Citation Nr: 1301452 Decision Date: 01/14/13 Archive Date: 01/23/13 DOCKET NO. 09-09 784 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUE 1. Entitlement to an increased disability rating in excess of 30 percent for service-connected acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), major depressive disorder, anxiety disorder, and mood disorder. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD William Alan Nelson II, Associate Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from August 1969 to June 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the RO in Boise, Idaho, which denied an increased rating for PTSD. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. The Veteran testified before a Decision Review Officer (DRO) at a May 2009 hearing at the RO. A transcript has been associated with the file. Since filing the initial claim for service connection, the Veteran has received diagnoses for other psychiatric symptoms or disorders. Based on the Veteran's contentions, private medical records, VA and private treatment records, and subsequent treatment of the claim by the RO, the Board has broadened and recharacterized the issue as entitlement to an increased rating for an acquired psychiatric disorder that includes PTSD, major depressive disorder, anxiety disorder, and mood disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). By decision dated in May 2012, the Board denied an increased disability rating in excess of 30 percent for PTSD. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court), and the Board's decision was vacated pursuant to a Joint Motion for Remand. The parties to the Joint Motion for Remand requested that the Court vacate the Board's decision denying an increased disability rating in excess of 30 percent for PTSD. The Joint Motion for Remand specifically stated that the Board needed to adequately address the Veteran's Global Assessment Functioning (GAF) scores. The Veteran's claims folder has been returned to the Board for further appellate review. The Board is aware of the Court's instructions in Fletcher v. Derwinski, 1 Vet. App. 394, 397 (1991), to the effect that a remand by the Court is not "merely for the purposes of rewriting the opinion so that it will superficially comply with the 'reasons or bases' requirement of 38 U.S.C. § 7104(d)(1). A remand is meant to entail a critical examination of the justification for the decision." The Board's analysis in this decision has been undertaken after such critical reevaluation of all the evidence as it pertains to the proper rating for the increased rating period that remains on appeal. The Veteran did not file a formal claim for a TDIU during the course of this appeal. However, at his DRO hearing in May 2009, the Veteran and his representative asserted that he could not work on account of his service-connected acquired psychiatric disorder. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a TDIU claim is part of an increased rating claim when such claim is reasonably raised by the record. In light of the Veteran's assertions at his hearing, the Board finds that the issue of entitlement to a TDIU is reasonably raised by the record and considered to be part of the Veteran's increased rating claim, as reflected on the first page of this decision. The issue of a TDIU is addressed in the REMAND portion of the decision below and is remanded to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDINGS OF FACT 1. For the entire increased rating period, the Veteran's acquired psychiatric disorder has been characterized by depression, anxiety, trouble concentrating, episodic passive suicidal and homicidal ideation, nightmares, memory loss, and hyperarousal. 2. For the entire increased rating period, the Veteran's acquired psychiatric disorder has not been characterized by occupational and social impairment, with deficiencies in most areas, such as (for example purposes only) 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; inability to establish and maintain effective relationships CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, for the entire increased rating period, the criteria for a 50 percent disability rating for an acquired psychiatric disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. 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. See 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of a veteran's disability. Schafrath, 1 Vet. App. at 594. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The schedular criteria, effective as of November 7, 1996, incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. §§ 4.125, 4.130. A rating of 10 percent is warranted for an acquired psychiatric disorder if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 38 C.F.R. § 4.130, DC 9411. A rating of 30 percent is warranted for an acquired psychiatric disorder if 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, or mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent rating is warranted if it is productive of 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 70 percent rating, may be assigned for 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); and inability to establish and maintain effective relationships. Id. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent schedular evaluation contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. 4.130, DC 9411. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychiatric, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). 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)." Id. 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)." Id. A GAF score of 61-70 indicates "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. Id. The GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard, 9 Vet. App. at 267; Carpenter v. Brown, 8 Vet. App. 240, 243 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue. The GAF score must be considered in light of the actual symptoms of a veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a) (2012). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive. The Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The U.S. Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Increased Rating for an Acquired Psychiatric Disorder The Veteran is in receipt of a 30 percent rating for service-connected acquired psychiatric disorder for the entire increased rating period, under the provisions of 38 C.F.R. § 4.130, DC 9411. After a review of all the evidence, lay and medical, the Board finds that, for the entire period of increased rating appeal, the Veteran's service-connected acquired psychiatric disorder has been characterized by depression, anxiety, trouble concentrating, episodic passive suicidal and homicidal ideation, nightmares, memory loss, and hyperarousal, which more nearly approximates the criteria for a higher 50 percent disability rating under DC 9411. 38 C.F.R. § 4.130. The Veteran was on medication management for his psychiatric disorder through VA prior to his July 2008 claim. The Veteran was seen for suicidal ideation after a panic attack at work at a local prison in September 2007. A February 2008 treatment note indicates that the Veteran had lost his job secondary to hearing problems. The Veteran reported having returned to construction for employment. An early June 2008 note indicated that the Veteran was having trouble finding a new job and was feeling useless and becoming more depressed as a result. The Veteran was admitted to the hospital in late June and into early July 2008 for a period of increased suicidal ideation. As discussed below, the Veteran has recurrent suicidal ideation, but rarely the intent to act on it. The Veteran had a period of intent and admitted himself to a VA Medical Center. At admission, the Veteran was alert, anxious and depressed at admission. He signed a safety plan. He was anxious to "feel better" and wanted to be less depressed so he could find a job. He was also drinking a six pack of beer per day, but claimed that this was less than usual. The Veteran was having insomnia in addition to depressed mood and suicidal thoughts. He was given a GAF score of 45. The Veteran had a VA psychiatric examination in September 2008. The examiner noted the Veteran's history in detail. The Veteran reported that interpersonal contacts had become progressively more difficult and that he had become more irritable and impatient. During the September 2008 interview, the Veteran displayed no psychomotor agitation or retardation. His expressive, reactive, and spontaneous movements were within normal limits. He had no evidence difficulty with goal-directed behaviors. His speech was unremarkable. His attitude toward the evaluation was friendly and forthcoming. He was appropriately deferential at all times. The Veteran reported that his mood was moderately elevated and had been in the recent past. His affect was mildly elevated, with a fairly labile change pattern tending toward anxiety. The Veteran displayed a severe degree of intensity with the intensity congruent to subjects discussed. The Veteran was alert and oriented times four. The Veteran had no difficulty with content or process-oriented knowledge problems. He had some difficulties with attention and concentration, performing at a lower than expected level relative to word spelling and digit span. His memory, immediate, recent and remote, appeared intact. He showed partial insight and good judgment. The Veteran displayed a number of ruminations relative to past perceived and actual slights, but no obsessions, delusions or compulsions. The Veteran reported ongoing suicidal and homicidal ideation without intent to act. The Veteran denied hallucinations. The Veteran reported that his sleep is moderately impaired with a good deal of hyperarousal and sleep disturbance in the form of nightmares. The September 2008 Axis I diagnoses were: alcohol abuse; cannabis abuse; anxiety disorder, not otherwise specified (NOS); and PTSD. The VA examiner assigned a GAF score of 50. In a September 2008 VA treatment record, the Veteran reported his mood was more stable and nightmares were less bothersome and reported no active suicidal or homicidal ideation. The VA examiner reported linear thought process and normal rate of speech. In a December 2008 VA treatment record, the Veteran reported getting more depressed and irritable, but reported no active suicidal or homicidal ideation. The VA examiner reported linear thought process and normal rate of speech. In a February 2009 VA treatment record, the Veteran reported medication had stabilized his mood and reported no active suicidal or homicidal ideation. The VA examiner reported linear thought process and normal rate of speech. In a May 2009 VA treatment record, the Veteran reported increased feelings of depression and memory problems. The Veteran reported no active suicidal or homicidal ideation. The VA examiner reported linear thought process and normal rate of speech. The Veteran testified at a May 2009 DRO hearing. The Veteran related the above history regarding his July 2008 admission and his VA treatment sessions every three months. He related some fluctuation in his symptoms and the medication management. The Veteran related his employment history over the past ten years. He stated that he had worked for a local university for five years starting in 2000, then a couple of construction jobs from which he was fired and then at the prison. The Veteran testified that he was let go from the prison because he took the medication that VA supplied him. The Veteran reported a lot of trouble with supervisors, particularly with the university. The Veteran claimed to have felt personal attacks, unfair treatment and discrimination. The Veteran reported a lot of verbal outbursts. The Veteran reported leaving the job before he could be fired. The Veteran reported having been married for 35 years. He denied having friends. He described himself as a loner, communicating only with his wife and their son. The Veteran complained of memory deficiencies and thinking that he was developing Alzheimer's. The Veteran described bad days in which he thought about suicide. The Veteran testified that he did not think he was capable of gainful or part time employment due to a combination of a physical condition and his mental attitude, but emphasized the physical condition. The Veteran reported problems of anger, irritability, and an inability to handle confrontation. The Veteran denied having ever made a Social Security Administration claim during the hearing. The Veteran indicated during the hearing that he had a long history of substance and alcohol abuse which he had finally stopped recently after the June-July 2008 VAMC admission. On review of all the evidence above, the Board finds that, for the entire increased rating period, the Veteran's acquired psychiatric disorder has been characterized by depression, anxiety, trouble concentrating, episodic passive suicidal and homicidal ideation, nightmares, memory loss, and hyperarousal. The Veteran's psychiatric symptoms have been relatively consistent and a 50 percent rating takes into account his social and occupational impairment. The Board further finds that the criteria for the next-higher 70 percent rating for an acquired psychiatric disorder have not been met for any period. For the entire period of increased rating appeal, the Veteran's acquired psychiatric disorder has not been characterized by occupational and social impairment, with deficiencies in most areas, such as, for example purposes only, work, school, family relations, judgment, thinking, or mood, due to such symptoms as: obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 lay and medical evidence in this case does reveal suicidal ideation; however, the reports show that the ideation is episodic and passive. The Veteran was admitted to the hospital in late June and into early July 2008 for a period of increased suicidal ideation. In the January 2006 VA treatment record, the Veteran reported intermittent passive suicidal ideations. The Board notes that the Veteran had experienced episodic passive suicidal ideations, but that he had no intent to act on such thoughts. In the September 2008 VA psychiatric examination, the Veteran reported ongoing suicidal and homicidal ideations without intent to act. In VA treatment records dated from September 2008 to May 2009, the Veteran reported no active suicidal or homicidal ideation. Evidence on this one of the 70 percent disability rating criterion does not demonstrate that the overall symptomatology or overall impairment due to an acquired psychiatric disorder more nearly approximates the criteria for a 70 percent rating. The lay and medical evidence in this case does not reveal any obsessional rituals that interfere with routine activities. The Veteran's speech is not intermittently illogical, obscure, or irrelevant. The September 2008 VA examiner reported the Veteran's speech was unremarkable. In VA treatment records dated from September 2008 to May 2009, the VA examiners reported linear thought process and normal rate of speech. The record reflects that the Veteran does not experience near-continuous panic or depression affecting the ability to function independently. The Veteran was seen for suicidal ideation after a panic attack at work at a local prison in September 2007. In the September 2008 VA psychiatric examination, the Veteran reported that his mood was moderately elevated. In a September 2008 VA treatment record, the Veteran reported his mood was more stable. In a December 2008 VA treatment record, the Veteran reported getting more depressed; however, in a February 2009 VA treatment record, the Veteran reported medication had stabilized his mood. The evidence of record does not show that panic attacks or depression have impaired the ability to function independently. The record also reflects the Veteran does not suffer from spatial disorientation, and that his appearance and hygiene are normal. During the September 2008 VA psychiatric examination, the Veteran was alert and oriented in all spheres and was dressed comfortably and appropriately for season and occasion. In VA treatment records dated from September 2008 to May 2009, the VA examiners reported the Veteran was alert and oriented in all spheres. The Veteran does have some irritability. In a December 2008 VA treatment record, the Veteran reported getting more irritable. In the May 2009 DRO hearing, the Veteran reported problems of anger, irritability, and an inability to handle confrontation; however, this report of irritability does not demonstrate unprovoked irritability with "periods of violence" as contemplated by a 70 percent rating. The lay and medical evidence of record demonstrates that the Veteran's service-connected acquired psychiatric disorder is characterized by depression, anxiety, trouble concentrating, episodic passive suicidal and homicidal ideation, nightmares, memory loss, and hyperarousal. The Board concludes that the Veteran's disability picture does not more nearly approximate the next-higher 70 percent rating criteria under DC 9411 for any period. Even though the Veteran exhibits some irritability and episodic passive suicidal ideation, the Veteran's acquired psychiatric symptoms, as a whole, are contemplated by the 50 percent rating. See 38 C.F.R. § 4.7 (the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating, otherwise, the lower rating will be assigned). The Board notes that the Veteran's GAF scores have varied between 45 and 50. The GAF scores of 45 to 50 reflect serious symptoms or any serious impairment in social, occupational, or school functioning. However, as noted above, the GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the evaluation issue. The GAF scores must be considered in light of the actual symptoms of a veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In this regard, it is important for the Veteran to understand that he does not meet all of the standards of 50 percent evaluation, or some of the standards examples within the 30 percent evaluation, let alone a higher evaluation. As the analysis above demonstrates, the Veteran only has some of the 50 percent acquired psychiatric disorder symptoms that, with the resolution of reasonable doubt in his favor, have been found to more nearly approximate the criteria for a 50 percent rating. The Veteran does not have flattened affect. His speech is coherent, goal-directed, logical and appropriate to circumstances, and not circumstantial, circumlocutory, or stereotyped. The Veteran does not report panic attacks more than once a week. He does not display difficulty in understanding complex commands. The Veteran's judgment and abstract thinking appear to be appropriate and the Veteran has some insight into his disorder. Turning to the evidence of the Veteran's life apart from the suggested symptoms, the Veteran has offered conflicting accounts concerning his most recent employment with the local prison. He first reported that he lost the job over hearing problems, then claimed he did not know why he lost the job, then testified that his psychiatric disorder and the medications led to his termination. These accounts cannot all be true. The Board considers the report closest in time to the event to be the most reliable and least affected by the pursuit of this appeal. The Veteran had some employment problems in the past, but does not appear to have had those problems at the prison. The Veteran was terminated for reasons other than his psychiatric disorder. The Veteran has testified that he had conflict with authority and supervisors. The Board discounts this testimony as he claimed the conflict drove his termination, a contention which the Board has rejected. The Veteran has not presented evidence regarding his relationship with rank-equivalent colleagues at the prison. It is not possible to determine from this whether the Veteran was unable or had difficulty establishing relationships with co-workers at the prison. The Veteran has, however, maintained his ordinary home routine and his family relationships. The Veteran has maintained a long marriage and a relationship with his son and functions independently in driving himself to run errands, maintaining his household and four dogs in the absence of his wife. The Veteran has also been able to achieve and maintain sobriety which, according to his report, had been a longstanding problem. Overcoming substance abuse is strong evidence of the adaptability, perseverance, and self-control necessary for appropriate occupational and social functioning. Additionally, the Veteran's medications function more effectively when he is sober. In a February 2009 VA treatment record, the Veteran reported that the medication had stabilized his mood and he was no longer depressed. Thus, the Veteran's sobriety tends to support a finding of lesser, rather than greater, severity of his psychiatric disorder. With only one symptom suggestive of the 70 percent rating and a long history of successful independent functioning, the Board finds that the preponderance of the evidence is against a finding that the Veteran has occupational and social impairment, with deficiencies in most areas due to his acquired psychiatric disorder. The Veteran's psychiatric symptomatology and social and occupational impairment manifested by his acquired psychiatric disorder are encompassed by the 50 percent disability rating criteria. For these reasons, an increased disability rating in excess of 50 percent is not warranted for any period. 38 C.F.R. §§ 4.3, 4.7, 4.130, DC 9411. The Board has considered whether an extraschedular evaluation would have been warranted for an acquired psychiatric disorder. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular 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. Therefore, initially, 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. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's acquired psychiatric disorder is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DC 9411, specifically provides for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's acquired psychiatric disorder has manifested depression, anxiety, trouble concentrating, episodic passive suicidal and homicidal ideation, nightmares, memory loss, and hyperarousal. These symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with an acquired psychiatric disorder, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Duties to Notify and Assist The Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The notification obligation in this case was met by way of letters from the RO to the Veteran dated in July and November 2008. See Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO also provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances of this case. In addition, the Veteran and his representative have not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal and have not argued that any errors or deficiencies in the accomplishment of the duty to notify or the duty to assist have prejudiced the Veteran in the adjudication of his appeal. The Veteran has been afforded a VA examination pertaining to the issue on appeal during the pendency of the appeal. The report from that examination reflects that the examiner reviewed the Veteran's medical records, recorded his current complaints, conducted an appropriate mental examination and rendered diagnoses and opinions consistent with the remainder of the evidence of record and pertinent to the rating criteria. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, the Board finds that the RO has satisfied the duty to notify and the duty to assist. ORDER An increased disability rating for an acquired psychiatric disorder of 50 percent, but no higher, for the entire increased rating period is granted. REMAND As noted above, the Court has held that a request for a TDIU is not a separate claim for benefits, but rather, can be part of any claim for increased compensation. See Rice, 22 Vet. App. at 453-54. If the claimant or the evidence of record reasonably raises the question of whether a veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Id. In this case, during the September 2008 VA psychiatric examination, the Veteran reported that his irritability and impatience with interpersonal reactions had risen to a level that would cause him to be dismissed from a job. During the May 2009 DRO hearing, the Veteran testified that he was unemployable, in part, as a result of his service connected psychiatric disorder. The Veteran's representative stated that the Veteran could not go back into the workforce due to his service connected psychiatric disorder. The Veteran also submitted documents reflecting administrative discipline for his behavior at a previous job. As such, the question of TDIU is raised by the record, and it is appropriate for the Board to address this matter. Accordingly, the issue of entitlement to a TDIU is REMANDED for the following action: 1. Provide the Veteran a VCAA notice letter notifying him and his representative of what is necessary to substantiate a claim for TDIU. The notice must also explain what information or evidence the Veteran must provide, and what information or evidence VA will attempt to obtain on his behalf. The Veteran and his representative should be provided with an opportunity to respond. 2. Then adjudicate a claim for total disability rating based on individual unemployability (TDIU). If the claim remains denied, provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate time for response. 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). ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs