Citation Nr: 1309864 Decision Date: 03/22/13 Archive Date: 04/01/13 DOCKET NO. 10-00 950 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE 1. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to total disability based on individual unemployability (TDIU), on an extraschedular basis. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD M. H. Stubbs, Counsel INTRODUCTION The Veteran served on active duty from November 1967 to March 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. The Veteran requested and was scheduled for a Board hearing via videoconference. He was given notice of the date of his August 2010 hearing in May 2010, but he failed to report for his scheduled hearing. This appeal was previously before the Board in September 2011 and September 2012. The Board remanded the claim so that treatment records could be requested, the AMC could readjudicate the issue after the addition of new evidence, and so the Veteran could be scheduled for a VA examination. The case has been returned to the Board for further appellate consideration. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDING OF FACT For the entire period on appeal the Veteran's PTSD manifested in occupational and social impairment with reduced reliability and productivity; however, occupational and social impairment with deficiencies in most areas is not shown at anytime during the course of the appeal. CONCLUSION OF LAW The criteria for a rating in excess of 50 percent, for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented at 38 C.F.R. § 3.159, amended VA's duties to notify and assist a claimant in developing the information and evidence necessary to substantiate a claim. First, VA has a duty under the VCAA to notify a Claimant and any designated representative of the information and evidence needed to substantiate a claim. In this regard, letters to the Veteran from the RO (to include letters in December 2007 and August 2008) specifically notified him of the substance of the VCAA, including the type of evidence necessary to establish an increase in severity of a service-connected disability, and of the division of responsibility between the Veteran and the VA for obtaining that evidence. Consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), VA essentially satisfied the notification requirements of the VCAA by way of these letters by: (1) informing the Veteran about the information and evidence not of record that was necessary to substantiate his claim; (2) informing the Veteran about the information and evidence VA would seek to provide; (3) informing the Veteran about the information and evidence he was expected to provide; and (4) requesting the Veteran to provide any information or evidence in his possession that pertained to the claims. The letters additionally informed the Veteran of how VA determines disability ratings and effective dates. Dingess v. Nicholson, 19 Vet. App. 473 (2006) Second, VA has made reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate his claims. 38 U.S.C.A. § 5103A. The information and evidence associated with the claims file include VA medical treatment records, private post-service medical treatment records, VA examinations, and statements and testimony from the Veteran, his relatives and his representative. With respect to the medical evidence of record, the various examination reports and treatment records including the October 2011 VA examination report, contains finding that are adequate to make an informed decision on the merits of the claim. The report of examination reflects that the examiner reviewed the Veteran's past medical history, recorded his current complaints, conducted an appropriate examination, and rendered an appropriate diagnosis consistent with the remainder of the evidence of record. The Board therefore concludes that the evidence of record is sufficient to rate the Veteran's disability under the appropriate rating criteria. See 38 C.F.R. § 4.2 (2012); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). There is no indication that there is any additional relevant evidence to be obtained by either VA or the Veteran. Laws and Regulations Disability evaluations are based upon the average impairment of earning capacity as determined by a schedule for rating disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate rating codes identify the various disabilities. 38 C.F.R. Part 4. In determining the current level of impairment, the disability must be considered in the context of the whole-recorded history, including service treatment records. 38 C.F.R. §§ 4.2, 4.41. The determination of whether an increased evaluation is warranted is based on review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. An evaluation of the level of disability present also includes consideration of the functional impairment of the veteran's ability to engage in ordinary activities, including employment, and the effect of pain on the functional abilities. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-06 (1995). Under the laws administered by VA, the Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 4.3. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 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. 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. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. In November 2007, the Veteran filed a claim for an increased rating for his service-connected PTSD. In a March 2008 rating decision, the RO granted an increased rating of 50 percent for PTSD, effective the date of the Veteran's claim (November 27, 2007). In July 2008, the Veteran expressed his desire to appeal the 50 percent rating he was assigned, and indicated his belief he was 100 percent disabled due to his PTSD. Subsequent January, March and July 2009 rating decisions continued the Veteran's 50 percent rating. Under Diagnostic Code 9411, for PTSD, a 50 percent rating is assigned when there is 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. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relationships, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals 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 worklike setting); inability to establish and maintain effective relationships. Lastly, a 100 percent evaluation 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; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, DC 9411. The Global Assessment of Functioning (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health- illness." [Citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.), p.32.] GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect 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). See also 38 C.F.R. § 4.130 [incorporating by reference the VA's adoption of the DSM-IV, for rating purposes]. Factual Background and Analysis VA treatment record from April 2007 included a diagnosis of PTSD and an assigned GAF score of 60. The Veteran reported good and bad days, and "mostly though [his] days are good." He reported good rest at night for seven or eight hours, with nightmares twice a week. He was neatly dressed and friendly during treatment. He was oriented, cooperative and coherent. He had an appropriate affect and denied suicidal and homicidal ideation. In August 2007, the Veteran reported his medication was not allowing him to have a full night's sleep and function in the morning. He continued to be neatly dressed, cooperative and coherent. He denied suicidal and homicidal ideation, and had a full and appropriate affect. He was assessed with PTSD and depressive disorder and assigned a GAF of 55. In November 2007, when the Veteran filed a claim for an increased rating for PTSD, he provided a private medical assessment from K.A., a licensed social worker. The October 2007 assessment noted the Veteran had been married twice and had three children. He worked full time from discharge to 1996, when he retired from Cooper Tire. Mental status evaluation revealed the Veteran had logical and sequential thoughts, good eye-contact, and fair insight and judgment for normal events. His cognitive function was noted to be in the low-average range. There was no presence of hallucinations, delusions, psychoses or thought disorders. He reported sensory illusions in the periphery of his vision "that is a function of his environmental visual awareness that is super sensitive to any type of movement that may be danger." His speech was clear and well-modulated. He had "marked short-term memory and concentration impairments that interfere significantly with his ability to remember and to complete rather simple instructions and plans." He had on-and-off recurrent depressive episodes which would last a few hours to a few days and then remiss. His depressive episodes were "characterized by feelings of helplessness; hopelessness; loss of interest, energy and motivation; sleep problems; nightmares; night sweats; suicidal ideation without plan or interest." Emphasis in the original. He additionally endorsed homicidal ideation, also without plan or intent, which K.A. attributed to his anger and sensitivity to injustice. He had panic attacks during the day and at night, when he would awaken from nightmares with rapid heartbeat, sweats, rapid breathing, fear and a sense of doom. He also endorsed recurrent and intrusive memories, sensory triggers, hyperarousal symptoms and avoidant behavior. He was assessed with chronic PTSD, and assigned a GAF of "no higher than 45 in the past year." In January 2008, the Veteran was afforded a VA PTSD evaluation. He underwent a clinical interview, his claims file was reviewed, and he was administered psychiatric tests. He reported PTSD treatment since 2002, with medication that did help him sleep, although he noted he had good and bad days. He was not involved in any counseling. He reported a history of heavy alcohol consumption and marijuana use in service, with occasional marijuana use since. He denied current substance abuse problems. He described symptoms of "being upset over the Iraq war on television," irritability, mood instability, anxiety, and some sleep disturbance ("sleeps ok with his medication"). He reported being reprimanded at work due to his anger. He also endorsed visual and auditory hallucinations (car doors slamming, shadows). He reported experiencing flashbacks three times a week and nightly nightmares when he is off medications. His nightmares decreased to once or twice a week while on medication. His irritability included anger control problems which were exhibited towards his wife and children, and that he felt distant from his children. One of his daughters died in an automobile accident in 2002. On mental status evaluation, the Veteran became "agitated and negative in the interview," however, once a rapport was established he "calmed down." He was logical coherent and relevant. He had poor social skills, but was well-dressed and well-groomed. He was impulsive and agitated; however, his speech was well understood. He was oriented to time, place, person and situation. He had some degree of psychomotor restlessness. And while his verbal communication was good, he seemed distractible. He reported a poor short-term memory. He indicated he had homicidal ideation but not suicidal ideation. He also reported "road rage." Psychometric testing revealed the Veteran was of average intelligence, and he produced an exaggerated response during the Minnesota Multiphasic Personality Inventory-2. He was assessed with PTSD and assigned a GAF of 55. A VA treatment record from February 2008 included complaints of increased mood disturbance and irritability. The Veteran's treating psychiatrist prescribed a different medication and assigned a GAF of 50. The Veteran was noted to be friendly, neatly dressed, coherent, and had an appropriate affect. He denied suicidal and homicidal ideation, and denied auditory hallucinations, but reported seeing shadows. He also endorsed anxiety. In April 2008, the Veteran reported being annoyed with a car repair shop that he felt had misused his vehicle while it was in their care. Otherwise, however, he reported his new medications were working and he felt calmer and less irritable. He was neatly dressed, friendly, oriented, cooperative, and coherent. He was slightly angry, but nonspcyhotic. He denied suicidal or homicidal ideation. He was assigned a GAF of 55. A July 2008 medical assessment update from licensed social worker K.A. included a diagnosis of PTSD, but was missing a page which may have included a GAF score. Attempts to have the Veteran submit forms providing the VA with consent to obtain private treatment records were not fruitful as he responded by stating he received all treatment from the VA. While the second page is missing, the third and final page of the assessment noted the Veteran endorsed symptoms of forgetfulness, isolation, numbing, emotional distancing, hyperarousal, intrusive memories, sleep disturbance, nightmares, panic attacks, "sensitivity to injustices, problems with authority figures," anxiety, irritability, and a lack of social outlets or activities. K.A. indicated that the Veteran's symptoms occurred during anniversary periods and he otherwise had "pretty good" judgment for normal events. During the anniversary period is insight and judgment are impaired and his "potential for harm to others increases markedly." He reported becoming spatially disoriented and needing to sit still until he is reoriented. He had "no capacity to adjust to new or stressful situations...his disorder interferes markedly in all areas of his life." In August 2008, the Veteran's brother described increased PTSD symptoms due to irritability (including road rage), and isolation from friends and family. He also reported the Veteran "saw things" including shadows, and heard helicopters that were not there. He stated the Veteran reported difficulty sleeping, with nightmares and night sweats. He also felt that the Veteran had a poor memory as he was always writing things down and keeping a calendar. In October 2008, the Veteran was afforded another VA PTSD evaluation. He reported mental health treatment every three months, and was on anti-anxiety medication. He reported his treatment was "fair" but that his PTSD symptoms had not improved. He described changes in mood, where he would be "at times good," and then he would no longer want to be around anyone, family included. He stated he did not have any close friends and preferred to be alone. He reported he liked to fish and ride his horse, and he enjoyed watching football and basketball. He also did his own yard work. He reported road rage, but stated he had not ever had a physical altercation and had never assaulted anyone. He did report verbally assaulting others. On mental status evaluation, he was tense, with slurred and mumbled speech. He was hostile, suspicious, contemptuous, irritable, aggressive and sarcastic. His affect was inappropriate, and he reported he was angry. He had attention disturbance and an evasive thought process. He endorsed sleep impairment and hallucinations. He denied obsessive or ritualistic behavior. He reported having panic attacks several times a week, sometimes lasting 30 minutes, and sometimes he would cry and want to be left alone. He reported his angry moods caused family members (grandkids) to be afraid of him. He reported drinking some moonshine on Labor Day, and the use of cannabis the day before the VA examination. He had mildly impaired memory, due to impaired attention and concentration. Psychiatric testing showed PTSD and a "severe personality disorder, somatoform disorder, psychosis, and alcohol and cannabis abuse." He was diagnosed with schizoaffective disorder, pain disorder with psychological factors, drug-induced mood disorder and PTSD. The examiner noted the Veteran's "severe personality disorder is independently responsible for impairment in psychosocial adjustment and a lowered quality of life. She also noted that "his severe personality disorder would overwhelmingly interfere with his ability to psychosocially function in an occupational environment. His PTSD signs and symptoms would have a mild impact upon his functioning as far as routine behavior, self-care and ability to communicate." In a December 2008 addendum, the evaluator noted the Veteran's pain disorder was independently responsible for impairment in his quality of life and would result in problems with calculations, attention and concentration, and in psychosocial adjustment, making him more irritable and unable to concentrate when he is in pain." She continued that "because depression is associated with [all of the Veteran's diagnoses], it is virtually impossible to try to separate out which specific symptoms are attributed to each diagnosis since the all involve depression." The overall GAF score for the Veteran was assigned as 56 (indicated as the GAF score if the Veteran was not using alcohol or marijuana), and the evaluator noted it would not be possible to assign GAF scores for individual diagnoses. A VA treatment record from December 2008 included the Veteran reporting that he was "all right." But that he would cry during certain television programs, and that he continued to have nightmares and would "see things" (for example: bugs). He reported his pain made "things worse." He was neatly dressed, friendly, alert, coherent, and cooperative. His affect was anxious. He denied suicidal or homicidal ideation. He described "being under more subjective stress and pain issues." He felt depressed and was overly sensitive to sad movies. He was assigned a GAF of 55. In April 2009, the Veteran vented his frustration with the VA compensation process with his VA psychiatrist. He indicated that the VA examiners had misreported information and that he had not drink or use drugs currently, that he had quit drinking alcohol in 1996 and that he had not smoked marijuana since service. He was agitated and his speech was louder than normal. He was neatly dressed and cooperative, but anxious. He reported physical side effects of a recently prescribed medication, which the psychiatrist changed during the visit. He was assigned a GAF of 45. In July 2009, the Veteran reported having mood swings, including crying over nothing for 15 minutes and then returning to normal. He reported sleeping well after the change in medication in April. He continued to lament against the 2008 examiner noting that he abused alcohol and marijuana. He stated he only abused alcohol and marijuana while in the service. He was neatly dressed, oriented, cooperative and coherent. He denied suicidal and homicidal ideation. He reported he was not being compensation for his PTSD. He also reported mood swings with down spells with crying and problems with irritability and friction with his family. He was assigned a GAF of 50. The VA psychiatric provided a written letter to the RO, where she (gender neutral name) described the Veteran as suffering from "significant problems with PTSD." She noted he used alcohol and marijuana to self-medicate during service and for several years after service, but that he had discontinued substance-abuse in the 1990s. She noted his PTSD symptoms included: flashbacks, nightmares, insomnia, anxiety and depression. She also noted his symptoms had "recently worsened." A week later, in July 2009, the Veteran reported to a VA nurse that he continued to have depression, but that his new medication helped him to sleep sound and had improved his mood some. By November 2009, the Veteran reported decreased symptoms on his new dose of Zyprexa. His overall mood and irritability were better, although he still cried at times. He said his girlfriend indicated he was "overall better." His VA treating psychiatrist assigned a GAF of 55. In June 2010, the Veteran reported nightmares and flashbacks to a new VA psychiatrist. He denied auditory and visual hallucinations. He also reported living alone, but noted he had a fiancé. He was irritable and angry, but well-groomed. He had a depressed mood and a restricted affect. He denied suicidal and homicidal thoughts. He was assigned a GAF of 55. In October 2011, the Veteran was afforded a fee-basis VA PTSD evaluation by a different evaluator than the 2008 evaluator. The evaluator diagnosed the Veteran with PTSD and depressive disorder, and found that it was not possible to differentiate symptoms between the different diagnoses. The evaluator noted the Veteran's PTSD resulted in occupation and social impairment with reduced reliability and productivity, but did not result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported he was married to his second wife, and they had been married for nearly 20 years. He reported the marriage was difficult because of his irritability and anger, but pointed out he was never actively violent. He reported loving his grown children but recognized he hurt their feelings with things he would say to them. He reported "snapping" at family members when he is irritable. He stated he did not have friends but that he was sociable with his neighbors. He stated he generally worked in his yard or watched television. He noted that his medication "helped to a point" in that it helped with his sleep and his nightmares, but it did not help with his intrusive thoughts. He stated that he would occasionally drink beer, but that he does not abuse alcohol. He also reported he is not supposed to drink alcohol with his current medications. He denied using "street drugs" but had a "remote" history of marijuana use. The Veteran endorsed nightmares, flashbacks, hallucinations, diminished interest in activities, avoidance behavior, feelings of detachment, irritability, hypervigilence, exaggerated startle response, depressed mood, anxiety, mild memory loss, chronic sleep impairment, and impaired impulse control. On mental status evaluation, the Veteran was neat, clean, and casually dressed. He had no abnormal movements or mannerisms. His speech was normal, although "there are some long response latencies when asked to identify specific functional deficits associated with his reported symptoms." He reported a depressed mood with crying spells and poor motivation and energy. He was alert, oriented, and had a normal thought process. He indicated he had hallucinations of bugs and shadows walking past on a daily basis. He did not report auditory hallucinations. He admitting having homicidal ideation at times but denied a plan or intent or identified victims. He denied suicidal thinking. He reported having difficulty remembering appointments, birthdays, and family events. He described daily intrusive memories, but could not provide specific functional deficits associated with the memories. He indicated he does not like frequenting stores or working with people who look Vietnamese. He stated he used to enjoy fishing, camping and horseback riding, but that he no longer participates in these activities. He does not indicate if that is due to disinterest or physical impairment. He noted his wife wishes he would socialize more. He reported fighting in his sleep, and if he does not take his medication he is sometimes unable to sleep. He had a distant relationship with his siblings, although he would talk to one sister. He described anger manifesting as road rage or irritation with his children. He participated in psychiatric testing, including the MMPI-2, which showed "strong evidence of symptom exaggeration." The profile the test revealed was "consistent with people who are in moderate psychological distress with hostility, suspiciousness, and paranoia." His scores on the Mississippi Scale test were consistent with moderate PTSD. Testing also suggested depression. The fee-basis evaluator noted that the Veteran's PTSD did not render him unemployable (less likely than not). The evaluator noted that when he was asked why he retired from Cooper Tire he reported it was due to medical reasons, but in 2010 in support of his VA claim he reported it was due to his mental condition. The evaluator noted his GAF scores from three different providers had been 55 since November 2009, which are indicative of moderate symptoms. The evaluator noted his testing during the 2011 evaluation also revealed moderate symptoms. The evaluator assigned a GAF of 55. In January, September, October and November 2011, the Veteran reported he continued to see and hear things. In January, he indicated he had good and bad days. He reported enjoying the holidays with his family. In November, the care provider indicated that that his auditory and visual hallucinations may be related to or affected by his cerebrovascular accident. He reported sleeping better. He was assigned a GAF of 55 on all dates (by two different providers). His medication was increased. By December 2011, he reported seeing and hearing "things" less frequently. He reported waking up "feeling better" and he would get out of bed and go outside. He stated he was not as aggressive and was getting along better with his wife. He was assigned a GAF of 55. VA treatment records from September 2012 included statements from the Veteran that he was sleeping well, and getting out of bed earlier. He stated he "felt great" and he denied suicidal and homicidal ideation. There was no evidence of hallucinations, delusions or psychosis. He was diagnosed with schizoaffective disorder and PTSD and assigned a GAF of 60. In October 2011, someone who indicated she was the Veteran's wife provided a letter describing his PTSD symptoms. She indicated he had mood swings and depression for a long time and that he does not like when people "get into his space." She indicated he had changed a lot in the last few years and that he was selfish and mean. She also stated his nightmares were getting worse, and that he would call out in his sleep. She also stated that sometimes he would not sleep very for days and other times he would sleep for "hours on end." She also reported he did not want to see his family or go shopping because he preferred to be alone and away from people. An undated letter, written on the same paper as the October 2011 letter, is noted to be from the Veteran's sister. She also noted he was irritable and had difficulty sleeping. She indicated that he would "fight" in his sleep due to his nightmares and that he scared his wife. She also reported that he would sometimes be "zombie"-like and not want to get up or talk to anyone. In adjudicating a claim, the Board must assess the competence and credibility of the Veteran. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board also has a duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001). The Board acknowledges that the Veteran is competent to give evidence about what he experienced. See Layno v. Brown, 6 Vet. App. 465 (1994). Competency of evidence, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); see also Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). See also Buchanan, (The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. If the Board concludes that the lay evidence presented by a veteran is credible and ultimately competent, the lack of contemporaneous medical evidence should not be an absolute bar to the veteran's ability to prove his claim of entitlement to disability benefits based on that competent lay evidence.) Here, the Board finds that the lay statements of the Veteran are only somewhat credible. While the Board believes the Veteran has not had any substance abuse problems during the pendency of this appeal and finds that he is credible in reporting his symptoms, the Board also finds that he was not entirely credible in reporting the severity of his symptoms. The Board notes that the Veteran continued to state that his symptoms were worsening to the RO and Board, while telling his treatment care providers that his symptoms were improving between 2009 and 2012. He additionally would endorse homicidal or suicidal ideation to VA examiners and in statements to the RO, but would deny the same to his treating psychiatrist. As noted by his 2011 VA evaluator he indicated he medically retired from Cooper tire during his October 2008 and 2011 evaluations and reported he retired due to an on-the-job injury to his back during his January 2008 evaluation, but provided a statement to the RO in 2010 that he had to retire due to his mental illness. Most importantly, testing during the October 2008 and October 2011 evaluations returned results of exaggeration of symptoms. The lay statements of relatives in the record are regarded as credible and indicate the Veteran has mood swings, irritability, sleep disturbances, and prefers to avoid social situations. Throughout the period on appeal, the Veteran has endorsed symptoms of depressed mood and disturbances in mood, sleep disturbance, nightmares, hypervigilence, intrusive thoughts, mild memory impairment, irritability, and decreased social interaction or participation in hobbies. He was noted on occasion to have loud or fast speech, but was always coherent and logical/understandable. He also reported panic attacks and night sweats connected to his nightmares. These symptoms are all consistent with criteria for a 50 percent rating. The record does not reflect that the Veteran suffered from symptoms such as illogical speech, obsessive rituals, near-continuous panic attacks or depression, impaired impulse control, neglect of personal appearance and hygiene or an inability to establish and maintain effective relationships. While the Veteran had disturbances in mood, he indicated good and bad days and on and off symptoms. Additionally, while the Veteran tended to express irritability and anger throughout the appeal period, he was able to control his impulses. Lastly, while it appears the Veteran divorced during the pendency of this appeal, he also began a new relationship and became engaged. He maintained relationships with his children, grandchildren, brother, sister, and neighbors. He appeared to have difficulty establishing and maintaining relationships, as consistent with a 50 percent rating. Regarding the Veteran's continued report of auditory and visual hallucinations, while the Board believes that he exaggerates his PTSD symptoms, the Board also finds that he is credible in reporting his hallucinatory symptoms. The criteria for a 100 percent rating include symptoms such as persistent hallucinations. The Board also notes the private licensed social worker K.A. indicated that during anniversary periods (such as the end of March) the Veteran's symptoms can increase so that "his potential to harm others increases markedly" and so that he becomes spatially disoriented. K.A. also indicated the Veteran is "unable to adjust to new or stressful situations." The symptoms noted by K.A. are more significant than any symptoms the Veteran reported to VA treatment providers or VA evaluators. When he endorsed homicidal ideation, he did not have a person or plan in mind, and when he consistently described road rage he noted that he had never been in an altercation with anyone. Additionally, while K.A. provided a GAF of 45 in October 2007, in April 2007 (close to his anniversary period) the Veteran had a GAF score of 60, and in August 2007 a GAF score of 58. As the Veteran did not describe symptoms of the severity noted in K.A.'s report to his psychiatrist, and psychological testing revealed he would on occasion exaggerate symptoms, the Board finds that the findings of K.A. are not as pertinent as those of the treating VA psychiatrist and VA evaluators. Global assessment of functioning scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the rating issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). The Veteran's GAF scores during this appeals period ranged from 45 to 60, which are reflective of moderate to severe symptoms. The Veteran had GAF scores of 45 in October 2007 and April 2009. The October 2007 GAF score was provided by K.A., and notably the Veteran's GAF score from his treating psychiatrist in August 2007 was 58. In April 2009, the VA treating psychiatrist provided a GAF score of 45, and noted the Veteran angry with the VA for not providing him with a higher rating. This treatment date would have also been within a couple weeks of his noted anniversary date. The majority of the GAF scores of record are 55, including from 2009 to 2012 when four different treatment providers assigned GAF scores of 55. The Board considered the GAF scores in the context of the entire record and finds that the preponderance of the evidence compels a finding that a 50 percent rating is warranted as both the GAF scores and the symptoms documented in the record are of an overall moderate severity during that term. Thus, while the Veteran's his credible complaints of hallucinations are consistent with the symptom criteria of a higher evaluation, the overall disability picture more nearly approximates the criteria described in a 50 percent rating. The indication of increased symptoms during an anniversary period does not equate to the next higher rating. As noted above, a mental disorder must be evaluated based on an overall severity of symptoms, including the frequency, severity, and duration of symptoms, and length of remission. 38 C.F.R. § 4.126. The Board considered the propriety of a referral for extraschedular consideration. See 38 C.F.R. § 3.321(b)(1). The evidence of record shows the rating criteria for the Veteran's PTSD adequately describes the symptoms and severity of the disability and addresses them with the scheduler ratings thereunder. This Veteran's disability picture is not exceptional. See Thun v. Peake, 22 Vet. App. 111 (2008). While the Veteran indicated he was forced to retired due to his mental condition, he also indicated he never missed work due to his PTSD, and he was forced to retired due to an on-the-job spine injury. There is no indication he has been hospitalized for his PTSD, and, in fact, he does not participate in counseling. In the absence of an exceptional disability picture, referral for extraschedular consideration is not indicated. 38 C.F.R. § 3.321(b)(1). ORDER Entitlement to a rating in excess of 50 percent for PTSD is denied. REMAND TDIU Benefits 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. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The Court has held that a claim for individual unemployability may be a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). The critical question is whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disability. Service connection has been established for PTSD with a rating of 50 percent disabling. He does not have any other service-connected disabilities, thus, his combined disability rating clearly does not meet the minimum percentage requirement for TDIU under 38 C.F.R. § 4.16(a). Where the percentage requirements for TDIU benefits under 38 C.F.R. § 4.16(a) are not met, entitlement to the benefit on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. VA has the duty to supplement the record by obtaining an examination which includes an opinion on what effect the Veteran's service-connected disability has on his ability to work. See Friscia v. Brown, 7 Vet. App. 294 (1994) (holding in the case of a claim for TDIU, that VA has a duty to obtain medical opinions as to employability). In awarding a TDIU, consideration is given to the Veteran's background, including his employment and educational history. Records show that the Veteran no longer maintains steady employment. While the December 2008 addendum and October 2011 VA evaluation report indicate the Veteran's psychiatric disorders do not render him unemployable, his levels of education and any continuing training are not indicated. The Veteran also described specific incidents at work where he felt his PTSD symptoms jeopardized his employment. The claims file additionally contains a July 2008 statement from a private licensed social worker that the Veteran's PTSD markedly interferes with all aspects of his life, and a 2010 statement from the Veteran that he had to retired due to his mental condition. As the current TDIU opinions are not adequate, the claims file should be remanded for an opinion on the Veteran's ability to retain or maintain any gainful employment that takes into account solely his service-connected disability, as well as his educational and employment history. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC is to provide the Veteran corrective VCAA notice which informs the Veteran of the evidence necessary to establish TDIU. 2. The Veteran should be asked to complete a VA Form 21-8940 (Veteran's Application for Increased Compensation based on Unemployability). He should provide specific information about any attempts he has made to obtain employment since retirement. After obtaining this information, provide a VA Form 21-4192 to any prior employer(s) referenced by the Veteran. 3. Afford the Veteran an appropriate VA evaluation to obtain an opinion as to the impact of the service-connected disability on the Veteran's ability to work. The Veteran's claims file, to include a complete copy of this REMAND, and access to Virtual VA must be provided to the examiner(s) designated to examine the Veteran, and the examination report(s) should note review of the file. The examiner(s) should interview the Veteran as to his employment and education history. The examiner(s) should provide an opinion as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that the service-connected PTSD precludes employment (marginal employment is not considered employment) consistent with the Veteran's education and occupational experience, without taking into account his age or any nonservice-connected disabilities. The examiner(s) should set forth a rationale for the conclusions reached. 4. After ensuring that the requested actions are completed, the RO or AMC should re-adjudicate the claim on appeal. If the benefits sought are not fully granted, the RO or AMC must furnish a supplemental statement of the case (SSOC), before the claims file is returned to the Board, if otherwise in order. No action is required of the Veteran and his representative until they are notified by the RO or AMC; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs