Citation Nr: 1301340 Decision Date: 01/14/13 Archive Date: 01/23/13 DOCKET NO. 09-34 059 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with associated depression and alcohol dependence from December 1, 2008 to July 20, 2010. 2. Entitlement to a disability rating in excess of 70 percent for PTSD with associated depression and alcohol dependence on and after October 1, 2010. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1975 to November 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Board notes that the Veteran was granted a temporary 100 percent disability rating from August 21, 2008 to November 30, 2008 and from July 21, 2010 to September 30, 2010 in rating decisions dated in August 2009 and September 2011. As the Veteran is receiving the maximum disability rating during those periods, the Board will not address the issue of entitlement to a higher disability rating regarding those times. Additionally, in the August 2009 rating decision, the RO granted an increased initial disability rating of 50 percent for this condition beginning December 1, 2008, and in the September 2011 rating decision, the RO granted an increased disability rating of 70 percent for this condition on and after October 1, 2010. Because the increased ratings assigned to the Veteran's service-connected PTSD with associated depression and alcohol dependence are not the maximum rating available for this disability, the claim remains in appellate status, and the Board has re-characterized the issues to include staged ratings as shown on the title page. See AB v. Brown, 6 Vet. App. 35 (1993); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center in Washington, DC. FINDINGS OF FACT 1. From December 1, 2008 to July 20, 2010, the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, thinking, and mood, due to such symptoms as: visual hallucinations, sleep impairment, obsessive and ritualistic behavior, panic attacks, and inability to establish and maintain effective relationships but not total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent ability to perform activities of daily living, disorientation to time or place, or memory loss for names of closest relatives, own occupation, or own name. 2. On and after October 1, 2010, the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas but not total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent ability to perform activities of daily living, disorientation to time or place, or memory loss for names of closest relatives, own occupation, or own name. CONCLUSIONS OF LAW 1. From December 1, 2008 to July 20, 2010, the criteria for a disability rating of 70 percent for PTSD with associated depression and alcohol dependence have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 2. On and after October 1, 2010, the criteria for a disability rating in excess of 70 percent for PTSD with associated depression and alcohol dependence have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS After review of the claims file, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions in this case with respect to the issue on appeal. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The information contained in a September 2008 letter satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Moreover, the Veteran was notified of regulations pertinent to the establishment of an effective date and disability rating in the September 2008 letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's service treatment records and VA treatment records have been obtained and associated with the claims file. The Veteran was provided VA examinations in December 2008 and January 2012 with respect to the issues on appeal. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The examiners reviewed the Veteran's claims file and his lay statements. Additionally, the examinations provided sufficient information to decide the issues on appeal. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). Therefore, the Board finds the examinations to be sufficient and adequate for rating purposes. There is no indication in the record that any additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). The Board has thoroughly reviewed all of the evidence in the Veteran's claims file. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matters on appeal. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability, and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). With respect to the period from December 1, 2008 to July 20, 2010, the Veteran's claim arises from his disagreement with the initial evaluation assigned following the grant of service connection for PTSD with associated depression and alcohol dependence. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice as to this claim is needed. With respect to the period from October 1, 2010 to the present, the primary concern for an increased evaluation for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). 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) (2012). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV), a global assessment of function (GAF) score reflects the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM IV, American Psychiatric Association (1994), pp.46-47; 38 C.F.R. §§ 4.125(a), 4.130 (2012). A GAF score 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; child frequently beats up younger children, is defiant at home, and is failing at school. 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). A GAF score of 51-60 represents 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 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, and has some meaningful interpersonal relationships. The Veteran's service-connected PTSD with associated depression and alcohol dependence has been rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides: 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; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating 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 disability rating is warranted when the Veteran experiences 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 work like setting); and inability to establish and maintain effective relationships. A 100 percent disability 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. 38 C.F.R. § 4.130. From December 1, 2008 to July 20, 2010 From December 1, 2008 to July 20, 2010, the Veteran's PTSD is currently rated as 50 percent disabling. To warrant a higher disability rating, the evidence must show 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130. The Veteran underwent VA examination in December 2008 in conjunction with his claim. Although the Veteran denied a history of outpatient treatment or hospitalization for a mental disorder, he reported that he was currently being treated for a mental disorder in the VA Medical Center's alcohol treatment program. On physical examination, the Veteran was clean, neatly groomed, and appropriately dressed with unremarkable psychomotor activity, thought process, and speech. The Veteran's affect was normal, his mood was anxious and depressed, and his attitude was cooperative, friendly, relaxed, and attentive. He was intact to person, time, and place, without delusions, and understood the outcome of his behavior. The Veteran reported symptoms of visual hallucinations, sleep impairment, obsessive and ritualistic behavior, and panic attacks. He denied any inappropriate behavior, homicidal thoughts, suicidal thoughts, and episodes of violence. The Veteran reported good impulse control, no memory impairment, and the ability to maintain minimum personal hygiene and perform activities of daily living. Specifically, the Veteran's PTSD was manifested by persistent re-experiencing of the traumatic event by recurrent distressing dreams, feeling as if the traumatic events were recurring, and intense psychological distress and physiological reactivity at exposure to internal or external cues that symbolized or resembled an aspect of the traumatic effect. He reported persistent avoidance of stimuli associated with the trauma, manifested by efforts to avoid thoughts, feelings, conversations, activities, places, and people that aroused recollections of the trauma. He also reported feelings of detachment and estrangement, a restricted range of affect, and a sense of a foreshortened future. The VA examiner found the Veteran's symptoms caused clinically significant distress or impairment in social and occupational areas of functioning. The Veteran reported that his usual occupation was a car salesman, although he had not been employed within the past year due to his growing anxiety and alcohol dependence. The VA examiner diagnosed PTSD and depression related to multiple stressors and assigned a GAF score of 42. The VA examiner stated the Veteran's traumatic experiences had impaired his overall functioning in the areas of performance in employment, social and interpersonal relationships, and recreation and leisure pursuits. The VA examiner found the Veteran's alcoholism and avoidance had been means of coping with PTSD and reported that the Veteran's prognosis was guarded in that it appeared he was only able to function in the hospital setting. In conclusion, the VA examiner stated the Veteran's PTSD had resulted in an inability to maintain interpersonal relationships and to work in his usual occupation. In his January 2009 Notice of Disagreement, the Veteran reported experiencing symptoms of sleep impairment, nightmares, anxiety, depression, hallucinations, panic attacks, short-term memory loss, previous suicide attempts, loss of employment, and avoidance of people, places, and things that reminded him of the traumatic events. In a February 2009 written statement, the Veteran reported problems with relationships and employment, nightmares, fear, and insomnia as the result of the traumatic in-service events. VA treatment records from January 2009 and April 2009 reveal GAF scores of 55. The Veteran reported feeling anxious, having difficulty sleeping, and seeing shadows, but he denied mood swings and suicidal ideation. On examination, the Veteran had a normal appearance, was appropriately groomed, and his personal hygiene was fair. His attitude was pleasant, polite, and cooperative, and he had no psychomotor agitation or retardation. His speech was fluent and coherent, without pressure and latency. His mood was neutral, affect was euthymic, appropriate, and mood congruent, and his thought flow was spontaneous, linear, logical, and goal directed. The Veteran denied hallucinations, delusions, and homicidal ideation. He was alert and oriented to all spheres, his memory was intact, his attention was fair, his intelligence was average, and his judgment was fair. The VA examiner diagnosed bipolar disorder, not otherwise specified, PTSD, and alcohol dependence early remission. The April 2009 VA physician found the Veteran was not suicidal, homicidal, acutely psychotic, or manic, and determined that the Veteran was psychiatrically stable and not a danger to himself or others at that time. A March 2009 VA treatment record reflects that the Veteran had been involved in the VA MC Cornerstone Work-Re-entry program since November 2008. The VA physician stated that although the Veteran had not been overtly problematic, he had shown little motivation or engagement. The Veteran had put out minimal job applications, had only recently acquired a sponsor, and had been reluctant to use his psychologist for assistance with PTSD symptom management. The VA physician stated that it was not clinically evident that the Veteran warranted further residential PTSD treatment because although PTSD symptoms were present, they could be managed on an outpatient basis. A July 2009 VA mental status examination shows the Veteran was well groomed, cooperative, and engaged, with normal activity, fluent speech, and dysthmic mood and affect. He denied hallucinations, delusions, suicidal ideation, and homicidal ideation. His thought flow was spontaneous, linear, logical, and goal directed, he was alert and oriented to all spheres, his memory was intact, and his attention, judgment, and insight were good. The VA examiner assigned a GAF score of 55. An August 2009 VA mental status examination reflects similar findings, although the Veteran's mood was described as mildly angry. Given the above record, the Board concludes that the evidence demonstrates the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas from December 1, 2008 to July 20, 2010. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.130, Diagnostic Code 9411. Initially, the Board notes that the Veteran experienced symptoms that are not listed in the rating criteria, and as a result, the Board has considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of occupational and social impairment with deficiencies in most areas. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The evidence demonstrates that during this period the Veteran's PTSD was manifested by depressed mood, visual hallucinations, sleep impairment, nightmares, obsessive and ritualistic behavior, panic attacks, and an inability to establish and maintain effective relationships. VA physicians assigned GAF scores ranging from 42 to 55, indicating, at best, serious symptoms such as suicidal ideation and severe obsessional rituals, or any serious impairment in social or occupational functioning. In addition, the Board finds the December 2008 VA examination findings particularly significant as they detailed the Veteran's specific symptoms associated with his PTSD. The VA examiner noted the Veteran's persistent re-experiencing of the traumatic events, persistent avoidance of stimuli associated with the trauma, numbing of general responsiveness, and persistent symptoms of increased arousal. Further, the VA examiner found the Veteran's symptoms caused clinically significant distress and impairment in social and occupational areas of functioning. Finally, the VA examiner stated the Veteran's prognosis was guarded because it appeared the Veteran was only able to function in a hospital setting. Therefore, the Board finds that a 70 percent rating is warranted for this period. See Hart v. Mansfield, 21 Vet. App. 505 (2007). However, the Board finds that a rating in excess of 70 percent is not warranted for the Veteran's service-connected PTSD with associated depression and alcohol dependence. The evidence of record does not show gross impairment in thought processes or communication; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; or memory loss for names of closest relatives, own occupation, or own name. Although the Board notes the Veteran's reports of short-term memory loss, VA examiners and physicians did not find the Veteran's memory to be impaired. Further, this single symptom is not severe enough to warrant an increased disability rating solely on that complaint. For these reasons, the Board finds that the criteria for a disability rating of 70 percent, but no more, for PTSD with associated depression and alcohol dependence have been met from December 1, 2008 to July 20, 2010. 38 C.F.R. § 4.130. On and after October 1, 2010 VA mental status examinations in November 2010 and March 2011 reflect that the Veteran had a normal appearance, was appropriately groomed, and his personal hygiene was fair. His attitude was pleasant, polite, and cooperative, and he had no psychomotor agitation or retardation. His speech was fluent and coherent, without pressure or latency. His mood was neutral, affect was euthymic, appropriate, and mood congruent, and his thought flow was spontaneous, linear, logical, and goal directed. The Veteran denied hallucinations, delusions, suicidal ideation, and homicidal ideation. He was alert and oriented to all spheres, his memory was intact, his attention was fair, his intelligence was average, and his judgment was fair. The VA physicians diagnosed alcohol dependence and bipolar by history. The VA physicians found the Veteran was not suicidal, homicidal, acutely psychotic, or manic, determined that the Veteran was psychiatrically stable and not a danger to himself or others at that time, and assigned a GAF score of 50. From May 25, 2011 to May 29, 2011, the Veteran underwent alcohol detoxification at the VA Medical Center. VA treatment records noted that the Veteran had a home and income, along with supportive Alcoholics Anonymous fellowship. During that time, the Veteran denied suicidal ideation and homicidal ideation, feelings of hopelessness and helplessness, but he reported isolating himself. VA treatment records from June 2011 and September 2011 show GAF scores ranging from 54 to 60, and in November 2011, VA physicians assigned GAF scores of 30. Throughout this time, the Veteran was observed as being alert and oriented to person, place, and time, his mood was described as depressed, and his affect was labile or congruent with his mood. The Veteran denied homicidal ideation, suicidal ideation, and hallucinations. His behavior was withdrawn, and his hygiene was fair. The evidence also reveals that the Veteran was admitted for alcohol detoxification during the periods of July 3, 2011 to July 5, 2011; August 25, 2011 to August 30, 2011; September 12, 2011 to September 14, 2011; and from November 1, 2011 to November 22, 2011. The Veteran underwent additional VA examination in January 2012 in connection with his increased rating claim. The VA examiner diagnosed alcohol dependence in early full remission, PTSD, and bipolar mood disorder, not otherwise specified, and assigned a GAF score of 51. With respect to the Veteran's current symptoms, the VA examiner reported that the Veteran's alcohol dependence was in remission with no current symptoms; his symptoms of hyperarousal, re-experiencing, and avoidance were linked to his PTSD; and the bipolar disorder was manifested by mood swings. The VA examiner opined that the Veteran's diagnoses resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood. The VA examiner stated that the alcohol dependence, PTSD, and bipolar disorder had each contributed to the Veteran's overall impairment and that it was therefore not possible to delineate separate contributions as the diagnoses had been very interrelated and interactive with each other. The Veteran reported living by himself in a mobile home and having a girlfriend and a grown daughter, with whom he described as having a good relationship. He also described having several friends with whom he maintained contact. The Veteran reported an occupational history in sales, although he had lost almost every job due to missing too much work. His last job was in the past year, until he was fired for walking off the job. The VA examiner found the Veteran persistently re-experienced the traumatic events through intense psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of the traumatic events. Persistent avoidance of stimuli associated with the traumatic events involved efforts to avoid thoughts, feelings, or conversations associated with the trauma, efforts to avoid activities, places, or people that aroused recollections of the trauma, and feelings of detachment or estrangement from others. The Veteran's persistent symptoms of increased arousal were manifested by difficulty falling or staying asleep, difficulty concentrating, and hypervigilance. The VA examiner noted that the Veteran's symptoms lasted longer than one month and found his symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The Veteran's reported symptoms were depressed mood; anxiety; panic attacks occurring weekly or less often; chronic sleep impairment; mild memory loss; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; and mood swings with hypomanic and/or manic episodes. The VA examiner also opined that the Veteran's PTSD by itself did not render him unable to secure or maintain substantially gainful employment. The VA examiner based the opinion on the Veteran's recent work and the fact that the Veteran's overall impairment was linked to several other disorders, including his alcohol dependence and bipolar disorder, not otherwise specified. On and after October 1, 2010, the Veteran's PTSD is currently rated as 70 percent disabling. To warrant a higher disability rating, the evidence must show 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/or memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130. In this case, VA treatment records and the January 2012 VA examination demonstrate that since October 1, 2010, the Veteran's PTSD was manifested by isolation, depressed mood, anxiety, hyperarousal, re-experiencing, avoidance, chronic sleep impairment, difficulty concentrating, panic attacks; mild memory loss; disturbances of mood and motivation; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances. The January 2012 VA examiner opined that the Veteran's symptoms resulted in occupational and social impairment with deficiencies in most areas, although the Veteran's PTSD alone did not render him unable to secure or maintain substantially gainful employment. Upon review, the Board finds the Veteran does not meet the criteria for a 100 percent disability rating on and after October 1, 2010. The evidence of record indicates that since October 1, 2010, the Veteran's speech was fluent and coherent, and his thought flow was spontaneous, linear, logical, and goal directed. The Veteran also denied hallucinations, delusions, suicidal ideation, and homicidal ideation. Additionally, he was alert and oriented to all spheres, his memory was intact, his attention was fair, his intelligence was average, and his judgment was fair. The evidence does not demonstrate intermittent ability to perform activities of daily living, grossly inappropriate behavior, or memory loss for names of closest relatives, own occupation, or own name. Since October 1, 2010, the Veteran's GAF scores ranged from 30 to 60. The Board acknowledges that GAF scores of 30 indicate symptoms that may include behavior that is considerably influenced by delusions or hallucinations, serious impairment in communication or judgment, or an inability to function in almost all areas. However, the record does not reflect any evidence of delusions or hallucinations, incoherent speech, grossly inappropriate behavior, or suicidal preoccupation during this period. Additionally, the Veteran did not report staying in bed all day or not having a home or friends. As a result, the Board finds the Veteran's disability picture more closely approximates occupational and social impairment with deficiencies in most areas, and therefore a disability rating in excess of 70 percent is not warranted. 38 C.F.R. § 4.130. Extraschedular Consideration An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extraschedular evaluation. 38 C.F.R. § 3.321(b)(1) (2012). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. The Board finds the Veteran's disability picture is not so unusual or exceptional in nature as to render the ratings assigned herein inadequate. The Veteran's service-connected PTSD with associated depression and alcohol dependence is evaluated as a psychiatric disability, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. Thun, 22 Vet. App. at 115; see also 38 C.F.R. § 4.130, Diagnostic Code 9411. From December 1, 2008 to July 20, 2010, the Veteran's PTSD was manifested by visual hallucinations, sleep impairment, obsessive and ritualistic behavior, panic attacks, and inability to establish and maintain effective relationships. On and after October 1, 2010, the Veteran's PTSD was manifested by isolation, depressed mood, anxiety, hyperarousal, re-experiencing, avoidance, chronic sleep impairment, difficulty concentrating, panic attacks; mild memory loss; disturbances of mood and motivation; difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are contemplated by a 70 percent disability rating for both periods. A rating in excess of 70 percent is provided for certain manifestations of PTSD, but the medical evidence demonstrates that those manifestations are not present in this case. The criteria for the 70 percent disability ratings assigned herein more than reasonably describe the Veteran's disability level and symptomatology and, therefore, the schedular evaluation is adequate and no referral is required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). By this decision, the Board has found that a 70 percent rating for PTSD is warranted based on the evidence of record for the period from December 1, 2008 to July 20, 2010 and on and after October 1, 2010. However, because total social and occupational impairment is not established, the preponderance of the evidence is against the assignment of a 100 percent disability rating for PTSD. Therefore, there is no doubt to be resolved, and a rating in excess of 70 percent for PTSD is not warranted for either period. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to an initial disability rating of 70 percent, but no more, for PTSD with associated depression and alcohol dependence is granted from December 1, 2008 to July 20, 2010. Entitlement to a disability rating in excess of 70 percent for PTSD with associated depression and alcohol dependence on and after October 1, 2010 is denied. REMAND The United States Court for Veterans Claims has held that a TDIU claim is part and parcel of an increased rating claim when raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). As a result, the Board has jurisdiction to consider the Veteran's possible entitlement to a TDIU when the issue is raised by assertion or reasonably indicated by the evidence and is predicated, at least in part, on the severity of the service-connected disability in question, regardless of whether the RO has expressly addressed this additional issue. See VAOPGCPREC 6-96 (Aug. 16, 1996); see also Caffrey v. Brown, 6 Vet. App. 377 (1994); Fanning v. Brown, 4 Vet. App. 225, 229 (1993); EF v. Derwinski, 1 Vet. App. 324 (1991). In this case, the Veteran filed a formal claim for a TDIU in November 2011, and in January 2012, the RO provided the Veteran with the statutory and regulatory notice with respect to the claim for a TDIU. Therefore, the issue of entitlement to a TDIU has been reasonably raised by the evidence of record and should be adjudicated as part of the claim on appeal. Id.; see also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Bowling v. Principi, 15 Vet. App. 1 (2001). As the issue of entitlement to a TDIU has not been properly developed for appellate review, the issue is remanded for appropriate action. Accordingly, the case is REMANDED for the following actions: 1. Schedule the Veteran for an examination to determine the impact of his service-connected disabilities on his employability. The claims file in its entirety should be provided to the VA examiner for use in the study of this case. Such examination should include the taking of a complete medical history and the conduct of all tests deemed necessary by the VA examiner. Upon completion of the above, the VA examiner is asked to provide an opinion as to whether it is at least as likely as not (50 percent or more probability) that the Veteran's service-connected disabilities, without consideration of his non-service-connected disabilities and without regard to his age, render him unable to secure or follow a substantially gainful occupation. The VA examiner should note that the Veteran is service-connected for PTSD with associated depression and alcohol dependence and also has non-compensable ratings for three other service-connected disabilities - residuals of surgery of the nasal septum, a scar on his forehead, and a scar on his lower chest/upper abdomen. A complete rationale for all opinions expressed must be provided, to include reference to specific clinical findings or documents in the claims file. 2. When the development requested has been completed, the case should be reviewed by the RO on the basis of additional evidence. If any benefit sought is not granted to the fullest extent, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further appellate review. 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 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. 2012). ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs