Citation Nr: 1313041 Decision Date: 04/18/13 Archive Date: 05/02/13 DOCKET NO. 04-37 985A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder prior to September 21, 2007. 2. Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder from September 21, 2007. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities. REPRESENTATION Appellant represented by: John S. Berry, Attorney ATTORNEY FOR THE BOARD J. Henriquez, Counsel INTRODUCTION The Veteran served on active duty from July 1970 to March 1972. He served in the Republic of Vietnam from May 1971 to March 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa, which continued a 30 percent evaluation for posttraumatic stress disorder (PTSD); and a July 2009 rating decision from the Des Moines RO, which denied entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). In August 2003 and August 2009, the Veteran submitted notices of disagreement and subsequently perfected his appeals in October 2004 and October 2009. The Board notes that the Veteran did not file a timely Substantive Appeal for his PTSD claim. However, inasmuch as the RO has taken actions to indicate to the Veteran that the present issue is on appeal, and it took no steps to close the appeal, the requirement that there be a timely Substantive Appeal is deemed waived. See Percy v. Shinseki, 23 Vet. App. 37 (2009); Gonzalez-Morales v. Principi, 16 Vet. App. 556 (2003) (per curiam order). In December 2007, the RO increased the Veteran's disability rating for PTSD to 50 percent, effective September 21, 2007. In February 2012, the RO again increased the Veteran's evaluation for PTSD to 70 percent, effective September 21, 2007. Because the RO did not assign the maximum disability rating possible, the appeal for a higher evaluation remains before the Board. See AB v. Brown, 6 Vet. App. 35 (1993) (where a claimant has filed an NOD as to an RO decision assigning a particular rating, a subsequent RO decision assigning a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). In May 2010 and May 2012, the Board remanded the claims to the RO for further evidentiary development. The record before the Board consists of the Veteran's paper claims file and an electronic file known as Virtual VA. 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. FINDINGS OF FACT 1. Prior to June 2, 2004, the Veteran's PTSD has not been manifested by occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking or mood. 2. From June 2, 2004 through September 20, 2007, the Veteran's PTSD was manifested by difficulty in establishing and maintaining effective work and social relationships, sleep disturbance, depression, and social isolation, productive of occupational and social impairment comparable to no more than reduced reliability and productivity. 3. From September 21, 2007, the Veteran's PTSD has not been manifested by total occupational and social impairment. CONCLUSIONS OF LAW 1. Prior to June 2, 2004, the criteria for a disability evaluation in excess of 30 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 2. From June 2, 2004, through September 20, 2007, the criteria for a disability evaluation of 50 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 3. From September 21, 2007, the criteria for a disability evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: Veteran status, existence of a disability, a connection between a Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). In this case, in June 2003, March 2006, February 2007 and December 2008 letters, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. These letters advised the Veteran to submit evidence from medical providers, statements for others who could describe their observations of his disability level, and his own statements describing the symptoms, frequency, severity and additional disablement caused by his disability. These letters also advised the Veteran of the necessity of providing medical or lay evidence demonstrating the level of disability and the affect that the disability has on his employment. The notice also provided examples of pertinent medical and lay evidence that the Veteran may submit (or ask the Secretary to obtain) relevant to establishing entitlement to a disability evaluation. See Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (VCAA notice in a claim for increased rating need not be Veteran specific). The case was last adjudicated in December 2012. The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran including service treatment records, VA medical treatment records, and VA examination reports. The Board also notes that the action requested by the prior Board remand has been taken with respect to the claim for an increased rating for PTSD. Specifically, following the May 2010 remand, additional VA treatment records were obtained and associated with the claims folder. In pertinent part, the May 2012 remand directives requested that the RO obtain disability records from Social Security Administration (SSA). A December 2012 memorandum outlines the RO's efforts to obtain the SSA records, and includes the determination that these records are not available. As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by submitting evidence and argument. Thus, the Veteran was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have affected the essential fairness of the adjudication or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of this matter on the merits. See Conway, 353 F.3d at 1374, Dingess, 19 Vet. App. 473; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function, will be expected in all cases. 38 C.F.R. § 4.21 (2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's PTSD is evaluated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411. The current regulations establish a general rating formula for mental disorders. 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, 16 Vet. App. 436. Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). Id. Pursuant to Diagnostic Code 9411, a 30 percent rating is warranted for occupational and social impairment with an 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). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation is warranted for PTSD 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or 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 the inability to establish and maintain effective relationships. A maximum 100 percent evaluation is for application when 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. In evaluating the evidence, the Board has considered the various Global Assessment of Functioning (GAF) scores that clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a GAF score of 61-70 reflects some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. A GAF score of 51-60 indicates 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). A GAF score of 41-50 reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 31-40 reveals some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). DSM-IV at 46-47. Private mental health treatment records dated from November 1997 to May 2003 show that, overall, the Veteran reported sleeping well and that his nightmares and flashbacks were adequately controlled. Daytime anxiety continued to be a struggle. Mental status examinations revealed that the Veteran had good grooming and hygiene. Eye contact ranged from good to guarded. His thoughts were logical and goal directed. He denied any suicidal or homicidal thoughts. His insight and judgment were good. The assigned GAF scores ranged from 65 to 70. The Veteran was afforded a VA psychiatric examination in June 2003. He reported nightmares two to three times a week and flashbacks on a daily basis. He stated that he was hypervigilant, paranoid and had significant problems with interpersonal relationships. He reported that he owned and operated his own pawn shop. He stated that he had never been married. He indicated that he had difficulty maintaining relationships stating that his longest relationship lasted approximately four years and that he had not been in a serious relationship for over six years. He also reported that he has no children and stated that other than his work, he has no active hobbies or anything that he enjoys doing. He indicated that he has been stable in his employment for the last six years or so. Mental status examination revealed that the Veteran was well groomed and appropriate throughout the interview. He was alert and oriented times three. He was in no apparent distress. His mood was fair. His affect was fair and congruent. He did get somewhat distressed while reporting his traumatic incidents from Vietnam, but in general, he was very appropriate. His speech was appropriate. His eye contact was good. His thought processes in general were logical and goal directed. His thought content was negative for any suicidal or homicidal ideation. No psychotic symptoms were reported or appreciated. Attention span, concentration and recent and remote memory were within normal limits. Insight and judgment appeared to be intact. He was somewhat loquacious at times and very detailed in describing his experiences in Vietnam. The examiner assigned a GAF score of 61. The examiner noted that the Veteran reported moderate impairment, particularly in social functioning and an inability to form a close, personal relationship with people. The Veteran underwent a VA psychiatric examination on June 2, 2004. He reported daily problems in interacting with customers at his pawn shop. He stated that he frequently gets angry, although he had to work hard to control his anger. When he did get angry, he stated that he gets loud, but he denied swearing or being physically violent. He indicated that he had to keep a constant vigilance to prevent himself from being physically violent. He described himself as frequently being angry. He continued to have nightmares two to three times a week. He tended to isolate himself and stated that he has very few friends. He did not describe anhedonia but indicated that it is hard for him to relax. He described ongoing increased startle reflex. He indicated that he was able to continue to work at his job, but it was quite a struggle and required much effort. He stated that he frequently has days that he did not feel like going to work because of concerns of having to interact with people. He indicated that he had a few friends. He interacted with his brother and would occasionally see his mother. The examiner noted that the Veteran had very little emotional support. Mental status examination revealed that the Veteran was fairly groomed. He was mildly restless but not overtly agitated. He fidgeted with some papers that he brought in. His speech was normal in rate, rhythm and volume. He did not display any pressured speech. His mood was tense and anxious. His affect was moderately anxious and became more anxious at the end of the discussion. He did not display any suicidal or homicidal ideations. There were no delusions or hallucinations. He was awake, alert and oriented times three. His insight and judgment were fair. The examiner assigned a GAF score of 58. The Veteran underwent a VA psychiatric examination on September 21, 2007. He reported that he was taking medication for management of his PTSD symptoms. He felt that the medications have helped some but he still had significant symptoms. He reported problems with anxiety, distrust of other people, interacting with others and increased social isolation. He used to hunt but he did not do that anymore. He stated that he gets angry easily and then he becomes anxious about that. He indicated that he has poor sleep even with medications. He cannot sleep more than two to three hours per night and he has nightmares two to three times a week related to Vietnam. He reported that he is single. He did not have a close relationship with his brother and his adoptive mother lived with him. He had a good relationship with his adoptive mother. He reported some acquaintances but no social activity. He denied a history of suicide attempts. He denied a history of violence/assaultiveness. Mental status examination revealed that he was appropriately dressed. His psychomotor activity was unremarkable. His speech was spontaneous. His attitude toward the examiner was cooperative. His affective was appropriate. His mood was good. He was oriented to person, time and place. His thought process and thought content were unremarkable. He did not have any delusions. His sleep was impaired. He did not have any hallucinations. The examiner noted that the Veteran did display inappropriate behavior. The Veteran reported that he had problems interacting with customers. He felt that it was more and more difficult to control his anger and temper but he did not have any current episodes of physical violence. He denied any obsessive/ritualistic behavior. He did have panic attacks. He did have homicidal thoughts. He indicated that he had thoughts of hurting or killing others all the time but he denied any current plan or intent. He considered himself a responsible person and stated that "it is against the law." He also had suicidal thoughts but he did not have any current plans or intent to harm himself. He thinks it is too permanent and thinks it will probably hurt. His impulse control was described as fair. He denied any episodes of violence. He had the ability to maintain minimum personal hygiene. He did not have any problems with activities of daily living. He reported that he hears things such as helicopters or sounds like a gunshot. He felt that his memory was impaired. He stated that he used to read a lot but now he can't sit still for five minutes and that it is difficult to concentrate. He had difficulty falling or staying asleep and difficulty with irritability or outbursts of anger. He had problems concentrating, was hypervigilant and had an exaggerated startle response. The examiner described the Veteran's PTSD symptoms as frequent and severe and assigned a GAF score of 55. On VA psychiatric examination in March 2009, the Veteran reported that he continued taking medication for treatment of his PTSD symptoms. He indicated that he closed his business in 2008. He stated that his mood has been down and depressed. Sometimes he sits and starts crying and he has no explanation for this. Something on the news may trigger these emotions. He continued to have difficulty sleeping and woke up three to four times a night. He felt more carefree in the past but he no longer feels this way. Some days he does not take a shower. He reported that he does not have any motivation and that he did not want to go anywhere. He felt that he used to be outgoing but over the years he believes his emotional condition has become worse. He reported experiencing severe anxiety and he usually stays at home three to four days. Usually his mother goes to the store and he sits in his truck. He felt that irritability has always been an issue for him. On a couple of occasions, he came close to having a physical altercation at his place of business but he restrained himself. He reported that his appetite has been variable. His energy level and interest in usual activities has been poor. He reported some difficulty with concentration and short-term memory. He acknowledged having thoughts of harming himself and others. He had suicidal ideation occasionally but he denied any intent or plan and stated that he is "not going to do it." He has had thoughts of harming. He indicated that he has occasional suicidal ideation but he denied any intent or plan. He stated that he would not actually harm himself or anyone else. He denied any auditory or visual ideation. He continued to live with his elderly adoptive mother and he reported a good relationship with her. He also reported having more contact with his brother who moved back from Florida. He did not have any contact with his half siblings or his biological mother. He reported that he has one friend who he sees every couple of weeks. Otherwise, he stays at home and is isolated. He reported that he has been a "loner" most of his life since his military days. He indicated that he has a lack of hobbies and that he mostly watches TV. He did not have a history of suicide attempts. He denied a history of violence/assaultiveness. He reported that he closed his pawn shop in June 2008 in part because of his emotional condition and due to stress. He was unemployed. Mental status examination revealed that the Veteran was clean, neatly groomed and appropriately dressed. He was fatigued. His speech was unremarkable, spontaneous, clear and coherent. His attitude toward the examiner was cooperative and attentive. His affect was constricted. His mood was anxious, depressed and dysphoric. His attention was intact. He was oriented to person, place and time. His thought process was unremarkable. He did display suicidal ideation and ruminations. He did not have any delusions. The Veteran described sleep impairment whereby he is up three to four times a night. He did not have any hallucinations. He avoided social contact due to anxiety. He did not want people to get too close to him. He had panic attacks if he was around large groups of people. He isolated himself. He did not display any obsessive/ritualistic behavior. He reported having panic attacks when he is out in public situations. He did not display any homicidal thoughts. He reported having occasional suidical ideation but he denied any intent or plan to harm himself or others. His impulse control was fair. He did not have episodes of violence. He had the ability to maintain minimal personal hygiene. His immediate memory was mildly impaired. He was assigned a GAF score of 45. The examiner noted that the GAF score was based on presence of suicidal ideation with serious impairment in social and occupational functioning. In an April 2009 addendum, the examiner concluded that the Veteran experienced near continuous panic attacks which adversely affected his ability to function independently, appropriately and effectively. This was evidenced by the presence of severe, generalized anxiety, persistent hypervigilance, social avoidance, and a high level of anxiety with associated physical symptoms in social situations. The examiner noted that the Veteran appeared to be in a constant state of anxiety and avoided all but very limited social contact in order to avoid as much as possible the likelihood of panic attacks. The examiner also noted that the Veteran's depression negatively affected his ability to function independently, appropriately, and effectively. This was evidenced by the presence of persistent, moderate to severe depression, and associated symptoms which included his sleep disorder, crying spells, fatigue, poor energy level, decreased interest and motivation for activities, anhedonia, appetite variability, social withdrawal and isolation, concentration and memory difficulties, suicidal ideation and irritability and violent thoughts toward others as well. The examiner noted that the Veteran's activities of daily living were also adversely affected as evidenced by his reduced motivation for self-care, bathing, and for recreational activities, social contact and other activities in general. VA treatment records dated from February 2009 to June 2010 document the Veteran's ongoing treatment for his PTSD. Overall, the Veteran reported no improvement in his PTSD symptoms. He indicated that he continued to sleep all day with little social contact and no significant relationships. He continued to feel worthless with a depressed mood with few interests other than watching TV. He denied any suicidal or homicidal thoughts. GAF scores ranging from 58 to 60 were assigned. In a September 2010 statement from a private physician, it was noted that the Veteran was at an increased risk and was rapidly becoming more of a problem to self and society. VA treatment records dated from May 2011 to March 2012, showed that the Veteran remained hypervigilant, had sporadic sleep and was chronically depressed with occasional crying spells. The Veteran was fully oriented and his speech was noted to be clear, concise, goal oriented and nonpressured. There were no signs of delusional or psychotic thinking and no evidence of thought of harm to others. His insight was adequate and his judgment was good. GAF scores ranging from 45 to 50 were assigned. On VA psychiatric examination in January 2012, the examiner indicated that the Veteran experienced the following symptoms: depressed mood; anxiety; suspiciousness; panic attacks that occur weekly or less often; chronic sleep impairment; disturbances of mood and motivation; difficulty in establishing an maintaining effective work and social relationships; difficulty in adapting to stressful circumstances; and suicidal ideation. The examiner also noted that the Veteran exhibited reduced concentration/motivation, chronic suicidal ideation without intent, and panic attacks that occur about three times a month. After examination and a review of the medical evidence, the VA examiner provided the following diagnoses: posttraumatic stress disorder, chronic with depression; alcohol dependence; and personality disorder, not otherwise specified. The examiner estimated that 50 percent of the Veteran's overall mental health disorder symptoms were due to his PTSD and 50 percent was due to his nonservice-connected personality disorder. However, the examiner indicated it is impossible to differentiate what symptoms are attributable to each diagnosis. A GAF score of 45 was assigned. The examiner concluded that the Veteran's mental diagnoses resulted in occupational and social impairment with reduced reliability and productivity. The examiner also indicated that it is impossible to differentiate what portion of the occupational and social impairment is due to each diagnosis. On VA psychiatric examination in October 2012, the examiner confirmed the diagnosis of PTSD and assigned a GAF score of 53. The examiner provided that the Veteran's mental illness resulted in occupational and social impairment with reduced reliability and productivity. The examiner noted symptoms of depressed mood, panic attacks that occur weekly or less often, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, and an inability to establish and maintain effective relationships. Prior to June 2, 2004 The Board finds that the evidence of record prior to June 2, 2004, was consistent with a PTSD evaluation of 30 percent disabling. Overall, the evidence shows that the Veteran was sleeping well and that his nightmares and flashbacks were adequately controlled. The Veteran displayed good grooming and hygiene. He reported difficulty with relationships but he was stable in his employment. His speech was appropriate and his thought content was negative for any suicidal or homicidal ideation. The June 2003 VA examiner noted that the Veteran's symptoms were of moderate impairment. The appellant's GAF scores of 61-70 during the period prior to June 2, 2004, are consistent with an evaluation of 30 percent. As noted above, a GAF score of 61 to 70 indicates the appellant had some mild symptoms or some difficulty in social or occupational functioning, but generally functioned pretty well with some meaningful interpersonal relationships. The GAF scores are consistent with the overall evidence of record which indicates that the appellant had generally mild symptoms of PTSD prior to June 2, 2004. In sum, the Board finds that an increased evaluation in excess of 30 percent for PTSD is not warranted prior to June 2, 2004. While the appellant is competent to report the symptoms he experiences, and the Board finds him credible in this regard, prior to June 2, 2004, the reported symptoms, discussed in detail above, are consistent with the assigned schedular evaluation. The Veteran's symptoms were consistent with 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). The evidence does not reflect that the Veteran had symptoms of occupational and social impairment more comparable to reduced reliability and productivity, which would warrant a 50 percent evaluation, occupational and social impairment with deficiencies in most areas, which would warrant a 70 percent evaluation, or total occupational and social impairment, which would warrant a 100 percent evaluation. The Veteran did not have panic attacks, impairment of memory, impaired judgment, impaired abstract thinking or circumstantial, circumlocutory or stereotyped speech. Consequently, the Board finds that an evaluation in excess of 30 percent for PTSD is not warranted, prior to June 2, 2004. From June 2, 2004 to September 20, 2007 The Board finds that the evidence from June 2, 2004 to September 20, 2007, indicates that the Veteran met the criteria for an evaluation of 50 percent due to symptoms productive of occupational and social impairment comparable to reduced reliability and productivity. The evidence indicates that during this period on appeal the Veteran experienced symptoms of significant social isolation, problems maintaining his anger at work, increased startle response and constant hypervigilance. As noted above, on VA examination on June 2, 2004, the Veteran reported that he had daily problems interacting with customers at his pawn shop and that he had problems controlling his anger. He reported that he was hypervigilant. He reported being isolated with very few friends. He felt that working was a struggle. Thus, the Board finds that during the period from June 2, 2004, through September 20, 2007, the Veteran's symptoms are consistent with occupational and social impairment with reduced reliability and productivity. The Veteran's symptoms of social withdrawal indicated that the appellant had difficulty in establishing and maintaining effective work and social relationships. However, the Board finds that the Veteran did not meet the criteria for an evaluation in excess of 50 percent from June 2, 004, though September 20, 2007. The Veteran denied having suicidal or homicidal ideation during this period on appeal. Although the Veteran isolated socially and had sleep disturbance, the June 2004 VA examiner found that he did not have any delusions or hallucinations. He was also noted to be fairly groomed. In regard to the appellant's GAF scores, a score of 58 was assigned by the June 2004 VA examiner. A GAF score of 51 to 60 indicates the Veteran has moderate symptoms or moderate difficulty in social, occupational, or school functioning. The score of 58 is consistent with an evaluation of 50 percent for occupational and social impairment with reduced reliability and productivity. Based on the evidence of record, including the appellant's competent and credible statements regarding his symptoms of PTSD, the Board finds that the appellant is entitled to a staged evaluation of 50 percent for PTSD from June 2, 2004, the date of the VA psychiatric examination which indicated that the Veteran's symptoms were more severe, through September 20, 2007. Overall, the evidence shows that the Veteran had serious symptoms of PTSD including difficulty in establishing and maintaining effective work and social relationships. From September 21, 2007 The preponderance of the evidence of record demonstrates that the Veteran is not entitled to a disability evaluation in excess of 70 percent from September 21, 2007, as he has not suffered from total social and occupational impairment. The Board is not disputing that the Veteran suffers from significant social impairment. A 70 percent disability evaluation is meant to compensate a Veteran with deficiencies in their social and occupational performance. A 100 percent disability evaluation, however, contemplates total social and occupational impairment. VA treatment reports and VA examination reports from September 21, 2007 document the Veteran's continuing difficulty with social functioning, however, the Veteran has reported a good relationship with his adoptive mother. He has also indicated that that he has had increasing contact with his brother. He indicated that he closed his pawn shop in June 2008, in part, due to his emotional condition and stress. This evidence demonstrates that the Veteran does not suffer from total social and occupational impairment. Rather, his symptomatology is more appropriately represented by a 70 percent disability evaluation, in that he suffers from deficiencies in most areas due to symptomatology such as an inability to establish further effective relationships. Therefore, the preponderance of the evidence demonstrates that the Veteran has not been entitled to a 100 percent disability evaluation at any time since September 21, 2007, as he has not suffered from total occupational and social impairment at any time. The above conclusions are supported by the GAF scores of record as well. According to the Veteran's VA examination reports and treatment records, he has suffered from GAF scores ranging from 45 to 60 during the pendency of his claim. These scores represent serious to moderate difficulty in social, occupational, or school functioning. These scores tend to suggest that the Veteran has not suffered from total occupational and social impairment. Other Considerations The Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet.App. 111, 115 (2008). Initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet.App. 57, 60 (1993) (a threshold finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate is required for extraschedular consideration referral). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Further, the Veteran has not alleged that the schedular criteria are inadequate. Therefore, the available schedular evaluations for that service-connected disability are adequate. Referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. Further inquiry into extraschedular consideration is moot. See Thun, 22 Vet. App. at 115. TDIU is an element of all appeals for an increased evaluation. Rice v. Shinseki, 22 Vet. App. 447 (2010). As noted in the remand below, the issue of entitlement to a TDIU is currently before the Board. ORDER Entitlement to an evaluation in excess of 30 percent for PTSD prior to June 2, 2004, is denied. Entitlement to an evaluation of 50 percent, but no higher, for PTSD from June 2, 2004, through September 20, 2007, is granted. Entitlement to an evaluation in excess of 70 percent for PTSD, from September 21, 2007, is denied. REMAND The Veteran is seeking entitlement to TDIU. The Board finds that there is insufficient medical evidence as to whether the Veteran is precluded from obtaining gainful employment due to his service-connected PTSD, and that further VA opinion is warranted. A February 2012 VA psychiatric examiner indicated that she could not state that the Veteran was "totally unemployable," but that "he would only be capable of handling a job on a very time limited basis." In its May 2012 remand, the Board noted that it was unclear from this conclusion whether the examiner believed that the Veteran could engage in gainful employment or whether she was suggesting that he could only engage in menial employment. As such, the claim was remanded to the examiner for an addendum opinion. The Board emphasized that a complete rationale for any opinion offered was required. Following a VA psychiatric examination in October 2012, a different VA examiner concluded that the Veteran's psychiatric symptoms do not currently present with sufficient severity to prevent him from gainful employment. No further discussion or rationale was provided by the examiner. In light of the above, the Board finds that the October 2012 opinion is inadequate as the VA examiner did not provide a rationale for the negative nexus opinion. Hence, another remand of this matter is required. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Accordingly, the case is REMANDED for the following action: 1. The claims folders should be provided to the October 2012 VA examiner, who should be requested to prepare an addendum providing a specific rationale for the previously provided opinion stating that the Veteran's psychiatric symptoms do not currently present with sufficient severity to prevent him from obtaining and maintaining gainful employment. If the October 2012 VA examiner is not available, the Veteran should be scheduled from an appropriate VA examination to determine the effect of his service-connected PTSD on his employability. The Veteran's claims folder should be provided to the examiner for review of pertinent documents therein and that such review was conducted should be noted in the examination report. The examiner should offer an opinion as to whether it is at least as likely as not that the Veteran is unable to secure or maintain substantially gainful employment solely as a result of his service-connected PTSD. It would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of that conclusion as it is to find against it. A complete rationale should be provided for any opinion offered. 2. If another VA examination is deemed necessary, the Veteran must be advised of the importance of reporting to the scheduled examination and of the possible adverse consequences, to include the denial of his claim, of failing, without good cause, to so report. See 38 C.F.R. § 3.655 (2012). A copy of the notification letter sent to the Veteran advising him of the time, date, and location of any scheduled examination must be included in the claims folder and must reflect that it was sent to his last known address of record. If he fails to report, the claims folder must indicate whether the notification letter was returned as undeliverable. 3. After completing the above actions and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraph above, the claim of entitlement to TDIU should be readjudicated. If the claim remains denied, a supplemental statement of the case should be provided to the Veteran and his attorney. After they have had an adequate opportunity to respond, the issue on appeal should be returned to the Board for further appellate review. 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). ______________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs