Citation Nr: 1316647 Decision Date: 05/21/13 Archive Date: 05/29/13 DOCKET NO. 08-38 741 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to a higher disability rating for posttraumatic stress disorder with alcohol and substance abuse and substance-induced mood disorder, initially rated as 50 percent disabling prior to October 31, 2012, and as 70 percent disabling thereafter. 2. Entitlement to a total disability rating based on unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Fleming, Counsel INTRODUCTION The Veteran served on active military duty from September 1968 to October 1971. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA) in Nashville, Tennessee. In a February 2011 decision, the Board granted the Veteran an increased initial evaluation of 50 percent for what it characterized at the time as posttraumatic stress disorder (PTSD). In that decision, the Board further denied an initial evaluation in excess of 50 percent and remanded the issue of entitlement to a total disability evaluation based on individual unemployability (TDIU). The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In July 2011, the Court remanded the Board's decision for development in compliance with a Joint Motion for Court Remand (Joint Motion). The Joint Motion noted that the issue of TDIU had been remanded by the Board and was thus not before the Court and indicated that the Court was not disturbing that portion of the Board decision that granted an initial 50 percent evaluation; the Joint Motion only addressed the evaluation in excess of 50 percent. Following the July 2011 Joint Motion, the Board again denied the Veteran's claim for an initial evaluation in excess of 50 percent for PTSD and again remanded the issue of TDIU. The Veteran again appealed the decision to the Court. In July 2012, the Court again remanded the Board's decision for development in compliance with a Joint Motion. Subsequent to the July 2012 Joint Motion, the Board again remanded the claim in an October 2012 for further evidentiary development and adjudication. In the remand the Board instructed the agency of original jurisdiction (AOJ) to obtain VA medical records, obtain an additional VA examination, and then re-adjudicate the claims. The AOJ obtained the identified VA medical records and scheduled the Veteran for VA examination, which was conducted in October 2012. The AOJ then issued the Veteran a supplemental statement of the case (SSOC) in November 2012, in which it awarded the Veteran an increased rating to 70 percent, effective October 31, 2012, for what it re-characterized as PTSD with alcohol and substance abuse and substance-induced mood disorder. Thus, as to the issue decided herein, there has been compliance with the Board's remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting that where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). Please note that this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT The Veteran's posttraumatic stress disorder with alcohol and substance abuse and substance-induced mood disorder has been manifested by reports of disrupted sleep, nightmares, suicidal thoughts, depression, isolating behavior, and difficulty with social interactions. These manifestations are indicative of occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking, and mood, but are not reflective of total impairment in occupational and social functioning. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for an increased schedular evaluation of 70 percent, but not greater, for posttraumatic stress disorder with alcohol and substance abuse and substance-induced mood disorder have been met for the entire appeal period. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist At the outset, the Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). In this case, the Board finds that all notification and development action needed to arrive at a decision on the claim decided herein has been accomplished. In this respect, through November 2006, June 2008, and February 2012 notice letters, the Veteran received notice of the information and evidence needed to substantiate the claim for increase. Thereafter, the Veteran was afforded the opportunity to respond. Hence, the Board finds that the Veteran has been afforded ample opportunity to submit information and/or evidence needed to substantiate his claim. The Board also finds that the November 2006, June 2008, and February 2012 notice letters satisfy the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). In the letters, the RO also notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom he wanted the RO to obtain and consider evidence. Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See Pelegrini v. Principi, 18 Vet. App. 112, 121 (2004). See also Notice and Assistance Requirements and Technical Correction, 73 Fed. Reg. 23,353 (Apr. 30, 2008) (codified at 38 C.F.R. § 3.159) (removing the prior requirement that VA specifically ask the claimant to provide any pertinent evidence in his possession). These requirements were met by the aforementioned November 2006, June 2008, and February 2012 notice letters. In addition, the Veteran was provided notice regarding an award of an effective date and rating criteria in the June 2008 and February 2012 letters. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board does not now have such issues before it. Consequently, a remand for additional notification on these questions is not necessary. Nothing about the evidence or any response to the RO's notification suggests that the case must be re-adjudicated ab initio to satisfy the requirements of the VCAA. The Board also points out that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claim decided herein. The Veteran underwent VA examination in February 2008, March 2012, and October 2012; reports of those examinations are of record. In that connection, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examinations obtained in this case are adequate, as they are predicated on consideration of all of the pertinent evidence of record, to include the statements of the Veteran and his representative, and document that the examiners conducted full psychological examination of the Veteran. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the claim decided herein has been met. 38 C.F.R. § 3.159(c)(4). In addition, records of the Veteran's VA medical treatment have been associated with the file. The Veteran has further been given the opportunity to submit evidence, and he and his representative have provided written argument in support of his claim. Otherwise, neither the Veteran nor his representative has identified, and the record does not indicate, existing records pertinent to the claim decided herein that need to be obtained. Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159. II. Analysis Disability evaluations are determined by comparing a Veteran's present symptoms with criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Here, the Veteran contends that he is entitled to initial ratings in excess of 50 percent prior to October 31, 2012, and in excess of 70 percent for thereafter, for his service-connected PTSD with alcohol and substance abuse and substance-induced mood disorder due to the severity and frequency of his symptomatology. In March 2008, February 2011, and November 2012 rating decisions, the Veteran's PTSD with alcohol and substance abuse and substance-induced mood disorder was evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Under the General Rating Formula For Mental Disorders, to include anxiety and depressive disorders and PTSD, a 50 percent rating is assigned for 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; 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 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; intermittently illogical, obscure, or irrelevant speech; 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. Id. A 100 percent evaluation is assignable where there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2012). Relevant evidence of record consists of records of the Veteran's ongoing treatment at VA medical facilities, as well as VA examinations conducted in February 2008, March 2012, and October 2012. In a September 2006 VA medical record, the Veteran reported increased loss of memory, confusion, lack of motivation, inability to concentrate, and depression. In another September 2006 record, the Veteran denied suicidal and homicidal ideations, but reported recurring thoughts. The Veteran was housed in the VA domiciliary program from October 2006 to January 2007 for treatment of alcohol dependence. In treatment records from that time, the Veteran reported depression, moodiness, anger, and irritation. He reported nightmares and flashbacks regarding Vietnam, as well as a hyper-startle response, paranoia, and hearing voices, but no visual hallucinations or suicidal or homicidal ideations. He reported having only one Vietnam veteran that he could talk to but stated that he had a good relationship with his older brother. He avoided news of war and crowds and reported disturbed sleep. On examination, the Veteran was found to be alert and oriented, with good grooming and hygiene, fair eye contact, and normal psychomotor activity. His mood was dysphoric with blunted affect, although his speech was spontaneous, his thought processes were logical and goal directed, and his thought content was without active suicidal or homicidal ideations or hallucinations. He had intact memory and concentration, average intelligence, and fair insight and judgment. A Global Assessment of Functioning (GAF) score of 50 was assigned. In an October 2006 VA record, the Veteran reported that he had no suicidal or homicidal ideation, and no psychosis was noted. Upon examination, the Veteran was in mild distress but was neatly dressed and well-groomed. His speech was clear and normal in rate, rhythm, and volume, and was not pressured. The Veteran's mood was nervous, and his affect was congruent with mood. His thought processes were noted as coherent, logical, and goal-directed, without suicidal or homicidal ideations or hallucinations. He had intact insight and fair judgment. A GAF score of 45 was assigned. In a January 2007 VA medical record, the Veteran reported depressive moods, worsening since his mother passed away. His speech was clear and coherent and his mood was down, with a congruent affect. He was again noted to have coherent and goal-directed thought processes, with no suicidal or homicidal ideations, no hallucinations, and no psychosis. The Veteran's insight was improving and his judgment was fair. The GAF score was 45. Similarly, in a March 2007 VA treatment note, the Veteran reported that things were going well. He was sleeping well, his moods were stable, and he had no thoughts of self-harm, harming others, or psychosis. He was neatly dressed and well-groomed. There was clear, normal speech, with coherent, logical, and goal-directed thoughts. The Veteran denied hallucinations and was found to have intact insight and fair judgment. The GAF score was 50. At a treatment visit in December 2007, the Veteran reported that he experienced nightmares several times a week, as well as intrusive disturbing memories of Vietnam, occasional flashbacks, and an exaggerated startle response. His mood was "pretty good" and his depressed moods did not last the entire day. The Veteran endorsed occasional crying episodes and difficulty concentrating, although he reported that he had recently signed up for classes at a local educational program. The Veteran denied having a girlfriend, but reported a few male friends. Upon examination, he was alert and oriented, with fair to good attention to grooming and eye contact. There was normal psychomotor activity, goal-directed speech, intact abstract reasoning, and fair to good insight. His affect was tense but appropriate. The Veteran denied suicidal and homicidal ideations, hallucinations, and delusions. His thought process was logical and coherent, and there was no evidence of a thought disorder. A GAF score of 50 was assigned. In a March 2008 VA medical record, the Veteran reported that he was sleeping adequately and denied suicidal and homicidal ideations. He reported, however, having problems with social isolation. Examination found him to be alert, oriented, and appropriate in appearance, with normal eye contact. His mood was within normal limits, but there was a blunted and mildly constricted range of affect. The examiner observed normal speech; logical, coherent, and goal-directed thoughts; intact abstraction ability; good insight and judgment; and no delusions. The Veteran was again seen in August 2008, at which time he reported feeling depressed. He also reported occasional thoughts of suicide, nightmares, hyperstartle response, paranoia, and avoidance. The treatment provider found the Veteran to be alert, oriented, and cooperative, with appropriate dress, normal speech, coherent thought process, depressed mood, and a congruent affect. The Veteran had fair insight and judgment. The GAF score was 50. Similarly, at a later August 2008 VA treatment visit, the Veteran reported depressive symptoms with low energy and motivation, as well as loss of interest in leisure activities, poor sleep and appetite, and occasional thoughts of suicide. He reported that his flashbacks and nightmares had worsened in recent weeks. The examiner found the Veteran alert, oriented, pleasant, and cooperative, with adequate grooming and hygiene. There was good eye contact, regular speech, and no psychomotor agitation or retardation, but a low mood and blunted affect. The Veteran's thought content was without delusions, obsessions, or paranoia, and his thought process was linear and goal directed. His insight and judgment were fair. The treatment provider assigned a GAF score of 40 to 45. In a September 2008 VA medical record, the Veteran reported feeling depressed and anxious. He reported nightmares, intrusive recollections, hyperstartle response, and hypervigilance, as well as feelings of hopelessness and helplessness and interrupted sleep. He felt anxious but denied suicidal and homicidal ideations. Examination showed the Veteran to be alert, oriented, and cooperative, with good eye contact. The treatment provider found the Veteran to have normal speech, fair mood, anxious affect, no psychosis, a coherent thought process, fair insight and judgment, and a grossly intact memory. The examiner assigned a GAF score of 52. Similarly, at an October 2008 treatment visit, the Veteran reported feeling more depressed and melancholy with low energy, poor concentration, and feelings of hopelessness. He experienced irritability, occasional nightmares, and frequent intrusive daytime thoughts. His main support was his brother. He denied suicidal or homicidal thoughts, hallucinations, and paranoia. Upon examination, the Veteran was alert, oriented, well-groomed, cooperative, and appropriately dressed, with appropriate behavior, good eye contact, regular speech, and linear thoughts that were logical and goal-directed. There was a restricted range of affect and a congruent mood but fair insight and judgment. The Veteran was assigned a GAF score of 55. In January 2009 VA medical records, the Veteran reported chronic longstanding feelings of wanting to harm others, as well as suicidal thoughts. He reported occasional flashbacks, with emotional numbing, intrusive memories, startle response, and no close female relationships. He admitted to constant paranoia and irritability. He lived alone and had limited psychosocial support. Examination indicated a melancholy mood with consistent affect, intact cognition, some psychomotor slowing, adequate eye contact, and no overt evidence of paranoia. He had intact judgment and some insight. He was adequately groomed and dressed and was calm and cooperative, with normal speech, irritable mood, and a blunted affect that was congruent with mood. There was intact memory, concentration, and abstract ability, with limited insight and judgment. The GAF score was 45. The Veteran was hospitalized for a week in February 2009 at a VA medical facility. Records from that hospitalization indicate that the Veteran reported frequent suicidal ideations as well as past suicide attempts. He reported decreased sleep; anhedonia; feelings of hopelessness, helplessness, and worthlessness; and decreased energy and concentration. He denied homicidal ideations, but reported hallucinations. He denied panic attacks, but reported worsening flashbacks, nightmares, hypervigilance, feelings of numbness, and inability to connect with others. He reported that he had poor social support and isolated in his apartment most of the time. Examination showed the Veteran was disheveled, subdued, and guarded, with poor eye contact and mild psychomotor slowing. There was a depressed mood and a dysphoric and blunted affect that was congruent with mood. The Veteran was alert, fully oriented, and cognitively intact, with a linear thought process, but had poor insight and judgment. He described a close relationship with his older brother, but was otherwise socially isolated. He was assigned an intake GAF score of 30. Records from the February 2009 hospitalization reflect that the Veteran's symptoms improved, and he denied current suicidal or homicidal ideations, hallucinations, and paranoia. After several days, he reported he that felt better, although he was still depressed. The Veteran was appropriately dressed and groomed and fully oriented, with intact memory, attention span, and concentration. His thought process was logical, linear, and goal-directed, and his insight and judgment were improving. The GAF score was 30. Upon discharge, the Veteran denied suicidal and homicidal ideation, hallucinations, and delusions. He was alert and oriented, with adequate eye contact, regular speech, fair mood, full and congruent affect, logical and linear thought process, intact concentration, fair insight, and no gross impairment of judgment. T he Veteran denied hallucinations, delusions, and paranoia. He reported that he felt good with the exception of racing thoughts, an inability to get to sleep, and nightmares. There was good eye contact, congruent affect, normal speech, and no hallucinations or suicidal ideations. At discharge his GAF score was 55. In a March 2009 VA medical record, the Veteran reported worsening mood as well as increased fatigue and loss of interest. He reported sleeping well, with an occasional crying spell. He denied suicidal and homicidal ideations, hallucinations, delusions, and paranoia. Examination indicated the Veteran was alert, oriented to all spheres, and appropriately groomed and dressed, with appropriate eye contact. There was no psychomotor agitation or retardation, and there was a dysthymic mood with slight blunting of affect. The treatment provider observed normal speech; a logical, linear, and goal-directed thought process; intact cognition; and improving insight and judgment. The GAF score was 50. In a June 2009 VA medical record, the Veteran reported experiencing nightmares as well as irritability, flashbacks, and memory problems. He denied suicidal ideations, homicidal ideations, and hallucinations. Examination showed adequate grooming and hygiene, with good eye contact, no psychomotor agitation, normal speech, a melancholic mood, and an appropriate and congruent affect. The Veteran's thought processes were linear, logical, and goal-directed. He was alert and oriented with intact attention, concentration, insight, and judgment. The GAF score was 55, a score that was also assigned at a September 2009 treatment visit. Further VA treatment records reflect that the Veteran has been hospitalized on multiple occasions for detoxification from his alcohol abuse. At a July 2011 intake evaluation for detoxification, the Veteran was noted to experience some suicidal ideation and paranoia, as well as limited judgment. His thought processes were noted to be normal. At that time, his treatment provider noted that he had been brought in by a friend and was often drinking on his sailboat with a group of "drinking buddies" he had met at the docks. His intake GAF score was 30. Later treatment records from that detoxification inpatient visit noted that the Veteran experienced both alcohol abuse and PTSD. He complained of nightmares and flashbacks, but these were not his primary concerns. His GAF later during the hospitalization was found to be 35-40. At a follow-up visit in August 2011, the Veteran reported that his nightmares had decreased, although he continued to complain of worry and anxiety. He denied suicidal and homicidal ideation and reported that he had several friends and enjoyed sailing, reading, and using his computer. At a second hospitalization intake evaluation in October 2011, the Veteran was noted to cry whenever Vietnam was discussed; he also complained of some visual hallucinations. His intake GAF score was 35. Later records from that hospitalization reflect that he reported some suicidal and homicidal ideation, as well as judgment and insight that were noted to be "impaired by addiction." He reported that he enjoyed sailing and reading, particularly history books, and drank when he became "bored." His GAF was noted to be up to 60 during his hospital stay and 50 at discharge, along with intact insight and judgment and no audio or visual hallucinations and no suicidal or homicidal ideations. Records from 2012 indicate that the Veteran has continued to be treated for PTSD and addiction issues by his VA treatment providers. During a March 2012 inpatient visit, his intake GAF score was 30, and he was noted to have poor insight and judgment, but to be oriented in all spheres, with thought processes within normal limits. During his inpatient stay, he was noted to need a fiduciary to protect his finances secondary to his history of alcohol addiction. At an April 2012 detoxification hospitalization, the Veteran's intake GAF score was noted to be 35, with a discharge GAF score of 55. During that hospital stay, the Veteran was noted to be alert and oriented, without hallucinations, suicidal or homicidal ideation, or delusions. His insight and judgment were found to be intact. At an inpatient detoxification evaluation in August 2012, the Veteran again reported having a friend at the docks where his boat was moored; he also stated that he kept in touch with two of his brothers. Intake evaluation from the August 2012 hospitalization reflects that the Veteran complained of depression, anxiety, panic attacks, and increased irritability. The Veteran endorsed nightmares and flashbacks but denied experiencing delusions. He did state that he had poor sleep and thought that people were watching and following him. He left against medical advice in September 2012, at which time he was noted to have a stable mood and no psychosis or suicidal or homicidal ideations. He was diagnosed with alcohol dependence and withdrawal and was assigned a GAF score of 40. Later in October 2012, the Veteran again complained of sleep problems and irritability, as well as ongoing alcohol abuse. He was found to have no suicidal or homicidal ideation or psychosis, and no paranoia or abnormal thought processes were noted. His judgment and insight were limited, but he was oriented in all spheres. His GAF score was noted to be 35. The Veteran underwent VA examination in February 2008. At that time, the Veteran reported anger, anxiety, and avoidance of crowds and news concerning war. He also reported depression, difficulty concentrating, fatigue, flashbacks, hyperstartle response, hypervigilance, increased irritability, isolative behavior, memory difficulties, paranoia, recurrent intrusive memories, sleep disturbance, nightmares, and suicidal ideations. The Veteran reported that he was divorced, had no children, lived alone, and was unemployed. Upon examination, the Veteran was alert and oriented, with clear, coherent, and normal speech. Communication and cognitive function were grossly intact. There were no delusions or signs or symptoms of any thought disorder. The Veteran denied hallucinations and homicidal ideations, but experienced suicidal ideations without intent. There were mild inefficiencies in delayed verbal memory. The Veteran's judgment showed no impaired ability to manage daily living activities or make reasonable life decisions. His mood was depressed and fatigued with a blunted affect. The examiner found that the Veteran's current symptoms had moderately affected his family relationships, and had severely affected his recreation, social interpersonal relationships, and occupation. The examiner assigned a GAF score of 57. The Veteran underwent VA examination in May 2012. At that time, the examiner assigned diagnoses of PTSD and alcohol dependence. The Veteran reported that he isolated from others, but the examiner noted that he kept in touch with his brothers on the phone and was friends with a few of his neighbors. He also reported enjoying fishing and reading history books. The Veteran reported receiving Social Security benefits but clarified that these benefits are not related to any disability. He also stated that he stopped working in construction due to a back injury but had also been fired from a job as a shoe salesman due to his alcoholism. The examiner found him to experience occupational and social impairment with reduced reliability and productivity due to the combined symptoms of his PTSD and alcohol abuse and opined that she was unable to separate the symptomatology of the two disorders. However, the examiner stated that the reason the Veteran was not working was due not to his PTSD but to his alcohol abuse. The examiner noted that the Veteran experienced symptoms of suspiciousness and depressed mood and found him to be capable of managing his financial affairs. The examiner stated that the Veteran would be able to work if he could manage his alcohol addiction. The Veteran again underwent VA examination in October 2012. At that time, the examiner assigned the Veteran diagnoses of PTSD, alcohol dependence, and substance-induced mood disorder. A GAF score of 55 was assigned, although the examiner noted that "only about 30 percent" of the Veteran's difficulties were attributable to PTSD, with the rest attributed to his substance abuse. The examiner noted that the Veteran experienced intrusive thoughts and nightmares about Vietnam, as well as avoidance of news about war and an exaggerated startle response. The Veteran reported that he stays in touch with one brother and occasionally sees his nieces and nephews, although he stated that his other brother "won't call him back." He stated that he enjoyed reading and sailing as well as going out on dates with women to whom he was introduced by mutual friends. He reported having gone on a date three to four weeks prior and also stated that he has several friends that he telephones and gets together with on his boat. The Veteran reported experiencing depressed mood, chronic sleep impairment, and mild memory loss. Mental status examination revealed good orientation and normal thought processes and speech. The Veteran's affect was mildly restricted, which was found to be consistent with a mildly depressed mood. No memory deficits were noted, although the Veteran displayed mildly impaired concentration. The examiner specifically found the Veteran to display occupational and social impairment with deficiencies in most areas but found that he did not experience total occupational and social impairment. The examiner further suggested that the Veteran needed a fiduciary to manage his finances as a way to manage his alcohol addiction, although she noted that the Veteran was "cognitively capable of managing his money." In addition, the Veteran and several friends have submitted statements to VA concerning the Veteran's psychiatric symptomatology. His friends have stated that the Veteran isolates, has problems sleeping, and experiences nightmares and flashbacks. Similarly, the Veteran testified in a July 2008 statement that he experiences suicidal and homicidal ideation and is often forgetful. He also stated that he isolates and does not have many relationships. Upon review of the evidence of record, the Board finds that, in this case, the clinical evidence more closely approximates the level of occupational and social impairment contemplated by a 70 percent rating for the entirety of the appellate period. Specifically, throughout the appeal period, the Veteran has been socially withdrawn and isolated, has experienced occasional homicidal and suicidal thoughts and panic attacks, has suffered from nightmares and flashbacks, and has displayed anti-social behavior which results in few interpersonal relationships with people, both within and outside of his own family. In addition, the Board notes that the Veteran has not been employed on a full-time basis for a number of years, and his alcohol abuse has reached such a level that it affects his ability to perform job-related tasks. This coupled with the fact that he has been divorced, has few to no friends, and maintains an emotionally distant relationship with some family members, is reflective of criteria enumerated under the 70 percent evaluation for PTSD. Suicidal ideation; panic or depression affecting the ability to function independently, appropriately, and effectively; and difficulty in adapting to stressful circumstances (including work or a work like setting) are listed under the criteria for the evaluation of a 70 percent evaluation for PTSD. However, the Board observes that a rating in excess of the 70 percent assigned herein is not warranted. This is so because the competent evidence of record does not demonstrate that the Veteran's symptomatology most closely approximates a 100 percent evaluation. In this regard, the Board notes that the Veteran's medical records do not contain evidence to support a finding that, at any time during the appellate period, he has displayed gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, or disorientation as to time or place. Indeed, the record establishes that the Veteran has maintained some relationship with family members, that he socializes on occasion with at least one friend at the docks where he moors his boat, and that he continues to perform his activities of daily living independently. He has not displayed grossly inappropriate behavior. In addition, although some transient suicidal and homicidal ideation has been noted, the Veteran's treatment providers and VA examiners have not deemed him to be a persistent danger to himself or others. Similarly, although some memory loss has been noted, the Veteran has not been shown to be disoriented to time or place or to have memory loss as to the names of his relatives or himself. Thus, a 100 percent disability rating is not warranted. In so finding, the Board has considered the holdings set forth in Mauerhan v. Principi, 16 Vet. App. 436 (2002), in which the Court established that symptoms recited in the rating schedule for mental disorders are to serve as examples of the type and degree of the symptoms and are not an exhaustive list. However, the Board finds compelling that, even when not separating the Veteran's PTSD symptomatology from that caused by his alcohol abuse, multiple VA examiners have found the Veteran to experience, at worst, occupational and social impairment with deficiencies in most areas. At no time has any treatment provider found the Veteran to experience total occupational and social impairment, regardless of symptomatology; to the contrary, his multiple VA examiners and treatment providers have consistently noted that the Veteran continues to maintain relationships with his brothers as well as at least one friend at the docks with whom he socializes regularly. In its analysis, the Board has considered the GAF scores assigned to the Veteran. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." It does not otherwise include impairment in functioning due to physical (or environmental) limitations. There is no question that the GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). Regardless, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, they must be considered in light of the actual symptoms of the Veteran's disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). In this case, the Board finds that the Veteran's GAF scores of 45 to 50, assigned at the March 2012 VA examination and at multiple VA treatment visits, more closely coincide with his stated psychiatric symptoms and with the rating of 70 percent assigned herein under the General Rating Formula for Mental Disorders. These GAF scores are more consistent with the Veteran's stated symptomatology and identified symptoms than the GAF scores of 30 to 35 assigned at his VA inpatient hospitalizations. The DSM-IV identifies scores in the range of 41-50 as "serious symptoms," which include suicidal ideation, severe obsessional rituals, frequent shoplifting, or any serious impairment in social, occupation, or school functioning, such as no friends or being unable to keep a job. In this case, the Board concludes that the frequently-assigned scores of 45 to 50 are most consistent with both the Veteran's identified symptoms and the 70 percent rating assigned herein. In that connection, the Board acknowledges that the Veteran has been assigned a multitude of different GAF scores, ranging as high as 60 and as low as 20. However, the Board notes that the most consistent evaluation of the Veteran's GAF score, for the entirety of the appeal period, is the score of 45 to 50, indicative of the serious symptoms contemplated by the 70 percent rating assigned herein. Moreover, the Board also notes that, while important, the GAF scores assigned in a case are not dispositive of the evaluation and must be considered in light of the actual symptoms of the Veteran's disorder. See 38 C.F.R. § 4.126(a). Accordingly, and based on this evidentiary posture, the Board concludes that the totality of the evidence of record has shown that the Veteran's PTSD with alcohol and substance abuse and substance-induced mood disorder warrants an initial rating of 70 percent, but no higher, for the entirety of the appeal period. Resolving reasonable doubt in the Veteran's favor as to the severity of his service-connected PTSD with alcohol and substance abuse and substance-induced mood disorder, the Board concludes that the criteria for an initial 70 percent evaluation are met throughout the appeal period. However, the criteria for a 100 percent schedular evaluation are not met, as the Veteran continues to maintain some basic social relationships. The GAF scores assigned most consistently reflect severe, but not totally incapacitating, PTSD. Thus, although the criteria for a 70 percent evaluation have been met throughout the appeal period and the appeal is granted to this extent, the criteria for a total schedular evaluation for PTSD with alcohol and substance abuse and substance-induced mood disorder are not met. In essence, the preponderance of the evidence is against an evaluation in excess of 70 percent for PTSD with alcohol and substance abuse and substance-induced mood disorder. As the evidence is not in equipoise, the provisions of 38 U.S.C.A. § 5107(b) regarding resolution of reasonable doubt are not applicable to warrant an initial evaluation in excess of 70 percent. The above determination is based upon consideration of applicable rating provisions. It should also be pointed out that there is no showing that the Veteran's acquired psychiatric disability has reflected so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2012). The symptoms of his disability have been accurately reflected by the schedular criteria. Without sufficient evidence reflecting that the Veteran's disability picture is not contemplated by the rating schedule, referral is not warranted for a determination of whether the Veteran's disability picture requires the assignment of an extra-schedular rating. In this case, the Board finds that the record does not reflect that the Veteran's PTSD with alcohol and substance abuse and substance-induced mood disorder is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. 38 C.F.R. § 3.321(b)(1)(2012). The threshold factor for extra-schedular 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. Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, 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 and the assigned schedular evaluation is therefore adequate, and no extra-schedular referral is required. Id.; VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation (38 C.F.R. § 3.321(b)(1)) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). In this case, the issue of the Veteran's entitlement to a TDIU is herein remanded for further evidentiary development. Furthermore, the Board finds that the rating criteria to evaluate the Veteran's PTSD with alcohol and substance abuse and substance-induced mood disorder fully and reasonably describe the Veteran's disability level and symptomatology. Therefore, the Veteran's disability picture is fully contemplated by the rating schedule, and no extra-schedular referral is required. 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). For all the foregoing reasons, the Board finds that the Veteran's service-connected PTSD with alcohol and substance abuse and substance-induced mood disorder warrants a rating of 70 percent. 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. This is so for the entirety of the appeal period. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for ratings higher than awarded by this decision, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to an initial disability rating of 70 percent for posttraumatic stress disorder with alcohol and substance abuse and substance-induced mood disorder is granted. REMAND Regrettably, the Board finds that remand is again necessary for further evidentiary development for the issue of entitlement to a TDIU. The Court has held that a remand by the Board confers on the appellant, as a matter of law, a right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Court has indicated that, if the Board proceeds with final disposition of an appeal, and the remand orders have not been complied with, the Board itself errs in failing to ensure compliance. Id. The Board acknowledges that under applicable criteria, a TDIU may be awarded where the schedular rating is less than total and when it is determined that the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). Under § 4.16(a), if there is only one service-connected disability, it must be rated at 60 percent or more. If there are two or more disabilities, at least one of those disabilities must be rated at 40 percent or more, and the total combined rating must be 70 percent or more. Disabilities resulting from common etiology or a single accident, disabilities of one or both of the upper extremities or of the lower extremities, disabilities affecting a single body system, multiple injuries incurred in action, or multiple disabilities incurred as a prisoner of war may be considered as one disability in applying the provisions of § 4.16(a). Despite these requirements, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). The Court has stated that, in order for a veteran to prevail on a claim for a TDIU, the record must reflect some factor that takes his case outside of the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In adjudicating a claim for a TDIU, the Board may not reject the veteran's claim without producing evidence, as distinguished from mere conjecture. Friscia v. Brown, 7 Vet. App. 294 (1995). In Friscia, the Court stated that VA has a duty to supplement the record by obtaining an examination which includes an opinion on what effect the appellant's service-connected disabilities have on his ability to work. Here, service connection has been granted for PTSD, herein evaluated as 70 percent disabling, and for tinnitus, evaluated as 10 percent disabling. The Veteran's total combined service-connected evaluation is 70 percent. As such, he meets the criteria for consideration of entitlement to TDIU on a schedular basis because his rating satisfies the percentage requirements of 38 C.F.R. § 4.16(a). He contends that his disabilities, specifically his PTSD, render him unable to secure or follow a substantially gainful occupation. Consequently, VA must determine whether the Veteran's service-connected disabilities, without consideration of any non-service-connected disabilities, combine to preclude him from engaging in substantially gainful employment (work that is more than marginal, which permits the individual to earn a "living wage"). Moore v. Derwinski, 1 Vet. App. 356 (1991). Here, the Board notes that the relevant evidence includes the Veteran's treatment records from VA treatment providers, as well as VA examinations provided in February 2008, March 2012, and October 2012. At the examinations, conducted to evaluate the Veteran's PTSD disability, the examiners did not make a determination as to whether the Veteran's service-connected disabilities, when considered together, rendered him unable to seek or maintain gainful employment. In addition, the Veteran has stated to VA on multiple occasions that he is unable to work due to his service-connected disabilities, in particular PTSD. The Board notes in that connection that no adequate VA opinion has been obtained that assesses the Veteran's employability, based on both a thorough assessment of all his service-connected disabilities and his educational and occupational history and experience. Accordingly, upon review of the record, the Board finds that a medical examination and opinion are needed to decide the Veteran's claim for a TDIU. Thus, on remand the Veteran's file must be provided to a qualified VA medical professional, who must conduct a thorough review of the medical evidence, examine the Veteran, and provide a medical opinion addressing the question of whether the Veteran's service-connected disabilities, when considered together and without consideration of his age or any non-service-connected disabilities, have combined to make him unemployable at any time during the appellate period. 38 U.S.C.A. § 5103A(d); Friscia v. Brown, 7 Vet. App. 294 (1995). Such opinion must be based upon consideration of the Veteran's service-connected medical conditions as well as his documented history and assertions, to include employment history and education, and medical evidence associated with the record. 38 U.S.C.A. § 5103A. In view of the foregoing, the case is REMANDED for the following action: 1. Send the Veteran a letter requesting that he provide sufficient information and, if necessary, authorization to enable VA to obtain any additional pertinent evidence not currently of record. The Veteran must also be invited to submit any pertinent evidence in his possession, and the AOJ must explain the type of evidence VA will attempt to obtain as well as the type of evidence that is his ultimate responsibility to submit. The letter must specifically provide the Veteran with information concerning the establishment of a claim for entitlement to a TDIU. 2. Schedule the Veteran for VA examination with a qualified VA medical professional to determine the effect, if any, of his service-connected PTSD with alcohol and substance abuse and substance-induced mood disorder and tinnitus on his employability. The Veteran's claims file, including a copy of this Remand, must be made available to the examiner for review in connection with the opinion, and a notation that this review has taken place should be made in the examination report. After thoroughly reviewing the Veteran's claims file and examining the Veteran, the examiner must opine as to whether it is at least as likely as not (i.e., there is at least a 50 percent probability) that the Veteran's service-connected PTSD with alcohol and substance abuse and substance-induced mood disorder and tinnitus combine to preclude him from engaging in substantially gainful employment that is consistent with his education and occupational experience. If the examiner finds that the Veteran's service-connected disabilities are of such nature and severity as to prevent him from securing or following substantially gainful employment, he or she must opine as to when the Veteran in fact became "unemployable" and as to which specific service-connected disability(ies) have rendered him unemployable. A complete rationale must be given for all opinions and conclusions expressed. If the examiner finds that he/she must resort to speculation to render the requested opinion, he/she must state what reasons, with specificity, that this question is outside the scope of a medical professional conversant in VA practices. 3. Ensure that the examination report complies with (and answers the questions posed in) this Remand. If the report is insufficient, it should be returned to the examiner for corrective action, as appropriate. 4. Then, readjudicate the issue remaining on appeal-entitlement to a TDIU. If this benefit remains denied, the Veteran and his representative must be provided a supplemental statement of the case and given an appropriate opportunity to respond. The case must then be returned to the Board for further consideration, if otherwise in order. No action is required of the Veteran until he is notified; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). He has the right to submit additional evidence and argument on the matter that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ______________________________________________ J. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs