Citation Nr: 1310169 Decision Date: 03/26/13 Archive Date: 04/02/13 DOCKET NO. 07-21 895 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for the period prior to July 10, 2007; entitlement to a disability rating in excess of 30 percent for the period from October 1, 2007 to October 12, 2011; and in excess of 70 percent for the period beginning October 13, 2012; for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A. Haddock, Associate Counsel INTRODUCTION The Veteran had active service from April 1967 to June 1969, with service in the Republic of Vietnam, for which he received a Combat Action Ribbon. He also had subsequent periods of active service from October 1991 to February 1992 and July 1992 to September 1992, with additional service in the United States Marine Corps Reserves. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2005 rating decision by the Waco, Texas Department of Veterans Affairs (VA) Regional Office (RO). This case was previously remanded by the Board in October 2010 for further development. The Board notes that during the pendency of this appeal the Veteran was granted a temporary total disability rating in an October 2007 rating decision for the period beginning July 10, 2007, based on the Veteran's need for a period of inpatient PTSD treatment. The October 2007 rating decision also reassigned a 30 percent disability rating beginning October 1, 2007, for the period following the Veteran's inpatient treatment. Additionally, in a December 2011 rating decision the RO assigned the Veteran a 70 percent disability rating, effective October 13, 2011. Therefore, the Board has limited its consideration accordingly. The Board has reviewed the Veteran's physical claims file and his file on the "Virtual VA" system to insure a total review of the evidence. As explained below, the Board has determined that it has jurisdiction over the issue of entitlement to a TDIU based on unemployability due to PTSD. As discussed below, the evidence currently establishes the Veteran's entitlement to a higher disability rating for PTSD. The Board has proceeded with a decision with regard to that issue and has addressed the issue of entitlement to a TDIU in the REMAND following the ORDER section of this decision. FINDINGS OF FACT 1. For the period prior to July 10, 2007, the occupational and social impairment from the Veteran's PTSD more nearly approximated deficiencies in most areas than occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks. 2. For the period from October 1, 2007, the occupational and social impairment from the Veteran's PTSD more nearly approximated total than deficiencies in most areas. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating of 70 percent, but not higher, for PTSD, for the period prior to July 10, 2007, are met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a disability rating of 100 percent for PTSD for the period beginning October 1, 2007, have been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran was granted entitlement to service connection for PTSD in a March 2005 rating decision and assigned an initial 30 percent disability rating, effective November 29, 2004. The Veteran appealed, requesting a higher rating. In January 2006 and August 2006 rating decisions, the RO continued the 30 percent disability rating, and the Veteran continued to appeal. In September 2007, the Veteran requested a temporary total disability rating on the basis that he had been in the hospital to receive inpatient PTSD treatment. In an October 2007 rating decision a temporary total disability rating was granted effective July 10, 2007 and a 30 percent disability rating was reassigned effective October 1, 2007. The Veteran perfected his appeal and in October 2010, the Board remanded the case for a new VA examination. Following the VA examination, in a December 2011 rating decision, the RO assigned the Veteran a 70 percent disability rating, effective October 13, 2011. The Veteran has continued his appeal as to the initial 30 percent disability rating assigned, the 30 percent disability rating assigned effective October 1, 2007, and the 70 percent disability rating assigned effective October 13, 2011. The Board notes it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. Psychiatric disability is rated under the General Rating Formula for Mental Disorders. PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides for a 30 percent evaluation for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss(such as forgetting names, directions, recent events). Id. A 50 percent evaluation is assigned 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 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; difficult establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is 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; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted where there is 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; and memory loss for names of close relatives, own occupation, or own name. Id. Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase 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 (2002). 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 on the basis of social impairment. 38 C.F.R. § 4.126(b). The Global Assessment Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996). A score of 31 to 40 reflects some impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood. A score of 41 to 50 is assigned where there are "[s]erious 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)." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV) 47 (4th ed. 1994). A score of 51 to 60 is appropriate where there are "[m]oderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers)." Id. A GAF score of 61 to 70 indicates the examinee has some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functions pretty well with some meaningful interpersonal relationships. Id. at 46. While particular GAF scores are not contained in the VA schedule of ratings for mental disorders, 38 C.F.R. § 4.130, they are a useful tool in assessing a Veteran's disability and assigning disability evaluations. However, they are just one of many factors considered when determining an evaluation. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two evaluations shall be applied, the higher rating 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. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, including degree of disability, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3 The United States Court of Appeals for Veterans Claims (Court) has held that when the rating appealed is the initial rating assigned with a grant of service connection, the entire appeal period is for consideration, and separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119 (1999). In March 2005, the Veteran was afforded a VA examination. At that time the Veteran reported that he experienced trouble sleeping; inability to fall asleep; nightmares that cause him to wake up fighting; waking up in cold sweats; and feelings of choking. The Veteran reported that once or twice a month, the nightmares were very severe and lasted for 30 seconds to 1 minute at a time. The Veteran reported that he had been married to his wife since 1971 and that he had two adult children and described his relationship with them as "fine." He reported that he drank alcohol daily, usually 3 to 4 beers a day, but sometimes up to 12 beers a day. However, he did report that he was trying to cut down on his alcohol consumption. The Veteran reported that he took prescription medication to manage his flashbacks caused by his PTSD. On mental status examination, the Veteran was found to maintain good eye contact and did not exhibit any inappropriate behavior. He had the ability to maintain his personal hygiene and his basic activities of daily living. He was not noted to have any impairment of thought processes or communication and he was orientated to person, place, and time. The Veteran did not experience any hallucinations, but did experience flashbacks of his time in the Republic of Vietnam. He denied suicidal or homicidal ideation and ritualistic behavior. He reported panic attacks brought on by watching the news about the current war and seeing the color red. He was noted to have minimal short-term memory loss and his mostly controlled impulse control. The Veteran was noted to be depressed with mild to moderate anxiety, sometimes severe. The examiner diagnosed PTSD and assigned the Veteran a GAF score of 50 and reported that the Veteran had mild to moderate depression, with substance abuse. He also noted that the Veteran had an anxiety disorder that included a hyper-startle reflex, a sensitivity to the color red, and the tendency to avoid crowds. In December 2005, the Veteran was afforded another VA examination. At that time the Veteran reported that he had been experiencing PTSD symptoms for 36 years. He reported nightmares once or twice a month and occasional flashbacks that were moderate in severity. The Veteran reported experiencing recurrent and intrusive distressing recollections of his time in the Republic of Vietnam, including images, thought, and perceptions. He reported that he avoided thoughts, feelings, and conversations associated with his time there; as well as activities, places, or people that aroused any recollections of his time there. The Veteran reported that he experienced irritability and outbursts of anger, difficulty concentrating, and exaggerated startle response. He also reported that he drank alcohol every day, fairly heavily. On mental status examination, the Veteran was found to be neatly groomed and appropriately dressed. His speech was unremarkable and his attitude toward the examiner was cooperative, relaxed, and attentive. His affect was constricted and he was not able to complete serial 7's. The Veteran was oriented to person, time, and place. His thought process was goal directed and relevant and his thought content was unremarkable. The Veteran did not experience delusions or hallucinations; however, his judgment was found to be partially impaired and he was noted to have mild sleep impairment. The Veteran did not exhibit any inappropriate behavior and denied any obsessive or ritualistic behavior. He also denied experiencing any panic attacks. The Veteran was found to have poor impulse control and was noted to have violent episodes. He denied suicidal and homicidal ideation and was found to be capable of maintaining minimum personal hygiene. The Veteran's remote, recent, and immediate memory was found to be moderately impaired and it was noted that he forgot things easily; he did not remember phone numbers or people's names, and would forget certain dates. The examiner diagnosed chronic PTSD with chronic alcohol abuse and assigned a GAF score of 55. The examiner reported that the Veteran had moderate difficulty in social and occupational functioning. The examiner explained that the Veteran had a fair functional status and a poor quality of life, but that his alcohol abuse was responsible for his poor quality of life, and that with treatment, he had a good prognosis. In March 2008, the Veteran was afforded another VA examination. At that time, the Veteran reported that he attended regular group and individual therapy. The Veteran also reported that he had received inpatient PTSD treatment from July 2007 through September 2007. He reported recurrent and intrusive distressing recollections of his time in the Republic of Vietnam and recurrent distressing dreams of his time there. He reported intense psychological distress at exposure to things that symbolized or resembled his time in the Republic of Vietnam and that he attempted to avoid such exposure. He reported efforts to avoid thoughts, feelings, and conversations associated with his time there and that he had a diminished interest in engaging in activities and felt detached or estranged from others. The Veteran reported difficulty falling or staying asleep, hypervigilance, and an exaggerated startle response. He reported that he did not go into public places, that he did not socialize, that holidays caused him to get depressed, that he tended to isolate himself, and that he felt anxious. The Veteran also reported that he had been married for 35 years and had two adult children. He reported that he and his wife "were just making it" and that they worked together running an auto body garage, but that they had different ways they wanted to run things. He reported that his relationship with his children was good. He reported that he had one friend that he grew up with and that was also a Vietnam Veteran and that he had a relationship with his brother. He reported leisure activities in the form of playing pool with his friend and restoring an old car. On mental status examination, the Veteran was found to be casually dressed with disheveled clothing. His psychomotor activity included hand wringing, restlessness, and chewing gum. The Veteran's speech was clear and coherent and his attitude toward the examiner was cooperative, friendly, attentive, and guarded. The Veteran's affect was constricted and his mood was slightly depressed with underlying anxiety. The Veteran was unable to do serial 7's, but was able to spell a word forward and backward. The Veteran was oriented to person, time, and place. His thought process was unremarkable, but he was noted to have suicidal ideation. The Veteran did not have any delusions or hallucinations, he was able to understand the outcome of his behavior, and he understood that he had a problem. He was noted to have a sleep impairment characterized by frequent intermittent awakening and nightmares, which left him tired the next day and slightly interfered with his productivity. The Veteran was found to exhibit inappropriate behavior in that he kept a loaded weapon under his bed for safety. He was not able to interpret proverbs appropriately. He did not report any obsessive or ritualistic behavior. The Veteran was found to have panic attacks once a month or less, of moderate intensity. He denied homicidal ideation, but, as noted above, reported suicidal ideation. The Veteran's impulse control was fair, he was able to maintain minimum personal hygiene, and he did not have problems with activities of daily living. The Veteran's memory was normal. The examiner diagnosed chronic moderate PTSD with depression and alcohol dependency in partial remission. The examiner explained that the alcohol dependency was in partial remission, as the Veteran still drank 2 to 3 beers a day in the evening and that the PTSD and depression are synergistic and ebbed and flowed together. The examiner assigned a GAF score of 60. The examiner reported that the Veteran had difficulty following instructions due to his PTSD, and that this caused problems related to his occupational functioning. In October 2011, the Veteran was afforded another VA examination. At that time the Veteran reported that he had distressing memories nearly every other day about his time in the Republic of Vietnam and that he had nightmares about once a night. He reported flashbacks that were triggered by rain and the sounds of war games from the Air Force Base near his home. He reported that hearing the war games caused him to startle and his heart to start pounding. He reported that he avoided talking or thinking about his time in the Republic of Vietnam and that he avoided activities that would remind him of his time there, i.e., Fourth of July celebrations and air shows. The Veteran reported that he stayed by himself all day and that he interacted with his wife as little as possible. He reported that he felt his future would be cut short. He reported trouble falling asleep and that he would frequently awake in the night. He reported that he easily became angry or irritable and that he had incidents of threatening and cursing with members of his church. He reported that he had difficulty concentrating and would frequently forget what he was going to do. The Veteran reported that he worked in an auto body shop behind his home that he owned with his wife. He reported that he only worked when he was hired for a job, and would typically do, at most, 3 jobs a month and work 20 to 30 hours a week. He reported that he began doing this work in 1974 after being fired from a car dealership, and that he did this work so that he did not have to take orders from anyone. The Veteran reported that he did not interact with customers, that his wife had performed that responsibility since 1985-86 after he got into an altercation with a customer. He reported that he had weapons in his shop behind his home, under his bed, and around his house. On mental status examination, the Veteran's mood was markedly distressed and highly agitated. The Veteran's affect was restricted. He had difficulty completing the serial 7's and was not able to say the months of the year in reverse order. The Veteran's speech was intermittently illogical, obscure, or irrelevant and he was noted to have impaired judgment. His thought processes were somewhat rambling and psychosis was indicated as the Veteran reported that he thought he heard voices and saw people when nobody was there. The Veteran had impaired impulse control, with unprovoked irritability and episodes of violence. Significant paranoid ideation was indicated, as the reason for the weapons in his home and shop and the Veteran reported that he believed he had special powers and that no one could mess with him. The Veteran was noted to have disturbances in motivation and mood and near continuous panic or depression that affected his ability to function independently, appropriately, and effectively. He was noted to be unable to establish and maintain effective work and social relationships and he had difficulty adapting to stressful circumstances. The examiner diagnosed PTSD and assigned a GAF score of 50. The examiner reported that the Veteran's PTSD symptoms caused total occupational and social impairment. The examiner went on to explain that the Veteran's social functioning was markedly limited and that he was profoundly socially withdrawn and isolated, even having minimal contact with his wife. The examiner reported that the Veteran attended a Veterans group therapy; however, he only minimally participated. Additionally, the examiner noted that the Veteran was unable to relate to customers at the business that he operated with his wife and as such his wife was required to interact with the customers. The examiner stated that the Veteran was barely able to tolerate the supportive, structured environment of the VA examination as he related in an agitated and hostile manner and needed redirecting to get him focused on the task at hand. Furthermore, the Veteran was unable to relate in a supportive environment, such as his church, as he acted out in a threatening and violent manner. The examiner opined that it was unlikely that the Veteran would be able to relate appropriately with supervisors, coworkers, or the public in a competitive work setting. A review of the record shows that throughout the pendency of this appeal, the Veteran has been receiving mental health treatment, in the form of therapy and medication management at the Big Spring VA Medical Center (VAMC) in San Angelo, Texas. VA treatment records reflect that throughout his treatment, the Veteran has consistently reported symptoms of visual and auditory hallucinations, nightmares, flashbacks, depression, anxiety, and irritability. The Veteran attends group PTSD therapy at the Big Spring VAMC, the treatment notes of which regularly document the Veteran's symptoms of restricted or flattened affect, moderate depression, and anxiety. The treatment notes reflect that the Veteran received inpatient psychiatric treatment for his PTSD at a VAMC facility in Waco, Texas from July 2007 through September 2007. While at the inpatient facility, the Veteran benefited from group and individual therapy where he received instruction on successful ways to cope and manage his PTSD symptoms. A June 2008 letter from the Veteran's treating social worker from the VAMC related the Veteran's difficulties in his employment, explaining that he was unable to interact with customers as he was prone to become frustrated and angry, and so he stayed in the garage and his wife handled all customer related responsibilities. The Veteran's social worker also reported that the Veteran's nervous body language had intensified and he had increasing difficulty sitting for any length of time during his group therapy sessions. The social worker stated that the Veteran's symptoms had increased and caused him to become less able to function outside of his home and garage and to provide for his family. The record also shows that the Veteran has been receiving private mental health treatment at the San Antonio Vet Center and that he has been attending regular group and individual therapy sessions for his PTSD since April 2007. On his initial visit to the San Antonio Vet Center, the Veteran was afforded a mental status evaluation. On mental status evaluation, the Veteran's appearance was found to be neat and his manner was friendly and cooperative. He was orientated to time, place, and person. The Veteran's memory function was found to be impaired and his motor activity was tense. His affect was appropriate. There was evidence of thought disorder, indicated by delusions and disorganized thinking, but no hallucinations were found to be present. The Veteran was not noted to have any sleep disturbances or any suicidal or homicidal ideation. Depression and anxiety were noted to be present. The Veteran was noted to be motivated for treatment and was recommended for weekly group and individual therapy. The private treatment records from the Veteran's group and individual therapy at the San Antonio Vet Center routinely document the Veteran's symptoms of depression, anxiety, nightmares, flashbacks, and anger. These treatment records reflect the Veteran's time at the inpatient VAMC facility, and show that for a brief period following his inpatient treatment, his symptoms slightly improved. However, the treatment notes beginning in November 2007 show that the Veteran's PTSD symptoms began to worsen as he was again noted to suffer from flashbacks, nightmares, and depression, and he began to withdraw during his group therapy sessions and would only participate when asked a direct question. Additionally, the Veteran submitted a January 2012 letter from his counselor, Dr. D.W., at the San Antonio Vet Center. In the January 2012 letter, Dr. D.W. reported that the Veteran's PTSD symptoms included nightmares, hypersensitivity to sounds, and problems with anger. Dr. D.W. reported that the Veteran had difficulty sleeping and that it was difficult for him to talk about his time in the Republic of Vietnam. Dr. D.W. noted that the Veteran had problems with social interactions, problems with his primary support group, occupational problems, economic problems, and other psychological and environmental problems related to his PTSD. Dr. D.W. assigned the Veteran a GAF of 48 and explained that the Veteran was no longer able to function in groups of people and avoided people, including his own family members. This isolation caused the Veteran financial difficulty as he could not interact with customers at his auto body business. Dr. D.W. noted that the Veteran tended to become tearful and shutdown when talking about his time in the Republic of Vietnam, and that he would continue to need weekly group therapy so that he could learn to cope with his traumatic memories. Also of record are several lay statements in support of the Veteran's claim. In a March 2005, the Veteran stated that his PTSD symptoms included short-temper, depression, panic attacks, nightmares, and flashbacks. In an April 2006 statement in support of his claim, the Veteran explained that since his service in the Republic of Vietnam he has isolated himself from his parents and siblings, he did not like being in crowds, and that when he was in a public place he always kept his back to the wall. He also explained that he opened his own body shop many years ago and that he did not hire anyone to work for him because he did not like being around people and did not like having people tell him what to do. In a January 2006 lay statement, a member of the Veteran's church, Ms. D. P., explained that she had known the Veteran since 1994. She stated that in the time that she had known the Veteran, she had witnessed his hyper-vigilant, nervous, and anxious behavior. She related an incident involving the Veteran and another person when the Veteran became very angry, and she feared he would become violent. Ms. D.P also stated that she had noticed the Veteran's excessive alcohol drinking, and when she asked him about it on one occasion, he told her he drank in order to prevent flashbacks and nightmares. In a February 2006 lay statement, the Veteran's sister-in-law, Ms. M.V., stated that after returning from his service in the Republic of Vietnam, the Veteran always appeared nervous, agitated, angry, and belligerent to his brother. She stated that the Veteran would drink alcohol frequently, which would cause him to become violent at times. In a lay statement received in May 2006, the Veteran's spouse stated that she had known the Veteran since 1970 and since that time he had always exhibited symptoms of his PTSD, but that they have worsened over the years. She stated that the Veteran would drink heavily, usually by himself, and that he no longer socialized or showed love and attention to her, their two children, or several grandchildren. In his August 2008 Notice of Disagreement, the Veteran stated that he was self-employed in order to allow himself to pick the times he worked, and that when his symptoms were at their worst he did not work. He reported that he had adapted his life to account for his PTSD symptoms, and that he avoided establishing any work or social relationships as he found interacting with people to be difficult. The Board finds that the Veteran is entitled to an initial disability rating of 70 percent for his PTSD, for the period prior to July 10, 2007. In this regard, the Board notes that the March and December 2005 VA examination reports, the VAMC and private treatment records, and the lay statements of record, show the Veteran to have occupational and social impairment with deficiencies in most areas for this period. This was manifested by such symptoms as: anxiety, depression, irritability, nightmares, flashbacks, hyper-startle reflex, hypervigilance, angry outburst, isolations, chronic alcohol abuse, auditory and visual hallucinations, panic attacks, memory impairment, difficulty concentrating, impaired judgment, poor impulse control, poor quality of life, trouble being in crowds, and difficult maintaining social and occupational relationships. The Board also notes that the VA treatment records show mental status evaluations in September 2004 and November 2004, during which the Veteran was assigned GAF scores of 50 and 55, respectively. Additionally, the Veteran was assigned a GAF score of 50 at his March 2005 VA examination and a GAF score of 55 at the December 2005 examination. As discussed above, GAF scores of 50 and 55 are indicative of serious to moderate impairment. The Board finds that the symptoms reported at this March 2005 and December 2005 VA examinations, and the symptoms documented in the VA and private treatment records, along with the Veteran's GAF scores during the period prior to July 10, 2007, indicate his PTSD symptoms produced impairment that more nearly approximated those contemplated by the 70 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board acknowledges that the results of the VA examinations and the symptoms described in the VA and private treatment records and the lay statements of record, do not indicate that the Veteran experiences all of the symptoms associated with a 70 percent disability rating for PTSD. However, the Court has held that the symptoms enumerated under the schedule for rating 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 disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, a finding that there is occupational and social impairment resulting in deficiencies in most areas is sufficient to warrant a 70 percent disability rating for the period prior to July 10, 2007, even though all the specific symptoms listed for a 70 percent rating are not manifested. Consideration has been given to assigning a higher disability rating for the period prior to July 10, 2007. However, the Board finds that there is no reasonable basis for concluding that the occupational and social impairment during this period more nearly approximated total than deficiencies in most areas. In this regard, there is no indication from the evidence of record that the Veteran had 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, and significant memory loss (i.e. for names of close relatives, own occupation or own name). Further, the evidence of record prior to July 10, 2007, indicated that the Veteran was still able to maintain a relationship, albeit somewhat strained, with his wife, children, and grandchildren. Therefore a higher evaluation is not warranted for the period prior to July 10, 2007. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board finds that the Veteran is entitled to a 100 percent disability rating for PTSD for the period beginning October 1, 2007, following the Veteran's period of inpatient treatment for his PTSD. In this regard, the Board notes that the Veteran received inpatient treatment for his PTSD from July 2007 through September 2007, and initial treatment records following his period of inpatient treatment indicate his PTSD symptoms had improved. However, the Board finds that any improvement in his PTSD symptoms following his inpatient treatment was only temporary, and that later treatment records tend to show that the Veteran's symptoms had increased in severity as to render him totally socially and occupationally impaired. In so finding, the Board places great weight on the June 2008 letter from the Veteran's treating social worker from the VAMC. This letter specifically noted that the Veteran was experiencing increasing difficulty making a living, even in the protected work environment of his self-run auto body shop. In her letter, the social worker also noted the Veteran's increasing isolation and his difficulty in successfully participating in group therapy. Additionally, the October 2011 VA examiner found that the Veteran was unable to relate in supportive environments, including his church and family, as he would act out in a threatening manner. The October 2011 VA examiner also opined that the Veteran's PTSD symptoms made it unlikely that he would be able to relate appropriately in a competitive work environment. Furthermore, the Veteran's counselor from the Vet Center explained in a January 2012 letter that the Veteran's PTSD symptoms had caused social, occupational, and economic problems. The Veteran's counselor also reported that the Veteran's PTSD had caused him to avoid people, including his own family. Therefore, as the medical evidence of record shows a significant worsening of the Veteran's symptoms and it is well documented that he had markedly increased difficulty functioning in his well-protected work environment, the Board find that the Veteran's PTSD has been productive of symptoms creating total occupational and social impairment from the period beginning October 1, 2007. Therefore, the Veteran is entitled to a 100 percent disability rating from that time. Again, the Board acknowledges that the results of the VA examination and the symptoms described in the mental health treatment notes and lay statements of record, do not indicate that the Veteran experiences all the symptoms associated with a 100 percent disability rating for PTSD for the periods specified above. However, as noted above, the Court has held that the symptoms enumerated under the schedule for rating 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. See Mauerhan, 16 Vet. App. 436 (2002). Thus, a finding that there is total occupational and social impairment sufficient to warrant a 100 percent disability rating for the period beginning October 1, 2007, even though all the specific symptoms listed for a 100 percent rating are not manifested. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). While the required notice should be furnished prior to the issuance of the appealed rating decision, any initial errors of notice will not be prejudicial if: (1) corrective actions (e.g., issuance of a post-adjudication notice letter containing the required information) are taken, and (2) the appeal is re-adjudicated (e.g., in a Supplemental Statement of the Case). See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Here, the VCAA duty to notify was satisfied by way of letters sent to the Veteran in January 2005, June 2005, and March 2006 that fully addressed all notice elements. These letters informed the Veteran of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. The Board notes that the June 2005 and March 2006 letters were not sent prior to the initial unfavorable decision on the claim by the RO. Under such circumstances, VA's duty to notify may not be "satisfied by various post-decisional communications from which a claimant might have been able to infer what evidence the VA found lacking in the claimant's presentation." Rather, such notice errors may instead be cured by issuance of a fully compliant notice, followed by re-adjudication of the claim. See Mayfield 499 F.3d 1317. Here, the Board finds that any error in the timing of the notice letters sent to the Veteran was not prejudicial because the actions taken by VA after providing notice have essentially cured the error in the timing of notice. Not only has the Veteran been afforded a meaningful opportunity to participate and respond, but the RO also re-adjudicated the claim on several occasions following the June 2005 and March 2006 notice letters. For these reasons, it is not prejudicial to the Veteran for the Board to proceed to finally decide the appeal as the timing error did not affect the essential fairness of the adjudication. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished and therefore appellate review of the claims addressed above may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained pertinent private and VA treatment records and he was afforded VA medical examinations in March 2005, December 2005, March 2008 and October 2011. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of his claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER The Board having determined that the Veteran's PTSD warrants an initial 70 percent rating, but not higher; and a 100 percent rating for the period from October 1, 2007; the benefit sought on appeal is granted to this extent and subject to the criteria applicable to the payment of monetary benefits. REMAND The Board is of the opinion that additional development is required before the Veteran's claim of entitlement to a TDIU, for the period ending July 10, 2007, is decided. At the outset, the Board notes that, in Rice v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim cannot be considered separate and apart from an increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Instead, the Court held that a TDIU claim is an attempt to obtain an appropriate rating for a service-connected disability. The Court in Rice also found that, when entitlement to a TDIU is raised during the adjudicatory process of the underlying disability, it is part of the claim for benefits for the underlying disability. In his May 2006 statement in support of his claim, the Veteran stated that he opened his own auto body shop because he was unable to work effectively with other people due to his PTSD. At his October 2011 VA examination, the Veteran reported that he opened his own auto body garage after being fired from a car dealership in 1974. He also reported that he would typically have 3 jobs per month and work only 20 to 30 hours per week. The Veteran reported on numerous occasions that he is unable to interact with customers as he is prone to angry outbursts, and at his October 2011 VA examination he reported a 1985 or 1986 incident with a customer that nearly ended in violence. The Veteran's statements regarding his employment situation indicated that he may be unemployable, even though he maintains some level of employment at the protected environment of his self-run auto body garage, due to symptoms of his PTSD. The Board notes that the June 2008 letter from the Veteran's treating social worker at the VAMC related how the Veteran's PTSD symptoms were impacting his ability to work and provide for his family. Additionally, the October 2011 VA examiner found that the Veteran was totally socially and occupationally impaired at the time of the examination, and he specifically noted that the Veteran's PTSD symptoms made it "difficult to imagine that he would be considered as a candidate for a competitive work position." However, the March 2005 and December 2005 VA examination reports do not provide a sufficient evaluation of the Veteran's functional impairment in order to determine whether the Veteran's PTSD symptoms rendered him effectively unemployable for the period ending July 10, 2007. Therefore, the Board finds that the Veteran's claims files should be reviewed by the October 2011 VA examiner to determine the level of functional impairment, and whether the Veteran was unemployable, for the period prior to July 10, 2007. Accordingly, the case is REMANDED for the following action: 1. The Veteran's claims files should be forwarded to the VA examiner who performed the October 2011 VA examination for a complete review of the claims files and an addendum opinion. Based on a review of the record, the examiner should provide an addendum opinion as to when the Veteran's PTSD was manifested by symptoms rendering him totally occupationally impaired. Specifically, the VA examiner is asked to review the March 2005 and December 2005 VA examination reports and contemporaneous medical records and opine as to when the Veteran's PTSD symptoms created such functional impairment as to render him unemployable. The supporting rationale for all opinions expressed must be provided. If the October 2011 VA examiner is not available, the claims files should be provided to and reviewed by another physician or psychologist with sufficient expertise to provide the required opinions with the supporting rationale. Another VA examination of the Veteran should only be performed if deemed necessary by the person providing the opinions. 2. The RO should confirm that the examination report and any opinions provided comport with this remand and undertake any other development it determines to be warranted. 3. Then, the RO should re-adjudicate the Veteran's claim on appeal. If the benefit sought on appeal is not granted, the Veteran and his representative should be furnished a supplemental statement of the case and provided an appropriate opportunity to respond. Thereafter, if in order, the case should be returned to the Board for further appellate action. 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). ______________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs