Citation Nr: 1313255 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 09-34 780 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to a service-connected disability (TDIU). REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from December 1967 to December 1969, with additional service in the Army National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office in Indianapolis, Indiana. The issue of entitlement to a TDIU is REMANDED to the RO via the Appeals Management Center in Washington, DC. VA will notify the Veteran if further action is required. FINDING OF FACT During the pendency of the appeal, the Veteran's service-connected PTSD was manifested by occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW Resolving the benefit of the doubt in favor of the Veteran, the criteria for a disability rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Duty to Notify 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 any 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA 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. VCAA notice should be provided to a claimant before the initial unfavorable decision by the agency of original jurisdiction on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In March 2006, the United States Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess/Hartman held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Upon receipt of an application for "service connection," therefore, VA is required to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and/or an effective date will be assigned if service connection is awarded. Accordingly, in VA correspondence dated in January 2008 and July 2008, the Veteran was informed of what evidence was required to substantiate the claim, of his and VA's respective duties for obtaining evidence, and of the criteria necessary for assignment of a disability rating and effective date. All the VCAA requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claims. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996). The Board finds the VCAA notice requirements have been met in this case. Duty to Assist With regard to the duty to assist, the claims file contains service treatment records, VA treatment records, records from the Social Security Administration (SSA), and lay statements provided by the Veteran. The Board notes that a February 2013 VA examination indicates additional VA treatment records exist that may not be a part of the claims file. Specifically, the February 2013 VA examiner stated records indicated the Veteran's PTSD symptoms were stable with no change since his last VA examination. In addition, the Veteran's most recent behavioral medicine examination in January 2013 indicated an improved sleep pattern and reduced anxiety. Further, the VA examiner noted that a December 2012 VA treatment record showed the Veteran's sleep was stable with fewer, if any, nightmares and also indicated that the Veteran was staying away from people. Finally, a December 2012 record showed the Veteran seemed stable with PTSD. Here, the VA examiner reviewed the Veteran's treatment records and cited to the pertinent evidence in support of the examination findings. In addition, the evidence cited reflects a similar set of symptoms when compared to the evidence already of record and corroborates the Board's findings herein. As such, the Board concludes that further action to obtain those records is not required. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (finding that strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (noting that remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant are to be avoided). The Veteran underwent VA examinations in connection with his claim in February 2008, February 2010, and February 2013. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The examiners reviewed the pertinent evidence of record and the Veteran's lay statements. Additionally, the examinations provide sufficient information to decide the issue on appeal, to include the findings relevant to the Veteran's functional impairment in daily life. 38 C.F.R. § 3.159(c)(4); Martinak v. Nicholson, 21 Vet. App. 447 (2007). Therefore, the examinations provide findings relevant to the criteria for rating the disability at issue. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Thus, the Board finds that VA's duty to assist with respect to obtaining an examination or opinion has been met. 38 C.F.R. § 3.159(c)(4). As all relevant facts have been properly and sufficiently developed in this appeal, no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claim. Essentially, all available evidence that could substantiate the claim has been obtained. Legal Criteria Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but 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). The primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2012). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV), a global assessment of functioning (GAF) score reflects the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM-IV, American Psychiatric Association (1994), pp. 46-47; 38 C.F.R. §§ 4.125(a), 4.130 (2012). A GAF score of 31-40 indicates 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). A GAF score of 41-50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51-60 represents 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 61-70 indicates 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. The Veteran's service-connected PTSD has been rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides: A 30 percent disability rating is warranted when there is 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). A 50 percent disability rating is warranted when the Veteran experiences 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 disability rating is warranted when the Veteran experiences 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 work-like setting); and inability to establish and maintain effective relationships. A 100 percent disability rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130. Analysis The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). Currently, the Veteran's PTSD is rated as 30 percent disabling. Therefore, to warrant a higher disability rating, the evidence must show 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. A January 2007 VA mental health record indicates the Veteran was neatly dressed and groomed, alert and oriented, with intact memory and organized thought content. The Veteran reported increased moodiness attributed to situational stress and denied suicidal ideations, homicidal ideations, hallucinations, and delusions. The Veteran was primarily focused on his concerns about his mother. The VA clinical nurse specialist assigned a GAF score of 60. An April 2007 VA mental health record reflects similar symptoms, except that the Veteran reported feeling fairly good with less irritability. He stated that he was going camping with friends in the next few weeks. The VA clinical nurse specialist assigned a GAF score of 60. In June 2007, the Veteran was noted as doing fair and working a full-time job. He reported nightmares, intrusive thoughts, and trying to avoid the news. The Veteran was neatly groomed and dressed, alert, oriented, pleasant, cooperative, with clear and coherent speech and intact memory. His mood was euthymic with full affect, and he denied thoughts of harming himself or others. There was no evidence of thought disorder or psychosis. A GAF score of 65 was assigned. In October 2007, the Veteran reported that he had been laid off from his job and told that he would have to start driving cross-country again. It was noted that the Veteran had great difficulty in the past performing those duties and that as a result had been working at a desk job for the past two to three years. The Veteran's mood was fine, his affect was consistent with his stated mood and anxious, his speech was unremarkable, and his memory was intact. The Veteran denied suicidal ideations and homicidal ideations, his thought process was linear, his insight was fair to good, his judgment was adequate, and there was no overt psychosis apparent. Treatment goals included investigating whether there was a job that the Veteran could handle despite his PTSD symptoms. A December 2007 VA mental health record reveals that the Veteran was very discouraged about his prospects of employment. He seemed anxious and almost tearful, and the psychiatrist found that his PTSD symptoms might have been a little worse. The Veteran avoided leaving his home and felt very anxious in public. He had interrupted sleep with nightmares at least twice a week and had decreased motivation and energy. On examination, the Veteran had poor eye contact, his mood was depressed, and his affect was consistent with his mood. His speech was slow and soft, his memory was intact, he denied suicidal ideations and homicidal ideations, and his thought processes were linear and logical. No overt psychosis was apparent, his insight was fair, and his judgment was adequate. The psychiatrist assigned a GAF score of 55. In January 2008, the Veteran was neatly dressed and groomed, alert and oriented, and his memory was intact. He denied suicidal ideations, homicidal ideations, hallucinations, and delusions. The clinical nurse specialist assigned a GAF score of 60. In February 2008, the Veteran underwent VA examination in connection with his claim. The VA examiner described the Veteran's "non-PTSD psychiatric symptoms" as including agitation; feelings of anger; crying spells; sleep disturbance; vague homicidal ideation; feelings of helplessness related to work situations; irritability; short-term memory problems; intrusive thoughts; feelings of panic; problems with decision-making; feelings of guilt and shame; and occasional obsessive thoughts about locking doors. The Veteran reported a good relationship with his wife, regular contact with his son, daughter, and three of his grandchildren, and some contact with a few male friends. The Veteran stated that he had quit his job in October 2007 because he was reassigned to resume cross-country hauls for the company. He reported that he could not deal with the stressors of driving long distances because of his PTSD symptoms but that he had been able to manage paperwork and perform short hauls. Since he quit his job, his activity level had decreased. The Veteran stated that he spent time cleaning the house, cooking, and working in the garage. The VA examiner found that despite the increased stressors that included his mother's illness and his loss of employment, there did not appear to be any significant decline in the Veteran's overall psychosocial functioning. The Veteran was appropriately dressed, with unremarkable speech, a cooperative attitude, and a constricted, blunted affect. His mood was agitated, and he had a short attention span. The Veteran's thought processes were unremarkable, he denied delusions, and he understood the outcome of his behavior. The Veteran averaged six hours of sleep with medication and had nightmares four to five times per month. He denied hallucinations, obsessive/ritualistic behaviors, and inappropriate behavior. The Veteran reported panic attacks and described being startled by loud noises and having to be close to an opening when in public. He stated that he had vague ideations about "wishing hurt" on his former employers but denied suicidal thoughts. His impulse control was described as fair with no episodes of violence, and his thought content included ruminations. The Veteran's symptoms had a moderate effect on shopping and a slight effect on traveling, driving, and other recreational activities. The Veteran described getting nervous when he was driving, particularly in traffic, and reported that he got angry at others driving. The VA examiner found the Veteran's remote memory was normal but his recent memory and immediate memory were mildly impaired in that he would forget what he was going to do. The Veteran's PTSD symptoms were manifested by persistent re-experiencing of the traumatic event by recurrent and intrusive distressing recollections of the event; recurrent distressing dreams; acting or feeling as if the traumatic event were recurring; intense psychological distress at exposure to internal or external cues; and physiological reactivity on exposure to internal or external cues. His persistent avoidance of stimuli associated with the trauma included efforts to avoid thoughts, feelings, activities, places, or people that aroused recollections of the trauma and feelings of detachment or estrangement from others. He had persistent symptoms of increased arousal that included difficulty falling or staying asleep; irritability; hypervigilance; and exaggerated startle response. It was noted that medication had decreased his sleep disturbances but that irritability, agitation, and hypervigilance continued to be a problem. The Veteran denied any periods of remission. The VA examiner assigned a GAF score of 60 and noted that the changes in the Veteran's functional status and quality of life since his last examination included performance in employment, social and interpersonal relationships, and recreational and leisure pursuits. The Veteran claimed his PTSD symptoms limited his employment opportunities, social interactions, and his ability to engage in recreational activities and caused marital strain. The VA examiner found the Veteran's presentation, in general, remained unchanged since his last examination in 2003. The VA examiner opined that there was not total occupational and social impairment due to the Veteran's PTSD symptoms and that the Veteran's unemployment was not due to a decline in his functioning. However, the Veteran's PTSD symptoms did result in deficiencies in the areas of thinking, family relations, work, and mood. VA treatment records from March 2008 to January 2010 reflect GAF scores ranging from 55 to 65. In support of his claim for SSA disability benefits, the Veteran submitted a June 2009 taped statement with his treating VA psychologist. The VA psychologist stated that he had diagnosed PTSD in 2003 and that in his opinion, the Veteran's symptoms had worsened in recent years. In particular, he noted that the Veteran had a hard time being around people and that in the past, the Veteran was pretty good at working as a road truck driver until stress had begun to greatly affect him. The VA psychologist found the Veteran had a difficult time holding on to jobs since he left the National Guard in 1997. In addition, the VA psychologist noted that the Veteran was in transportation during active duty in Vietnam and that over the years it had begun to affect him more while working as a road truck driver. The VA psychologist reported that the Veteran stayed home and did not go out too much because he needed to be in control. The VA psychologist also opined that the Veteran had a hard time having contact with the general public and being around other co-workers. According to the VA psychologist, if the Veteran were exposed to extreme criticism, he would have a very hard time handling it. The VA psychologist also stated that he did not see the Veteran going out and getting a full-time job. He felt the Veteran might be able to handle a part-time position where he could work a lot by himself and not have to worry about people. The VA psychologist also opined that the Veteran would need to take frequent breaks throughout the work day due to the stress and that he would have to miss two or more days of work per month if working full-time as the result of his symptoms. SSA records reflect the Veteran's reports that he experienced panic attacks a few times per week and sometimes daily. Because of his PTSD symptoms, he stated that he did not go to the store with his wife and he did not drive. An SSA examiner found the Veteran's impairment caused moderate restriction in activities of daily living, marked difficulties in maintaining social functioning, marked difficulties in maintaining concentration, persistence, or pace, and no episodes of decompensation, each of extended duration. The Veteran underwent additional VA examination in February 2010. The Veteran reported occasional nightmares at least two to three times per week related to Vietnam. He also stated that he had episodes of increased irritability but was able to control himself. He continued to avoid the subject of war and stated that his flashbacks had improved with medication, with the last flashback occurring approximately four months ago. The Veteran reported that he felt startled by loud noises and therefore avoided crowds of people and did not go to social events. He mainly stayed at home with his wife. The Veteran reported that he had participated in no activities or leisure pursuits since his last examination. He denied any destructive ideations at that time. His interactions with his family and friends had been minimal, although his relationship with his wife had improved over the years. On mental status examination, the Veteran was cooperative, adequately dressed, and showed no impairment of thought processes or communication. He denied any visual hallucinations or delusions and maintained good eye contact. The Veteran also denied any suicidal or homicidal ideations, plans, or intent. His memory appeared to be baseline, and there were no obsessive or ritualistic behaviors reported. The Veteran denied panic attacks but reported episodes of edginess and problems handling stress. With respect to his PTSD symptoms, the Veteran showed avoidance, heightened physiological arousal, increased isolation, and hypervigilance. However, he maintained some improvement in controlling his temper with medication. The Veteran reported an improvement of at least 30 percent overall in his symptoms and at least 50 percent or less of the overall symptomatology related to his PTSD symptoms. The Veteran still had some decrease in productivity due to problems handling stress and duties requiring intensive focus or concentration. The VA examiner assigned a GAF score of 65. In February 2013, the Veteran underwent VA examination using telehealth assessment to determine the current nature and severity of his PTSD symptoms. The Veteran reported weekly intrusive thoughts and at least weekly dreams or nightmares. The Veteran had daily avoidance of people and conversations concerning Vietnam and daily estrangement from others. He reported variable irritability, hypervigilance, and mostly mild startle response. The VA examiner assigned a GAF score of 60 and found the Veteran's symptoms were relatively stable with no change since his last examination. The VA examiner opined that the Veteran's symptoms were manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. The Veteran reported that he was close with his family but mostly stayed to himself at his house during the day. He stated that he had not worked since 2007 as the result of his PTSD symptoms. With respect to the PTSD criteria, the Veteran reported recurrent distressing recollections and dreams; efforts to avoid thoughts, feelings, conversations, and activities related to the trauma; markedly diminished interest in activities; feelings of detachment or estrangement from others; difficulty falling asleep; irritability; hypervigilance; and exaggerated startle response. It was noted that the Veteran's PTSD symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The VA examiner found the Veteran had symptoms of suspiciousness related to his PTSD diagnosis. Mental status examination revealed that the Veteran was oriented to person, place, and time; his thoughts were logical; his speech was fluent; his mood and affect were appropriate; his dress was clean; his insight and judgment were intact; and he had no suicidal or homicidal ideations. Given the above record, the Board concludes that the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity. Initially, the Board notes that the Veteran experienced symptoms that are not listed in the rating criteria, and as a result, the Board has considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of occupational and social impairment with deficiencies in most areas. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Here, the evidence demonstrates that the Veteran's PTSD was manifested specifically by sleep impairment, impairment of recent and immediate memory, irritability, constricted and blunted affect, frequent panic attacks, hypervigilance, disturbances of motivation and mood, and increased isolation. In February 2008, it was noted that the changes in the Veteran's functional status and quality of life since his last examination included performance in employment, social and interpersonal relationships, and recreational and leisure pursuits. In June 2009, the Veteran's treating psychologist testified that the Veteran's PTSD symptoms had worsened since 2003 and opined that the Veteran had a hard time having contact with the general public and being around other co-workers. The VA psychologist also stated that he did not see the Veteran acquiring a full-time job because he would need to take frequent breaks throughout the work day and would have to miss two or more days of work per month as the result of his symptoms. Instead, he opined that the Veteran might be able to handle a part time position where he could work alone and not have to worry about people. In this respect, the Board is cognizant that the Rating Schedule is meant to reflect the average impairment of earning capacity resulting from service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. The Board also affords significant value to the SSA examiner's conclusions that the Veteran's impairment caused moderate restriction in activities of daily living, marked difficulties in maintaining social functioning, and marked difficulties in maintaining concentration, persistence, or pace, each of extended duration. Finally, the Board finds credible the Veteran's assertions that his PTSD symptoms affect his occupational performance, especially considering the evidence indicating that he quit his last job due to the specific change in duties. Throughout this period, VA physicians assigned GAF scores ranging from 55 to 65, indicating a range of mild symptoms or some difficulty in social and occupational functioning to moderate symptoms or moderate difficulty in social and occupational functioning. Here, the Board finds the Veteran's specific symptoms more often than not align with the symptoms indicated by the lower range of GAF scores assigned. Specifically, the evidence reflects symptoms of constricted affect, panic attacks, frequent nightmares, memory impairment, disturbances in motivation and mood, and increased isolation. Further, the Board finds the effect of the Veteran's PTSD symptoms on his occupational functioning represents more serious impairment based on the analysis presented by the SSA examiner and VA treating psychologist. Finally, while there were times wherein the Veteran's GAF score improved or worsened, the symptoms manifested remained largely constant. As such, the Board concludes that the evidence as a whole more nearly approximates the criteria for a 50 percent disability rating for the entire pendency of the appeal. 38 C.F.R. §§ 4.7, 4.130 Diagnostic Code 9411. However, the Board finds that a rating in excess of 50 percent is not warranted for the Veteran's service-connected PTSD. The evidence of record does not reflect symptoms of suicidal ideations; 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; spatial disorientation; or neglect of personal appearance and hygiene. Further, the Veteran has been able to maintain a good relationship with his wife and some interpersonal relationships with his family and a few friends. His GAF scores consistently show moderate symptoms and the evidence does not suggest a finding of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. Where there is some impairment in some of those areas, it is not severe and not present in most areas. For these reasons, the Board finds that the criteria for a disability rating of 50 percent, but no higher, for PTSD have been met. 38 C.F.R. § 4.130. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service. 38 C.F.R. § 3.321(b)(1) (2012). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. Here, the Board finds the Veteran's disability picture is not so unusual or exceptional in nature as to render the rating assigned herein inadequate. The Veteran's service-connected PTSD is evaluated as a psychiatric disability, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. Thun, 22 Vet. App. at 115; see also 38 C.F.R. § 4.130, Diagnostic Code 9411. During the appeal period, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity, due to such symptoms as sleep impairment, impairment of recent and immediate memory, irritability, constricted affect, panic attacks, hypervigilance, disturbances of motivation and mood, and increased isolation. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are contemplated by a 50 percent disability rating. A rating in excess of 50 percent is provided for increased severity of PTSD, but the medical evidence demonstrates that the Veteran's PTSD is not more severe than that contemplated by the 50 percent rating. The criteria for the 50 percent disability rating assigned herein more than reasonably describe the Veteran's disability level and symptomatology, and therefore, the schedular evaluation is adequate, and no referral is required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). By this decision, the Board has found that a 50 percent rating for PTSD is warranted based on the evidence of record. However, because the preponderance of the evidence is against the assignment of a 70 percent disability rating for PTSD, there is no doubt to be resolved, and a rating in excess of 50 percent for PTSD is not warranted. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to a disability rating of 50 percent, but no higher, for PTSD is granted. REMAND The Court has held that a TDIU claim is part and parcel of an increased rating claim when raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). As a result, the Board has jurisdiction to consider the Veteran's possible entitlement to a TDIU when the issue is raised by assertion or reasonably indicated by the evidence and is predicated, at least in part, on the severity of the service-connected disability in question, regardless of whether the RO has expressly addressed this additional issue. See VAOPGCPREC 6-96 (Aug. 16, 1996); see also Caffrey v. Brown, 6 Vet. App. 377 (1994); Fanning v. Brown, 4 Vet. App. 225, 229 (1993); EF v. Derwinski, 1 Vet. App. 324 (1991). In this case, the Veteran has not filed a formal claim for a TDIU; however, on VA examination in February 2008, the Veteran reported that he had to quit his job because of his PTSD symptoms. The evidence of record also includes records from the SSA that demonstrate the Veteran was awarded disability benefits, in part, on the basis of his PTSD symptoms. These records show that the Veteran reported being unable to maintain steady, gainful employment as the result of his PTSD symptoms. Therefore, the Board finds that the issue of entitlement to a TDIU has been reasonably raised by the evidence of record and should be adjudicated as part of the claim on appeal. Id.; see also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001); Bowling v. Principi, 15 Vet. App. 1 (2001). As such, the claim for entitlement to a TDIU is remanded for appropriate action. Accordingly, the case is REMANDED for the following actions: 1. The RO should send the Veteran VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, with instructions to return the form to the RO. 2. The RO should complete any additional evidentiary development necessary to adjudicate a claim for a TDIU, to specifically include collecting and verifying information concerning the Veteran's complete educational and occupational history. 3. The RO should schedule the Veteran for an examination to determine the effect of his service connected disabilities on his ability to secure or follow a substantially gainful occupation. The examiner is requested to offer an opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's service-connected disabilities, alone or in combination, prevent him from securing or following a substantially gainful occupation. When offering this opinion, the examiner should not consider the effects of age, or any non-service connected disability. 4. When the development requested has been completed, adjudicate the claim for entitlement to a TDIU. If the benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs