Citation Nr: 1311565 Decision Date: 04/08/13 Archive Date: 04/19/13 DOCKET NO. 08-26 668 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUE Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) from May 20, 2008. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Curameng, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from February 1968 to December 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision of the Buffalo, New York RO that granted service connection for PTSD, rated 10 percent, effective July 24, 2006. A July 2008 Decision Review Office (DRO) decision increased the rating for PTSD to 50 percent, effective May 20, 2008. A December 2008 rating decision granted a temporary total rating (based on hospitalization under 38 C.F.R. § 4.29) for the PTSD for the period from September 2, 2008 to October 1, 2008 and continued the 50 percent rating, effective October 1, 2008. An October 2012 rating decision (found in Virtual VA) granted another temporary total rating for hospitalization (from December 20, 2011 to February 1, 2012) and continued the 50 percent rating, from February 1, 2012. For the periods of temporary total rating, the matter of an increased rating is moot, and those periods are not before the Board. In August 2009, a hearing before the undersigned was held in Washington D.C. A transcript of the hearing is associated with his claims file. In September 2009, the case was remanded for additional development. In January 2011, the Veteran waived RO consideration of additional evidence that would be received at a later date. In May 2011, the Veteran's representative submitted Vet Center treatment records. At the hearing, the Veteran limited his appeal of the rating for PTSD to the matter of the rating for the period beginning May 20, 2008. The Board has characterized the issue accordingly. The matter of entitlement to a total disability rating based on individual unemployability (TDIU) is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if action on his part is required. FINDING OF FACT Throughout since May 20, 2008 (except for periods during which a temporary total rating based on hospitalization has been assigned) the Veteran's PTSD is reasonably shown to have been manifested by symptoms of occupational and social impairment with deficiencies in most areas; PTSD symptoms productive of total occupational and social impairment are not shown. CONCLUSION OF LAW A 70 percent (but no higher) schedular rating for PTSD is warranted from May 20, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.3, 4.7, 4.21, 4.126, 4.130, Diagnostic Code (Code) 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). As the rating decision on appeal granted service connection and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). A July 2008 statement of the case (SOC) provided notice on the "downstream" issue of entitlement to an initial increased rating; while a December 2008 supplemental SOC (SSOC) readjudicated the matter after the appellant and his representative responded and further development was completed. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). The Veteran has had ample opportunity to respond/supplement the record. He has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) ("where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (discussing the rule of prejudicial error). The Veteran's pertinent treatment records and Social Security Administration (SSA) records have been secured. The RO arranged for VA examinations in June 2007, May 2008 and April 2010. The Board notes that the VA examination reports contain sufficiently specific clinical findings and informed discussion of the pertinent history and features of the disability on appeal to provide probative medical evidence adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (finding that VA must provide an examination that is adequate for rating purposes). The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide this matter, and that no further development of the evidentiary record is necessary. See generally 38 C.F.R. § 3.159(c)(4). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Accordingly, the Board will address the merits of the claim. Factual Background The Board notes it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic data storage system), 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. On May 2008 VA examination, the Veteran's appearance, attitude and behavior were generally within normal limits. His attire was somewhat unkempt, and he seemed somewhat disheveled. He was cooperative and answered all questions appropriately. He made good eye contact and his sensorium was intact. His speech was relevant, coherent and productive. His thought processes were rational and goal-directed. There was no evidence of hallucinations or delusions, and no evidence of specific obsessions, compulsions, phobias or ritualistic behavior. He was oriented in all three spheres. His short term memory and concentration were intact with no marked impairments noted. He reported recurring disruptions in focus and concentration of late, which the examiner thought was due to PTSD and sleep deprivation. He estimated that the Veteran's intellectual skills were in the above-average range. The Veteran's mood was generally pleasant and euthymic, although somewhat subdued. There was no evidence of marked agitation or distress. His affect was appropriate with full range noted. The Veteran reported 4 to 5 nightmares per week and daily intrusive thoughts and recollections. He also experienced recurring flashbacks. He presented with moderate social anxiety and some degree of social avoidance. He was tense and anxious in crowds and seemed quite hypervigilant. There was evidence of a decline in his ability to enjoy daily activities along with recurring and moderate episodes of emotional detachment, isolation, psychic numbing and estrangement from others. He reported some mild anger-related issues. His impulse control was generally intact. He was not prone to marked problems with rage or anger, and physical aggression. He was hypervigilant in public. He was sleep impaired. He had startle responses to loud noises. There was evidence of some related depression including low mood state, and decreased energy and motivation, and personal grooming and hygiene. He reported some problems with memory and concentration. He was not suicidal or homicidal. There was no evidence of psychosis. The diagnosis was chronic and moderate PTSD with some related depression; and a GAF score of 55 was assigned. An August 2008 VA psychiatry note shows that the Veteran was neat and well groomed, pleasant and cooperative. His affect was also pleasant and cooperative with euthymic mood. He denied audio/visual hallucinations and suicidal/homicidal ideations. He was alert and oriented in all three spheres. His attention, concentration, insight and judgment were good. An August 2008 VA treatment record notes that the Veteran experienced increased flashbacks and nightmares. He slept a few hours at night and napped during the day. He described hypervigilance and avoidance behaviors. He was socially isolated. He had difficulty being in crowds since he would feel trapped. He described anxiety, worry and trouble with concentration. He had a history of problems with anger management. He had lost a job years ago due to his temper. He denied any recent trouble managing his temper and tended to hold his feelings in. He denied psychosis and described emotional numbness. He described symptoms of depression-low energy, low motivation and anhedonia. Six weeks prior, he had fleeting suicidal thoughts, but no plan or intent. He denied any current suicidal/homicidal ideation. A May 2009 psychiatric/psychological impairment questionnaire from Damon A. Tohtz, M.D. notes poor memory, sleep disturbance, mood disturbance, emotional lability, delusions/hallucinations, recurrent panic attacks, psychomotor agitation/retardation, difficulty thinking/concentrating, social withdrawal/isolation, decreased energy, intrusive recollections of a traumatic experience, generalized persistent anxiety, and hostility and irritability. The Veteran endorsed combat-related nightmares, flashbacks, problems with crowds, explosive anger and depression. Conclusions derived from the evaluation included that the Veteran's capacity to sustain an activity over a normal workday and workweek (on an ongoing basis in a competitive work environment) was markedly limited (he was effectively precluded him from performing an activity in a meaningful manner). The diagnosis was PTSD and assigned a GAF score of 50 was assigned (with the lowest GAF score in the past year a 45). Regarding his understanding, memory, sustained concentration and persistence, the ability to remember locations and work-like procedures, and to understand and remember and to carry out one or two step instructions was moderately limited. The ability to understand and remember and to carry out detailed instructions was markedly limited. Also markedly limited was his ability to maintain attention and concentration for extended periods of time; to perform activities within a schedule, maintain regular attendance and be punctual within customary tolerance; to sustain ordinary routine without supervision, and to work in coordination with or proximity to others without distraction; and the ability to complete a normal workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods. The ability to make simple work-related decisions was moderately limited. As for social interactions, there was no evidence of inability to interact appropriately with the general public and to ask simple question/request assistance. Abilities to accept instructions and respond appropriately to criticism from supervisors, to get along with co-workers/peers without distracting them/exhibiting behavioral extremes, and to maintain social appropriate behavior; and to adhere to basic standards of neatness and cleanings were mildly limited. Regarding adaptation, the Veteran's ability to respond appropriately to changes in the work setting was moderately limited. His ability to travel to unfamiliar places or use public transportation was mildly limited. There was no evidence of any limitation in the ability to be aware of normal hazards and take appropriate precautions; and the ability to set realistic goals or make plans independently. November 2008 to November 2009 VA treatment records show that the Veteran actively participated in a PTSD Recovery and Support Group. In April 2009, he spoke about celebrating his birthday with neighbors (with whom he bartered rides for dinners) and that his spirits had markedly improved since making such friendships. In September 2009, he described a recent reunion with four other veterans. At a January 2009 VA individual therapy session the Veteran was described as casual in appearance. He was cooperative and had good eye contact. He was calm. His affect was appropriate. His mood was described as "Normal, Depressed". His speech was also normal and his thought process was intact. There were no hallucinations or delusions. He was fully oriented in all four spheres. His immediate, recent and remote memory was intact, and his cognitive function, abstraction, judgment and insight were intact. In January 2009, the Veteran was described as dressed appropriately and exhibiting fair hygiene. He was friendly and cooperative. Psychomotor activity, eye contact and speech were normal. He displayed full affect and reported being in fair spirits. He was alert and oriented, and his though process was entirely linear. He denied suicidal ideation and did not report homicidal ideation. His short term and long term memory were good, and his judgment was intact. Later in January 2009, the Veteran was described as alert and oriented in all four spheres, and able to carry out routine tasks. He was casually groomed with adequate hygiene. He had good eye contact. He was pleasant and cooperative and engaged well in the interview. His speech was clear and of good quantity and quality. It was spontaneous and goal-directed. He had an expressive affect. His mood was mildy depressed and anxious. There were no obsessions, auditory/visual hallucinations, delusions, thought disorder, or suicidal/homicidal ideation. He was alert and oriented in all three spheres. His attention and concentration ranged from fair to good. He was able to spell a word forward and backward. He was seen two days later in January 2009, and described ongoing flashbacks that have been less frequent and intense as they had been in the past. He denied any panic attacks. He had been isolating himself more recently, but did talk to a couple of veterans who lived in his neighborhood. He reported problems with irritability and anger, but felt that they are under better control. He denied any physical aggression. He described problems with decrease concentration, hypervigilance and exaggerated startle response. He described emotional numbing. Chronic PTSD was diagnosed. In March 2009, the Veteran's appearance was described as disheveled. He was cooperative with good eye contact. His motor activity was calm. His affect was appropriate and worrisome. His mood was normal, depressed, and anxious. His speech was also normal. Thought process, memory (immediate, recent and remote), cognitive function, abstraction, judgment and insight were intact. He was always oriented in all four spheres. A July 2009 SSA decision found that the Veteran had been disabled since December 31, 2007 and listed PTSD as one of his severe impairments. At the August 2009 hearing, the Veteran testified he had been a teacher and that he became irritated with his coworkers and "flipped out" on his students. He interacted with one or two neighbors. He was not in touch with his brother or his brother's ex-wife. He complained of short-term and long-term memory losses, panic attacks, paranoia, nightmares, anger, sleep disturbance and temper. He was not able to go into a mall, but was able to shop for groceries (only for a short period of time). He took a bus to attend the hearing and stayed at the bus station overnight after feeling as if he had a panic attack trying to figure out where to find lodging. August 2009 and October 2009 VA treatment records show the Veteran was casual in appearance and was cooperative. He was calm and his affect was appropriate. His mood and speech were normal. His thought process was intact. Cognitive function, abstraction, judgment and insight were intact. An August 2009 VA treatment record notes that he paid off his debts, and walked a mile on a nightly basis. On April 2010 VA PTSD examination, mental status evaluation found that the Veteran was alert and oriented in all three spheres and was able to carry out routine tasks. He was casually groomed, with adequate hygiene. He had good eye contact. He was cooperative and able to engage well in the interview process. His speech was somewhat pressured, clear, coherent and goal-directed. His affect was somewhat irritable and his mood was congruent with affect. He denied auditory/visual hallucinations. There were no delusions and evidence of thought disorder. He denied suicidal/homicidal ideations. He was able to concentrate to complete the interview process. On April 2010 VA examination, it was noted that the Veteran drove himself to the appointment and arrived on time. His appearance, attitude and behaviors were generally within normal limits. His attire was casual, neat and appropriate; and his hygiene and grooming were good. He was fully cooperative and answered all questions appropriately. He made good eye contact and his sensorium was intact. His speech was generally relevant, coherent and productive. His thought processes were rational and goal directed. There was no evidence of hallucinations or delusions. There was no evidence of specific obsessions, compulsions, phobias or ritualistic behavior. He was oriented in all three spheres. The Veteran's basic short-term memory and concentration skills were grossly intact per mental status testing. He subjectively reported a history of significant problems in terms of short-term memory, focus and concentration in both of daily tasks and work-related tasks for some time. The examiner found that his intellectual skills were in the above-average range. The Veteran's mood, while overtly pleasant, did reflect mild anxiety. His affect was appropriate with full range noted. The examiner found that the current evaluation was consistent with chronic and severe PTSD with related mild to moderate clinical depression. The examiner found that there was an increase in severity of symptoms since the May 2008 examination (when they were moderate). The Veteran experienced three to four nightmares a week, which was a mild improvement after taking prazosin; and also experienced intrusive thoughts on a daily basis. He experienced generally severe social anxiety and hypervigilance in crowds. He engaged in mostly solitary activities. He only felt comfortable around his daughter-in-law and other veterans. He had no significant relationship with anyone other than his son and granddaughter. He presented with moderate to severe and ongoing isolation and withdrawal from others. There was prominent psychic numbing and emotional detachment. He had a history of significant anger and irritability primarily affected negatively on his work. His anger overall had decreased in actual episodes, but the examiner was not convinced that this reflected a genuine improvement in the symptom. The Veteran reported recurring disruptions in focus and concentration along with short term memory which were likely due to sleep deprivation. There was also distraction caused by intrusive thoughts and flashbacks. There was evidence of early clinical depression and mild to moderate low mood that tended to be fairly sustained. He had had episodes of inadequate attention to personal grooming and hygiene. He was not suicidal or homicidal. There was no evidence of psychosis. His insight and judgment regarding his symptoms were generally good. The examiner noted that the Veteran's symptoms had been worsening over the past three or four years. The diagnosis was chronic and severe PTSD. A May 2010 VA discharge summary notes chronic PTSD with a GAF score of 45 to 49. He reported an overall improvement in his symptoms of PTSD and depression due to outpatient care and residential admissions. Medication was helpful. He had problems sleeping and had an increase in intrusive thoughts. He described flashbacks that have been less frequent and less intense that they had been in the past. He described some symptoms of depression as low energy and low motivation, but denied feeling hopeless, helpless or suicidal. He denied panic attacks. He had been isolating himself more recently, but did talk to a couple of veterans in his neighborhood. He described problems with concentration, but less than before. He described hypervigilance and exaggerated startle response. A June 2010 VA treatment record notes that the Veteran had a well-groomed and casual appearance. He was cooperative and had good eye contact. His affect was appropriate, worrisome and apathetic. His mood was normal and anxious. His speech was delayed and his thought process was circumstantial. There were no hallucinations and delusions. He was always fully oriented in all four spheres. Immediate, recent and remote memory was intact. Cognitive function, abstraction, judgment and insight were intact. At a VA group therapy session in June 2010, the Veteran reported spending a day with friends and that talking to others was a good distraction. An August 2010 VA treatment record notes a GAF score of 75 (with no detailed explanation). A November 2010 Vet Center record notes the Veteran had no suicidal thought, plan or attempts. There were also no feelings of hopelessness or despair, suicidal/homicidal thoughts, excessive fatigue, sleep disturbance, irritability/aggression, anxiety, depression, affective liability, speech difficulty and slowed thinking. On mental status evaluation, he was described as neat in appearance, friendly and cooperative. He was noted to be of average intelligence and had appropriate speech. His memory function was normal. His affect was appropriate and judgment was good. There were no delusions, disorganized thinking and hallucinations. There was early, middle and late insomnia. A December 2010 VA PTSD Program Intake record shows that the Veteran had been re-experiencing symptoms, avoidance symptoms, and hyperarousal symptoms. He also experienced depression and memory problems. There was no evidence of lethality. He was not in a relationship, but had one "close friend". He visited his son, who was incarcerated, twice a month. He reported that his son and grandkids gave his life meaning. He was given a diagnosis of chronic moderate PTSD and a GAF score of 61. A December 2010 Vet Center record notes that the Veteran was neat, and his speech and affect were appropriate. He was oriented in all three spheres and was friendly. He had average intelligence, normal memory and fair judgment. There was no evidence of delusions, disorganized thinking or hallucinations. He reported trouble sleeping and would either have no sleep to too much sleep. He reported low energy levels. He denied suicidal or homicidal thoughts. He took anti-depressant medication. A January 2011 Vet Center client treatment plan notes the Veteran's hyperarousal, hypervigilance, intrusive thoughts, nightmares and flashbacks. Planned intervention included group psychotherapy on a biweekly bases for PTSD symptom management and education on relaxation strategies to help the Veteran manage his symptoms. Expected outcomes included decreased anxiety in public situations, increased acceptance of limits of personal control, increased ability to realistically appraise threats and tolerate acceptable risks, decreased reactivity to stressful life events, decreased mood lability, and decreased emotional reactivity when thinking about wartime experiences. January 2011 to March 2011 Vet Center records show the Veteran's continued participation in group therapy. C. Legal Criteria and Analysis 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. Under Code 9411 (for PTSD and under the General Rating Formula for Mental Disorders (General Formula)), a 50 percent rating is warranted when the evidence shows occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when the evidence shows occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is warranted when the evidence shows total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, 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 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) (4th ed. 1994). A score of 51 to 60 reflects that 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)." 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. 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, the benefit of the doubt in resolving each such issue, including degree of disability, shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 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). A longitudinal review of the record found that the Veteran's PTSD has been characterized by waxing and waning of symptoms and related functional impairment. The disability picture of the PTSD presented by the record is not one apparent from "snapshot" views of symptoms on specific days of examination and treatment, but is better reflected by an overview of the symptoms and level of functioning shown throughout. The Veteran has participated in VA treatment for his PTSD throughout the evaluation period (including group and individual therapy and periods of hospitalization). While the periods when he was hospitalized are not for consideration herein (as a total rating was assigned), they do have bearing on the overall disability picture. That the treatment has been deemed necessary for such an extended period of time (and does not appear to have produced lasting results) is of itself a reflection of significant psychiatric disability with impact on occupational functioning (as regular treatment requires being away from a work setting). has not resulted in , extensive the Veteran The Veteran's treatment records show that his PTSD has been manifested panic attacks and depression. The Veteran was unable to maintain employment due to problems with anger/irritation (when he worked as a teacher, coworkers and students irritated him). His social contacts appear to be limited to his son, grandchild, and other veterans. At times, he neglects personal care/grooming (note treatment reports when he was described as disheveled). At times he has shown inability to cope with stressful situations (note his Travel Board testimony description of becoming overwhelmed by circumstances at the time). He has had intrusive thoughts/flashbacks, difficulty sleeping, nightmares, depression, hypervigilance and startle response. At one point he was described at semi-dependent and was unable to function outside the home. Records reflect psychic numbing, reduced grooming and hygiene, and withdrawal. The Veteran's GAF scores have been as low as 41 (reflecting serious symptoms), and the scores listed predominantly have been from 45 to 55 (reflecting a severe to lower moderate level of disability). (Isolated higher scores, including 75 and 61, are not adequately explained; at any rate, they do not reflect sustained improvement of the PTSD disability. Notably, the veteran has been awarded Social Security Administration (SSA) disability benefits (primarily for psychiatric disability). While such award has no binding effect on VA, it reflects that he is acknowledged to have substantial occupational impairment (due to psychiatric disability). The Board finds that the overall disability picture presented by the Veteran's PTSD is (or at least approximates; see 38 C.F.R. § 4.7) one of occupational and social impairment with deficiencies in most areas, fitting the criteria for a 70 percent rating. Accordingly, the assignment of such rating for the period, throughout, is warranted. The Board has considered whether a 100 percent schedular rating is warranted. However, the Veteran is not shown to have had the type of totally disabling psychiatric symptoms that are consistent with such rating (i.e., no gross impairment in thought process or communication, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name). There have been no indications of inappropriate behavior at individual and group therapy sessions; he has always been cooperative with medical personnel/was responsive to questions (including at the hearing before the undersigned). Although he does not socialize with his daughter-in-law, he interacts with her regarding his grandchild. He regularly visits his son in person, takes daily walks with a neighbor, and shuttles his neighbor's children in exchange for a home-cooked meal. In short, he exhibits no symptoms consistent with (the gravity of) a disability picture of total occupational and social impairment. The Board has considered whether referral for extraschedular consideration is indicated. There is no objective evidence, or allegation of any symptoms or impairment not encompassed by the criteria for the 70 percent rating that is now assigned. Therefore, those criteria are not inadequate, and referral for extraschedular consideration is not indicated. See 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111 (2008). Consequently, referral for extraschedular consideration is not warranted. The matter of entitlement to a TDIU rating has been raised by the record, and is addressed in the remand below. ORDER A 70 percent schedular rating for PTSD is granted, effective from May 20, 2008, and subject to the regulations governing payment of monetary awards. REMAND In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. If the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue of whether a TDIU is warranted as a result of that disability. Here, a December 2008 rating decision denied the Veteran a TDIU rating, and he did not appeal that determination. However, in February 2013, the Veteran's representative specifically re-raised the matter of the Veteran's entitlement to a TDIU rating. The matter of entitlement to a TDIU rating is also raised by the Veteran's award of SSA disability benefits (based primarily on his psychiatric disability). [The denial of TDIU by the RO in December 2008 was made without consideration of the SSA award.] As the RO has not developed or readjudicated anew (since the December 2008 rating decision) the matter of whether the Veteran is entitled to a TDIU, under Rice, the Board must remand this case for such action. This will require development of the Veteran's employment history, education and work history, and all other factors having a bearing on the matter. Accordingly, the case is REMANDED for the following: The RO should complete all indicated notice and evidentiary development to properly address the matter of the Veteran's entitlement to a TDIU rating. He must assist in such development by providing all information sought, completing all requisite forms (and providing any releases needed to secure any pertinent private records). The RO should then adjudicate de novo the matter of the Veteran's entitlement to a TDIU rating. He should be notified of the determination. If it is not favorable, and if he timely files an NOD and perfects an appeal in the matter (after an SOC is issued), this matter should be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. _________________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs