Citation Nr: 1306087 Decision Date: 02/21/13 Archive Date: 02/27/13 DOCKET NO. 10-07 459 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with major depressive disorder prior to April 4, 2012, and in excess of 70 percent thereafter. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) due to the service-connected disability. REPRESENTATION Appellant represented by: National Association of County Veterans Service Officers ATTORNEY FOR THE BOARD C. R. dela Rosa, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1965 to October 1968. The appeal comes before the Board of Veterans' Appeals (Board) from a June 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which awarded service connection for PTSD with major depressive disorder and assigned an initial 50 percent rating, effective June 6, 2008. A November 2012 rating decision granted an increased rating of 70 percent effective April 4, 2012. However, as that increase does not represent a total grant of benefits sought on appeal, the claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). The U.S. Court of Appeals for Veterans Claims has held that TDIU may be a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the question of entitlement to a TDIU was raised by the evidence of record. The Board also notes that, in addition to the paper claims file, there is a paperless, electronic claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are potentially relevant to the issue on appeal. Thus, any future consideration of this appellant's case should take into account the existence of this electronic record. For the reasons explained below, the issue of entitlement to TDIU is REMANDED to the RO via the Appeals Management Center (AMC). VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. For the period prior to April 4, 2012, the most persuasive evidence does not reflect that the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. 2. For the period since April 4, 2012, the competent evidence does not reflect that the Veteran's PTSD been manifested by total occupational and social impairment. CONCLUSION OF LAW 1. For the period prior to April 4, 2012, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code 9411 (2012). 2. For the period from April 4, 2012, the criteria for a rating in excess of 70 percent have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, in a September 2008 letter, issued prior to the rating decision on appeal, and a January 2011 letter, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letters also advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. He did not provide any signed releases forms in response to these letters. "The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). In any event, the appeal arises from the initial award of service connection. In Dingess, the Court held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (section 5103(a) notice is no longer required after service-connection is awarded); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Thus, VA's duty to notify in this case has been satisfied. Moreover, the prior remand directives have been substantially complied with. VA treatment records were obtained and a VA examination was conducted. A March 2012 letter requested that the Veteran provide the names and addresses of all medical care providers who have treated his psychiatric disorder. The March 2012 letter also requested the name and location of any VA medical facility in which the Veteran sought treatment. In a March 2012 response, the Veteran indicated that he has not sought treatment from any private physician since the late 1970s and received treatment at the VA clinic in Sewell, New Jersey. Additional VA medical records have been obtained and associated with the Veteran's electronic Virtual VA folder. The Veteran further provided medical evidence from Dr. A. Jensen, Ph.D., dated in April 2012. Accordingly, the Board finds that the prior remand order has been substantially complied with. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where Board's remand instructions were substantially complied with). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran including service treatment records, VA treatment records, Social Security Administration (SSA) records, private physician reports, and VA examination reports. As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate the claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between the Veteran and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument. Therefore, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the Veteran. See Pelegrini, 18 Vet. App. at 121. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Conway, 353 F.3d at 1374; Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). In the process of evaluating a mental disorder, VA is required to consider a number of pertinent factors, such as the frequency, severity, and duration of a veteran's psychiatric symptoms. See 38 C.F.R. § 4.126. After consideration of these factors, and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is experiencing. PTSD is rated under Diagnostic Code 9411, which is governed by the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Rather, all symptoms of a claimant's condition that affect the level of occupational and social impairment are to be considered. See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, then the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Under the General Rating Formula for Mental Disorders a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and/or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name. Id. 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. One factor for consideration is the Global Assessment of Functioning (GAF) 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 DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed.) (DSM-IV)). A GAF score of 11 to 20 indicates that there is some danger of hurting oneself or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement), or an occasional failure to maintain minimal personal hygiene, or gross impairment in communication. A GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech at times illogical, obscure, or irrelevant), or where there is 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). A GAF score of 41 to 50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 indicates moderate symptoms (e.g., flattened affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61 to 70 indicates some mild symptomatology (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or social functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. While the Rating Schedule does indicate that the rating agency must be familiar with the DSM-IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126. A March 2009 private psychological evaluation noted that the Veteran's symptoms appeared to have become progressively worse over the years. The Veteran reported that he did not want to be near anyone and could only work when he worked alone. He was concerned about his outbursts of rage and his constant feelings of loneliness. He described a deficit in his ability to concentrate and he withdrew from others. He had frequent nightmares and he would wake up screaming, sweating, and very upset; sleep interruption was very common for the Veteran. He experienced numerous flashbacks. The Veteran also withdrew from close personal relationships and his wife often complained that he was very distant from her and from their relatives and friends. The Veteran also had frequent and unpredictable outbursts of rage that were extremely frightening to his wife and others around him. He frequently experienced moods of depression when he moved even farther away from interpersonal relationships. He had suicidal thoughts but not with a specific plan. He also had severe headaches and occasionally became disoriented and found it extremely difficult to keep his attention focused. The clinician determined that the Veteran was unemployed due to his medical and emotional state. The diagnosis was chronic, severe PTSD and the GAF score was 40 In May 2009, the Veteran was accorded a VA compensation and pension (C&P) PTSD examination. During the examination, the Veteran reported daily thoughts and memories that were unwanted and intrusive. He continued to have dreams about Vietnam. He also indicated that he maintained a low level of socialization due to a decreased interest in social activities. However, he maintained several social activities that included occasionally going to dinner with his wife, staying in close contact with his relatives, and practicing his hobbies of art and listening to music. He had chronic insomnia and chronic irritability with a low frustration threshold and occasional outbursts of anger. He also expressed hypervigilance with an over-concern for security. He also had an exaggerated startle reflex. The Veteran had a low mood associated with decreased energy, decreased motivation, and poor appetite. He also had thoughts of suicide. The Veteran retired in 2007 and specifically denied that his psychiatric symptoms interfered with his ability to work or caused his retirement. A mental status examination revealed the Veteran was neatly dressed and groomed. His speech was normal in all aspects and his psychomotor functions were full and normal. He had no difficulty performing activities of daily living. He was perfectly oriented times three and his memory was excellent for recall of remote and recent events. His mood was noticeably low and his affect was sad. He had a moderately high level of anxiety that persisted throughout the interview. He had no history or evidence of inappropriate behavior, and he had occasional brief thoughts of suicide that were not associated with past suicide attempts or suicide planning. He had no problem with homicidal thoughts. He had chronic insomnia with sleep interrupted by dreams related to Vietnam. He had a consistently poor appetite and complained of a very low level of energy and decreased motivation. The Veteran had a high level of irritability. His insight and judgment were very good. The examiner determined that the Veteran had intense symptoms related to re-experiencing and increased arousal. He also had mild symptoms related to avoidance behaviors. The diagnoses were PTSD of severe intensity and major depressive disorder secondary to PTSD of moderate intensity. The GAF score assigned was 48. In a June 2009 letter, the Veteran's wife indicated that she noticed several changes beginning in the 1970's, including him becoming more introverted than normal. And he was treated for anxiety attacks several times. He lost interest in his hobbies and kept to himself instead of talking things out with his wife or a friend. He also had bad dreams where he shook and cried out in the night. She also indicated that he lost his temper very easily. In July 2009, the Veteran indicated that he experienced extreme anxiety, panic attacks, nervousness, and short-tempered outbursts that affected his decision making. He also indicated that his diagnoses affected his relationship with his wife and family and he had become withdrawn, very irritated over little things, and argumentative. He stated that he would occasionally pick something up and throw it in anger. VA outpatient treatment records dating from May 2008 to October 2009 reveal the Veteran denying suicidal ideation. During this time period he reported feeling depressed 3 to 4 days a week for part of the day but being able to distract himself by working on his music. He denied being emotionally withdrawn. He also reported that he enjoyed life. He noted he experienced anxiety attacks once a year with a known stressor. He reported having a good relationship with his wife. His mood was described as depressed, anxious, frazzled, or alright during this time period. Mental stats examination noted he had excellent hygiene, was cooperative friendly, polite and sincere. His speech was normal and he had good eye contact. Thought processes were goal directed with no tangentiality or circumstantiality. In addition to denying suicidal ideation he also denied homicidal ideation, hallucinations and delusions. His insight and judgment were considered good. His affect was generally noted to be euthymic during this period. He did report having flashbacks several times a month, but noted they were not all military related; some were related to the death of his grandson. During this period, GAF scores of 65 were assigned in June 2008, August 2008, and June 2009. GAF scores of 55 were assigned in September 2009 and October 2009. A June 2009 report noted the Veteran indicated that he had a lot of things going on with his business. An August 2009 report to SSA from Dr. Jensen notes the clinician indicating the Veteran's speech was slow but deliberate. In July and August 2010 private psychological evaluations from Dr. Jensen, the clinician reported that the Veteran's symptoms appeared to have become progressively worse over the years. He preferred to work alone. He was concerned about his outbursts of rage and constant feelings of loneliness. He had frequent nightmares that resulted in him waking up screaming, sweating, and very upset. He also experienced numerous flashbacks and nightmares. He withdrew from close, personal relationships and he stated that when he had had to work in a close relationship with others, he often had to remove himself or quit the job. It was not uncommon for the Veteran to have terrible emotional outbursts of rage that frightened his wife and those around him. The clinician indicated that the Veteran tried to work on several occasions but has never been successful. The clinician also determined that the Veteran was unemployable due to his medical condition and his emotional status. The diagnosis was chronic, severe PTSD and the GAF scores were 40 and 39. In February 2011, the Veteran was accorded another C&P PTSD examination. His symptoms included intrusive thoughts and images, nightmares, flashbacks, avoidant behavior, diminished interest in activities, feelings of detachment and estrangement from others, a sense of a foreshortened future, sleep difficulties, irritability and anger outbursts, concentration issues, hypervigilance, startle response, depressed mood, anhedonia, fatigue, decreased motivation, some suicidal ideation with no plan, feeling like a failure, decreased concentration and memory issues, and decreased decision making. The examiner determined that the Veteran's disability significantly interfered with his normal daily activities. The Veteran reported that he was still married to his wife and had been for 43 years. He noted that his irritability and anger have impacted his two sons and affected his relationship with his grandchildren. He indicated that he saw his sister twice a year and his brother once a year. He had one friend that he saw twice a week but indicated that he isolated himself from his other friends. The Veteran also reported that he no longer engaged in activities that he once enjoyed. He had a decrease in motivation and an increase in alcohol consumption. During the examination, the Veteran reported that he retired in 2007 and indicated that he did so because his anger outbursts, irritability, and argumentativeness were getting in the way of his ability to perform his job. The Veteran reported that his intrusive thoughts had worsened since his last examination. He also reported no remissions from his PTSD symptoms. The examiner determined that the Veteran's PTSD symptoms have changed since the prior examination in that they have increased in frequency, severity, and duration. The examiner also indicated that the Veteran's impairment in social functioning increased since the last examination. However, the examiner noted no impairment in the Veteran's thought process or communication. The Veteran denied plan with his suicidal ideation and also denied homicidal ideation. There did not seem to be any issues with his activities of daily living. Regarding other diagnosed mental disorders, the examiner found that the Veteran exhibited anhedonia and the Veteran stated that he found no enjoyment in things. The examiner questioned whether the Veteran's sleep disorder was more closely related to his depression or to the anxiety and increased arousal of PTSD. The diagnoses were PTSD, chronic and major depressive disorder, secondary to PTSD. The GAF score was 41, based on the Veteran's reported symptoms and impairment in functioning. VA treatment records dating from October 2009 to June 2011 note the Veteran denying suicidal and homicidal ideation. In November 2009 the Veteran reported that Zoloft made him less irritable. He reported a good relationship with his wife. Mental status findings were consistent with those noted during the other 2009 treatment reports. A GAF score of 55 was assigned. The Veteran was seen on September 30, 2010 for a mental health intake evaluation. He reported that his concentration was non-existent and that he was easily distracted. He denied suicidal ideation and noted his commitment to his wife and children prevented self harm thoughts. It was noted the Veteran is a licensed pilot. It was also noted that the Veteran owns his own graphic arts business and his son works with him. The Veteran reported that work pressure is worsening. He questioned his decision making process. He reported ongoing anxiety symptoms but denied panic symptoms. No mental status examination was provided. The diagnosis was PTSD and depressive disorder and a GAF score of 45 was assigned. In November 2010 the Veteran the Veteran reported a marked improvement in awareness after staring Sertraline. He denied suicidal and homicidal ideation. He was noted to have a calm demeanor in January 2011, but reported financial and business stressors. He reported a low mood in March 2011. His affect was congruent, thought process was clear and goal directed, and demeanor was calm. Similar findings were noted in May 2011 but his mood was noted as improved. He noted that he had a close bond with his wife. He reported that combat related dreams had decreased. In July 2011 it was noted that his niece's husband committed suicide and his dog died. He processed his grief feelings well, and denied suicidal and homicidal ideation. Again, his affect was congruent, thought process was clear and goal directed, and demeanor was calm. In July 2011 he noted his interest and motivation were declining. In November 2011 he noted his interest and motivation were fair, and he expressed a desire and need to get out of his business. In an April 2012 private psychological evaluation, the Veteran's symptoms appeared to have become progressively worse over the years. He preferred to work alone. He was concerned about his outbursts of rage and constant feelings of loneliness. He described a deficit in his ability to concentrate and still withdrew from others. He had frequent nightmares that resulted in him waking up screaming, sweating, and very upset. He also experienced numerous flashbacks and nightmares. He withdrew from close, personal relationships and he stated that when he had had to work in a close relationship with others, he often had to remove himself or quit the job. It was not uncommon for the Veteran to have terrible emotional outbursts of rage that frightened his wife and those around him. He frequently experienced moods of depression when he moved away from interpersonal relationships. He also had suicidal thoughts but not with a specific plan. He had severe headaches and had occasionally been disoriented and found it extremely difficult to keep his attention focused. The clinician indicated that the Veteran tried to work on several occasions but has never been successful. The clinician also determined that the Veteran was unemployable due to his medical condition and his emotional status. The diagnosis was chronic, severe PTSD and the GAF score was 39. Upon review of the record, the Board notes a large discrepancy in the symptoms reported to the Veteran's VA treating clinicians, and the symptoms reported on VA examinations and by the Veteran's private psychologist. In this regard, the Veteran has always denied experiencing suicidal thoughts or ideation to his VA treating clinicians, frequently reporting that he enjoys life during his 2008 and 2009 treatment. However, when presenting for VA examinations, he has alleged that he does experience such ideation, but has no plan. Indeed, even when faced with the significant stressors of the death of his niece's husband and death of his dog, he denied experiencing suicidal ideation. At one point he reported that he had been trying to get a pilot's license but was not motivated. However, he was later noted to have his pilot's license in 2009. The letter from the private clinician indicated that the Veteran has tried to work but has never been successful. Yet, the VA treatment records reflect that the Veteran owns his own graphic design business. While the Veteran contends that he totally backed off the business in 2008, and recently reported to his VA examiner that he retired in 2007, VA treatment records note he runs the business with his son, that it was stressful, and in 2011 expressed a desire to get out of the business. Such is clearly inconsistent with the private clinician's inference that the Veteran has never worked successfully. Moreover, the private physician reported to social security that the Veteran's speech was slow and deliberate. However, the Veteran has never been noted to have impaired speech during treatment or VA examinations. The private clinician has noted the Veteran has significant social impairment, yet VA treatment records note the Veteran reports a good relationship with his wife, and reported on the 2011 VA examination that he goes out for beers with a close friend twice a week. Due to the inconsistencies in the private records when compared with the Veteran's own statements and the other medical evidence of record, the Board finds the statements from the private clinician are afforded little probative weight. See Madden v. Gober, 123 F.3d 1477, 1481 (Fed. Cir. 1997) (the Board is entitled to discount the weight, credibility, and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence). Moreover, the Board finds the extent of symptomatology reported to VA examiners has been somewhat inconsistent with that reported to VA treatment providers. As noted above, the Veteran recently indicated to the VA examiner that he retired in 2007 and that there had been no remission in PTSD symptoms. However, VA treatment records note variable improvement in symptoms, noting that he is calmer and less anxious at times with changes in medication. Moreover, these records suggest his interest and involvement in his business is greater than reported to the VA examiner. In short, the Veteran's self-reported functioning and symptoms when seeking VA treatment are inconsistent with the severity of symptoms being reported for purposes associated with his claim for an increased rating. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (VA cannot ignore a veteran's testimony simply because the veteran is an interested party; personal interest may, however, affect the credibility of the evidence). While the symptomatology such as depression, anxiety, and sleep disturbances have been consistently reported, symptoms to support a higher 70 percent rating have not been. While suicidal ideation is mentioned in VA examinations and the private report, the Veteran has always denied this during VA treatment. He has alleged significant work impairment, yet treatment records suggest he is significantly more involved in his business than is being reported during VA examinations, and the private provider appears under the impression that the Veteran cannot work and has never been successful with working. The Board finds the VA treatment records to be more credible and probative than the information being provided during VA examinations and by the private provider for the purposes of seeking higher compensation benefits. The Board acknowledges there is some occupational and social impairment, which is consistent with the 50 percent evaluation assigned. However, notwithstanding the varying GAF scores assigned, the Veteran has not been shown to have deficiencies in most areas. In this regard, his judgment and thinking have been noted to be good in the probative evidence, he is participating in the activities of the graphic design business he owns (notwithstanding that he reports that he does not take an income from it), and his relationship with his wife has been reported as good. While he has reported problems with mood, such is contemplated in the 50 percent rating criteria. Accordingly, upon review of the record and for the reasons set forth above, the Board finds that the preponderance of the credible and probative evidence is against the claim for an evaluation in excess of 50 percent for the period prior to April 4, 2012. For the period beginning April 4, 2012, the Board finds that the Veteran's symptoms do not more nearly approximate total occupational and social impairment. As noted above, the reports from the Veteran's private treatment provider that the Veteran tried to work on several occasions but has never been successful and that he is unemployable due to medical condition and emotional status, are inconsistent with reports to VA treatment providers and are not probative. Indeed, the evidence reflects the Veteran owns his own graphic design business and was involved in the activities thereof with his son. Thus, total occupational impairment is not shown. Nor is the Veteran is totally impaired socially. He remains married and has a relationship with his wife and family members, and noted that he does go out for beers with a close friend twice a week. The probative medical evidence also does not reveal such symptoms as gross impairment in thought processes and communication. In this regard, he was coherent in his examinations and able to communicate effectively with the examiner. He never exhibited delusions or hallucinations. He has never reported nor has any clinician indicated that his behavior is grossly inappropriate and he has not been assessed as in persistent danger of hurting himself or others. There is no indication that he is a persistent danger to himself or others, nor do even the lower GAF scores reported suggest that any clinician believes such to be true. He is able to maintain his personal hygiene and is oriented times three. In addition, while memory issues have been noted, he did not report forgetting the names of close relatives, his own occupation or his own name. Accordingly, the preponderance of the evidence is against a finding that the Veteran's PTSD with major depressive disorder has resulted in total occupational and social impairment. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extra-schedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The Court has set out a three-part test for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the rating criteria contemplate the Veteran's disability from his service-connected PTSD with major depression. Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology and provide for additional or more severe symptoms than currently shown by the evidence. Indeed, psychiatric symptoms not specifically mentioned in the rating schedule are to be considered when evaluating psychiatric disorders, as the focus in evaluating such claims is the overall impact a veteran's specific psychiatric symptoms have upon his level of occupational and social functioning. See Mauerhan, 16 Vet. App. 436. Thus, the Board concludes that the Veteran's level of occupational and social impairment is adequately reflected by the current schedular ratings. As such, the Board finds that the manifestations of the Veteran's PTSD are contemplated in the rating criteria. There is no indication of any exceptional or unusual disability picture. The rating criteria are therefore adequate to evaluate the Veteran's service-connected PTSD and referral for consideration of extraschedular rating is not warranted. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b) (West 2002); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). ORDER Entitlement to a rating in excess of 50 percent for PTSD, for the period prior to April 4, 2012, is denied. Entitlement to a rating in excess of 70 percent, for the period from April 4, 2012, is denied. REMAND Finally, 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, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). TDIU may be a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, entitlement to a TDIU has been raised by evidence of record, and therefore must be addressed on remand. The Veteran has not received notice pursuant to the VCAA concerning a claim for a TDIU. In addition, he should be asked to complete a TDIU claim form so he can provide information concerning his employment, education, training, and other relevant factors. The Board notes that the Veteran has not been provided with VCAA notice of the requirements for a TDIU claim. Such should be accomplished on remand. Additionally, the Veteran should be asked to complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, especially in light of the evidence suggesting he owns his own business and has been working there with his son. Further, the Veteran should also be asked to submit copies of his tax returns for the period of the claim to establish that he has not, in fact, been receiving income from his business during the period in question. Accordingly, the case is REMANDED for the following action: 1. Send the Veteran proper VCAA notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) that advises the Veteran about what is needed to substantiate a claim for a TDIU. The Veteran should be asked to fully complete a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. 2. Ask the Veteran to submit copies of his income tax returns for 2008 to the present, to verify whether he receives income from his business. 3. After the above has been completed to the extent possible, the RO/AMC should adjudicate the claim for a TDIU. If additional development is necessary, such as obtaining a medical opinion as to whether the Veteran is unemployable due to PTSD with major depression, such should be accomplished. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC), which includes the relevant laws governing claims for TDIU, and be given a reasonable opportunity to respond. Thereafter, the issue should be returned to the Board if in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ K. A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs