Citation Nr: 1314673 Decision Date: 05/03/13 Archive Date: 05/15/13 DOCKET NO. 00-21 254 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to August 22, 2002. 2. Entitlement to a disability rating in excess of 70 percent for PTSD from August 22, 2002 to February 6, 2010. 3. Entitlement to service connection for malaria. 4. Entitlement to an effective date earlier than August 22, 2002 for the award of a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Appellant (the Veteran) is represented by: Sandra E. Booth, Attorney ATTORNEY FOR THE BOARD L. Cramp, Counsel INTRODUCTION The Veteran had active service from January 1966 to December 1968, to include combat service in the Republic of Vietnam. The Veteran was awarded the Bronze Star Medal with "V" device for "heroism in connection with military operations against a hostile force." This appeal comes before the Board of Veterans' Appeals (Board) in part from a June 2006 rating decision of the RO in Nashville, Tennessee, which granted TDIU effective August 22, 2002. This appeal also comes before the Board of Veterans' Appeals (Board) in part from a March 2012 Order of the United States Court of Appeals for Veterans Claims (CAVC). That portion of the appeal originates from July 2001 and February 2006 rating decisions of the RO in Nashville, Tennessee. In a July 2001 decision, the Board denied service connection for malaria, denied a rating in excess of 50 percent for PTSD prior to August 22, 2002, and denied a rating in excess of 70 percent for PTSD from August 22, 2002 to February 6, 2010. The Board granted a disability rating of 100 percent for PTSD, effective February 6, 2010. The Veteran appealed the denied issues to the CAVC. In an Order dated in March 2012, pursuant to a Joint Motion for Remand, the CAVC vacated the Board's decision with respect to the denied issues and remanded those issues back to the Board for development as stipulated in the Joint Motion. In July 2011, the Board also remanded the issue of an effective date for TDIU prior to August 22, 2002. That issue has since been returned to the Board for further appellate action. In reviewing this case the Board has not only reviewed the Veteran's physical claims file, but also his file on the "Virtual VA" system to insure a total review of the evidence. The issues of entitlement to service connection for malaria and entitlement to TDIU prior to August 22, 2002 are addressed in the REMAND below and are therein REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the issues decided herein has been accomplished. 2. Prior to August 22, 2002, the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment with reduced reliability and productivity. 3. From August 22, 2002 to February 6, 2010 (excluding the period of a temporary total rating), the Veteran's PTSD was manifested by symptoms productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSIONS OF LAW 1. Prior to August 22, 2002, the criteria for a disability rating higher than 50 percent for PTSD were not met for any portion of the period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. From August 22, 2002 to February 6, 2010 (excluding the period of a temporary total rating), the criteria for a disability rating higher than 70 percent for PTSD were not met for any portion of the described period. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107, 7104 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the 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, VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The United States Court of Appeals for Veterans Claims (CAVC) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Because the appeal of the ratings for PTSD arises from the Veteran's disagreement with the initial evaluation following the grant of service connection, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the CAVC have held that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for 'downstream' issues following a service connection grant, such as initial rating and effective date claims). The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, records from the Social Security Administration (SSA), and the Veteran's written assertions, and those of his attorney. In addition, the Veteran was afforded VA examinations to evaluate his PTSD. A current VA examination is not necessary in this case, as the Veteran is currently assigned the maximum 100 percent rating for PTSD. During the periods under consideration in this case, the record contains not only VA examinations, but records of ongoing VA mental health treatment. The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of these claims that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of these claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Disability Ratings - Laws and Regulations Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When a claimant is awarded service connection and assigned an initial rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). \ In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In the process of evaluating a mental disorder, VA is required to consider a number of pertinent factors, such as the frequency, severity, and duration of a veteran's psychiatric symptoms. See 38 C.F.R. § 4.126. After consideration of these factors, and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering. The VA Secretary, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the VA Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). The schedular criteria incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. §§ 4.125, 4.130. The evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The Court of Appeals for the Federal Circuit has recently clarified its interpretation of the rating schedule for mental disorders in Vazquez-Claudio v. Shinseki, ___F.3d ___, No. 2012-7114 (Fed. Cir. April 2013). The Federal Circuit held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. The General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130 provides the following ratings for psychiatric disabilities: a 10 percent rating is warranted for PTSD if there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is warranted for PTSD if 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, or mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted if it is productive of 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 compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating, may be assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent rating contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. 4.130, Diagnostic Code 9411. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). Initial Matters The claim for service connection was received on June 4, 1999. In a December 1999 rating decision, the RO granted service connection for PTSD and assigned a 30 percent initial rating under Diagnostic Code 9411, effective June 4, 1999. The Veteran appealed the initial rating. In a June 2001 decision, the Board granted an increased initial rating of 50 percent for PTSD and specifically found that "a rating greater than 50 percent is not warranted." A July 2001 decision of RO promulgated the Board's decision and assigned a 50 percent rating for PTSD, effective June 4, 1999. The Board's June 2001 decision was final when issued. 38 U.S.C.A. § 7103(a) (West 2002); 38 C.F.R. § 20.1100(a) (2012); see Hayslip v. Principi, 364 F.3d 1321, 1326 (Fed. Cir. 2004) (holding that the plain language of 38 U.S.C. § 7103(a) and 38 C.F.R. § 20.1100(a) dictate that a Board decision is final on date stamped on the face of the decision absent an order for reconsideration by the Chairman of the Board); Donovan v. West, 158 F.3d 1377, 1382 (Fed. Cir. 1998). Reconsideration of the decision was neither requested nor ordered according to 38 U.S.C.A. § 7103(a) and 38 C.F.R. § 20.1100(a). In addition, the Veteran did not file an appeal of the June 2001 Board decision with the CAVC. 38 U.S.C.A. § 7266 (West 2002). In the July 2001 implementing decision, the RO did not consider any additional evidence, but listed only the June 2001 Board decision under the "evidence" section. Instead of appealing or seeking reconsideration of the Board's decision, the Veteran filed a purported Notice of Disagreement with the RO's July 2001 implementing decision. The RO accepted the Notice of Disagreement; and, in May 2004, the Board accepted jurisdiction over the appealed initial rating. Because the Board's unappealed final decision issued in June 2001 is determinative, as a matter of law, that the evidence then before it did not show entitlement to an initial rating in excess of 50 percent for PTSD, in effect, the Veteran is collaterally estopped from receiving another Board decision on the same issue. 38 U.S.C.A. § 5110(b)(2). Where an unappealed final decision is determinative of an issue, an appellant is collaterally estopped from "relitigating the same issue based upon the same evidence, albeit for a different purpose." Hazan v. Gober, 10 Vet. App. 511, 520-21 (1997). See also DiCarlo v. Nicholson, 20 Vet. App. 52, 55-56 (2006) ("when a case or issue has been decided and an appeal has not been taken within the time prescribed by law, the case is closed, the matter is ended, and no further review is afforded"); Leonard v. Nicholson, 405 F.3d 1333, 1337 (Fed. Cir. 2005) (quoting Cook v. Principi, 318 F.3d 1334, 1339 Fed. Cir. 2002) (en banc)(stating that the "purpose of the rule of finality is to preclude repetitive and belated readjudications of veterans' benefits claims"). See also Flash v. Brown, 8 Vet. App. 332, 340 (1995) and Routen v. West, 142 F.3d 1434, 1437-38 (Fed. Cir. 1998) (applying finality and res judicata to VA decisions). For this reason, any assertion of entitlement to a higher rating following the Board's June 2001 decision would necessarily be a claim for increased rating, rather than continued appeal of the initial rating question, which was addressed in the Board's June 2001 decision that was final when issued. 38 U.S.C.A. § 7104; 38 C.F.R. § 20.1100. An increased disability rating for PTSD must be based upon a different factual predicate than the one utilized in the assignment of the initial rating. Notably, the June 2001 decision was based principally on September 1999 and January 2000 VA examination reports, and Vet Center treatment records beginning in 1999, as well as a January 2000 written account of symptoms. The Board certainly acknowledges that there may be aspects of an implementing RO decision that are appealable. In other words, an implementing RO decision may address matters that were not directly decided by the Board, such as the effective date of the rating, and an appellant is entitled to appeal those matters. However, in this case, the Veteran disagreed with the 50 percent rating assigned, which was the precise matter decided by the Board. The Veteran asserted "I am entitled to a higher rating for PTSD." The Board finds that the July 2002 document, erroneously styled a "Notice of Disagreement" by the Veteran, should have been accepted as a new claim for an increased rating for PTSD. 38 C.F.R. § 3.155 (2012). That document should not have been recognized as a notice of disagreement with the rating assigned in the July 2001 rating decision, wherein the RO merely promulgated or implemented the final June 2001 Board decision by assigning a 50 percent initial rating for PTSD. Suttman v. Brown, 5 Vet. App. 127, 136 (1993) (when entitlement to the benefits may be predicated upon the increase in severity of a disability occurring after the prior final denial, the new claim is not the same claim as the previously and finally denied claim, and, is a different claim based, at least in part, upon different facts); see also Procelle v. Derwinski, 2 Vet. App. 629, 631 (1992). To find otherwise would vitiate the rule of finality, which was expounded upon in Cook v. Principi, 318 F.3d 1334 (Fed. Cir. 2002). While the Board will not here reconsider the issue on the same factual basis as decided in the final June 2001 decision, the Board acknowledges that there remains a period prior to the current August 22, 2002 effective date of the 70 percent rating and after the June 2001 Board decision, during which a higher rating may yet be assigned. The Board also acknowledges that treating the July 2002 document as a claim rather than a Notice of Disagreement raises questions about whether the current appeal was perfected. With respect to any deficiencies in proper filing or naming of appellate documents, the Board finds that such deficiencies must be waived. The CAVC has held that where the RO certifies an issue for appeal without having received a timely substantive appeal, the requirement for a substantive appeal is essentially waived. See Gonzalez-Morales v. Principi, 16 Vet. App. 556 (2003) citing Rowell v. Principi, 4 Vet. App. 9 (1993). Here, the RO has certified the issue of entitlement to a disability rating in excess of 50 percent for PTSD prior to August 22, 2002. Accordingly, any procedural deficiencies in the perfection of an appeal are waived. The Board notes that it cannot and does not waive the finality of its June 2001 decision. However, this simply affects the dates under consideration, and not whether the appeal can even be considered. As discussed above, in a May 2004 decision, the Board denied this appeal. The Veteran appealed the Board's May 2004 decision to the CAVC. In a February 2005 order, the CAVC effectuated a Joint Motion of the parties for Remand, and remanded the case back to the Board. In a May 2005 rating decision, prior to any additional action by the Board, the RO granted a temporary total rating for convalescence from July 19, 2004 to October 1, 2004. In July 2005, the Board remanded the appeal to the RO for action to implement the Joint Motion for Remand. In a June 2006 rating decision, the RO granted an increased 70 percent rating for PTSD, which was effective from August 22, 2002 to July 19, 2004 and since October 1, 2004, the temporary total rating having been effective from July 19, 2004 to October 1, 2004. In a July 2011 decision, the Board denied a rating in excess of 50 percent prior to August 22, 2002, denied a rating in excess of 70 percent from August 22, 2002 to February 6, 2010 (excluding the temporary total period from July 19, 2004 to October 1, 2004), and granted a 100 percent rating effective February 6, 2010. The Board's July 2011 decision was also appealed to the CAVC, resulting in the March 2012 Joint Motion and Order of the CAVC. This brings us to a discussion of the merits of the appeal. PTSD Evaluation Prior to August 22, 2002 The Veteran seeks a disability rating higher than 50 percent for the period prior to August 22, 2002. After a review of all of the evidence, the Board finds that the weight of the evidence demonstrates that, prior to August 22, 2002, the criteria for a disability rating in excess of 50 percent for PTSD are not met. In evaluating the Veteran's symptomatology during this period, the Board notes that certain VA outpatient records dated prior to the June 2001 Board decision were not of record and were not considered by the Board in that decision. While the Board cannot assign any higher rating prior to its final decision, these records may be pertinent to the period under consideration here, and the Board will consider all of the evidence, including evidence previously considered, and that which was in existence but not of record. As set out above, in order for entitlement to a 70 percent rating to be substantiated, there must be occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Regarding deficiencies in work, a June 2000 VA psychiatry treatment note indicates that the Veteran was working as the Chief of Police at a college campus, which he found very stressful and political. He reached a point where he could not handle the stress anymore, and he quit. A January 2001 VA psychiatry note indicates that the Veteran was working again. An April 2001 VA treatment record indicates that the Veteran quit the job that he began in January. An October 2001 VA psychiatry note indicates that the Veteran was selling real estate at that time, and he felt that this job worked for him because he could set his own schedule. A November 2001 VA treatment record notes that the Veteran would like to work with troubled children, as he has a degree in sociology. He stated that he "can" (presumed to be cannot) tolerate a structured work environment or returning to police work. In January 2002, it was noted that the Veteran was considering doing volunteer work with children, but that he had not pursued this option. An April 2002 VA psychiatry note indicates that the Veteran was not satisfied with his work, but liked the freedom of his schedule. While the Board acknowledges that the Veteran was able to adapt to his symptoms and find work that he could manage, the Veteran stopped doing police work due to stress, and he has reported to VA that he experienced frequent panic attacks, which are attributed to his PTSD. Thus, the evidence demonstrates difficulty in adapting to stressful circumstances (including work or a work-like setting), resulting in a work deficiency. Regarding deficiencies in family relations, a November 2000 VA psychiatry note indicates that the Veteran had reduced his drinking to a couple of beers on occasion with no regular consumption, and that this had a positive impact on his relationship with his wife. The Veteran told a January 2000 VA examiner that he had many friends. While the Veteran's PTSD is presumed to have had an impact on his family and social relationships, the Board finds that this impact is entirely consistent with a difficulty in establishing and maintaining effective work and social relationships; however, there is not an "inability" to establish and maintain effective relationships. Regarding deficiencies in school, a January 2001 VA psychiatry note indicates that the Veteran would be attending training classes though March. An October 2002 VA addiction severity index report notes that the Veteran had 16 years of education and 19 months of technical training. The Veteran has not described any particular deficiency in regard to school performance. To some degree, the Veteran's school performance is inherently linked to thinking and judgment. Regarding deficiencies in thinking, while the Veteran reported in January 2000 that he uses grossly impaired decision making and has an inability to think clearly, this is not supported by the clinical evidence. An October 2001 VA psychiatry note indicates that the Veteran's thoughts were well organized. A November 2000 VA psychiatry note indicates that the Veteran presented with clear organized thinking. A May 2000 psychiatrist note reveals that, although the Veteran reported severe concentration problems, these were not evident on focused testing. Reported memory problems were also not supported by test results. While the Veteran is competent to describe his symptoms, in this case, he has not described any specific examples of thinking deficiencies, but merely asserted that he has such deficiencies. The Board finds the evaluations of the clinicians in this case to be more reliable and persuasive than the Veteran's unsupported assertions. Similarly, regarding deficiencies in judgment, while the Veteran reported in January 2000 that he had poor judgment, he provided no description or example of this. A bare assertion that one meets the criteria for a higher rating, without any meaningful description of the associated symptomatology is not persuasive evidence. Thus, to summarize the evidence regarding deficiencies in school, judgment, and thinking, the Board acknowledges that the Veteran's PTSD affects all aspects of his life to some degree. However, experiencing difficulties in these aspects of life does not equate to a deficiency. The Board finds that the evidence does not demonstrate deficiencies in school, judgment, or thinking during this period. Regarding deficiencies in mood, a May 2000 VA psychiatry note indicates that the Veteran had a terrible temper. An October 2001 VA psychiatry note indicates that the Veteran's mood was slightly depressed. He reported increased intrusive thoughts about Vietnam. An April 2002 VA psychiatry note indicates that the Veteran's mood remains up and down, and he has good and bad days. Based on the intermittent nature of the Veteran's mood impairment, the Board finds that it more closely approximates disturbances of motivation and mood than deficiencies in mood. While the Board acknowledges some impact of the Veteran's PTSD in all areas encompassing social functioning and occupational functioning, during this period, the symptoms described by the Veteran and by VA clinicians more nearly approximate occupational and social impairment with reduced reliability and productivity than occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. While the Board has found there to be a work deficiency during this period, there are no demonstrated deficiencies in school, judgment, or thinking, and the Veteran's social impairment more closely approximates a difficulty in establishing and maintaining effective social relationships than an "inability" to establish and maintain effective relationships. Regarding the particular symptom examples enumerated under the 70 percent rating, neither the Veteran's assertions nor the clinical evidence supports obsessional rituals which interfere with routine activities, or impaired impulse control (such as unprovoked irritability with periods of violence). While the Veteran has reported suicidal thoughts, such as in a May 2000 evaluation, he also reported no plan or attempts. He denied suicidal ideation on the September 1999 examination. To the extent that the Veteran has had occasional suicidal thoughts, the evidence reflects that these thoughts have not significantly impacted his occupational or social function and have not resulted in a mood deficiency. In determining entitlement to any particular rating, it is the combination of symptoms and their effect on occupational and social function that is determinative. Vazquez-Claudio, supra. The Board notes that the Veteran reported frequent panic attacks in January 2000 correspondence; however, this assertion is not probative of entitlement to a rating at the 70 percent level, which contemplates near-continuous panic, which the Veteran has not asserted, and which is not otherwise demonstrated. Moreover, the January 2000 VA examiner disagreed entirely with the Veteran's assessment that these were panic attacks, but thought they sounded more like anxiety and depression. The Board finds that the Veteran's description of frequent panic attacks, even if accurate, more nearly approximates panic attacks more than once a week, as described under the criteria for a 50 percent rating. Regarding an inability to establish and maintain effective relationships, the Board notes that the Veteran told a January 2000 VA examiner that he had many friends. While he certainly has difficulties in maintaining relationships, he is not unable to do so. The evidence is not consistent with speech intermittently illogical, obscure, or irrelevant. A November 2000 VA psychiatry note indicates that the Veteran presented with clear articulation. The evidence is not consistent with spatial disorientation or neglect of personal appearance and hygiene. The same November 2000 VA psychiatry note indicates that the Veteran presented with full range of affect and was neatly groomed. While the Veteran was shown to have depression, there is no indication that this affected his ability to function independently, appropriately and effectively. The Board acknowledges that the Veteran displayed a difficulty in adapting to stressful circumstances (including work or a work-like setting). This was demonstrated in employment changes during this period, addressed above. Also significant in the Board's finding that the criteria for a rating in excess of 50 percent are not met during this period, the GAF scores assigned during this period generally ranged from 55 to 65. GAF scores in the range of 51 to 60 indicate 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). The Board finds that, in the context of a rating schedule that ranges from 0 to 100 percent, a description of moderate symptoms is entirely consistent with a 50 percent rating, and does not suggest any higher rating. In contrast, GAF scores of 45 were assigned beginning in August 2002. This indicates that the Veteran's level of functioning decreased at the time of the assignment of the current 70 percent rating. In finding that the GAF score assigned during this period do not reflect symptomatology of the type and degree contemplated for a 70 percent rating, the Board acknowledges that the GAF score ranges are not specifically tied to any particular rating. However, there is a symmetry between the 70 percent criteria of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood and the GAF score range of 41-50, which 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). The reference to social, occupational, or school functioning in the rating schedule appears to mirror the reference to work, school, and family relations in the GAF examples. In addition, the symptom examples for the 70 percent level of the rating schedule include suicidal ideation and obsessional rituals, both of which are included in the GAF examples. This reinforces the Board's finding that the GAF score indicating moderate impairment reflects symptoms of less severity than are contemplated for a 70 percent rating. The Board notes that the parties to the Joint Motion stipulated that, in finding that the evidence did not reflect occupational and social impairment with deficiencies in most areas, so as to entitle the Veteran to a 70 percent rating, the Board analyzed only the individual symptoms from the rating criteria and the Veteran's occupational impairment. It did not address the extent to which he suffered from social impairment. As set out above, the Board has herein addressed both aspects of the rating criteria. The Joint Motion also emphasized that a September 1999 VA examination showed that the Veteran suffered from anger, isolation, and withdrawal, and was found to have impaired thought processes and communication, as well as major areas of concern regarding situational and characterological indices of anxiety, tension, depression, isolation, social estrangement, and alienation. A January 2000 psychiatric outpatient note revealed that the Veteran suffered from depression, anxiety, and difficulty dealing with minor problems. And, in November 2000, the Veteran was assigned a GAF score of 50, indicating serious symptoms. As discussed above, the September 1999 VA examination, and the January 2000 report were considered by the Board in the final June 2001 decision. The Board will not readjudicate the claim on the same factual basis that was decided in a final Board decision. However, the Board acknowledges that the records noted in the Joint Motion may shed some light on the Veteran's symptomatology after the final June 2001 decision. Moreover, while the November 2000 report was in existence at the time of the June 2001 Board decision, it was not of record and was therefore not considered by the Board. The Board has considered this evidence to the extent that it may be pertinent to the period after the June 2001 Board decision, and the Board has addressed this evidence in the discussion above. The Board notes that the stipulation in the Joint Motion that, upon examination in September 1999, the Veteran was found to have impaired thought process and communication, is incorrect. In fact, the examiner found "no obvious impairment of thought processes or communication." Thus, the Joint Motion misstates the evidence on this point. The Board also notes that concurrent treatment records from the Vet Center include a questionnaire completed by the Veteran in which he reported no disorganized thinking. His speech was appropriate, he was oriented to time, place and person, and had normal memory function. As noted in the Joint Motion, the September 1999 examiner found major areas of concern regarding situational and characterological indices of anxiety, tension, depression, isolation, social estrangement, and alienation. In addition, a January 2000 psychiatric outpatient note revealed that the Veteran suffered from depression, anxiety, and difficulty dealing with minor problems. As already discussed in detail above, the Board acknowledges that the Veteran's PTSD has impacted all areas of his life. However, an impact does not equate to a deficiency. Depression, tension, anxiety, social isolation and estrangement are only indicative of entitlement to a 70 percent rating where such symptoms result in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In this case, the most persuasive evidence regarding the September 1999 and January 2000 findings is the fact that the September 1999 examiner found overall moderate difficulty in social and familial functioning and assigned a GAF score of 60. As discussed above, such assessments are entirely consistent with the criteria for a 50 percent rating and do not suggest entitlement at any higher level. Regarding the GAF score of 50 assigned in the November 2000 report, that score reflects the Veteran's level of functioning on the day it was assigned, well prior to the June 2001 Board decision. While it suggests that the Veteran's level of functioning was variable, it does not suggest that the Veteran's level of functioning was impaired to the same degree during the period under consideration here. The GAF scores assigned have varied somewhat throughout the period on appeal; however, as discussed above, the GAF scores assigned after the June 2001 Board decision until the August 22, 2002 effective date of the 70 percent rating have ranged from 55 to 60, reflecting a higher level of functioning during this period. For these reasons, the Board finds that the weight of the evidence is against a finding of an initial rating in excess of 50 percent for PTSD prior to August 22, 2002. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. PTSD Evaluation From August 22, 2002 to February 6, 2010 The Veteran seeks a total disability rating for the period from August 22, 2002 to February 6, 2010 during which a 70 percent rating is currently assigned (exclusive of the temporary total period from July 19, 2004 to October 1, 2004). After a review of all of the evidence, the Board finds that, exclusive of the temporary total period from July 19, 2004 to October 1, 2004, the weight of the evidence demonstrates that the criteria for a total disability rating are not met from August 22, 2002 to February 6, 2010. The Board notes that, effective August 22, 2002, a TDIU is in effect. This reflects that, as of August 22, 2002, there is total occupational impairment due to the combined effect of service-connected disabilities. In addition to PTSD, these include chronic obstructive pulmonary disease (30 percent), as well as tinnitus, irritable bowel syndrome, diabetes mellitus, and a shrapnel wound scar, each rated at 10 percent. There are also additional noncompensable disabilities. Regarding total occupational impairment due to PTSD, an August 22, 2002 VA psychiatry note indicates that the Veteran had quit his job. An October 2002 VA addiction severity index report notes that the Veteran had 16 years of education and 19 months of technical training. His longest full-time job was 30 years. His usual (or last) occupation was business manager. In the past three years, his usual employment pattern has been retired/disability. A January 2003 questionnaire from the Office of Disability Determination of the State of Florida indicates that the Veteran gets stressed out and cannot handle deadlines or schedules. A September 2003 private mental impairment questionnaire indicates that the Veteran was unable to meet the competitive standards with respect to maintaining regular attendance and to be punctual within customary, strict tolerances; working in coordination with or proximity to others without being unduly distracted; completing a normal workday/workweek without interruptions from psychologically based symptoms; accepting instructions and responding appropriately to criticism from supervisors; getting along with co-workers or peers without unduly distracting them or exhibiting behavioral extremes; responding appropriately to changes in a routine work setting; and dealing with normal work stress. A May 2004 private mental impairment questionnaire notes that the Veteran is unable to handle the stress of semi-skilled or skilled employment. The physician indicated that, on average, the Veteran's mental health impairment would cause him to be absent from work more than four days per month. In light of these findings, the Board finds that, during the time period under consideration here, there was total occupational impairment due to PTSD. Regarding social impairment, a June 2003 VA examination report notes that the Veteran had been married for 34 years. An August 22, 2002 VA psychiatry note indicates that the Veteran and his wife were arguing and he went on a nine day drinking binge. An October 2002 VA addiction severity index report notes that the Veteran was married and satisfied with this situation. He reported that he has not been bothered at all by family/social problems in the month prior to the interview. A January 2003 questionnaire from the Office of Disability Determination of the State of Florida indicates that the Veteran used to participate in a lot of social activities; however, he does not do so anymore. He does not visit friends or relatives. He indicated that he is not interested in being around people; however, with immediate family he gets along good. A February 2003 VA psychiatry treatment record notes that the Veteran had been completely sober for the past two months and was volunteering two days a week. He enjoyed spending time with a veteran he goes to see. He reported that they play cards together. An October 2003 psychiatry note reveals that the Veteran and his wife were doing more together and the Veteran felt their relationship was improving. A May 2004 private mental impairment questionnaire notes that the Veteran had a moderate restriction of activities of daily living due to his PTSD, as well as moderate deficiencies of concentration, persistence, or pace. He was noted to have a marked difficulty in maintaining social functioning. A December 2005 VA examination report notes that the Veteran does little more than sit at home. He participates in group therapy at the Vet Center. He has trouble showing affection for his wife and he is verbally abusive toward his wife. He has one son with whom he is close. He has three to four social friends and one close friend. He enjoys playing poker two to three times a week. He likes to go fishing and does this about once a week in the summer. He enjoys taking care of his dog and likes to watch television and rent movies. The Veteran complained of anxiety provoked by even minor day to day stress. He reported having difficulty being out in public. On occasion, he has had to run out of a grocery store to get relief from anxiety attacks. He reported anxious and panicky feelings while driving or when in public. He avoids crowds. While there was total occupational impairment due to PTSD during this period, the Board finds that the Veteran's social impairment was not total. Despite some marital difficulties and anxiety attacks in public places, the Veteran retained a significant degree of social function, and demonstrated the ability to maintain social relationships inside and outside the family. Significantly, he reported that he has at least a few friends and does engage in limited social activities. Thus, although there is social impairment during this period, it is not total. As set out above, the criteria for a 100 percent rating for PTSD contemplate total occupational and social impairment. Turning to the symptom examples set out under the 100 percent rating, the Board finds that the Veteran has not demonstrated symptoms like or similar to gross impairment in thought processes or communication. A November 2002 private report of psychological evaluation reveals that speech was normal in rate, tone, and inflection. Responses were linear and goal-directed, and they were without circumstantialities, tangentiality, or loose associations. There was no evidence of a formal thought disorder, paranoia, grandiosity, flight of ideas, ideas of reference, delusions, episodes of thought control, insertion, or withdrawal. Judgment and insight were adequate. A January 2003 questionnaire from the Office of Disability Determination of the State of Florida indicates that the Veteran had trouble concentrating; however, a June 2003 VA examination reveals that attention and concentration were good. The Veteran's speech was normal, and without evidence of circumstantialities, tangentiality, flight of ideas, or loose association. The Veteran's insight was fair and his judgment was intact. An August 2004 VA case management note indicates that the Veteran's speech was at a normal rate, tone, and volume. The Veteran's thought processes were goal-directed. His insight was noted to be partial and his judgment was noted to be fair. An October 2005 psychiatry note reveals that thoughts were clear and linear. Insight and judgment were sufficient. A December 2005 VA examination report notes that the Veteran's speech was normal for rate and volume. It was clear, coherent, and goal-directed. There was no evidence to suggest that he was responding to internal stimuli. A January 4, 2006 VA psychiatry outpatient report reveals that the Veteran's speech was normal in rate, rhythm, and volume. His thought process was logical and cognition and judgment were intact. A January 12, 2006 report reveals speech was normal in tone, rate, and rhythm. Concentration was good. Judgment was not impaired. In sum, the Veteran has little if any impairment in communication, and his thought processes are adequate. While he was noted in one instance to have trouble concentrating, findings for concentration are otherwise adequate. Based on the evidence, the Board finds that there was not gross impairment in thought processes or communication during this period. The Veteran has not demonstrated symptoms like or similar to persistent delusions or hallucinations. A November 2002 private report of psychological evaluation reveals that the Veteran denied auditory and visual hallucinations. A June 2003 VA examination report notes that the Veteran had no hallucinations or delusions. A December 2005 VA examination report notes that the Veteran at times can hear his mother or father, although the voices are garbled. However, the examiner specifically found that this is not indicative of a psychotic symptom. The Veteran denied visual hallucinations, delusions of reference, bizarre or delusional beliefs, paranoia, or grandiosity. A January 12, 2006 report reveals no perceptual or thought disturbances. To the extent that there are auditory hallucinations present in this case, they are, by the Veteran's own description ("at times") occasional, and they are not productive any significant occupational or social impairment. The Veteran has not demonstrated symptoms like or similar to grossly inappropriate behavior. A June 2003 VA examination report notes that the Veteran's impulse control was good. A December 2005 VA examination report notes that the Veteran had no psychotic symptoms. A December 2005 VA examination report notes that the Veteran did not display inappropriate or bizarre behavior during the interview. Indeed, the Veteran has not described any specific behavior that is grossly inappropriate. The Veteran has not demonstrated symptoms like or similar to persistent danger of hurting self or others. A November 2002 private report of psychological evaluation reveals that the Veteran denied homicidal ideation, plan or intent. An October 2002 VA addiction severity index report notes that the Veteran denied suicidal ideation. A June 2003 VA examination report notes that the Veteran denied past or present suicidality or homicidality. The Veteran's mood was described by him as "not a good day." However, his affect was inconsistent with his mood and he appeared more euthymic. An August 2004 VA case management note indicates that the Veteran's mood was anxious; however, his thought content was devoid of suicidal or homicidal ideation. A December 2005 VA examination report notes that the Veteran reported suicidal ideation two or three times a month, but it would pass after two or three hours. He had no intent or plan to harm himself. His affect was anxious. He described his mood as, "I'm as depressed as I have ever been." However, he specifically denied current suicidal ideation. A January 4, 2006 VA psychiatry outpatient also report reveals that the Veteran denied suicidal ideation. A January 12, 2006 report reveals no suicidal ideation or homicidal ideation. While there appears to be occasional suicidal ideation during this period, the Veteran has not described symptoms of the type and degree as would suggest that there is a persistent danger of his hurting himself or others. The Board finds that the Veteran has not demonstrated symptoms like or similar to intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). A November 2002 private report of psychological evaluation reveals that the Veteran was adequately groomed. A January 2003 questionnaire from the Office of Disability Determination of the State of Florida indicates that the Veteran did not do any chores. He stated that he used to pay bills and mange his own money but now he does not. On bad days he stated that he does not shave or get dressed. A June 2003 VA examination report notes that the Veteran was neatly groomed. An August 2004 VA case management note indicates that the Veteran was neatly dressed, pleasant, and cooperative. A January 4, 2006 VA psychiatry outpatient report reveals that the Veteran was dressed appropriately. A January 12, 2006 report reveals good personal hygiene and grooming, as do reports in March 2006, April 2006, May 2006, November 2006, December 2006, and January 2007. Thus, it appears that the Veteran may have periods where does not shave or dress, the evidence does not indicate that he is ever unable to do so. Indeed, a December 2005 VA examination report notes that the Veteran has the capacity to complete activities of daily living. Moreover, on each instance where he was clinically assessed, he was adequately groomed. The Board finds that the Veteran has not demonstrated symptoms like or similar to disorientation to time or place. A November 2002 private report of psychological evaluation reveals that the Veteran was alert and fully oriented. Eye contact was good and rapport was deemed adequate. A June 2003 VA examination report notes that the Veteran was fully oriented. An August 2004 VA case management note indicates that the Veteran was alert and fully oriented. A December 2005 VA examination report notes that the Veteran was alert and fully oriented. A January 2006 VA psychiatry outpatient report reveals that the Veteran was oriented to person, place, time, and purpose, as do reports in April 2006 and May 2006. A November 2006 psychiatry note reveals orientation to time, place, and person. Indeed, the Veteran has not described any disorientation to time or place. The Board finds that the Veteran has not demonstrated symptoms like or similar to memory loss for names of close relatives, own occupation, or own name. A January 2003 questionnaire from the Office of Disability Determination of the State of Florida indicates that the Veteran described his short-term memory as very very bad; his long terms memory was better. However, a November 2002 private report of psychological evaluation reveals that short-term memory was found to be adequate and long term memory appeared fine. A June 2003 VA examination report notes that the Veteran's immediate memory was full and his short-term memory was slightly off. His remote memory was intact. A December 2005 VA examination report notes that the Veteran was able to recall only one out of three objects after a delay of a few minutes. He was given a second series of three objects but he said he could not recall any of them after a short delay. A January 12, 2006 report reveals intact memory. While the evidence regarding memory is inconsistent, there does appear to be some demonstrable memory impairment, at least at times; however, there is no suggestion that the Veteran is ever unable to remember his own name or names of close relatives. Thus, the type and degree of memory impairment contemplated for a 100 percent rating are not met. The Board notes that the July 19, 2004 effective date for the temporary total rating is based on the date of hospital treatment, pursuant to 38 C.F.R. § 4.29. While an earlier effective date for that award is not on appeal, the Board has reviewed the evidence pertinent to that hospitalization to determine whether, notwithstanding the provisions of 38 C.F.R. § 4.29, the schedular rating criteria for a 100 percent rating were actually met prior to July 19, 2004. The Veteran was admitted to attend a stress residential treatment program. While the July 2004 hospitalization report reflects a recent worsening of symptoms, the Veteran was found to be stable on admission. His mood was described as "slightly depressed." His affect was mood congruent. His thoughts were organized, with no evidence of a thought disorder. The Veteran's insight, judgment, and impulse control were stable, and there was no suicidal ideation or homicidal ideation. Based on this evidence, the Board finds that entitlement to a 100 percent rating for PTSD is not factually ascertainable at any time prior to the July 19, 2004 effective date of the temporary total rating. In so finding, the Board notes that 38 C.F.R. § 4.29 permits a 100 percent rating on the basis of admission to a VA hospital for treatment of a service-connected disability, and does not require that the schedular rating criteria for a 100 percent rating be met. Based on the Veteran's level of symptomatology at the time of admission, the Board finds that the schedular criteria for a 100 percent rating for PTDS were not met at that time. In addition, the Board notes that the GAF scores from August 22, 2002 to July 19, 2004, and from December 1, 2004 to February 6, 2010, generally ranged from 45 to 50, which 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 November 2002 private report of psychological evaluation reveals a GAF score of 70. The examining psychologist opined that, despite his PTSD, the Veteran was doing very well over the years. His affective condition had worsened, and this was what was mainly impacting his daily functioning. A June 2003 VA examination report notes that the Veteran's GAF score was 60. A December 2005 VA examination report notes that the Veteran's GAF score was 48. The Board acknowledges that the basis for the CAVC remand of this issue, as stipulated in the Joint Motion, was that the Board assigned the effective date of February 6, 2010 simply on the basis of the examination report of that date. The Board believes its discussion above is adequate to describe the Veteran's occupational and social functioning during the year prior to the February 2010 examination. It is not factually ascertainable at any time during that period that the criteria for a 100 percent rating were met. For these reasons, the Board finds that the weight of the evidence is against a finding of a rating in excess of 70 percent for PTSD during this period. To the extent any higher level of compensation is sought, the preponderance of the evidence is against this claim, and hence the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The potential application of the various other provisions of Title 38 of the Code of Federal Regulations have also been considered, including 38 C.F.R. § 3.321(b)(1) (2012), which provides procedures for referral or assignment of an extraschedular evaluation. Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The VA Compensation and Pension Service is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd 572 F.3d 1366 (Fed. Cir. 2009). In this case, the Board finds that the schedular rating criteria contemplate the Veteran's service-connected PTSD. All the Veteran's PTSD symptoms are either explicitly part of the schedular rating criteria under the general formula for rating mental disorders at 38 C.F.R. § 4.130; are analogous to the schedular rating criteria (see 38 C.F.R. §§ 4.20, 4.21), or are "like or similar to" the schedular rating criteria (see Mauerhan at 442-43). The Veteran has reported sleep disturbance, flashbacks, irritability and anger, social isolation, avoidance of memories that remind him of combat, panic attacks, depression, and impaired concentration and thinking. The schedular rating criteria under Diagnostic Code 9411 specifically provide for disability ratings based on a combination of history and clinical findings. The Veteran's symptoms are all specifically included in the rating schedule. The assigned 50 percent disability rating prior to August 22, 2002, and the 70 percent rating from August 22, 2002 to February 6, 2010 are based on the degree of occupational and social impairment, including due to specific symptomatology. The GAF scores indicated in the DSM-IV, which reflect overall degree of impairment due to psychiatric disorders, and which the Board weighed and considered in this case, are part of the schedular rating criteria. Because the schedular rating criteria are adequate to rate the Veteran's service-connected PTSD, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). ORDER Prior to August 22, 2002, a disability rating in excess of 50 percent for PTSD is denied. From August 22, 2002 to February 6, 2010 (excluding the period of a temporary total rating), a disability rating in excess of 70 percent for PTSD is denied. REMAND The Veteran was provided a VA examination as to the nature and etiology of malaria and/or residuals in February 2010. The report stated that the Veteran was diagnosed with malaria in 1968. However, the examiner concluded that there was no evidence that the Veteran had malaria in the past and that he likely had pneumonia of bacterial origin. In the Joint Motion, the parties stipulated that the examiner did not comply with the November 2009 examination request. The Joint Motion noted that the Veteran had complained of weight loss, stomach pains, abdominal bloating, occasional diarrhea, constipation, occasional sweating with nausea and lightheadedness, and occasional migraines. The parties stipulated that the examiner did not address whether any of the symptoms of which the Veteran then complained could be residuals of malaria, because the examiner did not support his conclusion that the Veteran was not diagnosed with malaria, but instead, had pneumonia in service, and because the examiner did not answer the question of whether the Veteran has any current, chronic disability resulting from malaria. The parties to the Joint Motion cited to 38 C.F.R. § 4.2 (duty to provide a medical examination requires that the examination be adequate for adjudication purposes); Bowling v. Principi, 15 Vet. App. 1,12 (2001) (it is incumbent upon the rating board to return a report as inadequate for evaluation purposes if it does not contain sufficient detail); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide an examination to develop a claim, the examination must be adequate or VA must inform the claimant why an examination will not be provided). The Board is bound by the findings contained in the Joint Motion, as adopted by the Court. See Chisem v. Gober, 10 Vet. App. 526, 527-8 (1997) (under the "law of the case" doctrine, appellate courts generally will not review or reconsider issues that have already been decided in a previous appeal of the same case, and therefore, Board is not free to do anything contrary to the Court's prior action with respect to the same claim). The claim of entitlement to service connection for malaria was received at the RO on August 17, 2001. As the outcome of entitlement to service connection for malaria will have a potential impact on the question of whether a TDIU is warranted prior to August 22, 2002, that issue is inextricably intertwined and the proposed development will encompass that issue. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). Accordingly, the issues of entitlement to service connection for malaria and entitlement to TDIU prior to August 22, 2002 are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of his claimed malaria and/or residuals. The relevant documents in the claims file should be made available to the VA examiner. The examiner is asked to review the claims file. Regarding service, the Veteran contends that he was treated at a hospital in Cam Ranh Bay for two weeks, and then placed on medications. The service treatment records and examination at separation do not mention malaria. After service, an August 1974 VA examination report notes that there were no symptoms or recurrences of malaria since service. Physical examination of the head, face, nose, sinuses, ears, cardiovascular system, digestive system, and respiratory system were all normal. The examiner diagnosed "history of malaria, alleged, not confirmed." In May 1999, a recent weight loss of 15 pounds in three to four months was noted. A December 2005 VA examination included findings of stomach pains, abdominal bloating, gas, occasional diarrhea, constipation, occasionally sweating with nausea and lightheadedness and occasional migraines. The diagnosis was irritable bowel syndrome. A February 2010 VA examination report notes that the Veteran indicated that he was very sick in Vietnam, and was told that he may have had malaria; however, the diagnosis was never confirmed. The Veteran complained that he still has some trouble breathing. He denied signs and symptoms of active infection. The VA examiner is requested to offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50-50 degree of probability) that the Veteran had malaria in service. * If it is found that the Veteran did not have malaria in service, please provide an explanation for this finding with reference to the evidence and generally accepted medical principles. * If it is found that the Veteran likely had malaria in service, the VA examiner is requested to offer an opinion as to whether it is at least as likely as not that the Veteran has any current, chronic disability resulting from in-service malaria. * If it is found that the Veteran did not have malaria in service, the VA examiner is requested to offer an opinion as to whether it is at least as likely as not that any or all of the Veteran's currently symptoms of stomach pains, abdominal bloating, gas, occasional diarrhea, constipation, occasionally sweating with nausea and lightheadedness and occasional migraines are etiologically related to service. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but that the medical evidence for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. All opinions are to be accompanied by a rationale consistent with the evidence of record. If the requested medical opinion cannot be given, the examiner should state the reason(s) why. 2. Readjudicate the remanded claims. If either benefit sought on appeal is not granted, the Veteran and his representative should be provided a supplemental statement of the case and an appropriate time period for response. The case should then be returned to the Board for further consideration, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the issues the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examinations, as failure to do so may result in denial of the associated claim. See 38 C.F.R. § 3.655 (2012). These claims 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). ______________________________________________ MARK W. GREENSTREET Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs