Citation Nr: 1302098 Decision Date: 01/18/13 Archive Date: 01/23/13 DOCKET NO. 10-29 410 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disability. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Kedem, Counsel INTRODUCTION The Veteran served on active duty from June 2004 to June 2008. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision by which the RO, in pertinent part, granted service connection for PTSD to which it assigned a 30 percent disability rating effective June 29, 2008. The Veteran appealed the initial disability rating assigned. In February 2012, the RO granted an increased rating of 50 percent to the service-connected PTSD effective June 29, 2008 (the Board notes that since June 29, 2008, the Veteran was granted temporary total ratings on two occasions pursuant to hospitalization). Although each increase represents a grant of benefits, the United States Court of Appeals for Veterans Claims (Court) has held that a decision awarding a higher rating, but less that the maximum available benefit does not abrogate the pending appeal. AB v. Brown, 6 Vet. App. 35, 38 (1993). Thus, this matter continues before the Board. In April 2011, the Veteran testified at a hearing before a decision review officer at the RO. A transcript of the hearing has been associated with the record. The Board notes that in the September 2009 rating decision, the RO denied service connection for a traumatic brain injury. The Veteran perfected an appeal regarding that issue, but as reflected in the April 2011 hearing transcript and in the representative's December 2012 Informal Hearing Presentation, the Veteran withdrew that matter from appellate status. The Board observes that the RO has not yet dealt with the matter of TDIU. As it appears to have been raised by the record, the Board is remanding it for further development consistent with the United States Court of Appeals for Veterans Claims (Court) decision in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether TDIU as a result of that disability is warranted. The issue of entitlement to 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. FINDING OF FACT The Veteran's service-connected PTSD is manifested by occupational and social impairment with no more than deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood; however, he does not have total occupational and social impairment. CONCLUSION OF LAW The criteria for entitlement to a disability evaluation of 70 percent, but not higher, for the Veteran's service-connected PTSD are met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) Under VCAA, Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of VCAA are codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Prinicipi, 353 F.3d 1369 (Fed. Cir. 2004). An RO letter dated in July 2009 informed the Veteran of all of the elements required by 38 C.F.R. § 3.159(b), as stated above. Also, this appeal arises from disagreement with the initial evaluation following the grant of service connection. The courts have held that once service connection is granted the claim is substantiated, additional VCAA 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). VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records and VA clinical records. Additionally, the Veteran was provided VA examinations in August 2009 and April 2011 for PTSD. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. Standard of Review After the evidence has been assembled, it is the Board's responsibility to evaluate the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3 (reasonable doubt to be resolved in veteran's favor). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Law and Regulations 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, 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. Fenderson v. West, 12 Vet. App. 119 (1999). 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 (2012). The Veteran's service-connected PTSD has been rated 30 percent disabling before October 3, 2012 and 50 percent disabling effective that date under Diagnostic Code 9411, which pertains to PTSD. The Board notes that mental disorders are rated under a formula, which is outlined in 38 C.F.R. § 4.130. A rating of 10 percent is warranted for PTSD 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, Diagnostic Code 9400. A rating of 30 percent is warranted for PTSD 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 compete 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, Diagnostic Code 9400. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, 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 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations OR serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). Id. A GAF score of 31 to 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 other children, is defiant at home, and is failing at school)." Id. A GAF score of 41 to 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 to 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 to 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. A GAF score of 71 to 80 reflects that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). 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 United States 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). The Board is precluded from differentiating between the symptomatology attributable to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Factual Background In May 2009, the Veteran had his first contact with the VA system for PTSD treatment. He complained of problems sleeping, nightmares, and intrusive thoughts. He reported hypervigilance and an exaggerated startle response. He was using psychotropic medication. He denied depression but endorsed anxiety. The Veteran was fully oriented, cooperative, friendly, and alert. Speech, thought processes, eye contact, attention, and memory appeared normal. Judgment and insight were fair. The Veteran's mood was anxious. PTSD, anxiety, and alcohol abuse were diagnosed. June 2009 VA records reveal a diagnosis of PTSD with a GAF score of 48. In July and August 2009, the Veteran attended a VA in-patient substance abuse program due to alcohol dependence. On discharge in late August 2009, chronic severe alcohol dependence in early remission, sedative hypnotic abuse, opiate abuse, and PTSD were diagnosed. A GAF of 55 was assessed. On August 2009 VA examination, the Veteran described problematic drinking, beginning in April 2006, that resulted in criminal charges for drunken driving on two occasions. He also described a history of Xanax and Lortab use that caused concern to family members. The Veteran, however, indicated that he only used the medications as prescribed. The Veteran's chief complaint was of anxiety and stress. He reported distractibility when thinking about military experiences and indicated feelings of hopelessness. He suffered from sudden panic attacks. He also indicated the presence of nightmares, flashbacks, an exaggerated startle response, difficulty concentrating, anger, and isolation. He described "feeling down" more often than not along with sleep problems. The Veteran stated that his symptoms did not have an impact upon work other than necessitating leave taking in order to attend mental health appointments. He denied excessive worry, obsessions, compulsions, hypomania, and psychosis. The examiner indicated that although the Veteran reported short term memory problems, no memory problems were apparent on examination. The perceived memory difficulty, according to the examiner, was likely attributable to concentration problems secondary to depression and anxiety. The examiner diagnosed PTSD, depression not otherwise specified, rule out panic disorder without agoraphobia, alcohol abuse, and rule out opioid and benzodiazepine abuse. A GAF of 58 was assessed. The examiner opined that the Veteran was suffering from mild to moderate PTSD. In September 2009, the Veteran was arrested due to driving while intoxicated. A December 2009 evaluation at the Vet Center reveals that the Veteran was not employed. He worked for a few months after separation from service, but it was difficult to keep the job while managing PTSD and keeping VA appointments. The Veteran indicated that his PTSD was "pretty bad" and that he was unable to work. Objectively, his appearance was neat, and he was alert and oriented. Affect was appropriate. His mood was depressed. The Veteran reported nightmares, disturbed sleep, problems concentrating, and occasional extreme anxiety. There was no suicidal or homicidal ideation. The examiner diagnosed PTSD and assigned a GAF score of 45. In March 2010, the Veteran was admitted to a VA in-patient program. The Veteran reported isolation, bad dreams, alcohol abuse leading to legal problems although he had stopped drinking six months earlier, and an inability to cope with the activities of daily living. The Veteran described difficulty sleeping due to back pain. He also indicated that he did not abuse prescription medication and that there had been a misunderstanding about that when he was an inpatient at a VA alcohol abuse program the previous year. As to employment, the Veteran indicated that after service separation, he worked in a customer service capacity but quit the job due to conflicts created by VA appointments. The Veteran described panic attacks. Objectively, he was fully oriented, insight was intact, and thoughts were coherent. On discharge in May 2010, the Veteran was said to have made excellent progress. It was recommended that he continue PTSD group therapy and medication and that he attend Alcoholics Anonymous meetings. Nonetheless, the discharge diagnosis was severe PTSD, recurrent severe major depressive disorder, history of opioid abuse, sedative abuse, nicotine dependence, and alcohol dependence with sobriety since September 2009. The Veteran's GAF was assessed as 30, and the highest GAF during the previous year was also assessed as 30. The Veteran's most disruptive symptoms were isolation, intrusive thoughts, rumination, and nightmares. He experienced hopelessness and anhedonia. He had difficulty concentrating. He had nightmares, irritability, anger, and anxiety. He was hypervigilant. He had panic episodes several times a week. The Veteran experienced emotional numbing. He had a hard time naming a friend he could call if he needed help. The examiner described the Veteran's PTSD symptoms as debilitating and indicated that the Veteran was not able to sustain significant relationships. The Veteran could not reasonably be expected to sustain employment for the foreseeable future. The Board notes that treatment reports reflect that the Veteran was taking psychotropic medication. An August 2010 VA mental health notation reflects that the Veteran was planning on entering a degree program in the fall. A significant substance abuse disorder was noted. The Veteran complained of insomnia, nightmares, and anxiety. He was involved in regular treatment for his PTSD and attended Alcoholics Anonymous meetings. The diagnosis was of PTSD with possible panic attacks, alcohol dependence, opiate and benzodiazepine abuse versus dependence, and depressive disorder not otherwise specified. A GAF score of 45 was assigned. On VA examination in April 2011, the Veteran reported social isolation although he had a good relationship with his immediate family. He was completing his first year at a university. He was majoring in architecture but was only pursuing two courses. He reported good grades despite alleged difficulty concentrating. The Veteran was not employed and had not been since January 2009, when he left a position in which he had worked for six months. As to work, the Veteran reported conflict with coworkers, irritability, and difficulty concentrating. The Veteran indicated that his primary support structure consisted of his mother and counselor. He did, however, have close friends and hobbies. Apparently, the Veteran visited the emergency room in February 2011 pursuant to a panic attack with chest pain and a racing heart. As to PTSD, the Veteran was being seen for medication management, individual counseling, and group therapy. The Veteran complained of nightmares two or three times a week, daily intrusive thoughts, flashbacks, anxiety, panic attacks several times a week, hypervigilance, avoidance, irritability, anger, poor sleep, difficulty concentrating, mild depression, and isolation. Objectively, eye contact was intermittent, and there was mild psychomotor agitation. The Veteran was cooperative. Speech and thought processes were normal. His mood was anxious. He was fully oriented. The examiner diagnosed chronic PTSD, panic attacks without agoraphobia, and a GAF of 50 was assigned. From August to September 2011, the Veteran attended a specialized in-patient VA PTSD treatment program. The discharge report reflects hopelessness and anhedonia, and occasionally low motivation. The Veteran reported trouble focusing. There were sleep problems as well as problems with irritability and anger. The Veteran was hypervigilant and anxious. He had intrusive thoughts and excessive worry about the future. He had ruminating thoughts and flashbacks. The Veteran had weekly panic attacks, which were less frequent than they had been due to medication. He felt detached from others, and his only significant relationship was with his mother. The Veteran denied current suicidal ideation. His treatment consisted of weekly psychotherapy sessions, weekly group therapy sessions, and medication management. The discharge diagnosis was of chronic severe PTSD, recurrent severe major depressive disorder secondary to PTSD, nicotine dependence, cannabis dependence, and alcohol dependence. A GAF of 30 was assigned, and the highest GAF score during the previous year was assessed as having been 30. Discussion The Veteran contends that his service-connected PTSD warrants an evaluation in excess of 50 percent. The Board notes that the Veteran suffers from psychiatric disorders such as alcohol abuse that are separate and apart from his PTSD. To the extent possible, the Board will consider only the symptoms associated with the service-connected PTSD. Mittleider, supra. A close review of the evidence of record reveals that the Veteran is motivated in seeking treatment for his mental health concerns. He is taking psychotropic medication and pursuing both individual and group psychotherapy. He attends Alcoholics Anonymous meetings, and he has also taken advantage of VA in-patient treatment programs for substance abuse and for PTSD. Nonetheless, he continues to suffer from considerable PTSD symptoms to include depression, anxiety, panic attacks, some social isolation, disturbed sleep, nightmares, difficulty concentrating, irritability, anger, ruminations, flashbacks, hypervigilance, and an exaggerated startle response. In addition, the Board is cognizant of the Veteran's GAF scores during the appeal period that have ranged from 30 to 58 indicative of significant difficulty functioning to merely moderate symptoms. Regarding the Veteran's GAF scores, the Board notes that in March 2010 and in September 2011, when GAF scores of 30 were assessed, they were assigned for the previous year. As such, it is arguable that a GAF score of 30 pertains to most if not all of the appeal period. Pursuant to the low GAF score of 30 coupled with the extent of PTSD symptoms, enumerated above, despite the diligence in pursuit of treatment, leads the Board to conclude that the Veteran's PTSD symptoms more closely resemble those pertaining to a 70 percent evaluation. 38 C.F.R. §§ 4.7, 4.130. Furthermore, due to the fact that low GAF scores have been applied to most, if not all, of the appeal period, the 70 percent evaluation is warranted throughout with the obvious exception of periods for which a 100 percent temporary total evaluation had been assigned. Fenderson, supra. The Board finds that a 100 percent evaluation is not warranted at any time during the appeal period, with the exception of those periods where temporary total (100 percent) evaluations have been assigned. Id.; 38 C.F.R. § 4.130. A 100 percent evaluation contemplates symptoms such as 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, and memory loss for names of close relatives, own occupation, or own name. While a GAF of 30 has been assigned, the Veteran does not suffer from the type of symptoms suggested in the criteria listed with respect to a 100 percent evaluation. For example, he has been consistently oriented, and while concentration has been a problem, he is not shown to be unable to retain and/or recall basic facts such as his own name or the names of his blood relatives. As well, while the Veteran has had legal problems stemming from drunken driving incidents, the record does not demonstrate that he is in persistent danger of hurting himself or others. The Veteran is fully oriented, apparently rooted in reality, and pursuing higher education in a demanding field. The Veteran has significant occupational impairment and has been found unable to sustain employment for the foreseeable future, which suggests total occupational impairment. However, he does not exhibit total social impairment. While he isolates, he still reported having a good relationship with his immediate family. He also indicated that he had close friends and hobbies, although his only significant relationship was his mother. While the Veteran's social impairment is significant, which is reflective of the 70 percent disability rating he has been assigned, he is not shown to be totally socially impaired. In short, while he arguably does exhibit total occupational impairment, he does not exhibit and does not claim to exhibit total social impairment. As such, a 100 percent evaluation for service-connected PTSD is not warranted. Id. Extraschedular Consideration The Board has considered whether an extraschedular evaluation would have been warranted for PTSD. 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 PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provide for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested in depression, anxiety, panic attacks, some social isolation, disturbed sleep, nightmares, difficulty concentrating, irritability, anger, ruminations, flashbacks, hypervigilance, and an exaggerated startle response. 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 PTSD, 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). ORDER An evaluation of 70 percent, but not higher, for the service-connected PTSD is granted, subject to the law and regulations governing the payment of veterans' benefits. REMAND In Rice, the Court held that a TDIU claim is part of an increased rating claim when such claim is raised by the record. In this case, the evidence reflects that the Veteran's PTSD might be productive of unemployability. The Veteran has indicated an inability to work as well as anger and irritability with colleagues. After a period of unemployment, he began to pursue higher education, but he is apparently only able to maintain a very light course load. As such, the issue of entitlement to TDIU is raised by the record. Hence, the issue is properly before the Board. A review of the record shows that further development is needed to properly adjudicate the TDIU claim. The law provides that a TDIU may be granted upon a showing that a veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). Consideration may be given to a veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or the impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012). While the Veteran has been afforded VA examinations, an opinion as to his unemployability and the effect of his service connected disabilities on his employability was not rendered. The Board finds that the Veteran should be afforded an appropriate VA examination to determine whether he is unable to secure or maintain substantially gainful employment as a result of his service-connected disabilities. In addition, the Veteran has not received VCAA notice regarding TDIU claims. Action in this regard is necessary. Accordingly, the case is REMANDED to the RO/AMC for the following action: 1. Send the Veteran a VCAA notice letter that pertains to claim of TDIU. 2. Schedule an appropriate VA examination for an opinion regarding whether it is at least as likely as not ( 50 percent or greater likelihood) that the Veteran's service-connected disabilities, in and of themselves, prevent him from securing or maintaining substantially gainful employment. A full rationale for all opinions and conclusions should be provided and a resort to speculation should be avoided. If the requested medical opinion cannot be given, the examiner should state the reason(s) why. The examination report must indicate whether pertinent records in the claims file were reviewed in conjunction with the examination. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but that the medical evidence for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. 3. Undertake any other development deemed necessary and readjudicate the issue of entitlement to TDIU. If the benefit sought on appeal remains denied, the Veteran and his representative should be issued a supplemental statement of the case. The Veteran and his representative should be given an opportunity to respond to the supplemental statement of the case. 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). ____________________________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs