Citation Nr: 1317191 Decision Date: 05/24/13 Archive Date: 05/31/13 DOCKET NO. 09-47 858 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to an initial rating higher than 30 percent for post-traumatic stress disorder (PTSD) for the period February 26, 2008 to October 8, 2012. 2. Entitlement to an initial rating higher than 30 percent for PTSD for the period since October 9, 2012. 3. Entitlement to a total disability rating based on individual unemployability (TDIU rating). REPRESENTATION Appellant represented by: Tennessee Department of Veterans' Affairs ATTORNEY FOR THE BOARD S. D. Regan, Counsel INTRODUCTION The Veteran served on active duty from January 1965 to December 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal of a rating decision in September 2008 of a Department of Veterans Affairs (VA) Regional Office (RO) that, in pertinent part, granted service connection and a 30 percent rating for PTSD, effective February 26, 2008. A July 2009 RO decision continued a 30 percent rating for the Veteran's service-connected PTSD. In September 2012, the Board remanded this appeal for further development. The issues of entitlement to an initial rating higher than 30 percent for PTSD for the period since October 9, 2012, and entitlement to a TDIU rating, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT For the period from February 26, 2008 to October 8, 2012, the Veteran's service-connected PTSD was manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to various symptoms. CONCLUSION OF LAW The criteria for an initial 70 percent rating for PTSD for the period from February 26, 2008 to October 8, 2012, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2009). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist Upon receipt of a complete or substantially complete application, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. The appeal arises from the Veteran's disagreement with the initial rating following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial and will not be discussed. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notices. See Shinseki v. Sanders, 556 U.S. 396 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination.); See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Veteran's service treatment records, VA treatment records, and private treatment records, have been obtained. 38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159. The Veteran's Social Security Administration determination, and the records considered in that determination, were obtained in December 2012. 38 C.F.R. § 3.159 (c) (2). VA examinations were conducted in August 2008 and January 2010; the Veteran has not specifically argued, and the record does not reflect, that such examinations were inadequate for rating purposes. 38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); 38 C.F.R. § 3.159(c)(4). There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 556 U.S. 129 (2009). Analysis Ratings for service-connected disabilities are determined by comparing the veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2012). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2012). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). A 30 percent rating is warranted for PTSD where 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 conversion normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires 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 affected 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 worklike setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In evaluating the evidence, the Board has noted various Global Assessment of Functioning (GAF) scores which clinicians have assigned. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (DSM-IV); Carpenter v. Brown, 8 Vet. App. 240 (1995). For example, a GAF score of 31 to 40 is meant to reflect an examiner's assessment of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood (e.g. depressed man avoids friends, neglects family, and is unable to work). A GAF score of 41 to 50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job). A GAF score of 51 to 60 indicates the examiner's assessment of moderate symptoms (e.g., a flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61 to 70 indicates the examiner's assessment of some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well and having some meaningful interpersonal relationships. An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126. VA treatment records dated from December 2007 to August 2008 show treatment for disorders, including variously diagnosed psychiatric disorders, including PTSD. For example, a December 2007 VA psychiatric consultation report related diagnoses of anxiety disorder and rule out PTSD. A GAF score of 55 was assigned. A June 2008 VA treatment entry indicated an assessment that included PTSD, combat related, severe, as manifested by social isolation, chronic mood problems, a sense that life has little meaning, constant environmental scanning, and other evidence of alertness. A mood disorder, not otherwise specified, secondary to multiple medical problems, including sleep apnea, obesity, chronic obstructive pulmonary disorder (COPD), and sleep deprivation due to PTSD, was also diagnosed. A GAF score of 50 was assigned. An August 2008 VA psychiatric examination report noted that the Veteran reported that he had been having problems since he was in Vietnam with memories of combat and nightmares, which had progressively worsened over the years. The Veteran stated that he had nightmares almost every night and that they consisted of one incident when a squadron leader was hit by a sniper bullet while the Veteran was in a foxhole. He indicated that he would often awaken from dreams sweating, shaking, and anxious. He maintained that he had intrusive thoughts about his combat experiences and that they had become much more severe, especially if triggered by something such as someone talking about such incidents, or when he would inadvertently catch some war news or a war movie. The Veteran reported that other triggers of intrusive thoughts included sounds like sirens or fireworks. He indicated that being around a lot of people made him anxious and reminded him of his experiences in Vietnam. The Veteran maintained that he isolated himself and that he did not go out in public on many occasions. He stated that he did not go near his family anymore. He stated that he had avoided going to church, but that he was finally able to go because he found a newly opened church where he could sit in the back, arrive late, and leave early, so as not to have contact with other parishioners. The Veteran reported that he also had a lot of emotional numbing, a lack of connection with others, feelings of guilt, and feelings of a lack of a future. He stated that he was often angry and irritable, that he was verbally short with others, and that he had been involved in fights in the past. He indicated that his concentration was poor and that he was always looking over his shoulder. It was noted that the Veteran reported that he had chronic depression, a loss of energy, poor concentration, and anhedonia. The Veteran maintained that he had some suicidal thoughts in the past, but that he had not had recent thoughts. He stated that he had never made an attempt to commit suicide. It was noted that the Veteran was visibly anxious during the interview and that he became more tremulous, anxious, and depressed when discussing Vietnam. The Veteran reported that following his discharge from service, he went to college for four years and received a degree in business. He stated that he drank and used drugs heavily during that time as a result of his PTSD symptoms. The Veteran indicated that he lost or quit several jobs in the business field and that most of those jobs involved interacting with people and going to meetings. He stated that he had his last job, however, for seventeen years because he only worked for one other person buying and repairing furniture. He related that he was able to essentially work by himself without interference from other people. The Veteran reported that he had to quit his last job because of his COPD and a difficulty with breathing sanding dust, etc. The Veteran reported that, following his return from Vietnam, he got married and that his first marriage lasted for ten years. He stated that after he quit drinking and using drugs, he remarried, but that his second marriage only lasted for ten months because his wife was using substances. The Veteran reported that he had been single for a number of years and that he lived alone in a trailer. He stated that he did not have any kind of a social life other than his infrequent trips to church, where he did not interact with anyone. He reported that he stopped using drugs and drinking alcohol fifteen years earlier because he embraced religion. The examiner reported that the Veteran was appropriately dressed, but mildly disheveled. The Veteran was alert, oriented times three, and his speech was slow and hesitant. The Veteran's mood bordered on irritable at times, but was generally appropriate. The Veteran's psychomotor activity was increased, with some anxiety and tremulousness noted. The Veteran's affect appeared blunt, and there were no indications of suicidal or homicidal ideations. There was no evidence of a formal thought disorder, hallucinations, or delusions. The Veteran's recent and remote memory was intact, but he stated that he was forgetful based on a poor ability to concentrate. The Veteran's fund of knowledge was adequate, and his insight and judgment were fair. The diagnosis was PTSD, chronic and severe. A GAF score of 45 was assigned. The examiner indicated that the Veteran appeared to be suffering from severe PTSD symptoms which appeared to be caused by his constant exposure to combat over a period of twelve months with numerous stressors. The examiner stated that as a result of his PTSD symptoms, the Veteran appeared to be severely impaired socially as manifested by the fact that he lived an essentially isolated existence with little contact with humanity. The examiner reported that the Veteran also had severe impairment in his occupational functioning, as shown by the fact that he was unable to hold any jobs that required human interaction. It was noted that the only reason why the Veteran was able to hold one job for a number of years was because he worked in isolation. The examiner said that, due to the severity of the Veteran's symptoms, which had lately increased, it was doubtful that he would be able to hold any kind of employment and must, therefore, be considered unemployable. Private and VA treatment records dated from September 2008 to November 2009 show that the Veteran was treated for multiple disorders. Such records specifically indicate that the Veteran was treated for PTSD on multiple occasions, and that he was hospitalized for suicidal ideation. Multiple GAF scores were assigned that ranged from 39 to 65. For example, a May 2009 VA treatment entry related a diagnosis of PTSD and a GAF score of 50. A July 2009 VA treatment entry indicated diagnoses of PTSD, combat related; depressive disorder, not otherwise specified; insomnia; nightmares; anxiety, not otherwise specified; and suicidal ideation. A GAF score of 45 was assigned. The examiner noted, as to an assessment summary, that the Veteran had severe PTSD, insomnia, and nightmares, and the Veteran temporarily had suicidal and assaultive ideation. A September 2009 VA treatment entry related diagnoses of major depression; PTSD, combat related; insomnia; nightmares; anxiety, not otherwise specified; suicidal ideation; homicidal ideation; intermittent explosive disorder; and bereavement. A GAF score of 40 was assigned. A September 2009 consultation report from the Lourdes Behavioral Health Center indicated that the Veteran presented to the emergency department with complaints of suicidal ideation. The Veteran reported that he was actually having thoughts of committing suicide. He stated that he did not have an actual plan in place, but that he was so severely depressed that he just wanted to die. He indicated that he had been having such thoughts for quite some time and that he made a voluntary admission. The impression included suicidal ideation, depression, and PTSD. An interdisciplinary discharge summary from the Lourdes Behavioral Health Center related diagnoses of major depression, recurrent, without psychotic features; post-traumatic stress syndrome, chronic; and cannabis dependency. A GAF score of 39 was assigned. A September 2009 discharge summary from the Lourdes Behavioral Health Center indicated that the Veteran was referred by a VA hospital. It was noted that the Veteran was depressed, that he had PTSD, and that the VA hospital could not contract for his safety. The discharge diagnoses were major depressive disorder, recurrent, with no suicidal ideation; PTSD; and cannabis dependency. A GAF score range of 40 to 60 was assigned. The examiner reported that the Veteran had improved with no suicidal or homicidal thoughts or plans. An October 2009 VA treatment entry related diagnoses of PTSD, combat related; major depression, in early remission; insomnia, improved; nightmares, unimproved; anxiety, not otherwise specified; suicidal ideation, in remission; homicidal ideation, in remission; intermittent explosive disorder; and bereavement. A GAF score of 65 was assigned. The examiner reported that the Veteran was seen after a six day hospital stay at the Lourdes Behavioral Medical Center and that he was much improved, but that he had ongoing PTSD symptoms and chronic persistent insomnia. A January 2010 VA psychiatric examination report noted that the Veteran reported that he had been hospitalized for suicidal thoughts. The Veteran indicated that he was currently receiving psychiatric treatment and that he was taking anti-depressant medication. He stated that the medications helped in that they made his mood softer, and that he was a little calmer and relaxed about things. He indicated that he stopped attending group therapy because it made him relive his battle experiences. The Veteran reported that he would become depressed about six times a year because he would feel sorry for soldiers who had to go to war and come back with no limbs. He felt sorry for their families. It was noted that the Veteran managed his hygiene on a daily basis. The Veteran reported that he had been married twice. He indicated that he had not been in a relationship for about two years. He stated that he had one son and that they would call each other every now and then and he would see his son about twice a year. He had a bad connection with his one living older brother. He would spend time with friends once a year and that they would eat and talk, or watch a ballgame. He would read the newspaper, watch television, do crossword puzzles, and go to church. He had a lot of problems with kids making a racket and the noise would bring back flashbacks. There was no history of suicide attempts or assaults. The Veteran reported that he last used alcohol in 2009, and last used marijuana the morning of the examination. The Veteran retired in 2006 due to physical problems. He reported that he worked restoring furniture for seventeen years. He had some arguments with his bosses because he saw them mistreating others. The examiner reported that the Veteran's initial facial expression was severe and scared, but that it softened during the interview. The Veteran was slightly disheveled and that his hat was dirty. The Veteran's psychomotor activity was tense and his speech was spontaneous, clear, and coherent. The Veteran was cooperative and attentive, but had an attention disturbance (easily distracted). The Veteran was oriented to person, time, and place, and that his thought processes were linear. The Veteran's thought content was appropriate to the conversation and there were no delusions. In regard to the Veteran's judgment, he did not understand the outcome of behavior. As to insight, the Veteran knew he had a problem. The Veteran had sleep impairment and had problems initiating sleep. The Veteran reported that marijuana use combined with his medications allowed him to sleep four hour a night. The examiner indicated that the Veteran did not have inappropriate behavior, obsessive or ritualistic behavior, or panic attacks. There was no presence of homicidal thoughts. The Veteran did have suicidal thoughts, but not in the previous two to three years. The Veteran denied any plan or intent of self harm. The Veteran's impulse control was good and he had no episodes of violence. The Veteran was not able to maintain minimal personal hygiene and, if he would shake severely, his cousin would help him dress. The Veteran's recent memory was normal and his remote memory was mildly impaired. As to specific PTSD symptoms, the examiner reported that the Veteran's sleep was poor enough that he used marijuana to help him sleep and calm down. The Veteran stated that he had an attitude sometimes which caused him a lot of trouble. Poor concentration was shown on attention tasks. The Veteran had no friends and was noticeably socially detached. The Veteran only involved himself in church. The Veteran could not articulate a future for himself and was unable to continue to involve himself in group therapy because he could not tolerate being exposed to war stories. The Veteran also had nightmares every night. The diagnoses were PTSD, chronic, severe, and cannabis abuse. A GAF score of 45 was assigned. The examiner indicated that, based on the medical records and the Veteran's presentation, it appeared that his symptoms were about at the same level of severity as at the time of the August 2008 VA psychiatric examination. The examiner reported that the Veteran was chronically using marijuana to medicate his anxiety and sleeplessness due to his PTSD. Depressive symptoms were not obvious at the time of the examination. The examiner indicated that there was not total occupational and social impairment due to PTSD signs and symptoms. The examiner maintained that the Veteran's PTSD signs and symptoms did result in deficiencies in the areas of judgment, thinking, family relations, work, mood, or school. The examiner reported that the Veteran had deficiencies in judgment with chronic marijuana use and deficiencies in thinking with poor concentration. As to family relations, it was noted that the Veteran had some distant relationships and two divorces. Private and VA treatment records dated from January 2010 to September 2012 show that the Veteran continued to receive treatment for disorders, including his PTSD, on numerous occasions. Multiple treatment entries related GAF scores ranging from 50 to 80. For example, a March 2010 VA treatment entry related diagnoses of combat PTSD; major depression, recurrent with psychotic features, in remission; and anxiety, not otherwise specified, in remission; nightmares; insomnia, in remission; and bereavement due to the death of his brother. A GAF score of 65 was assigned. An October 2010 VA treatment entry indicated diagnoses of combat PTSD; major depression, recurrent with psychotic features, in remission; and anxiety, not otherwise specified, in remission; nightmares, improved; and insomnia, improved, with a GAF score of 75. A November 2010 mental evaluation report from P. T. Harris, Ph.D., apparently for SSA purposes, related a diagnosis of PTSD, combat related. Dr. Harris indicated that the Veteran's impairments or treatments would cause him to be absent more than four days a month from work. It was also noted that GAF scores indicated mild to moderate symptoms, consistently closer to moderate. A December 2010 psychological evaluation report from the West Tennessee Psychological group related an impression of a major depressive disorder, recurrent, severity unspecified (rule out psychotic features), and PTSD. The examiner assigned a GAF score of 50. As to a summary, the examiner indicated that the Veteran described experiencing nightmares and flashbacks related to his experiences in Vietnam. The examiner stated that the Veteran reported that he had auditory hallucinations for the past year, but that his description of such experiences suggested that they might be flashbacks as opposed to hallucinations. It was noted that the Veteran indicated that he would hear voices from Vietnam. The examiner maintained that there were no visual hallucinations or systemic delusions. The examiner stated that the Veteran's mood was severely dysphoric, that his short-term memory was impaired, and that his long-term memory was intact. It was noted that the Veteran had significant anxiety. A December 2010 mental evaluation report from R. Kelley, M.D., apparently for Social Security Administration (SSA) purposes, indicated that the Veteran had chronic, severe, combat-related PTSD. Dr. Kelley stated that the Veteran had been seriously psychologically depressed with suicidal ideation, and that he was presently in partial remission. Dr. Kelley indicated that the Veteran was permanently disabled and that he would be absent from work all the time. Records from the SSA indicate that the Veteran was receiving disability compensation. The Veteran's severe impairments were listed as asthma, hypertension, depression, and PTSD. The Veteran was considered disabled as of March 2006. A June 2012 VA treatment entry related a diagnosis of PTSD. A GAF score of 65 was assigned. The evidence for the period from February 26, 2008 to October 9, 2012 showed that the Veteran had been divorced twice and that he lived alone in a trailer. He had one son and that they would call each other now and then. He would spend time with friends once a year. He retired in retired in 2006 due to physical problems. A January 2010 VA psychiatric examination report indicated a GAF score of 45. A GAF score of 45 suggests 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 Veteran's PTSD signs and symptoms did result in deficiencies in the areas of judgment, thinking, family relations, work, mood, or school. A prior August 2008 VA psychiatric examination report also related a GAF score of 45; the Veteran appeared to be severely impaired socially as manifested by the fact that he lived an essentially isolated experience with little contact with humanity; and the Veteran had severe impairment in his occupational functioning, as shown by the fact that he was unable to hold any jobs that required human interaction. Private and VA treatment records for the period from February 26, 2008 to October 8, 2012 include GAF scores that range from 39 to 80; although the majority of the GAF scores during that period were in the 45 to 65 range. The Veteran was hospitalized for suicidal ideation at the Lourdes Behavioral Health Center in September 2009 and was initially assigned a GAF score of 39. A GAF score of 39 reflects an examiner's assessment of some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood (e.g. depressed man avoids friends, neglects family, and is unable to work). On discharge from the Lourdes Behavioral Health Center in September 2009, a GAF score range of 40 to 60 was reported. A GAF score of 60 is reflective of moderate symptoms (e.g., a 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). There are several treatment records with conflicting reports as to the severity of the Veteran's symptoms. For example, a November 2010 mental evaluation report from Dr. Harris, apparently for SSA purposes, noted that GAF scores indicated mild to moderate symptoms, but consistently closer to moderate. Dr. Harris stated that the Veteran's impairments or treatments would cause him to be absent more than four days a month from work. A December 2010 mental evaluation report from Dr. Kelley, also apparently for SSA purposes, indicated that the Veteran would be absent from work all the time and that he was permanently disabled. A later June 2012 VA treatment entry noted a GAF score of 65, suggestive of only mild symptoms. Viewing all the evidence for the period from February 26, 2008 to October 8, 2012, the Board finds that there is a reasonable basis for finding that the Veteran's PTSD was productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to various symptoms, supporting a higher rating of 70 percent. See 38 C.F.R. § 4.7. In fact, the examiner pursuant to the January 2010 VA psychiatric examination report specifically indicated that the Veteran's PTSD signs and symptoms resulted in deficiencies in his judgment, thinking, family relations, work, mood or school. The Board cannot conclude based on the psychiatric symptomatology that the Veteran's PTSD is of such a severity as to produce total occupational and social impairment as required for a 100 percent rating for the period from February 26, 2008, to October 8, 2012. The evidence does not show symptoms such as grossly inappropriate behavior; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name, that are indicative of a 100 percent rating. While the Veteran was noted to have suicidal ideation, and the possibility of auditory hallucinations, he simply does not show many of the symptoms necessary for a 100 percent rating for the stated period. Thus, the 70 percent rating being assigned adequately addresses his PTSD symptomatology for the period from February 26, 2008 to October 8, 2012. As this is an initial rating case, consideration has been given to "staged ratings" (different percentage ratings for different periods of time, since the effective date of service connection, based on the facts found). Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are not indicated in the present case, as the Board finds the Veteran's PTSD has been 70 percent disabling for the period from February 26, 2008 to October 8, 2012. All the medical evidence cited above would only provide negative evidence against the claim for a rating above 70 percent for that period. Thus, a higher rating to 70 percent, and no more, is warranted for PTSD for the period from February 26, 2008 to October 8, 2012. There is no doubt to be resolved. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's disability. The Veteran's occupational impairment is contemplated by the criteria set forth in Diagnostic Code 9411. Moreover, there are no other indicia of an exceptional or unusual disability picture, such as marked interference with employment, i.e., beyond that contemplated by the criteria set forth in Diagnostic Code 9411, or frequent periods of hospitalization. As such, referral for extraschedular consideration is not warranted. ORDER An initial higher rating of 70 percent, but not greater, is granted for PTSD for the period from February 26, 2008 to October 8, 2012. REMAND The remaining issues on appeal are entitlement to an initial rating higher than 30 percent for PTSD for the period since October 10, 2012, and entitlement to a TDIU rating. The Veteran was last afforded a VA psychiatric examination in October 2012. The diagnoses were PTSD and cannabis abuse. A GAF score of 55 was assigned. The examiner reported that the Veteran's psychiatric disorder, alone, did not impair his ability to engage in physical and sedentary forms of employment. The examiner also indicated that the Veteran's PTSD symptoms caused occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with routine behavior, self-care, and normal conversion normal. Additionally, recent VA treatment records dated from 2012 include diagnoses of PTSD and GAF scores of 65, suggesting significant improvement of the Veteran's symptomatology. However, prior private and VA treatment records, including VA examination reports, appear to contradict the more recent treatment reports. For example, a January 2010 VA psychiatric examination report related diagnoses of PTSD, chronic, severe, and cannabis abuse. The examiner assigned a GAF score of 45. The examiner specifically maintained that the Veteran's PTSD signs and symptoms did result in deficiencies in the areas of judgment, thinking, family relations, work, mood, or school. Therefore, the Board finds that the record clearly raises a question as to the current severity of the Veteran's service-connected PTSD for the period since October 9 2012. As such, the Board has no discretion and must remand this matter to afford him an opportunity to undergo a contemporaneous VA examination to assess the current nature, extent and severity of his psychiatric disability. See also Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43,186 (1995). Prior to the examination, any outstanding records of pertinent treatment must be obtained and added to the record. Additionally, the Board observes that a request for a TDIU rating, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when a TDIU rating is raised during the appeal of a rating for a disability, it is part of the claim for benefits of the underlying disability. Id at 454. An August 2008 VA psychiatric examination report indicated a diagnosis of PTSD, chronic and severe. The examiner commented that due to the severity of the Veteran's symptoms, which had lately increased, it was doubtful that he would be able to hold any kind of employment and must, therefore, be considered unemployable. A December 2010 mental evaluation report from R. Kelley, M.D., apparently for Social Security Administration (SSA) purposes, indicated that the Veteran had chronic, severe, combat-related PTSD. Dr. Kelley indicated that the Veteran was permanently disabled and that he would be absent from work all the time. There is, however, a substantial amount of other evidence of record that goes against a finding of unemployability, and the Board finds that, while the record at least raises the issue of a TDIU claim, the evidence is insufficient to permit an informed decision. Accordingly, the case is REMANDED for the following: 1. Ensure that all notification and development action required by 38 U.S.C.A. §§ 5102, 5103 and 5103A (West 2002) are fully complied with and satisfied with respect to the issue of entitlement to a TDIU rating. The notice must include an explanation as to the information or evidence needed to establish a disability rating and effective date of any increase for the claim on appeal, as outlined by the Court in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 2. Ask the Veteran to identify all medical providers who have treated him for PTSD since September 2012. After receiving this information and any necessary releases, contact the named medical providers and obtain copies of the related medical records which are not already in the claims folder. Document any unsuccessful efforts to obtain records, inform him of such, and advise him he may obtain and submit those records. 3. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the extent and severity of his PTSD for the period since October 9, 2012. The entire claims file (i.e., the paper claims file and any medical records contained in Virtual VA, CAPRI, and AMIE) must be reviewed by the examiner. If the examiner does not have access to Virtual VA, any relevant treatment records contained in the Virtual VA file that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All signs and symptoms of the service-connected PTSD must be reported in detail (including all information necessary for rating the disability under Diagnostic Code 9411). The examiner must report all pertinent findings and assign a GAF score. The examiner must also opine as to whether, without regard to the Veteran's age or the impact of any nonservice-connected disabilities, it is at least as likely as not that his service-connected disabilities, either alone or in the aggregate, render him unable to secure or follow a substantially gainful occupation. In doing so, the examiner must take into consideration the Veteran's level of education, training, and previous work experience, but not his age or any impairment caused by nonservice-connected disabilities. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that the requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 4. Review the claims file to ensure that all of the foregoing development has been completed, and arrange for any additional development indicated. Then readjudicate the claims on appeal. If either benefit remains denied, issue an appropriate supplemental statement of the case and provide the Veteran and his attorney an appropriate period of time to respond. The case is to then be returned to the Board for further appellate review. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs