seek help for the nightmares; prior to the medication, they were nearly nightly in addition to intrusive thoughts. Since she began taking Paxil and Wellbutrin, the nightmares decreased to about once a month and the intrusive thoughts happened only occasionally. She did report avoiding talking about her experiences in Vietnam and avoiding reminders of service there. Her irritability was worse prior to the medications as well. She did not tolerate crowds well and would not sit with her back to the door. She also reported ducking at loud sounds. She did try to be active in church and had two very supportive roommates. Objectively, the examiner noted she was alert and attentive with tracked the conversation adequately. She was oriented, with psychomotor activity with was within normal limits. Speech functions were appropriate to rate, volume, and fluency. Memory was grossly intact for recent and remote events and factual information. The thought processes were goal directed and thought content was within normal limits. The Veteran described her mood as somewhat anxious and the examiner found the affect the same. The Veteran denied current suicidal and homicidal ideation and denied symptoms of perceptual disorder. She maintained her own activities of daily living. She was well dressed; judgment was intact and insight appeared adequate. Her symptoms were consistent with PTSD and she even reported her symptoms had improved since she started VA treatment. The examiner also noted she had a history of a major depressive disorder that may have been related in part to the PTSD, though currently the depressive symptoms appeared to be controlled. GAF was 60, which the examiner specifically noted was assigned only to the PTSD. The Veteran continued to receive treatment. In a February 2008 evaluation with Dr. C., she reported staying busy with yard work and being involved with her church. In March 2008 and April 2008 she reported she had obtained employment in a restaurant and liked the work. Dr. C noted euthymic affect and goal directed speech. However in two evaluations in September 2008, the Veteran reported to the clinician that she had been fired from her job because she had become frustrated with management and challenged the supervisor to go outside and "settle" some issues. She reported this was the third job in a row she had lost. The clinician observed intense anger which the Veteran expressed with control and modulation that became less intense after venting the anger. Speech remained goal directed. She did expect to draw Social Security soon as she approached the age of retirement. GAF was 45. In October 2008 the Veteran submitted an application to SSA for disability benefits. She reported to SSA that she sought disability for PTSD and that it was PTSD that interfered with her ability to work. While she denied social activities, she reported that she went to church monthly and socialized with family and friends daily. Her hobby was fishing and she tried to go once a month. She also reported having a short attention span and being unable to recall events of the previous evening. On her handwritten application, she reported having difficulty sleeping with nightmares often, night sweats and screaming out in addition to trouble remembering things. She also reported that she did not spend time with others, yet went to church on Sundays and was a deacon in her church. She reported she now had guns near-by, though seldom shot anymore. The SSA application underlying evidence also contained statements by her roommates, one of which reported the Veteran had no friends other than her roommates, but she did talk to people at church and with her children on the phone, both approximately two to three times a month. The roommate also reported the Veteran did need reminders to take her medicine. The Veteran reported to Dr. C in an October 2008 mental health clinic visit that she planned to attend her son' s upcoming wedding. She reported being angry about the current economy and world events. Her son was in the service and expected to be deployed soon. She continued to have trouble sleeping, though she looked forward to her social security check, which she reported was approved. She was observed to be well-dressed, with a serious affect, and goal-directed speech. GAF was 55. In the November 2008 mental health clinic visit she reported receiving SSA benefits now that she was retirement age and that she felt better with the increased income and falling gas prices, such that she could resume fishing again. She reported her temper had cost her last four or five jobs, but now she did not have to work again. Her affect was fairly calm, sentences were goal directed, and there were no complaints of homicidal or suicidal ideation or hallucinations. GAF was 55. The Veteran submitted a statement, dated in July 2008, though received by VA in February 2009. In the statement, the Veteran contended her PTSD warranted a higher rating because she had just lost the fourth job in six years, which she attributed (as "directly relative") to her emotional situation from her PTSD. She reported she was more belligerent, angry, intolerant, and combative, challenging authority and resented being given instruction. She responded to frustrating situations with aggression, such that she asked others to "set outside" and settle disagreements physically. She reported she did not consider the consequences of her actions. She reported being easily distracted and forgetting her tasks, in addition to "sliding" from one mood to another. She reported being a deacon in her church and participating in services as much as she was financially able, yet she reported having no social life at all and having no one to socially interact other than her roommates. Her only hobby was fishing, yet she seldom went for financial reasons. When fishing, she displayed a sheath knife to discourage others from "messing" with her. She rarely initiated conversation with others. She also reported she continued to have problems sleeping and experienced the combat related nightmares, which included dreams of events she knew had never occurred. In June 2009 she was evaluated by Dr. C and reported trouble around crowds and feeling anxious in restaurants, and so did not go to movies or concerts. She reported mixed feelings about the recent Memorial Day holiday, in that she had gone down to the beach as a volunteer and was dismayed at the partying she witnessed, as she had traveled to the Vietnam War memorial ("the Wall") in Washington, D.C. and so viewed the holiday as a day to remember the service and sacrifice of those who died. Nightmares and trouble sleeping continued. The Veteran was again observed as well dressed, though she would not sit by a window. Speech remained goal-directed and affect was euthymic. GAF was 60. In August 2009 the Veteran was evaluated by both Dr. C., her long time clinician and Dr. M. Dr. M noted her affect was fairly calm, euthymic and reactive, that her speech remained goal directed, and there were no complaints of audio or visual hallucinations or homicidal or suicidal ideations. She reported the possibility of gaining another roommate so that they could all share expenses. GAF was 60. Also in August 2009, Dr. C. noted that two recent incidents had upset the Veteran. She had attended a concert with a friend and experienced an episode of feeling very nervous and anxious in the crowd, which dissipated when they were seated. Dr. C noted that the Veteran referred to this as a panic attack. In another incident, the Veteran was fishing and was disturbed by the language used by others. After asking nicely, she then confronted the young men, "collared" one and threatened violence. She was upset for days and did not sleep for two nights. She recently acquired a new puppy and the puppy made her feel more safe when she was sleeping or in the shower. Affect was controlled and speech remained goal directed. GAF was 55. In October and November 2009, the Veteran was evaluated by both of her long-time clinicians, Dr. C., and Dr. M. She reported to both she was enjoying her new dog and things were alright. Her son had returned home from deployment, and she remained well-dressed with an euthymic affect. Both clinicians assigned a GAF of 62. In February 2010 the Veteran was afforded another VA psychiatric examination. The claims file was reviewed. The Veteran reported frustration with being unable to hold a job because she could not seem to keep her mouth shut; she also expressed her frustration knowing that she was smarter than everyone placed above her. She described herself as fiercely angry and easily set-off, as she cannot accept others telling her what to do or how to do it. Her terrorizing dreams were now only occasional. She reported she did not like crowds and did not like to be alone. She preferred animals to people because they do not lie or deceive. She reported being unable to go anywhere without a gun, such that she slept with one and fished and went hiking with one. Yet, she attributed her concern for being killed and attacked to her being transgendered. She reported these symptoms weekly to daily since the last VA examination. The Veteran reported she had lost four jobs since 2007 to the previous year (2009), mainly because she could not take orders from people placed in a position above her, such that she invited most of them "to the woodshed." The VA examiner noted that in her mental health treatment notes, the Veteran had attributed her employment difficulties with the discomfort of others with her transgendered status. Regarding family, friends, and social functioning, the Veteran reported she was in contact with two of the three children with whom she was close, in addition to one of her older brothers. She reported almost no contact with her ex-spouse, yet when they did have contact, it was cordial. She continued to live with two roommates and they had their ups-and-downs. She had another friend she went hiking with and she was friendly with people at church. For recreation, she fished a lot and went out on to the range and stayed current with her weapons, played with her dog, some woodworking, and watched T.V. The VA examiner found her fully oriented, well-groomed, friendly, and cooperative. Mood was euthymic to mildly irritated with full and reactive affect. She denied suicidal and homicidal planning or ideations, as well as delusions and hallucinations. Attention, memory, and judgment appeared to be within normal limits. The PTSD symptoms appeared to be controlled by continuous medication. GAF was 75. The Board has considered the Veteran's statements and the overall record clearly shows impairment due to the PTSD. However, although the Veteran may sincerely feel that the current 30 percent rating does not adequately reflect the severity of the PTSD, the Board is bound by the regulatory rating criteria and must weigh the evidence as to the types of PTSD symptoms outlined in the rating criteria and apply such rating criteria. Weighing in favor of assignment of a higher disability rating is the evidence that the Veteran has difficulty in establishing and maintaining effective work and social relationships. The Board also notes that evidence showing that the Veteran experiences irritability and anger, to the extent that such may be considered disturbances of motivation and mood, also provides some support to the claim. Weighing against the Veteran's claim is the fact that the VA examinations have consistently shown the Veteran not to have circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week, not to have difficulty in understanding complex commands; objectively determined impairment in short-term and long-term memory, not to have impaired judgment; and not to have impaired abstract thinking. The evidence does indicate that the Veteran has reported some mild or minor deficit in short-term memory, concentration, and focus and her roommate's statements, as included in the 2008 SSA application, referenced reminders to her to take her medicine. This appears to more nearly approximate the level of disability contemplated by the criteria for a 30 percent rating and not the criteria for a 50 percent rating. A 30 percent rating contemplates "mild memory loss (such as forgetting names, directions, and recent events)," whereas a 50 percent disability rating contemplates "impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks)." The Board notes that the evidence shows no impairment of long-term memory. The evidence also indicates that the Veteran experiences depressed mood, anxiety, irritability, and chronic sleep impairment. However, all of these symptoms are contemplated by the criteria for the currently assigned 30 percent disability rating. The Board notes that the Veteran has reported having experienced suicidal ideation in the past, when she first initiated treatment with VA in October 2006, but has made no other reports of any suicidal ideation since. Her clinicians regularly noted there were no reports of homicidal or suicidal ideation. The Board has also given consideration to the Veteran's reported difficulties adapting to stressful situations including work or a work like setting. However, the Board notes that the Veteran has also reported her previous loss of employment was due to others discomfort with her transgendered status and to her temper. Further, though the Veteran has reported in her statement to VA that she was isolated, throughout the record the Veteran referred to her satisfactory living arrangements with not one, but two roommates, relationships with at least two of her three children, with one brother, and regular mentions of her participation with her church, such that the Veteran referred to herself as a deacon with her church. These many reports of social contact weigh against subjective statements of the Veteran being socially isolated. Additionally, although the evidence shows that the Veteran has reported very frequently anxiety and feeling anger or rage, the evidence (including the VA examination findings) indicates that this does not significantly impair the Veteran's ability to function independently, appropriately, or effectively. The evidence does not indicate obsessional rituals of a nature that interfere significantly with routine activities, significantly impaired speech, impaired impulse control (the evidence shows that while the Veteran has reported her irritable anger has caused her to call out and offer to take to the "woodshed" her former supervisors, she has not reported actual fights, such that the one instance in which she "collared" a young man left her upset for days), neglect of appearance or hygiene, or an inability to establish and maintain effective relationships. The Board finds that the evidence does not otherwise reflect "deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood" to more nearly meet the criteria for any disability rating in excess of 30 percent. The most recent VA examination report explicitly found her PTSD symptoms were controlled by her medication. The Board notes that this observation matches the level of severity specifically described in the criteria for the currently assigned 30 percent rating. The Board notes that the VA examinations and most of her clinical evaluations show Global Assessment of Functioning (GAF) scores in the 51-60 range with only a few scores at 50 and over 60. According to the DSM-IV, a GAF between 51 and 60 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). GAF scores are not determinative by themselves. Review of the actual reported psychiatric symptoms does not support a finding that the disability picture more nearly approximates the criteria for a rating in excess of the current 30 percent. There is no persuasive objective evidence of flat affect, circumstantial speech, and impaired judgment. The record does repeated difficulty sleeping, nightmares, anger, and perceived difficulty in establishing and maintaining effective work and social relationships, but the preponderance of the evidence is against a finding that the Veteran's psychiatric disability picture more nearly approximates the criteria for a rating in excess of 30. The evidence shows occupational and social impairment with arguable occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. However, the evidence shows that the Veteran is generally functioning satisfactorily. Again, the Board does not question the fact that the Veteran's service-connected psychiatric disability does result in impairment, the question is to what degree. The Veteran may in good faith believe that the impairment is worse, but the totality of the evidence is against a finding that the criteria for a higher initial rating have not been met. Staged ratings are not of application since the Veteran's psychiatric disability is adequately contemplated by the 30 percent rating throughout the initial rating period. Should the psychiatric disability increase in severity so that the regulatory criteria for a higher rating are more nearly approximated, the Veteran may always file a new claim for an increased rating. As the record now stands, the initial 30 percent rating has adequately and accurately reflected the degree of impairment consistent with the types of PTSD/psychiatric symptoms under Diagnostic Codes 9411. In this decision, the Board has found that the evidence discussed above presents highly probative evidence with regard to evaluating the severity of the Veteran's PTSD on appeal. The reports specifically document and address the Veteran's symptom complaints, document the pertinent specialized clinical findings, and present competent medical examiners' assessments of the disability informed by direct interview and inspection of the Veteran together with consideration of the pertinent history. The Board has reviewed the entirety of the evidence of record, including the Veteran's statements and treatment records. The Board finds that none of the evidence of record probatively contradicts the findings discussed above, nor does any of the evidence of record otherwise probatively show that the criteria for any increased rating are met in this case. The Board acknowledges that the Veteran, in advancing this appeal, believes that the disability on appeal has been more severely disabling than the assigned disability rating reflects. Medical evidence is generally required to probatively address questions requiring medical expertise; lay assertions do not constitute competent medical evidence for these purposes. Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). However, lay assertions may serve to support a claim by supporting the occurrence of lay-observable events or the presence of symptoms of disability subject to lay observation. 38 U.S.C.A. § 1154(a) (West 2002); 38 C.F.R. § 3.303(a) (2012); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The Board has carefully considered the Veteran's contentions. Lay testimony is competent to describe certain psychiatric symptoms and experiences; the Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and is contemplated by the disability rating currently assigned. In this case, the competent medical evidence offering detailed specific findings and specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal. The Board accepts the Veteran's statements with regard to the matters it is competent to address, but relies upon the competent medical evidence with regard to the specialized evaluation of cognitive function, psychiatric symptom severity, and details of clinical features of the pathology. The lay testimony has been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The preponderance of the most probative evidence does not support assignment of any increased rating in this case. The above determination is based upon consideration of applicable rating provisions. It should also be pointed out that there is no showing that the Veteran's PTSD has reflected so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2012). The symptoms of her disability have been accurately reflected by the schedular criteria. Without sufficient evidence reflecting that the Veteran's disability picture is not contemplated by the rating schedule, referral for a determination of whether the Veteran's disability picture requires the assignment of an extra-schedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). For the foregoing reasons, the Board finds that the claim for an initial rating in excess of 30 percent for PTSD must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for a higher initial rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2012); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An initial evaluation in excess of 30 percent for PTSD is denied. REMAND The May 2009 rating decision denied entitlement to TDIU. The Veteran's September 2009 substantive appeal for her PTSD can reasonably interpreted as a notice of disagreement (NOD) with the May 2009 decision regarding TDIU. At the time, the Veteran and her representative appeared to indicate that she did not wish to appeal the TDIU denial. However, the Veteran's representative later expressly stated that the September 2009 submission should in fact be considered a NOD. A statement of the case (SOC) is required when a claimant protests a determination. 38 C.F.R. § 19.26 (2012). To date, no SOC has been furnished regarding the TDIU issue. Therefore, in light of the fact that there was indeed a timely NOD, the issuance of a SOC is required regarding issue of entitlement to TDIU. The Board must remand the issue for such an action. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). Accordingly, this issue is REMANDED for the following action: Prepare a SOC in accordance with 38 C.F.R. § 19.29 (2012) regarding the issue of entitlement to TDIU. This is required unless the matter is resolved by granting the full benefit sought, or by the Veteran's withdrawal of the NOD. If, and only if, the Veteran files a timely substantive appeal should this issue be returned to the Board. The Veteran 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 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. 2012). ____________________________________________ RYAN T. KESSEL Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs