Citation Nr: 1302483 Decision Date: 01/23/13 Archive Date: 01/31/13 DOCKET NO. 10-11 519 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to an effective date earlier than May 10, 2005, for the grant of service connection for residual scar of shrapnel wound between the eyes. 2. Entitlement to an effective date earlier than July 21, 2005, for the grant of service connection for posttraumatic stress disorder (PTSD). 3. What evaluation is warranted for PTSD prior to July 21, 2005? 4. What evaluation is warranted for posttraumatic stress disorder (PTSD) from July 21, 2005 to August 19, 2006? 5. What evaluation is warranted for PTSD from September 30, 2006 to September 10, 2009? 6. What evaluation is warranted for PTSD from August 31, 2010 to March 13, 2011? 7. What evaluation is warranted for PTSD since March 14, 2011? REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD P. Olson, Counsel INTRODUCTION The Veteran had active military service from June 1967 to May 1969. This matter comes before the Board of Veterans' Appeals (Board or BVA) on appeal from a May 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Board acknowledges the judicial holding in Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In that decision, the United States Court of Appeals for Veterans Claims held that a request for a total rating based on individual unemployability (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate 'claim' for benefits, but rather, can be part of a claim for increased compensation. In other words, if the claimant or the evidence of record reasonably raises the question of whether the 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 whether a TDIU is warranted as a result of that disability. In the present case, the Veteran has claimed that he is unable to work due to his service-connected PTSD. Entitlement to a TDIU was denied in a March 2012 rating decision, and the Veteran has not yet disagreed with that determination. Nothing in Rice suggests that the finality of the March 2012 decision can be overcome by subsequent allegations that the Veteran is entitled to a total rating (that is - by a subsequent informal TDIU claim). Therefore, in the circumstances of this case, the Board declines to apply Rice and take jurisdiction over a TDIU claim. The issue of what evaluation is warranted for PTSD prior to July 21, 2005 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. The Veteran filed an original claim for service connection for shrapnel between eyes and PTSD on August 22, 2003; that claim was denied in January 2004 rating decision. 2. Service connection for PTSD and residuals of shrapnel between the eyes was granted in a February 2009 Board decision based in part on service department records which was not of record at the time of January 2004 rating decision and which confirmed that the Veteran's ship engaged in gunfire support off the coast of Vietnam during the time the Veteran was aboard ship. 3. From July 21, 2005 to August 19, 2006, September 30, 2006 to September 10, 2009, August 31, 2010 to March 13, 2011, and since March 14, 2011, the Veteran's PTSD has been manifested by symptomatology that resulted in occupational and social impairment with deficiencies in most areas. 4. At no time from July 21, 2005 to August 19, 2006, September 30, 2006 to September 10, 2009, August 31, 2010 to March 13, 2011, or since March 14, 2011, has the Veteran's PTSD been manifested by total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for an effective date of August 22, 2003, for service connection for residual scar of shrapnel wound between the eyes have been met. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. §§ 3.156(c), 3.400 (2012). 2. The criteria for an effective date of August 22, 2003, for service connection for PTSD have been met. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. §§ 3.156(c), 3.400 (2012). 3. The criteria for an evaluation of 70 percent evaluation, but no higher, for service-connected PTSD are met from July 21, 2005 to August 19, 2006, September 30, 2006 to September 10, 2009, and August 31, 2010 to March 13, 2011. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2011); 38 C.F.R. § 4.1, 4.7, 4.130, Diagnostic Code 9411 (2012). 4. The criteria for a 100 percent evaluation for service-connected PTSD are not met from July 21, 2005 to August 19, 2006, September 30, 2006 to September 10, 2009, and August 31, 2010 to March 13, 2011, or since March 14, 2011. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2011); 38 C.F.R. § 4.1, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 As service connection, an initial rating, and an effective date have been assigned, the notice requirements of 38 U.S.C.A. § 5103(a) have been met. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Consequently, discussion of VA's compliance with VCAA notice requirements would serve no useful purpose. With respect to VA's duty to assist under the Veterans Claims Assistance Act of 2000, the Veteran's service treatment records, post-service medical treatment records, and Social Security Administration records have been obtained, to the extent available. 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. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. The Veteran was accorded VA examinations in May 2009 and March 2011. The May 2009 and March 2011 VA examiners addressed the severity of the Veteran's PTSD in conjunction with a review of the claims file and physical examination of and interview with the Veteran. There is no objective evidence indicating that there has been a material change in the severity of the Veteran's PTSD since he was last examined. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. The May 2009 and March 2011 VA examination reports are thorough and supported by VA outpatient treatment records. The examinations in this case are adequate upon which to base a decision on the correct assignment of disability evaluations from July 21, 2005 to March 14, 2011. The Board notes that VA examinations were scheduled for the Veteran to assess the severity of his PTSD in March 2012. The Veteran failed to report to this examination. VA regulations provide that when a claimant fails to report for a scheduled medical examination, without good cause, an original compensation claim shall be rated based upon the evidence of record. See 38 C.F.R. § 3.655 (2012). See generally Turk v. Peake, 21 Vet. App. 565 (2008) (where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating). Examples of good cause include, but are not limited to, the illness or hospitalization of the claimant, death of an immediate family member, etc. 38 C.F.R. § 3.655(a). As the Veteran has not provided good cause for his failure to report to his VA examination scheduled in March 2012, the Board will adjudicate the claim based upon the evidence of record. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (Reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.) Effective Date The Veteran contends that he is entitled to earlier effective dates for the grants of service connection for residual scar from shrapnel wound between the eyes and PTSD. The Veteran's original claim for compensation benefits was received by VA on August 22, 2003. He listed three claimed disabilities, including suffering a shrapnel injury between eyes, and PTSD. The Veteran reported on his original application for compensation that due to the horrific things that he witnessed and had to do while in Vietnam, he had had difficulty with sobriety, depression, suicidal thoughts, nightmares, night sweats, and insomnia. The claims were denied in a January 2004. Service connection for residuals of a shrapnel wound between the eyes was denied on the basis that the Veteran's service medical records did not show any record of his being treated for shrapnel wound between the eyes during service. Service connection for PTSD was denied on the basis that the service medical records did not show evidence of treatment for PTSD during service and the available evidence was insufficient to confirm that he had actually engaged in combat or was exposed to more than ordinary stressful environment. On his Notice of Disagreement with the January 2004 rating decision, the Veteran reported that he was wounded by a sniper aboard ship. The Veteran stated that the bullet had missed him by only inches; but that it had shattered, and pieces hit him between the eyes and on his forehead necessitating six to eight stitches. Although the Veteran submitted his Notice of Disagreement with the January 2004 rating decision, he did not perfect his appeal after issuance of the Statement of the Case. The Veteran filed a petition to reopen his claim for service connection for gunshot wound to the head on May 11, 2005; and he filed a petition to reopen his claim for service connection for PTSD on July 21, 2005. In an April 2005 letter to Social Security, it was noted that the Veteran served on a destroyer off the coast of Vietnam from May 1968 to June 1970; that his military occupational specialty was damage control fireman; that there were "lots of incoming;" and that that he suffered a gunshot wound from sniper fire when a bullet ricocheted off the bulk head, hitting him in the head. Evidence received in December 2006 included deck logs from the USS SHELTON (DD -790) from March 7-21, 1969 indicating firing from the ship to the shore of Vietnam. The claims were reopened and ultimately granted in a February 2009 Board decision. The assignment of effective dates of awards is generally governed by 38 U.S.C.A. § 5110 (West 2002) and 38 C.F.R. § 3.400 (2012). Unless specifically provided otherwise, the effective date of an award based on a claim reopened after final adjudication "shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of application therefor." 38 U.S.C.A. § 5110(a) (West 2002). The implementing regulation clarifies this to mean that the effective date of an evaluation and an award of compensation based on a reopened claim will be, "[d]ate of receipt of claim or date entitlement arose, whichever is later." 38 C.F.R. § 3.400(q) (emphasis added). Generally, once an effective date has become final, a claimant's only recourse is to have the final decision revised on the grounds of clear and unmistakable error (CUE). Rudd v. Nicholson, 20 Vet. App. 296 (2006). The Veteran has not filed a CUE motion. Significantly, however, in the case of a petition to reopen a previously denied claim for service connection, pertinent regulations governing new and material evidence require VA to reconsider previously denied claims on the merits whenever relevant service records unavailable at the time of the last final rating decision are submitted. 38 C.F.R. § 3.156(c) (2012); Vigil v. Peake, 22 Vet. App 63 (2008). Reconsideration of the original claim does not apply to records that VA could not have obtained when it decided the claim because the records did not exist when VA decided the claim, or because the claimant failed to provide sufficient information for VA to identify and obtain the records from the respective service department, the U.S. Army and Joint Service Records Research Center (JSRRC), or from any other official source. In the present case, the claims for service connection were granted in part based on information obtained from JSRRC. This included a June 2006 letter to the Veteran's attorney and deck log extracts indicating that the Naval Gunfire Support Ship, USS SHELTON, served off the Vietnam coast conducting shore bombardments and harassment fire during the Veteran's tour of duty. Unlike service treatment records, a search of alternative service records is not automatically requested in response to a claim. Rather, JSRRC is typically contacted in an effort to corroborate information provided by the Veteran. JSRRC researches Navy records containing historical information on individual units as well as some personnel records as they relate to the events described by veterans claiming service connection. JSRRC provides regional offices with summaries of its findings but does not evaluate evidence, render opinions, make conclusions, or decide the merits of a claim. Many records are quite voluminous, which is the reason behind JSRRC's requirement that the Veteran provide, at a minimum, a 60-day time period in which the claimed event occurred. Thus, in order to properly conduct a search, a veteran must provide fairly detailed information. In this case, service connection for both residual scar between the eyes and PTSD was established based upon one incident, i.e., that the Veteran was hit between the eyes with a shell fragment from a sniper during combat operations. Significantly the deck logs which in part provided the basis for service connection, did exist at the time of the appellant's initial claim in August 2003. The Board recognizes that at the time of the original adjudication, VA did not have the information that it needed to conduct a research as to this incident. In September 2003, VA sent the Veteran asking him to complete an enclosed PTSD questionnaire. In November 2003, VA sent another letter advising that a favorable decision could not be made and that he needed to submit additional evidence. This letter was returned as undeliverable. It was noted that the Veteran had moved and left no forwarding address. The Veteran's daughter was contacted by email in December 2003 who advised that the Veteran did not have a home mailing address at that time but that mail could be sent to her and she would get it to her father. The January 2004 rating decision was mailed to the daughter's address, and on his Notice of Disagreement, the Veteran indicated a change in his address to that of his daughter's address. There is no indication in the record, however, that the September or November 2003 letters were ever resent to the daughter's address. Thus, it is likely that the Veteran was unaware that he needed to provide such specific evidence. In this case, the United States Court of Appeals for Veterans Claims' guidance in Mayhue v. Shinseki, 24 Vet. App. 273 (2011), is instructive. In Mayhue, the Court applied an interesting interpretation of the regulation. In that case, the stressor ultimately corroborated was not one described by the veteran during the prior adjudications. The Court held that the relevant point was that the information ultimately used to verify the stressor in that case was always part of the claims file, and thus VA's failure to verify the stressor was somehow the result of an administrative error in locating the veteran's unit records. The Board finds that the Court's reasoning is applicable to the case at hand. VA was aware during the prior adjudication of the name of the Veteran's ship and his dates of service. Despite the Veteran's silence as to the specific details involved, the deck logs did exist, and were in the possession of the Government. As such, VA should have reconsidered the Veteran's claim as opposed to reopening it. Therefore, the Board finds that the date of claim at issue in this case is the original claim filed on August 22, 2003. The Board points out that the Veteran did not file a claim for service connection earlier than that date, and this is not in dispute. Moreover, the August 2003 claim was filed several years after the Veteran's discharge from service. The determination of the date of claim in this case is not the end of the inquiry. The effective date is the date of claim or date entitlement arose, whichever is later. With respect to the phrase "the date entitlement arose," the regulation has not defined that term. However, the date evidence is submitted or received is irrelevant when considering the effective date of an award. McGrath v. Gober, 14 Vet. App. 28, 35 (2000). In McGrath, the Board found that the earliest date that a VA examiner had diagnosed PTSD was "the date entitlement arose" and used that date, rather than an earlier date of receipt of the pending claim (the claim had pended for over 20 years), as the effective date. The Board infers from this that the "date entitlement arose" is not meant to be the date of an examination. According to 38 U.S.C.A. § 5110(a), unless specifically provided elsewhere in Title 38, the effective date based on a claim reopened will be fixed in accordance with facts found, but will not be earlier than the date of receipt of application therefor. The only other provision that appears elsewhere in Title 38 is 38 U.S.C.A. § 5110(g), where the phrase "...pursuant to any Act or administrative issue, ..." is used. This phrase delimits the effective date based on a new or changed regulation to a date no earlier than the date of the new or revised regulation. The phrase "date entitlement arose," as used in VA regulations, does not appear in the statute. Conversely, the phrase "pursuant to any Act or administrative issue," appears in the statute, but does not appear in the regulation. The Board infers from these facts that the phrase "date entitlement arose" as used in 38 C.F.R. § 3.400 likely refers to § 5110 (g) "...pursuant to any Act or administrative issue." Therefore, the "date entitlement arose" likely refers to the effective date of an Act or issue, rather than the date that a physician offered a favorable diagnosis or medical nexus opinion. In this case, the "date entitlement arose" refers to the date of enactment of current 38 U.S.C.A. § 1110 (Basic entitlement), which authorizes compensation for any service-connected disability. The effective date of that act of Congress is September 2, 1958. The latter of the date entitlement arose or date of receipt of claim is August 22, 2003, the date of receipt of claim. Two exceptions exist for an effective date prior to the date of claim. First, the date of service connection may be assigned as of the date of separation from service, if the date the claim was received was within one year of separation. The Veteran separated in May 1969, and the claim was received in August 2003. As such, the first exception is not available. Second, an effective date for service connection prior to the date of receipt of a claim may be assigned where compensation is awarded or increased pursuant to a liberalizing law or liberalizing VA issue. 38 C.F.R. § 3.114(a)(3) (2012). PTSD was added to the rating schedule as a disability for which service connection was available on April 11, 1980. See 45 Fed. Reg. 26,326 (1980). VA's General Counsel has held that the addition of PTSD as a diagnostic entity in the schedule for rating mental disorders was a "liberalizing VA issue" for purposes of 38 C.F.R. § 3.114(a). See VAOPGCPREC 26- 97. Thus, any claim for service connection for PTSD received within one year of April 11, 1980, would receive the earlier date of service connection if entitlement arose prior to April 11, 1980. As no such claim was received within one year of April 11, 1980, the second exception is also not available. The Board, therefore, finds that the date of claims of service connection for residual scar from shrapnel wound between the eyes and PTSD is August 22, 2003. The Veteran met all eligibility criteria for service connection as of August 22, 2003. In light of the above discussion, the Board concludes that an effective date of August 22, 2003, is warranted for service connection for residual scar from shrapnel wound between the eyes and service connection for PTSD. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran is appealing the original assignment of a disability evaluation following an award of service connection for PTSD. As such, it is not the present level of disability which is of primary importance, but rather the entire period is to be considered to ensure that consideration is given to the possibility of staged ratings; that is, separate ratings for separate periods of time based on the facts found. Fenderson v. West, 12 Vet. App. 119 (1999). As noted above, the Board has granted an earlier effective date of service connection for residual scar from shrapnel wound between the eyes and PTSD effective August 22, 2003. The Veteran contests the initial ratings assigned for PTSD. As the RO has not had the opportunity to assign a disability evaluation for the Veteran's PTSD from August 22, 2003 to July 21, 2005, the Board's consideration of that term at this time is impermissible. Thus, the Board will only consider the evidence of record since July 21, 2005. The Veteran's PTSD has been evaluated as 50 percent disabling from July 21, 2005 to August 19, 2006, from September 30, 2006 to September 10, 2009, from August 31, 2010 to March 13, 2011, and as 70 percent disabling from March 14, 2011. Temporary total evaluations have been awarded under 38 C.F.R. § 4.29 (2012) for the periods August 20, 2006 to September 29, 2006 and September 11, 2009 to August 30, 2010. The Veteran has not asserted that he is entitled to an extension of the temporary total evaluations he received for his PTSD-related hospitalizations. There is also no indication in the clinical documentation that the Veteran's PTSD was manifested by any of the symptomatology required for a temporary total disability rating for the period after the temporary convalescence rating ended. The Board finds that such an extension is neither claimed nor warranted. Thus, the Board will proceed to evaluate the Veteran's PTSD under applicable diagnostic codes. Under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Codes 9411, a 50 percent requires occupational and social impairment, but with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, 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 task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for even greater occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting 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. The maximum rating of 100 percent requires total occupational and social impairment due to such symptoms as: 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. Id. One factor for consideration is the Global Assessment of Functioning score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM -IV)). A global assessment of functioning score of 51 to 60 reflects 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 global assessment of functioning score of 41 to 50 reflects 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 global assessment of functioning score of 31 to 40 indicates the examinee has 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). While the Rating Schedule directs that the rating agency be familiar with the DSM-IV, it does not assign disability percentages based solely on global assessment of functioning scores. See 38 C.F.R. § 4.130 (2012). Thus, in order for the Veteran's PTSD to warrant a rating higher than 50 percent, the Veteran must demonstrate occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood. In order for a rating higher than 70 percent, the Veteran must demonstrate total occupational and social impairment. Medical evidence dated from July 21, 2005 to August 19, 2006 VA treatment records include hospital discharge summaries dated in June and August 2006 with diagnoses of alcohol dependence, opiate/opioid dependence, nicotine dependence, depression not otherwise specified, and PTSD. The summaries note that Veteran presented requesting admission for alcohol detoxification and that his hospital course included treatment for depression and PTSD. Global assessment of functioning scores of 60 and 50 were assigned respectively. Medical evidence dated from September 30, 2006 to September 10, 2009 VA treatment records include hospital discharge summaries dated in October 2006, December 2008, and August 2009 with diagnoses of polysubstance abuse and depression in October 2006; acute alcohol intoxication and alcohol withdrawal, depression, and PTSD in December 2008; and alcohol dependence in August 2009. In August 2009, global assessment of functioning scores ranging from 35 on admission to 55 at discharge were assigned. On admission in August 2009, the Veteran was alert, oriented, and cooperative. He demonstrated fair eye contact, nonpressured speech with normal volume and tone, depressed mood, blunted affect, and limited insight and judgment. The Veteran's thought process was noted to be linear with questions and answers, and he denied suicidal ideation and hallucinations. At discharge the Veteran was dressed in VA pajamas and was unkempt. He was alert and oriented and cooperative, making good eye contact and demonstrated no psychomotor retardation or agitation. His mood was noted to be "better." He demonstrated nonpressured speech with normal volume and tone, congruent affect, and fair insight and judgment. The Veteran's thought process was noted to be linear, organized, and goal directed. He denied suicidal ideation and hallucinations. Other VA treatment records indicate that in August 2007, the Veteran demonstrated a constricted affect. He demonstrated fair hygiene and grooming; normal speech and motor activity; a euthymic mood; good behavior, attitude, abstract abilities, and intelligence; logical and coherent thought process, clear and logical thought content; intact memory; and clear sensorium. There were no perceptual disturbances, impulsivity, suicidal ideation, or homicidal ideation reported. A global assessment of functioning score of 50 was assigned. In April 2008, the Veteran reported having a lot of anxiety. In May 2008, the Veteran reported anxiety, nervousness, and irritable and frustrated mood. A global assessment of functioning score of 50 was assigned. In June and October 2008, the Veteran reported that his anxiety had improved and he felt much better and relaxed. He demonstrated constricted affect; fair hygiene and grooming; normal speech and motor activity; euthymic mood; good behavior, attitude, judgment, and insight; logical and coherent thought process, clear and logical thought content; intact memory; and clear sensorium. There were no perceptual disturbances, suicidal ideation, or homicidal ideation reported. Global assessment of functioning scores of 50 were assigned. In December 2008, the Veteran was brought into the emergency room by his son in law with an alcohol level of 319. The Veteran was alert and oriented and talked about his mother who had passed away just days before. At a May 2009 VA examination the appellant was clean and casually dressed; however, the examiner noted that the Veteran was unshaven and reported that the appellant often did not shave, change clothes, or shower. The Veteran reported having trouble falling and staying asleep but noted that with medication, he got about eight hours of sleep. The Veteran reported having persistent auditory and visual hallucinations; panic attacks once or twice a month; and suicidal thoughts without current plan. The Veteran denied episodes of violence and homicidal thoughts. Mental status examination revealed that the Veteran was oriented to person, place, and time. He demonstrated hopelessness, agitation, depression, a fearful mood, a short attention span, and persecutory delusions. His remote, recent, and immediate memory were mildly impaired. He also demonstrated unremarkable psychomotor activity, speech, thought process, and thought content; normal affect; cooperative and attentive attitude toward examiner; average intelligence; and fair impulse control. There was no inappropriate behavior; and although the examiner noted that the Veteran understood that he had a problem. The examiner also noted that the appellant did not understand the outcome of his behavior. The Veteran was diagnosed as having PTSD and alcohol abuse. A global assessment of functioning score of 50 was assigned. The examiner stated, "Although his PTSD does not sound severe, it is as likely as not that his alcohol abuse is associated with his PTSD." Medical evidence dated from August 31, 2010 to March 13, 2011 VA treatment records indicate that on August 31, 2011, the Veteran was referred to psychology. The Veteran was alert, cooperative, and easily engaged. His speech was slow, but fluent and coherent; his mood was euthymic; and his affect was congruent. There was no evidence of a thought disorder. Medical evidence dated since March 14, 2011 The Veteran underwent VA examination on March 14, 2011 at which time he reported that he lived alone, did not participate in any treatment or post-rehab groups, and had no social connections although he noted that he lived in a house close to his daughter. He also reported seeing his 13 year old grandson, and seeing his son play soccer. The Veteran reported that he could tolerate other people because it was a small country town. The Veteran noted that he did some gardening, and that he watched television primarily. The Veteran reported that he had sporadic sleep, that he fell asleep but awakened in early morning around 2:00 to 3:00 a.m., and that he felt worse after awakening than he did before he went to sleep. The Veteran described feeling a sense of dread about getting up and about what kind of bad things might happen that day. The Veteran reported that he was suicidal when admitted to the hospital but not since then. He also reported having trouble remember things. With respect to depression, the Veteran described that on some days, he got up and said, "What's the use." On other days if, for example, he saw his grandson, he felt better and was sometimes excited. The Veteran described feeling flat with little to look forward to. The Veteran noted, "I feel like I've done so many bad things that I don't deserve to have any happiness, I don't deserve anything." He denied delusions, hallucinations, obsessive or ritualistic behavior that interfered with routine activities, and panic attacks. Mental status examination demonstrated that he was oriented to person, place and time. There was no noted impairment of thought process or communication. The Veteran made appropriate eye contact and he was cooperative and seemed alert and involved in the interview. The Veteran's ability to maintain minimal personal hygiene and other basic activities of daily living were intact. A global assessment of functioning score of 45 was assigned. The VA examiner summarized that the Veteran's current level of disability was most likely caused by his PTSD symptoms which were judged to be interfering with his ability to function adequately outside of the limited confines of his home and immediate surroundings. The examiner noted that although the Veteran had a history of substance abuse, he had had several years of being clean and sober. The examiner noted that the appellant's symptom awareness, and by extension, his ability to fully describe his condition, was increasing which would not be the case were his primary impediment the substance abuse. The examiner noted that the Veteran appeared to have some insight into the function of alcohol in his past as a way of "forgetting" his trauma experience. In addition, although the appellant could verbalize an awareness of the importance of a support system, his general sense of unworthiness prevented him from seeking help that might benefit him. The examiner noted that the Veteran had cyclical and intermittent difficulty with personal hygiene as well as fairly consistent difficulty with activities of daily living such as feeding himself adequately and household care. The examiner noted that the Veteran reported that the depression and sense of unworthiness kept him "inside his head" at times with the effect of his generally low level of functioning becoming even lower and his feeling trapped in his life, unable to shift toward flexibility and unable to work. The VA examiner opined that the Veteran's PTSD symptoms resulted in deficiencies in most the following areas: work, social relations, judgment, thinking, and mood. The evidence shows that co-existing diagnoses of PTSD and polysubstance abuse have been made. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (if VA cannot distinguish by competent medical opinion the extent of symptoms that are attributable to service-related causes from those that are not, VA effectively must presume that all symptoms in question are related to service, i.e., part and parcel of the service-connected disability). In this case, the Veteran's alcohol abuse has been associated by competent medical evidence to his PTSD. Thus, there is no need to for the Board to attempt to disassociate the impact of his PTSD symptoms from the impact of his alcohol abuse. The findings of record indicate that at different times during the appeal period, the Veteran's PTSD symptoms match some of the rating criteria for a 30 percent rating (depressed mood, anxiety, panic attacks, chronic sleep impairment, and mild memory loss), some of the rating criteria for a 50 percent rating (flattened affect; impairment of short- and long-term memory; impaired judgment; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships), and criteria for a 70 percent rating (suicidal ideation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances). Clearly, the Veteran suffered from occupational and social impairment due to his psychiatric symptomatology, as evidenced by his numerous hospitalizations over the years for his alcohol abuse, his lack of attention to his physical appearance and hygiene, and his anxiety, depressed and irritable mood, and blunted/ constricted affect. The Board notes that in March 2009, the Veteran reported that he often did not shave, change clothes, or shower. He also described persistent auditory and visual hallucinations; panic attacks one or twice a month; and suicidal thoughts without current plan. In this case, the global assessment of functioning scores are highly probative as they relate directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. For the most part, since July 21, 2005, the Veteran's global assessment of functioning scores have ranged from 35 to 60, with most scores assigned at 50. The scores of 35 to 60 span a range of moderate to very serious symptoms, as cited above. Thus, as the global assessment of functioning scores indicate, the Veteran's PTSD symptoms have fluctuated throughout the appeal period. Per DSM-IV, the lowest score of 35 on admission for alcohol detoxification in August 2009 contemplates some impairment in reality testing or communication or major impairment in several areas such as work, family relations, judgment, thinking, or mood; the highest score of 60 in June 2006 contemplates moderate symptoms. The majority of the scores assigned by the Veteran's mental health providers from July 21, 2005 to August 19, 2006, September 30, 2006 to September 10, 2009, August 31, 2010 to March 13, 2011, and since March 14, 2011,contemplate serious symptoms or any serious impairment in social, occupational, or school functioning. After reviewing the record, the Board has determined that the assigned global assessment of functioning score are most consistent with a 70 percent rating. While a global assessment of functioning score is not determinative by itself. In this case, however, the scores of 50 assigned during the March 2009 VA examination as well as in August 2006, August 2007, October 2008, appear to reflect the overall and most consistent occupational and social functioning of the Veteran. The Board acknowledges that the Veteran does not meet all of the criteria for a 70 percent evaluation. For example, the Veteran has never demonstrated obsessional rituals that interfere with routine activities; or intermittently illogical, obscure, or irrelevant speech. He has not shown near-continuous panic or depression affecting ability to function independently, appropriately and effectively. Further there is no evidence of impaired impulse control, spatial disorientation, or an inability to establish and maintain effective relationships. The specified factors for each incremental psychiatric rating are not, however, requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the Board finds that from July 21, 2005 to August 19, 2006, from September 30, 2006 to September 10, 2009, from August 31, 2010 to March 13, 2011, and since March 14, 2011, the Veteran's PTSD was and has been manifested by symptomatology that resulted in occupational and social impairment, with deficiencies in most areas, such as work, and family relations, judgment, thinking or mood. Therefore, the Veteran's symptoms due to PTSD during these terms exceed the criteria for the 50 percent rating and more nearly approximate the criteria for the 70 percent rating. At no time during these terms did or has the Veteran's PTSD symptoms approached the severity contemplated for the 100 percent rating. As set forth above, the criteria for a 100 percent rating are met when the Veteran experiences total occupational and social impairment, which is clearly not demonstrated in this case. There has never been any indication of a gross impairment in his thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, disorientation as to time or place, or memory loss for names of close relative, own occupation or own name. Although the Veteran reported persistent auditory and visual hallucinations at the May 2009 VA examination, he denied any hallucinations many times prior to and after that examination. Accordingly, a 70 percent evaluation, but no more than 70 percent, is warranted for the periods from July 21, 2005 to August 19, 2006, September 30, 2006 to September 10, 2009, and August 31, 2010 to March 13, 2011. 38 C.F.R. § 4.130, Code 9411 The Board is aware that an extraschedular rating is a component of an increased rating claim. Barringer v. Peake, 22 Vet. App. 242 (2008); see Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Thun v. Peake, 22 Vet. App. 111 (2008). In the present case, the Board finds no evidence that the Veteran's service-connected PTSD presents such an unusual or exceptional disability picture at any time so as to require consideration of an extra-schedular evaluation pursuant to the provisions of 38 C.F.R. § 3.321(b)(1). The criteria pertaining to psychiatric disabilities in the Rating Schedule focus on occupational and social impairment due to psychiatric symptoms. As discussed above, the disability percentage for his PTSD has been assigned based on the occupational and social impairment due to the Veteran's psychiatric symptoms. Thus, the schedular criteria adequately compensate for any loss in earning capacity, and referral for extraschedular consideration is not warranted. Id. ORDER Entitlement to an effective date of August 22, 2003, for the grant of service connection for residual scar of shrapnel wound between the eyes is granted. Entitlement to an effective date of August 22, 2003, for the grant of service connection for PTSD is granted. Entitlement to an evaluation of 70 percent from July 21, 2005 to August 19, 2006 for PTSD is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to an evaluation of 70 percent from September 30, 2006 to September 10, 2009 for PTSD is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to an evaluation of 70 percent from August 31, 2010 to March 13, 2011 for PTSD is granted subject to the law and regulations governing the payment of monetary benefits. Entitlement to an evaluation in excess of 70 percent since March 14, 2011 for PTSD is denied. REMAND The Board has granted entitlement to an earlier effective date of service connection for PTSD of August 22, 2003, as discussed above. The RO, however, has not had the opportunity to assign an initial disability rating for the Veteran's PTSD from August 22, 2003 to July 21, 2005. Where the Board addresses a question that has not been addressed by the agency of original jurisdiction, it must consider whether the claimant has been given adequate notice and opportunity to respond and, if not, whether the claimant will be prejudiced thereby. See Bernard v Brown, 4 Vet. App. 384 (1993). To avoid such prejudice, it is the Board's opinion that the case should be remanded so that the RO can assign a disability rating for the Veteran's PTSD prior to July 21, 2005. Accordingly, the case is REMANDED for the following action: A disability rating should be assigned for the Veteran's PTSD disability from August 22, 2003 to July 21, 2005. If the rating assigned for PTSD is not a total rating under 38 C.F.R. § 4.130, the Veteran and his representative must be furnished a supplemental statement of the case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters 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). ______________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs