Citation Nr: 1303620 Decision Date: 02/01/13 Archive Date: 02/08/13 DOCKET NO. 07-34 794A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to a staged initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to November 3, 2011. 2. Entitlement to a staged initial disability rating in excess of 70 percent for PTSD from November 3, 2011 to May 3, 2012. 3. Entitlement to an increased rating for diabetes mellitus with early diabetic nonproliferative changes and early cataracts of both eyes and mild sensory polyneuropathy, currently evaluated as 20 percent disabling. 4. Entitlement to an initial disability rating in excess of 20 percent for peripheral neuropathy of the left lower extremity. 5. Entitlement to an initial disability rating in excess of 20 percent for peripheral neuropathy of the right lower extremity. 6. Entitlement to Total Rating for Compensation Based on Individual Unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from June 1960 to May 1967. These matters come before the Board of Veterans' Appeals (Board) from an October 2006 (PTSD) and March 2009 (peripheral neuropathy) rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Oakland, California. These matters were previously before the Board in August 2011 and were remanded for further development. They have now returned to the Board for further appellate consideration. The Board finds that the RO substantially complied with the mandates of its prior remand with regard to the issues adjudicated below. The issue of entitlement to an initial rating in excess of 20 percent for diabetes mellitus with early diabetic nonproliferative changes and early cataracts of both eyes and mild sensory polyneuropathy, and the issue of entitlement to TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to November 3, 2011, the appellant's service-connected PTSD was manifested by symptoms such as episodes of depressed mood, avoidance, anxiety, sleep disturbance, intrusive thoughts, anger, and hyper vigilance, productive of no more than occupational and social impairment comparable to reduced reliability and productively. 2. From November 3, 2011 to May 3, 2012, the appellant's service-connected PTSD was manifested by symptoms such as episodes of depressed mood, avoidance, anxiety, sleep disturbance, intrusive thoughts, anger, and hyper vigilance, productive of no more than occupational and social impairment with deficiencies in most areas. 3. Throughout the rating period on appeal, the Veteran has exhibited an ability to maintain social relationships, personal hygiene, fair to good judgment, and coherent thought processes. 4. Throughout the rating period on appeal, the Veteran's neurologic impairment in his left lower extremity has resulted in a disability analogous to no more than moderate incomplete paralysis a peripheral nerve. 5. Throughout the rating period on appeal, the Veteran's neurologic impairment in his right lower extremity has resulted in a disability analogous to no more than moderate incomplete paralysis of a peripheral nerve. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial staged evaluation in excess of 50 percent for PTSD, prior to November 3, 2011, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for entitlement to an initial staged evaluation in excess of 70 percent for PTSD, from November 3, 2011 to May 3, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for an initial rating in excess of 20 percent for peripheral neuropathy of the neuropathy, left lower extremity, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Codes 8520-8530 (2012). 4. The criteria for an initial rating in excess of 20 percent for peripheral neuropathy, right lower extremity, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.124a, Diagnostic Codes 8520-8530 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). See also Vazquez-Flores v. Shinseki, 24 Vet. App. 94 (2010). This appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. VA also has a duty to assist the Veteran in the development of a claim, which is not abrogated by the granting of service connection. The claims file contains VA and private medical records and the statements of the Veteran in support of his claims. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. The Veteran was afforded a VA examination in October 2011 (peripheral neuropathy), July 2006 (PTSD), November 2011 (PTSD), and May 2012 (PTSD). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the examinations are adequate, as they include clinical examinations and interviews with the Veteran with regard to his symptoms. The reports of the examination contain findings necessary to evaluate the Veteran's service-connected disabilities under the applicable diagnostic code rating criteria. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4). Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claim. Essentially, all available evidence that could substantiate the claim has been obtained. Legal Criteria Rating Disabilities - in general Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. Id. § 4.3. In determining whether a claimed benefit is warranted, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107(a); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Moreover, an appeal from the initial assignment of a disability rating, such as the appeal in this case, requires consideration of the entire time period involved, and contemplates staged ratings where warranted. See Fenderson, supra. Specific schedular criteria for rating mental disorders PTSD is rated by applying the criteria in 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411 (2012). The VA Schedule rating formula for mental disorders reads in pertinent part as follows: 100 percent rating - 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. 70 percent - 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); inability to establish and maintain effective relationships. 50 percent - 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. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Global Assessment of Functioning (GAF) GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)). According to the pertinent sections of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994) (DSM-IV), a GAF score of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions so psychosocial stressors and there is no more than slight impairment in social, occupational, or school functioning. A GAF score of 61 to 70 indicates some mild symptoms or some difficulty social occupational or school functioning but that a examinee is generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. See Quick Reference to the Diagnostic Criteria from DSM-IV, 46-47 (1994). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence for the rating period on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. PTSD The Veteran is service connected for PTSD with an assigned disability evaluation of 50 percent from October 18, 2005; 70 percent from November 3, 2011; and 100 percent from May 3, 2012. In order to be assigned a particular rating, a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The key element for a rating under the General Formula for Mental Disorders is the degree of social and occupational impairment caused by the Veteran's symptoms. Prior to November 3, 2011 In order to warrant a 70 percent or higher rating the Veteran must have occupational and social impairment, with deficiencies in most areas. The Board finds that the evidence, as discussed below, does not reflect that a rating in excess of 50 percent is warranted. An August 2005 VA examination report for diabetes mellitus reflects that the Veteran was noted to be "extremely active." The record reflects that he "works full-time as a limousine driver, and in his spare time he dives for abalone, does work around the house and chops wood." In a statement dated in November 2005, the Veteran reported that he had difficulty "hanging onto" his sense of humor, that he feels much better when he is alone or has a "couple friends with" him, does not like to hunt anymore, has memories of Vietnam, has depression, has a short temper, has "road rage," and has sleep difficulties, A November 2005 report from C.H., a counselor in marriage, family, and child counseling, reflects that the Veteran had recently separated from his spouse, but hoped for reconciliation. He reported that he was "mostly alienated" from his three children from his first marriage and that they resent him. The Veteran was noted to live alone in a trailer park and drive a limousine for a retirement community. It was also noted that he "volunteers his time to help seniors there or neighbors in his trailer park. He reported being quite solitary, reclusive, with 'no real friends.'" The Veteran reported that he feels constantly tense, has "road rage waiting to happen", has sleep problems with frequent nightmares, often feels nervous and appeared to be experiencing frequent, persistent and intense episodes of depression. The Veteran reported that he drinks three to four rum cocktails in the late afternoon to relax. C.H. opined that the Veteran tends to minimize or deny that he has had problems. He found the Veteran to have loud speech, depressed mood, chronic fatigue, blunted and very controlled effect, hyper vigilance, intrusive thoughts and memories, and reaction to certain sounds and smells. He also found that the Veteran was mistrustful and cynical about authority, reclusive, easy to anger, claustrophobic at times, had avoidance of Vietnam, and had fair judgment. The Veteran had generally coherent thought processes, and had no delusional thinking, no perceptual disturbances, and no suicidal or homicidal ideation. C.H. assigned a GAF score of 48 based on social and familial isolation, marital problems, alcohol problems, and anger management problems. C.H. further stated that the Veteran appears "moderately to severely depressed," and that the Veteran reported that his wife left him due to sleep problems and arguing with others. A December 2005 report from C.H. reflects that the Veteran was neat and clean in appearance. He was friendly and cooperative; however he was also stiff, nervous, and "edgy." He had chronic fatigue, frequent claustrophobia and avoidance, and frequent sleep disturbances and nightmares. He was hyper-alert and hyper-vigilant, had exaggerated startle response, had appropriate but somewhat loud speech, and had daily painful and intrusive thoughts and memories. He was mistrustful, uncomfortable with unfamiliar people and places, and tended to isolate and be reclusive when not working. C.H. opined that the Veteran self-medicated with alcohol frequently. He assigned the Veteran a GAF score of 48. A March 2006 report from C.H. reflects that the Veteran was reconciling with his wife and his grown children. He had persistent episodes of depression that are moderate to severe in nature but which were of shorter duration, anger management problems, intrusive thoughts and memories, and little patience or tolerance with authority. He was neat, and clean, friendly, and cooperative. He continued to be tense and edgy but reported feeling less tense. It was noted that since counseling, he was gaining insight into his PTSD symptoms but had an increase in intrusive thoughts. He had hyper-alertness and hyper-vigilance, chronic fatigue, sleep difficulties (medication was noted to be helping with sleep problems somewhat). He was noted to be claustrophobic and have avoidance behavior. He had coherent thought processes, appropriate speech, no delusional thinking, no perceptual disturbances, and no suicidal or homicidal thoughts. The clinician assigned a GAF score of 47. A June 2006 report from C.H. reflects that the Veteran had reunited with his wife, and that the Veteran had learned to delay reactive verbal behavior and consider more appropriate responses to marital stresses. It was also noted that the Veteran was "now eager and successful reconciling with grown children from his first marriage." He had continued problems with sleep, and was using alcohol daily although he had reduced his consumption. It was further noted that he had started a job with security and was beginning to gain confidence. He was still nervous, reported memory issues, daydreaming, hyper-alert and hyper -vigilance, isolation, intrusive thoughts and memories, was easily frustrated, irritable, had difficulty tolerating changes, and had recurrent persistent depressive episodes which were at least moderate in severity. He was neat, clean, friendly, cooperative, reported less agitation, and was stiff and tense with regard to motor activity. The Veteran's speech was generally appropriate, but the Veteran could be tangential and circumlocutory at times. He was described as being mistrustful, better at managing anger, having labile affect, having fair to good judgment, and having coherent thought processes. He did not have perceptual disturbances, suicidal ideation, or homicidal ideation. The clinician assigned a GAF score of 47. A July 2006 VA examination report reflects that the Veteran had recently switched jobs and was working in security. He reported that the new job involved working the swing shift for the first time and the Veteran was learning new responsibilities and having some difficulty coping with the job. The Veteran reported that he did not drink to the level of intoxication, and had never abused drugs. The Veteran reported that he does some abalone diving, and has a large house which requires a lot of maintenance. He reported a "few friends" but difficulty making close friends. He was clean-shaven and appropriately dressed. He had no impairment of thought process or communication. He had no psychotic thinking, no delusions, no hallucinations. He had good eye contact and appropriate interaction and behavior. He had no suicidal or homicidal thoughts, ideas, plans, or intensions. He maintains personal hygiene. He was oriented to person, place, and time. He had no impairment of short or long term memory. He had no obsessive or ritualistic behaviors. His speech was fluent, logically constructed and goal directed. He had startle reaction without panic attacks. Periods of despondence and anxiety. No impulse control problems. GAF of 55. August 2006 correspondence from S.T. reflects that the Veteran persistently avoided stimuli associated with Vietnam, to include smell of diesel oil. The Veteran reported feelings of estrangement and detachment from others. He had a restricted range of affect. He reported increased arousal, difficulty sleeping, irritability and outbursts of anger, difficulty concentration, and exaggerated startle response. He reported "road rage waiting to happen." The clinician assigned a GAF score of 46. September 2006 records from C.H. reflect that the Veteran had "fairly frequent episodes of moderate depression," is easy to frustration, has irritability, and had reactive anger. He reported that he was using less alcohol, and had been getting along and communicating better with his wife. He remained noticeably suspicious and mistrustful, cynical, and critical with labile affect. The Veteran reported that he was sleeping better with less alcohol. The Veteran also reported that he continues to prefer to be alone, except for his wife, and that he has feelings of unworthiness and low self-esteem. He was neat, clean, friendly, cooperative. His speech was occasionally tangential and circumlocutory. The Veteran reported that he often forgets things, is hyper-alert, hyper-vigilant, has intrusive thoughts and memories. It was noted that the Veteran had a renewed relationship with his children. He also had fair to good judgment, and no delusional thinking. The clinician found that the Veteran had "reduced capacity for establishing and maintaining effective social relationships because of negative attitudes, cynicism, and lack of trust." He assigned the Veteran a GAF score of 47. December 2006 records from C.H. reflect the above noted symptoms. He was noted to have depressive episodes which were "moderate to severe in nature." His affect was noted to be "labile or flattened." It was further noted that the Veteran was learning anger management skills which "have certainly helped with his marital relationship." It was noted that the Veteran had moderated his use of alcohol. He reported memory problems, intrusive thoughts, and decreased ability to remain attention worrying. The Veteran report "more healthy and considerate communication in his marital relationship which continues to improve." The clinician assigned the Veteran a GAF score of 46. An October 2007 report, with November 2007 addendum, from C.H. reflects that the Veteran reported that he had daily intrusive thoughts and memories, and considerable reduction in use of alcohol. It was noted that he was "somewhat reclusive" although he continued to work as a security officer. He was socially avoidant, preferring to be at home alone with his wife. The examiner found that the Veteran had difficulty in establishing and maintaining relationships, and was quite sarcastic at times, highly critical and cynical. The Veteran was neat, and clean in appearance, friendly, and cooperative. His motor activity was tense, edgy, and he was described as "squirmy;" although a subsequent record by C.H. reflects that the squirminess may be due to back and neck pain. The Veteran's speech was appropriate, but the examiner found that the Veteran minimized and discounted what bothers him. The Veteran reported that he felt good about curbing his reactive verbal anger, "which has improved his marital relationship considerably." The Veteran reported that he remained easy to frustration and irritability, mistrustful, forgetful, hyper-alert, and hyper-vigilant. The examiner found that the Veteran had labile affect. The Veteran reported that he was drinking alcohol only on days off from work and only one to two drinks. He had no delusions, no perceptual disturbances, and no suicidal or homicidal ideation. His thought processes were coherent. The clinician assigned a GAF score of 46 due to reclusive, social isolation, past marital problems, past problems with alcohol, anger management problems. A May 2008 periodic report from C.H. reflects the same symptoms as above and notes that the Veteran reported a "continuing positive relationship with his wife, although he is stressed by her medical problems. It was noted that the Veteran does not like "change." A November 2008 report from C.H. reflects that there had been no decrease in the Veteran's level of irritability, and he was having some disputes at work with supervisors, co-workers, and policies. It was noted that he was tense, edgy, and had intrusive thoughts, sleep disturbances nightly, and consumed alcohol only on weekends. The Veteran had a neat, clean, casual appearance, was friendly and cooperative, and had a squirmy, tense, edgy manner. His speech was often tangential and circumlocutory, and he tended to minimize issues. The clinician found that the Veteran uses sarcastic humor to present his cynical views of authority. It was noted that the Veteran had better control of his reactive verbal anger, and that his marital relationship was solid and positive. The Veteran reported that he was hyper-alert and hyper vigilant, and had recurrent episodes of depression. He had labile affect, fair judgment, coherent thought processes, no delusional thinking, no perceptual disturbances, and no suicidal or homicidal ideation. The clinician assigned a GAF score of 45. In a February 2009 statement, the Veteran stated that he had long and short term memory loss, mood swings that include violence, and periods of depression. He reported that he was a loner and has problems making social relationships. The Board acknowledges the Veteran's complaints of memory problems; however, he has not been found to have memory problems upon examination. (See July 2006, November 2011, and May 2012 VA examination reports.) Moreover, the records are generally negative for periods of violence and he has been clinically found to not be a persistent danger to others, and not to have impaired impulse control with periods of violence. An October 2009 periodic report from C.H. reflects that the Veteran continues to have difficulties managing frustration, irritability, and reactive anger; however, he also reported that he and his wife have a "very positive relationship, no longer having arguments or sarcastic exchanges." Correspondence from the Veteran and a VA Form 21-4192 reflect that the Veteran resigned from work on October 20, 2010. He reported that he had "enjoyed working" with his employer for the past four and a half years, but had found it too difficult to get along with people. In September 2011 correspondence, the Veteran reported that he was loner and had no relationship with his three children. He also stated that he has memory loss, feels very angry, has zero tolerance for things, and that his refusal to communicate has caused problems between himself and his wife. September 2011 correspondence from Dr. S.T. reflects that the Veteran is a "very angry gentleman." It was noted that he does not have to engage in a lot of social contacts due to living in a remote, very rural area. It was noted that he gets angry easily, so he avoids people, feels anxious when he thinks about the war every day, experiences guilt, struggles with alcohol consumption, is unable to trust others, checks out noises and checks the perimeter before bed. Dr. S.T. stated that he was convinced that the Veteran was unemployable. Based on the foregoing, the Board finds that the Veteran did not experience the majority of symptoms in the rating criteria which are listed as examples of impairment significant to warrant a 70 percent rating criteria. The evidence is against a finding that he had suicidal ideation, obessessional rituals, speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; neglect of personal appearance and hygiene; or inability to establish and maintain effective relationships, homicidal ideation, hallucinations, or delusions. Moreover, and importantly, the effect of the Veteran's PTSD symptoms are not so severe as to approximate those listed in the 70 percent rating. For example, his reported memory impairment, depressed mood, anxiety, suspiciousness, and chronic sleep impairment are symptoms which are examples of a level of disability which warrants a 30 percent or 50 percent disability, and not higher. The Board finds it significant that during the rating period on appeal, the Veteran was not only able to remain married, but actually improved his relationship with his wife and his children. Although the Veteran stated in September 2011 that he had no relationship with his three children; this is contrary to the clinical records which reflect an improved relationship. Such factors, especially his improved communication skills, improved anger management skills, and improved relationship with his spouse, are against a finding that the Veteran has an inability to establish and maintain effective relationships. The Board also finds it notable that the Veteran was employed for the majority of the rating period. The Board acknowledges that the Veteran resigned in October 2010 because he felt that his employment was too stressful; however, this is not synonymous with an inability to work in a less stressful occupation with less social interaction. In addition, the Veteran had fair judgment, good eye contact, a "couple" friends, volunteered his time to help seniors and neighbors in his trailer park, did not have personal hygiene problems, had no impairment of thought process or communication, was able to have recreational experiences outside the home and workplace such as abalone diving, and was oriented to person, place, and time. Although he had depressive episodes, the evidence is against a finding that he had a near continuous depression; to the contrary, his depressive was noted to be episodic, with episodes shortening in duration. In finding that an increased rating is not warranted, the Board has considered the effect of all of the Veteran's reported symptoms on his ability to function, both occupationally and socially. Such symptoms have included being nervous, having memory issues, daydreaming, being hyper-alert and hyper-vigilant, having intrusive thoughts and memories, becoming easily frustrated and irritable, isolating himself, being mistrustful and cynical, and that he had stiff and tense motor activity and labile affect upon examination. Although he has reported that he is "road rage waiting to happen," he has not been shown to have had acts of violence against anyone due to his PTSD. In sum, the evidence, as a whole, is against a finding that his symptoms were so severe as to warrant a 70 percent, or higher, rating. The Board has also considered the assigned GAF scores. A GAF score of 51 to 60 indicates the examinee has moderate symptoms or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 indicates the examinee has serious symptoms or a serious impairment in social, occupational, or school functioning. A GAF score is not dispositive of the issue on appeal, and must be considered in conjunction with the overall objective evidence of record. The Board acknowledges that the Veteran had GAF scores of 45, 46, 47, and 48 indicating serious symptoms or impairment. However, the actual symptoms are negative for psychosis, suicidal ideation, homicidal ideation, panic attacks, delusions, severe memory difficulty, or problems with hygiene. In addition, the Veteran was able to maintain full time employment; which is indicative that his symptoms were not as severe as indicated by the GAF scores in the 40s. As noted above, correspondence from the Veteran and a VA Form 21-4192 reflect that the Veteran resigned from work on October 20, 2010 because the previous months had been difficult and stressful for him. Significantly, he reported that he had "enjoyed working" with his employer for the past four and a half years. Again, this is indicative that his symptoms were no so severe, prior to his resignation, that he could not establish and maintain an effective relationship, or that his symptoms warranted an evaluation in excess of 50 percent. The Board notes that clinical findings are more probative than the GAF scores as these findings more accurately portray the relevant symptoms of the Veteran's service-connected PTSD. From November 3, 2011 to May 3, 2012 In order to warrant a 100 percent rating (the maximum schedular rating), the Veteran must have total occupational and social impairment. The Board finds that the evidence does not reflect a rating in excess of 70 percent is warranted. A November 2011 statement from Dr. S.T. reflects that the Veteran is a "very angry gentleman." It was noted that he does not have to engage in a lot of social contacts due to living in a remote rural area. The Veteran reported several angry encounters with "locals at the local grocery store, etc." He further reported a depressed mood and displayed a restricted affect and heightened level of psychomotor activity. He was appropriately dressed and groomed, his speech was normal in range pitch and tone, his thought process was clear and his thought content was free of delusions. He denied any current suicidal or homicidal ideation. His insight was good, his judgment was intact, and he had no serious memory impairment. He was noted to be cynical, mistrustful, critical, and confrontational. It was noted that he had done "a little better with family members out of a sense of obligation." The clinician assigned a GAF score of 39. S.T. noted that he had met with the Veteran once in 2006, and once previously in 2011. He stated that the Veteran was not progressing with many of his PTSD symptoms and reported that he was getting worse in others. A November 2011 VA examination report is also of record. It reflects a GAF score of 44 and notes that PTSD symptoms and depression have significantly increased over the past two years. The examiner stated that the Veteran had "occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment thinking and/or mood." The Veteran's symptoms were noted to be depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, suicidal ideation. The Board notes that the examiner also found that he Veteran had an inability to establish and maintain effective relationships; however, it was noted that the Veteran was married and did not have total occupational social impairment. The Veteran was not noted to have impaired judgment, impaired abstract thinking, gross impairment in thought processes or communication, impairment of memory, panic attacks, near continuous depression affecting ability to function independently, impaired impulse control, obessional rituals, spatial disorientation, persistent delusions or hallucination, grossly inappropriate behavior, persistent danger of hurting himself or others, neglect of personal hygiene, intermittent inability to perform activities of daily living, or disorientation to time or place January 2012 and April 2012 correspondence from Dr. S.T. reflects his prior noted symptoms and also that the Veteran's sleep hygiene was worse along with his experiencing increased nightmares, and he was more reclusive with the exception of his wife. Dr. S.T. noted that the Veteran reported that he thinks about the war every day, is unable to trust others, checks the perimeter before going to bed, and feels trapped in closed places. Dr. S.T. stated that he believes that the Veteran is "unemployable, due largely to anger outbursts, irritably, and lack of sleep. He noted that the Veteran had few friends or social contacts. He stated that the Veteran "deserves a rating for individual unemployability" and was 100 percent disabled. He further opined that the Veteran was unemployable, due largely to anger outbursts, irritability and lack of sleep. He assigned GAF scores of 39 and 40. The Board notes that the Veteran does not exhibit the symptoms listed as examples of serious enough symptomatology to warrant a 100 percent rating. The evidence does not reflect 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; or memory loss for names of close relatives, own occupation or own name. In addition, the evidence does not reflect other symptoms which would be indicative of total social impairment. Throughout the rating period on appeal, the Veteran was able to maintain his marriage and his relationship with his children. Although the examiner opined that this was "out of a sense of obligation," the Veteran was still able to maintain such relationships. With regard to the GAF scores, the Board again finds that the Veteran's symptoms are more indicative of his disability than the GAF scores. The Board has considered the opinion that the Veteran is unemployable; however, a 100 percent rating for PTSD requires both total occupational and social impairment. Moreover, the private clinician's opinion that the Veteran is 100 percent disabled does not accurately correspond to the facts that the Veteran has a relationship with his wife. Conclusion (PTSD) As noted above, in order to be assigned a particular rating, a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan, 16 Vet. App. at 442. The key element for a rating under the General Formula for Mental Disorders is the degree of social and occupational impairment caused by those symptoms. The Board has considered the Veteran's assigned GAF scores, the opinions of the clinicians, and the Veteran's symptoms as they relate to the General Formula for Mental Disorders. The Board finds that the Veteran's symptoms, regardless of whether they are in the general formula, reflect a disability which is not severe enough to warrant a rating in excess of 50 percent prior to November 3, 2011 and 70 percent from May 3, 2011. Consequently, the Board finds that the currently assigned evaluations appropriately reflect the clinically established impairment experienced by the Veteran. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Peripheral Neuropathy - left and right lower extremity The Veteran is service connected for peripheral neuropathy of the left lower extremity evaluated as 20 percent disabling, and the right lower extremity evaluated as 20 percent disabling from July 25, 2008. He asserts that higher ratings are warranted. Under DC 8520, a 10 percent evaluation is warranted for mild incomplete paralysis of the sciatic nerve; a 20 percent evaluation requires moderate incomplete paralysis of the sciatic nerve; a 40 percent evaluation requires moderately severe incomplete paralysis, a 60 percent evaluation requires severe incomplete paralysis with marked muscular atrophy. An 80 percent evaluation requires complete paralysis (the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or lost). When involvement is wholly sensory, the rating should be for the mild, or at most moderate degree. An October 2008 VA clinical record reflects that the Veteran was not aware of any definite neurological complications of diabetes. He reported that he experiences occasional foot tightness and tingling of the toes. He reported occasionally feeling that his feet are numb, but reported no weakness or difficulties with walking. He was noted to have evidence of a "very mild sensory polyneuropathy." 2009 VA clinical records reflect that the Veteran reported that he had foot pain. His feet were normal to inspection, his pulses were palpable but his sensation was abnormal. He was "insensate to SW 5.07 monofilament." Private medical records dated in 2010 and 2011 reflect symptoms such as feelings of numbness alternating with shooting pain, severe pain, stabbing sensation on the balls of the feet, and "pins and needles." An October 2011 VA examination report reflects that the Veteran reported five years of complete numbness of the toes. The Board notes that this is contrary to the October 2008 reports by the Veteran. He also reported daily cramps, especially at night, in his feet and calves. He reported tingling and "pins and needles" in the feet and shins daily which waxes and wanes and is worse with touching, becoming painful. He reported that cramps in his feet prevent him from falling asleep. He reported that it feels like he is always wearing several pairs of socks even when barefoot, and the numbness makes it difficult to navigate uneven terrain. The Veteran had mild constant pain, moderate intermittent pain, moderate paresthesias and/or dysesthesias, and moderate numbness of the lower extremities. He had full strength of knee extension and flexion and full strength of ankle plantar flexion and dorsiflexion. He had 0 deep tendon reflexes of the right knee, and 1+ of the left; he had 0 deep tendon reflects of the ankle. He had decreased, but not absent, light touch/monofilament, vibration, and cold sensation testing results of the ankle/lower leg, and foot/toes. The examiner opined that the Veteran had mild incomplete paralysis of the sciatic nerve and mild incomplete paralysis of the femoral nerve. A May 2012 VA examination report reflects that the Veteran complained of numbness, tingling and intermittent pain of his feet and calf muscles. He reported that it is difficult to ambulate with incline and uneven surfaces. The intermittent pain was noted to be moderate. He also had moderate paresthesia and/or dysesthesias and moderate numbness. Upon clinical examination, the Veteran had full strength upon knee extension and flexion, and full strength upon ankle plantar flexion and dorsiflexion. Upon light touch/monofilament testing, he had normal knee and thigh testing results, and decreased, but not absent, results of the ankle/lower leg and foot/toes. Upon position strength testing, he had decreased, but not absent, position sense of the lower extremities. He had decreased, but not absent, vibration sensation of the lower extremities and cold sensation of the lower extremities. He did not have muscle atrophy. The 2012 VA examiner opined that the Veteran had moderate incomplete paralysis of the sciatic nerve. He had normal femoral nerve. Based on the foregoing, the Board finds that the Veteran's symptoms warrant a 20 percent evaluation for the right lower extremity, and a 20 percent evaluation for the left lower extremity, and no higher, for the entirety of the rating period on appeal. In evaluating the Veteran's symptoms from the October 2011 VA examination report, he would be entitled to a 10 percent evaluation under DC 8520 (sciatic nerve) and a 10 percent evaluation under DC 8526 (femoral nerve). In evaluating the Veteran's symptoms from the November 2012 VA examination report, he would be entitled to a 20 percent evaluation under DC 8520 and a noncompensable evaluation under DC 8526. In sum, the evidence does not reflect that an evaluation in excess of 20 percent is warranted for any time period on appeal for each of the lower extremities, regardless of the diagnostic code. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2010), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Extra schedular Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). An extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) . The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected disabilities. The Veteran's PTSD is manifested by impairment in social and occupational functioning and the rating criteria contemplate these impairments. The Veteran's peripheral neuropathy symptoms, which include tingling, shiny skin and numbness, are contemplated by the schedular criteria. Hence, referral for consideration of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to a staged initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to November 3, 2011 is denied. Entitlement to a staged initial disability rating in excess of 70 percent for PTSD from November 3, 2011 is denied. Entitlement to an initial disability rating in excess of 20 percent for peripheral neuropathy of the left lower extremity is denied. Entitlement to an initial disability rating in excess of 20 percent for peripheral neuropathy of the right lower extremity is denied. REMAND Diabetes The Veteran underwent VA examinations in October 2011 and May 2012. The October 2011 VA examination report reflects that the Veteran had neuropathy of the upper extremities due to diabetes. The report also reflects that the Veteran had nocturia due to diabetes. The May 2012 VA examination reflects that the Veteran did not have upper extremity neuropathy. In addition, the report does not reflect any findings of a urinary disability due to diabetes. A September 2012 VA memorandum from the AMC noted that clarification from the VA examiner was requested; however, no subsequent VA opinion was obtained and it appears that the AMC referred the claim to the RO. The findings from the October 2011 and May 2012 VA examinations are necessary to rate the claim before the Board and clarification is required for the Board to appropriately evaluated the Veteran's service connection diabetes mellitus. A remand to obtain any such evidence is warranted. TDIU TDIU is an element of all appeals of an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to TDIU is raised where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). However, TDIU is not raised in an increased rating claim unless the Roberson requirements are met. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). In the present claim, the evidence of record includes correspondence from Dr. S.T., dated in January 2012 and April 2012, which reflects his opinion that the Veteran is unemployable due to his PTSD. The Board notes that in a September 2012 rating decision, the RO stated that "entitlement to individual unemployability was considered for the period from November 3, 2011 to May 3, 2012. The available evidence shows that the Veteran elected to retire from his last position as security patrol, although concessions were made to accommodate a work environment that requires contact with members and co-workers." The RO does not reference the above noted clinical correspondence; thus, it appears that it may not have been considered. In addition, the Veteran has alleged that he is unemployable due to his diabetes mellitus. The Veteran is service-connected for PTSD, evaluated as 100 percent disabling from May 3, 2012. The award of a 100 percent disability rating does not render moot the claim of entitlement to TDIU. A separate TDIU rating predicated on one disability (although perhaps not ratable at the schedular 100 percent level) when considered together with another disability separately rated at 60 percent or more could warrant special monthly compensation under 38 U.S.C.A. § 1114(s). See Bradley v. Peake, 22 Vet. App. 280 (2008). Thus, it might benefit the Veteran to retain or obtain the TDIU rating even where a 100 percent schedular rating has also been granted. Id. at 293-94. As the Veteran's claim for a higher initial rating for diabetes is being remanded, the Board finds that the issue of entitlement to TDIU should also be remanded as it is inextricably intertwined. Accordingly, the case is REMANDED for the following action: 1. Return the claims folder to the examiner who completed the May 2012 VA examination to obtain a supplemental opinion which addresses whether the Veteran has a urinary disability and/or upper extremity neuropathy due to, or aggravated by, his diabetes. If the examiner is unavailable or determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for an appropriate examination to determine the current severity of the diabetes mellitus and any related disability, including the eyes, peripheral neuropathy of the upper and lower extremities or any urological complaints. 2. After undertaking any other development deemed appropriate, the RO should readjudicate the issues on appeal. In determining whether the Veteran is entitled to TDIU, the RO should consider the entire claims file, to include the private correspondence, dated in January 2012 and April 2012, which reflects the opinion of the private clinician that the Veteran is unemployable due to his PTSD. 3. If a benefit sought on appeal is not granted, the RO should issue a supplemental statement of the case and provide the Veteran and his representative with an appropriate opportunity to respond. The case should then be returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the 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). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs