Citation Nr: 1314510 Decision Date: 05/02/13 Archive Date: 05/15/13 DOCKET NO. 07-06 846 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) (with the exception of periods of temporary total hospitalization ratings under 38 C.F.R. § 4.29), prior to August 1, 2006. 2. Entitlement to an evaluation in excess of 50 percent for PTSD, from August 1, 2006. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Wade R. Bosley, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and J.M. ATTORNEY FOR THE BOARD M. J. In, Associate Counsel INTRODUCTION The Veteran had active service from September 1966 to May 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal from February 2006 and February 2008 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO) in Indianapolis, Indiana. The February 2006 rating decision denied an evaluation in excess of 30 percent for the Veteran's service-connected PTSD, and the February 2008 rating decision denied entitlement to a total rating for compensation purposes based on individual unemployability (TDIU). During the pendency of this appeal, a January 2007 rating decision granted a 50 percent rating for PTSD, effective from August 1, 2006. In an April 2009 decision, the Board denied the claims. The Veteran appealed the Board decision to the United States Court of Appeals for Veterans Claims (Court). In October 2009, the Court granted the parties' Joint Motion for Remand, vacated the Board's April 2009 decision, and returned the case to the Board. In a December 2010 decision, the Board again denied the Veteran's claims. The Veteran appealed the Board's December 2010 decision to the Court. The Court, in an August 2012 memorandum decision, reversed and remanded the part of the Board's December 2010 decision that found that Veteran did not meet the schedular requirements for TDIU for the period beginning August 1, 2006, and vacated and remanded the remainder of the Board's December 2010 decision, and returned the case to the Board. In February 2009, the Veteran and a witness testified during a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the Veterans Law Judge (VLJ) who conducts a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the February 2009 Board hearing, the undersigned VLJ stated the issues on appeal. The Veteran was assisted at the hearing by an attorney; however, the VLJ asked questions to ascertain the extent of severity of the disability at issue. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or his attorney. The Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims for TDIU and an increased rating, and the basis for achieving a higher rating for his PTSD. The Veteran did not suggest any deficiency in the conduct of the hearing. Therefore, the Board finds that, consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). Addtionally, as the decision herein grants a 100 percent schedular rating for PTSD, as well as entitlement to a TDIU, throughout the rating period on appeal. As such, the maximum benefits sought have been granted, and the Veteran may not be held to have been prejudiced by any deficiency in fulfilling the duties set forth in 38 C.F.R. § 3.103(c)(2). In January 2013, the Veteran's attorney submitted additional evidence in support of the Veteran's claims with a waiver of RO review in accordance with 38 C.F.R. § 20.1304 (2012). FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's posttraumatic stress disorder (PTSD) has been manifested by chronic depression, anger outbursts, feelings of guilt, intrusive recollections, sleeping disturbance with nightmares, flashbacks, anxiety attacks, irritability, hypervigilance, increased startle response, mood swings, poor concentration, violent thoughts, social isolation, lack of interest and motivation, fleeting suicidal ideation, avoidance behaviors, neglect of personal hygiene, variable mood and affect, tense motor activity, and occasionally a btangential thought process productive of functional impairment comparable to total occupational and social impairment. 2. The evidence of record demonstrates that, throughout the rating period on appeal, the Veteran's service-connected PTSD alone rendered him unable to secure or follow a substantially gainful occupation consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. The criteria for a 100 percent rating for PTSD, for the periods from July 14, 2004 through September 20, 2005, from November 1, 2005 through June 22, 2006, and from August 1, 2006, have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a total disability rating for compensation purposes based on individual unemployability (TDIU) have been met throughout the rating period on appeal. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (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, 5126 (West 2002) redefined VA's duties to notify and to assist the veteran 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, 3.326(a) (2012). Without deciding whether the notice and development requirements have been satisfied, the Board is not precluded from adjudicating the Veteran's claims because the Board is granting a 100 percent schedular rating for PTSD, as well as entitlement to a TDIU, throughout the rating period on appeal. As such, the maximum benefits sought have been granted. Hence, this decision poses no risk of prejudice to the Veteran. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); see also Pelegrini v. Principi, 17 Vet. App. 412 (2004); VAOPGCPREC 16-92, 57 Fed. Reg. 49,747 (1992). Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2012). Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In general, the degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). However, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran entered a VA substance abuse treatment in October 2004, and participated with chemical dependence counseling group sessions. An October 2004 VA discharge summary reflects that on mental status examination, the Veteran's speech was loud, coherent, spontaneous and goal-directed. His mood was anxious and his affect was appropriate. No suicidal or homicidal ideation was shown. He was fully oriented and his insight into the issues was good. A December 2004 VA initial assessment report from a VA psychologist, Dr. Michael Sheehan, stated that the Veteran was referred from chemical dependence unit for aftercare. Dr. Sheehan noted that the Veteran had led a violent and chaotic life. The diagnoses were chronic PTSD, major depression, and alcohol abuse on Axis I; and antisocial personality disorder on Axis II. A GAF (Global Assessment of Functioning) score of 48 was listed. The Veteran continued to see Dr. Sheehan for approximately six more sessions from January through June 2005 for individual counseling. He returned to see Dr. Sheehan in August 2006, at which time PTSD was diagnosed again and a GAF score of 53 was assigned. The Veteran continued to see Dr. Sheehan in group therapy from December 2006 to February 2010. Following conducting a comprehensive psychiatric evaluation in August 2006, Dr. Sheehan diagnosed PTSD on Axis I with no Axis II diagnosis, and a GAF score of 53 was listed. The Veteran reported avoidance behaviors, social isolation, intrusive thoughts, and anxiety attacks. On psychological assessment, the Veteran was fully oriented, cooperative, coherent, and eager to participate. The clinical impression was that the Veteran was afflicted with severe PTSD which was exacerbated by the war in Iraq. In the Veteran's group treatment notes dated from April 2006 through December 2007, Dr. Sheehan noted that the Veteran was making moderate progress. The Veteran was seen by a VA psychiatrist, Dr. Uddin, who diagnosed him with dysthymic disorder and depression in February, April and June 2005. The Veteran reported that things were going well. On mental status examination, he was alert, oriented, brighter, positive but still reported depression and decreased sleep. His judgment and insight were intact. He was not psychotic, homicidal or suicidal. The Veteran received inpatient PTSD treatment at VA from September 21, 2005 to October 13, 2005. An October 2005 VA discharge summary reflects that the Veteran complained of depression, isolation, sleep problems with nightmares and night sweats, increased startle response, avoiding crowds, hypervigilance, anxiety, flashbacks, anger problems, feelings of guilt, and intrusive thoughts. On mental status examination, he was alert, fully oriented, and cooperative. He was casually groomed and he showed pleasant mood and congruent affect. There was no evidence of suicidal or homicidal ideation or any psychosis. His speech was loud but clear and coherent and he displayed good eye contact. His attention, concentration and judgment for treatment were good, but his insight was limited. The diagnoses were PTSD and polysubstance abuse in remission, and a GAF score of 39 to 40 was assigned. A June 2005 Vet Center report reflects that the Veteran was seeking readjustment counseling. The report noted the Veteran's history of antisocial behaviors with extensive legal history. He stated that most of his adult life he was a "functional drunk." He lived alone and his cousin was his power of attorney. On mental status examination, the Veteran exhibited unkempt appearance, suspicious and defensive manner, above average intelligence, rapid and pressured speech, full orientation, impaired memory function, labile affect, tense motor activity, and poor judgment. No delusions, disorganized thinking or hallucinations were shown. He denied suicidal or homicidal thoughts. He was taking medications for sleep, anxiety and depression. The Veteran stated that after he returned from Vietnam he had three jobs but "I could not stand to be there." He had been a baseball umpire about once a week. He lived alone with his dogs and cat. He was married for a short period of time but got divorced. He was close to his cousin and power of attorney, J.M. The Veteran reported lifetime of adjustment problems since his military service and endorsed PTSD symptoms of flashbacks, startle response, nightmares, hypervigilance, intrusive distressing recollections, as well as antisocial behaviors with poor impulse control and extensive history of legal problems and extensive history of substance-related problems. Progress notes from the Veteran's Elkhart group meetings dated from August 2005 to June 2006 show a continuing diagnosis of PTSD. In February 2006, the Veteran stated that he enjoyed his dogs and umpiring baseball and that he also worked with Toys of Tots. January 2005 and January 2006 VA psychiatry reports noted diagnoses of bipolar disorder, PTSD, and history of polysubstance abuse. The Veteran reported symptoms of isolation, lack of desire to do anything, insomnia, and wide mood swings. He denied suicidal ideations, hallucinations, or paranoia. Objectively, he was alert, fully oriented, casually dressed and pleasant. His affect was wide-ranged and mood was labile. No perceptual disturbances, suicidal or homicidal thoughts were shown. He had occasional nightmares related to Vietnam. A June 2006 VA discharge summary reflects that the Veteran was admitted with a chief complaint of ongoing PTSD symptoms that he described as depression, isolation and poor sleep. On mental status examination, the Veteran was alert, fully oriented, cooperative, appropriately dressed and groomed, and with good eye contact. His affect and mood were pleasant and his speech was verbally relevant, spontaneous and goal-directed. He denied suicidal or homicidal ideation, or auditory or visual hallucinations. He reported hyper-alertness. It was noted that the Veteran attended both individual and group therapy and was described as an active participant. His identified problems included avoidance, social isolation, depression; poor anger control; flashbacks, hypervigilance, and intrusive thoughts; sleep disturbance; and ongoing medical problems. In an August 2006 statement, J.M. related that she became very good friends with the Veteran since April 2003 after his mother passed away. At that time, the Veteran was drinking and using substance, which J.M. undoubtedly believed was to numb his pain of Vietnam. She reported her observations as to the Veteran's symptoms of inability to trust others, social isolation and withdrawal, anxiety attacks, flashbacks, chronic depression, irritability, violent tendency, impaired short-term memory, difficulty with sleep and concentration, and mood swings. She further stated that the Veteran had always been the type that never stuck with a job very long and that the longest that he had stayed with any employer was 3 to 4 years. He did not like to take orders, rarely completed tasks, and had no ambition at times, and his personal hygiene was sometimes not the best. She also reported totally inappropriate social behaviors and intermittent disorientation. There was no pattern or expected routine and he has lived on the "edge." The Veteran attended a VA examination in November 2007. The VA examiner indicated that the Veteran's claims file was reviewed. The Veteran reported that he last worked in 2004 at an animal shelter for three months through vocational rehabilitation services and that he currently lived alone. The Veteran complained of disturbing dreams of Vietnam, intrusive thoughts of Vietnam, difficulty with loud noises, preference to isolate himself socially, anger control problems, as well as severe history of substance dependence and antisocial behaviors. The examiner noted that generally, the Veteran's mental health problems appeared to be of moderate severity. The Veteran indicated that he had not worked in a real job since 2003 when he was a welder. At that time, he worked for two years for the same company but he had been off a lot for sick leave. More recently, he stated that he worked as an animal shelter worker for three months in 2004. Regarding his social and family relationships, the Veteran reported a close and positive relationship with his daughter and grandchild who he saw at least once a month and talked once a week. He enjoyed spending time with them and he occasionally attended his granddaughter's school events. He also had a close and positive relationship with his cousin, J.M., whom he saw every day. The Veteran was currently actively involved in Toys for Tots campaign in the community and he stated that he enjoyed going to church once or twice a month with his friend. He enjoyed going out to breakfast with his male friend regularly, before church. He was able to care for his personal hygiene and activities of daily living. He denied recent problems with suicidality or violence/aggression. On mental status examination, the Veteran was casually dressed with average grooming and hygiene. He maintained good eye contact and displayed no inappropriate behaviors. He was alert and fully oriented, and had good memory and concentration. His speech was fluent, well-articulated, logical, relevant, coherent, and goal-directed. No psychotic symptoms, such as hallucinations, delusions or disorders of thought or communication were shown. He stated that at times he felt that he became angry and tried to distance himself from others to avoid any impulse control problems. He denied any current suicidal or homicidal thoughts. No obsessive or ritualistic behaviors that might interfere with routine activities were reported. The diagnoses were PTSD and substance dependence on Axis I, and antisocial personality disorder on Axis II; and a GAF score of 53 was listed. The examiner stated that the current GAF score of 53 represented the cumulative impact of his various psychiatric disorders, and a separate GAF score for his PTSD would be 56. The examiner found that the Veteran's reported psychosocial dysfunction could be attributed to PTSD-like symptoms; however, much of his psychosocial dysfunction could be attributed to other lifelong problems including a marked antisocial personality disorder, as demonstrated by a history of dysfunctional interpersonal relationships and occupational history resulting in depression and anger. The examiner further noted that although many symptoms involved in antisocial personality disorder overlapped with bipolar disorder and PTSD, the Veteran's antisocial personality disorder was seen to be entirely separate from his PTSD. As to the effects of PTSD on occupational and social functioning, the examiner found that there was reduced reliability and productivity due to PTSD signs and symptoms; however, his antisocial personality disorder also had significantly impacted his reliability and productivity in the occupational and social functioning; in addition, his chemical dependency had negatively impacted his psychosocial functioning. In a February 2008 statement, the Veteran claimed that the November 2007 VA examination report contained inaccurate or incomplete findings as to his reported PTSD symptoms. Specifically, the Veteran clarified that his employment with the animal shelter in 2004 lasted only 3 months out of the 6 month assignment because of his reaction to the "backbiting from the city employees." He stated that the "close and positive relationship" with his daughter and grandchild was not steady and that currently, his daughter refused to let him see his grandchild because of his PTSD symptoms that scared her. The Veteran further stated that although the VA examiner noted that the Veteran enjoyed going out to breakfast with a male friend, the friend was a 94 year old World War II veteran and they had not been able to go to church for at least six months. Finally, the Veteran reported that he had been completely sober since July 4, 2004. In VA psychiatry notes dated from February through March 2012, a VA psychiatrist, Dr. Picard, noted diagnoses of PTSD and bipolar disorder. The Veteran reported doing fine as long as he stayed in his "comfort area," his local area. He stayed within a small radius to avoid the stress and risk of dealing with the public because he feared of losing control. His cousin was very involved in his life and was a stabilizing influence. He reported symptoms of road rage, lasting depression, isolation, sporadic sleeping, expansive moods, violent thoughts, nightmares, and hypervigilance. In July 2011, J.M. related that the Veteran had been disoriented, agitated and not rational at times. However, the Veteran stated that he took his pet's medications by mistake. Objectively, he exhibited fair grooming and hygiene, clear and loud speech, coherent but occasionally tangential thoughts, and varied mood and affect. He denied suicidal ideation most of the times but reported occasional and fleeting suicidal thoughts in February 2011. In a May 2011 addendum, Dr. Picard noted that the Veteran's PTSD and bipolar disorder were considered stable as long as the Veteran limited his activities to his local, low-stress environments, and people that he trusted and was unlikely to have significant conflict with; within this limited range of activity, the Veteran got by without any major signs, symptoms, or conflicts. Dr. Picard noted that he revised the Veteran's GAF to 50 as it had been judged a bit too high in the past because he was doing well, which was largely because he limited his activities and contacts with others. At his February 2009 hearing before the Board, J.M. testified that the Veteran currently had no contact with his daughter and granddaughter. She believed that he was unable to maintain a relationship due to his extreme irritability. She further reported his symptoms of depression, anxiety attacks, inability to concentrate, lack of personal hygiene, and violent tendencies that had sometimes led to property damages. She lived close to the Veteran and saw him every day; she helped the Veteran with house chores as he was unable to do his daily chores. The Veteran reported that since his military service, he experienced chronic depression and was unable to hold a job because of his inability to conform to authorities, outbursts of anger and lack of social interaction. In February 2009, the RO received a statement from the Veteran's VA PTSD clinical psychologist, Dr. Sheehan. Dr. Sheehan indicated that the Veteran participated in his PTSD group psychotherapy since 2004 and that he presented with chronic severe PTSD from his participation in the Vietnam War. Dr. Sheehan opined that the Veteran's antisocial personality is a component of his PTSD and was not present prior to his PTSD. It was noted that the Veteran was from a solid working class family and his adolescent rebellion was well within the normal range and not characteristic of antisocial personality. He had friends, was well-liked, and did not have problems with authorities at school; nor did he have job problems when he started working at age of 15. However, Dr. Sheehan noted that after the war, the Veteran was unable to hold a job mostly because he could not conform to authority or his outbursts of temper would cost him jobs. He could function in short term tasks that had an end point, after which he could return to his isolation. He did not like being around people and he was afraid of his own violence. He always had a knife on himself and was prepared to defend himself; being constantly on guard made it difficult to hold a job, have a friend, or function in society. In February 2010, Dr. Sheehan wrote that the Veteran was what the members of his PTSD group called a "bush vet." He was not capable of living in civilization with other human beings so he lived as close to the wilderness as he could and interacted with as few human beings as possible. His dogs were his closest companions. His cousin ran interference for him to keep him out of trouble and drove him to appointments because if he drove by himself he would likely get road rage and get into trouble. The Veteran reported his murderous impulses and why it was so important that he not live in society. In March 2010, the Veteran underwent a private psychiatric evaluation by J. Mangold, Ph.D. Dr. Mangold indicated that the Veteran's entire record, including the claims file, was reviewed. On mental status examination, the Veteran was casually dressed and there were no indications of impaired reality testing. He was oriented and his remote and recent memory was good. He reported PTSD symptoms of intrusive recollections three times a week, nightmares about his tour of duty, flashbacks triggered by trauma-related stimuli, difficulty with sleep, anger and irritability, avoidance behaviors, poor concentration, hypervigilance, suicidal ideation, markedly diminished interest or participation in significant activities, and feelings of detachment or estrangement from others. The diagnoses were severe PTSD and polysubstance dependence in sustained full remission, by report, and a GAF score of 37 was assigned based on social isolation, hypervigilance and extreme persisting anger. In contrast to the November 2007 VA examiner's finding that the Veteran's antisocial personality disorder and chemical dependency had significant effects on his psychosocial dysfunction, Dr. Mangold opined that the Veteran was not conduct-disordered as a child and did not now have an antisocial personality disorder. In support of this opinion, he noted that for a diagnosis of antisocial personality disorder, the individual must have had history of some symptoms of conduct disorder before age of 15 years but this was not shown in the Veteran's case. Concerning the impact of the Veteran's chemical dependency on his psychosocial functioning, Dr. Mangold noted that even though the Veteran has been clean and sober for about two years now there had been little improvement in his functional level. Based on an extended diagnostic interview and review of the record, Dr. Mangold concluded that the Veteran clearly had very severe occupational and social impairment with deficiencies in most areas, such as work, family relations, and judgment due to such symptoms as suicidal ideation, impaired impulse control (such as unprovoked irritability with periods of violence), neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work-like setting), and a near complete inability to establish and maintain effective relationships. Dr. Mangold further stated that all of these impairments were due to his PTSD-related symptoms and that it was clear from the record that the severity of his impairment had been at this level since the early 2000's. PTSD The Rating Schedule establishes a general rating formula for mental disorders. 38 C.F.R. § 4.130 (2012). 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). Accordingly, the evidence considered in determining the level of impairment 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. For the periods at issue in this decision - one year prior to the date of receipt of the Veteran's claim for an increased rating to the present - the Veteran's PTSD has been rated 30 percent or 50 percent disabling pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. (From September 21, 2005 through October 31, 2005 and from June 23, 2006 through July 31, 2006, the Veteran was assigned a 100 percent rating for the disability due to hospitalization, pursuant to 38 C.F.R. § 4.29.) PTSD is rated as 30 percent disabling 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). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory, such as 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. Id. 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. Id. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent 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. At the outset, the Board notes that it is precluded from differentiating between the symptomatology attributable to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). In this case, multiple psychiatric diagnoses were shown, to include PTSD, bipolar disorder, substance dependence, and personality disorder, among others. However, VA and private clinicians have not clearly distinguished between the level of impairment due to PTSD and the overall level of impairment attributable to the Veteran's other psychiatric conditions. As such, the Board has considered all of the Veteran's psychiatric symptoms and their severity in reaching the conclusion below. In evaluating the evidence, the Board has noted the various 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 DSM-IV; Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a GAF score of 51-60 indicates moderate symptoms, such as flat affect, circumstantial speech, occasional panic attacks, or moderate difficulty in social or occupational functioning, such as having few friends or having conflicts with peers or co-workers. DSM-IV at 46-47. A GAF score of 41 to 50 is assigned where there are serious symptoms, such as suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social or occupational functioning, such as no friends, unable to keep a job. DSM-IV at 46-47. A GAF of 31-40 is defined as exhibiting some impairment in reality testing or communication, such as speech is at times illogical, obscure, or irrelevant, or any major impairment in several areas, such as work, family relations, judgment, thinking or mood, such as a depressed man that avoids friends, neglects family, and is unable to work. DSM-IV at 46-47. The evidence of record supports a 100 percent rating for the Veteran's PTSD. The GAF scores noted during the period on appeal fluctuated from 37 to 56, which contemplate moderate symptoms, such as circumstantial speech, occasional panic attacks, or moderate difficulty in social, occupational or school functioning, for example, having few friends or having conflicts with peers or co-workers; as well as serious symptoms, such as suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social or occupational functioning, such as no friends, unable to keep a job; or exhibiting some impairment in reality testing or communication, such as speech is at times illogical, obscure, or irrelevant, or any major impairment in several areas, such as work, family relations, judgment, thinking or mood, such as a depressed man that avoids friends, neglects family, and is unable to work. DSM-IV at 46-47. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. The other evidence of record demonstrates that the Veteran had chronic depression, anger outbursts, feelings of guilt, intrusive recollections, sleeping disturbance with nightmares, flashbacks, anxiety attacks, irritability, hypervigilance, increased startle response, mood swings, poor concentration, violent thoughts, social isolation, lack of interest and motivation, fleeting suicidal ideation, avoidance behaviors and neglect of personal hygiene. The Board finds that the totality of evidence demonstrates manifestations of the PTSD are productive of functional impairment comparable to total occupational and social impairment. With regard to the Veteran's social functioning, a strong pattern of social isolation and withdrawal has been shown. The Veteran lived alone in his lake retreat and avoided social interaction with others to the extent possible. He had a close and positive relationship with his cousin and power of attorney, J.M., who is noted to be a stabilizing influence in his life. However, he stayed within a limited "comfort area," to avoid the stress and risk of dealing with the public because he feared losing control. To that effect, Dr. Sheehan, who has treated the Veteran for PTSD since 2004, notes that the Veteran is what his PTSD group members called a "bush vet," in that he was not capable of living in civilization with other human beings therefore he lived as close to the wilderness as he could and interacted with as few human beings as possible; his dogs were his closest companions. Concerning this, the Veteran reported his violent impulses and why it was so important that he not live in society. Although the November 2007 VA examination report stated that the Veteran had a close and positive relationship with his daughter and grandchild with whom he had frequent contact and enjoyed spending time, in the February 2008 statement, the Veteran reported that his daughter refused to let him see his grandchild because of his PTSD symptoms that scared her. He further indicated that he used to go to church and go out to breakfast with a veteran friend but they had not been able to do so for at least six months. At the February 2009 Board hearing, the Veteran's cousin stated that the Veteran no longer had contacts with his daughter and grandchild and that he was unable to maintain any relationship due his extreme irritability. She also testified regarding an incident where the Veteran's anger problems and violent tendency led to damage to her personal property. With regard to the occupational functioning, the record reflects that the Veteran had not been able to hold a job since his military service. On the November 2007 VA examination, the Veteran indicated that he had not worked in a real job since 2003, at which time he worked as a welder for two years for the same company but had been off a lot for sick leave. In February 2008, the Veteran reported that he lasted only three months out of a six month placement through his vocational rehabilitation service due to inability to get along with coworkers. In the August 2006 statement, J.M. reported that the Veteran had always been the type that never stuck with a job for very long and that the longest he stayed with any employer was 3 to 4 years because he did not like to take orders, rarely completed tasks, and had no ambition at times. She also reported the Veteran's neglect of personal hygiene, totally inappropriate social behaviors and intermittent disorientation. To that effect, Dr. Sheehan opined in the February 2009 letter that the Veteran was unable to hold a job mostly because he could not conform to authority, did not like being around people and was afraid of his own violence. Overall, the objective evidence of record shows that the Veteran's disability picture more closely approximates a 100 percent rating throughout the rating period on appeal. 38 C.F.R. § 4.7 (2012) (where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating). In reaching this conclusion, the Board finds Dr. Mangold's March 2010 opinion, that the Veteran clearly has very severe occupational and social impairment with deficiencies in most areas, and a near complete inability to establish and maintain effective relationships, as having significant probative value. The Board also finds that this is consistent with Dr. Sheehan's February 2009 statement that the Veteran was constantly on guard, which made it difficult to hold a job, have a friend, or function in society. Accordingly, in considering the evidence of record under the laws and regulations as set forth above, the Board concludes that an increased rating of 100 percent is warranted for the Veteran's service-connected PTSD during the entire appeal period. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Staged ratings have been considered. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence of record does not show a distinct period of time on appeal during which a rating of less than 100 percent would be warranted for the Veteran's service-connected PTSD. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The medical evidence of record reflects that the Veteran had similar PTSD symptoms which appear to have remained of such severity throughout the rating period on appeal. Under Thun v. Peake, 22 Vet App 111 (2008), there is a three- step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. The Veteran has been assigned a 100 percent schedular rating for PTSD, the maximum benefit assignable. As such, referral for extraschedular consideration is not warranted. See VAOPGCPREC 6-96. TDIU TDIU is warranted when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for TDIU benefits; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Service connection is in effect for bilateral hearing loss, currently rated as noncompensable; tinnitus, currently rated as 10 percent disabling; and PTSD, now rated as 100 percent disabling throughout the rating period on appeal. The Veteran's combined disability rating is 100 percent throughout the rating period on appeal. See 38 C.F.R. § 4.25 (2012). As such, the Veteran meets the minimum schedular criteria for TDIU throughout the rating period on appeal. 38 C.F.R. § 4.16(a). The record reflects that the Veteran finished high school before he entered into military service in 1966. After military discharge, he worked as a welder until approximately 2003. However, various written statements and lay testimony before the Board reflect that the Veteran had been unable to hold a job with any employer for more than 3 to 4 years due to inability to conform to authorities, anger outbursts at work and inability to socially interact with coworkers. On the November 2007 VA examination, the Veteran indicated that he had not worked in a real job since 2003, at which time he worked as a welder for two years for the same company but had been off a lot for sick leave. In February 2008, the Veteran reported that he lasted only three months for a six month assignment at the animal shelter due to inability to get along with coworkers. In the August 2006 statement, J.M. reported that the Veteran had always been the type that never stuck with a job for very long and that the longest he stayed with any employer was 3 to 4 years because he did not like to take orders, rarely completed tasks, and had no ambition at times. She also reported the Veteran's neglect of personal hygiene, totally inappropriate social behaviors and intermittent disorientation. Furthermore, Dr. Sheehan opined in the February 2009 letter that the Veteran was unable to hold a job mostly because he could not conform to authority, did not like being around people and was afraid of his own violence. As noted above, TDIU is warranted if the Veteran is unable to follow a substantially gainful occupation due his service-connected disabilities. 38 C.F.R. § 3.340(a)(1). In this case, applying the doctrine of reasonable doubt, the Board finds that the evidence of record is at least in equipoise as to whether the Veteran is unable to follow a substantially gainful occupation due to his service-connected PTSD. To that effect, after a comprehensive psychiatric evaluation, Dr. Mangold opined that it is as least as likely as not that the Veteran's PTSD-related symptoms have rendered him unable to secure and follow a substantially gainful occupation since at least the early 2000's. In particular, Dr. Mangold noted that the Veteran's lack of effort regarding his personal hygiene, violent outbursts which at times led to property damage, and his need for daytime naps due to his PTSD-related sleep impairment would prevent him from retaining employment. This is further supported by the Veteran's long history of extreme irritability and violent tendencies and social isolation from others. Accordingly, considering the lay statements, as well as the medical evidence of record regarding the severe functional impairments exhibited by his service-connected PTSD, as well as his educational and employment history, the Board finds that the Veteran has been unable to follow a substantially gainful occupation consistent with his education and occupational experience, due to his service-connected PTSD, throughout the rating period on appeal. Accordingly, a TDIU is warranted. Gilbert, 1 Vet. App. at 54. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a 100 percent rating for PTSD, for the periods from July 14, 2004 through September 20, 2005, from November 1, 2005 through June 22, 2006, and from August 1, 2006, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a TDIU, throughout the rating period on appeal, is granted, subject to the laws and regulations governing the payment of monetary benefits. ______________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs