Citation Nr: 1319651 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 05-00 821 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial disability rating in excess of 50 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Helena M. Walker, Counsel INTRODUCTION The Veteran served on active duty from April 1968 to October 1971, including honorable service in the Republic of Vietnam. This case comes before the Board of Veterans' Appeal (Board) on appeal of an August 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In that decision, service connection for PTSD was established and an initial 30 percent rating was assigned, effective August 2, 2002. The Veteran appealed the rating assigned. In a July 2012 Board decision, a 50 percent rating was awarded for the entire timeframe on appeal. The Veteran appealed this decision to the Court of Appeals for Veterans Claims (Court). In January 2013, the Court granted a Joint Motion for Remand (JMR) filed by the parties, which requested that the Veteran's claim of entitlement to an increased rating for PTSD be vacated and remanded. The JMR specifically requested that the issue on appeal is limited to the denial of a rating in excess of 50 percent for the service-connected PTSD. The appeal has now returned to the Board for further development. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's PTSD is manifested by symptoms such as anxiety, depression, flashbacks, nightmares, intrusive memories, avoidance, sleep impairment, irritability, anger outbursts, concentration problems, hypervigilance, startle response, obsessive thoughts, and some short- and long-term memory problems, all resulting in moderate social and occupational impairment; occupational and social impairment with deficiencies in most areas is not shown. 2. The Veteran's service-connected PTSD did not present an exceptional or unusual disability picture. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411 (2012). 2. Application of the extraschedular rating provisions is not warranted in this case. 38 C.F.R. § 3.321(b) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the Veteran is expected to provide; and (4) request that the Veteran provide any evidence in his possession that pertains to the claim. The requirement of requesting that the Veteran provide any evidence in his possession that pertains to the claim was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. VA satisfied its duty to notify. With respect to the Veteran's claim for higher initial rating for his PTSD, the Board notes that in cases where a compensation award has been granted and an initial disability rating and effective date have been assigned, the typical claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also VAOPGCPREC 8-2003 (December 22, 2003). Thus, because service connection for PTSD has already been granted, VA's VCAA notice obligations with respect to that issue are fully satisfied, and any defect in the notice is not prejudicial. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) [where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements]. If any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome in this case by the following: (1) based on the communications sent to the Veteran over the course of this appeal, the Veteran clearly has actual knowledge of the evidence the Veteran is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to the Veteran by VA, it is reasonable to expect that the Veteran understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). In this case, the Veteran has been continuously represented by an experienced Veterans Service Organization and has submitted argument in support of his claim. These arguments have referenced the applicable law and regulations necessary for a grant of an increased rating. Thus, the Board finds that the Veteran has actual knowledge as to the information and evidence necessary for him to prevail on his claim and is not prejudiced by a decision in this case. As such, a remand for additional notice would serve no useful purpose and would in no way benefit the Veteran. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on the VA with no benefit flowing to the Veteran are to be avoided). The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records (STRs), Social Security Administration (SSA) records, and post service medical records are in the file. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. With respect to claims for increased ratings, the duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the Veteran. See Green v. Derwinski, 1 Vet. App. 121 (1991). In addition, where the evidence of record does not reflect the current state of the Veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2011). The RO provided the Veteran appropriate VA examination most recently in November 2011. The VA examination report is thorough and supported by the other treatment evidence of record. The examination report discussed the clinical findings and the Veteran's reported history as necessary to rate the disability under the applicable rating criteria. The examination report also discussed the impact of the disability on the Veteran's daily living. Based on the examination, the absence of evidence of worsening symptomatology since the examination, and the fact there is no rule as to how current an examination must be, the Board concludes the November 2011 examination report in this case is adequate upon which to base a decision. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Legal Criteria Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is prohibited. 38 C.F.R. § 4.14. The Court has held that a veteran may not be compensated twice for the same symptomatology as "such a result would over compensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. The Court has acknowledged, however, that when a veteran has separate and distinct manifestations attributable to the same injury, he should be compensated under different Diagnostic Codes. Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225 (1993). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct period where the service-connected disability exhibits symptoms that would warrant different ratings.); see also Fenderson v. West, 12 Vet. App. 119, 126 (2001). A disability may require re-evaluation in accordance with changes in a veteran's condition. It is thus essential, in determining the level of current impairment, that the disability be considered in the context of the entire recorded history. 38 C.F.R. § 4.1. The Board is required to analyze the credibility and probative value of the evidence, account for any evidence that it finds persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Daye v. Nicholson, 20 Vet. App. 512, 516 (2006). It is noted that competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). It is important to note that if two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.1. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the veteran. 38 C.F.R. § 4.3. The Veteran's PTSD has been evaluated using Diagnostic Code 9411 of 38 C.F.R. § 4.130, which sets forth criteria for evaluating post-traumatic stress disorder using a general rating formula for mental disorders outlined in Diagnostic Code 9440. Pertinent portions of the general rating formula for mental disorders are as follows: 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...........100 percent Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships..............................70 percent 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; difficulty in establishing and maintaining effective work and social relationships......................50 percent Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupation tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events).....................30 percent In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to DSM-IV. See 38 C.F.R. § 4.125(a). Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). According to the DSM-IV, a GAF score between 41 and 50 is indicative of 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 between 51 and 60 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers); a GAF between 61 and 70 is indicative of 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, has some meaningful interpersonal relationships; a GAF between 71 to 80 is indicative that if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in school work). Factual Background and Analysis The Veteran contends that his PTSD warrants a rating in excess of 50 percent. By way of background, service connection for PTSD was originally awarded in an August 2003 rating decision. A 30 percent rating was assigned, effective August 2, 2002. The Veteran appealed the initial rating. In a July 2012 Board decision, reasonable doubt was found in favor of the Veteran, and a 50 percent rating was assigned for the entire timeframe on appeal. As noted above, the Veteran appealed the rating to the Court. In the January 2013 JMR, the parties agreed that the Board provided inadequate bases for not granting a rating in excess of 50 percent for the Veteran's PTSD. The Veteran was afforded a VA examination dated in August 2002. The examiner indicated that the Veteran's claims file had been reviewed in connection with the examination. The examiner noted that the Veteran had combat service in the Army and was awarded the Purple Heart Medal, after being shot in the face and left elbow by a sniper. The Veteran has received psychiatric treatment at VA for depression and insomnia. He had been diagnosed with PTSD and depressive disorder, NOS. The Veteran reported holding several jobs and, since 1991, had worked part time repairing pumps. The examiner noted that the Veteran had been married and divorced six times. The Veteran reported chronic nightmares that were so frightening that he sometimes defecated in his sleep. He also reported that he was physically abusive during his second marriage, and consumed a lot of alcohol for the first 7 or 8 years after he returned from Vietnam. Upon examination, the Veteran was alert and fully oriented, and was indicated to have good short term memory and no evidence of long-term memory deficit. There was no evidence of obsessions, compulsions or panic symptoms. His speech was clear and coherent without evidence of circumstantial, tangential or loss associations. The Veteran's speech was goal oriented and he denied ever experiencing hallucinations or bizarre delusions. He further denied any paranoid or grandiose beliefs. The examiner indicated that the Veteran's range of affect was mildly restricted. The Veteran reported feeling depressed once or twice a week and that he needed sleep aides to sleep normally. The Veteran reported poor energy in the last three to four years, although he indicated that his appetite was good. He endorsed difficulties in concentration and impaired self-esteem. The examiner also noted that the Veteran had significant guilt related to his experiences in Vietnam that distorted his perceptions and personal interactions. The Veteran denied current suicidal ideation, although he indicated that he had thought about it in the past. The Veteran was also noted to have a lot of guilt related to losing 10 out of 12 men in his squad in Vietnam. The Veteran reported that he had unwanted memories of the war three to four times during the prior week that sometimes lasted up to three hours, as well as two nightmares in the previous week. The Veteran also reported that he experienced flashbacks and that sometimes that were so vivid that he totally disassociated. These involved visual and auditory stimuli. The Veteran indicated that he would become tearful when reminded of the war and that he would avoid talking and thinking about the war. He indicated that he felt detached most of the time and that he felt numb 25-30 percent of the time. On the other hand, the Veteran reported feeling happy in the prior week and indicated that he felt a lot of love for his daughter and her mother. The Veteran indicated some concentration difficulties, some irritability, and significant hypervigilance. The Veteran was not diagnosed as having PTSD, but was found to have depressive disorder. He was assigned a GAF score of 55. The Veteran was again examined by VA in August 2003. The examiner indicated that the Veteran's claims file had been reviewed in connection with the examination and report. The Veteran's family and military history were noted. After service, the Veteran was noted to work in the well drilling business until 1991 when it went bankrupt. Since that time he worked part time repairing pumps. The Veteran also had a general insurance license. The Veteran indicated that he had been married six times, the last 10 years ago, and had a daughter from the second marriage and a grandson. The Veteran had a history of multiple head injuries, including a motor vehicle accident in service. He had a history of diagnoses related to his head injury, including other psychiatric disabilities, such as generalized anxiety disorder, PTSD, and depression. The Veteran indicated he drank heavily after service, but now only occasionally drank. The Veteran indicated that he was in receipt of SSA disability benefits due mental instability, and as such, he is unemployable. On examination, the Veteran was well groomed, alert, and oriented. His manner was defensive and subtly hostile. He spoke with a normal rate and rhythm, his mood was dysphoric, and his affect restricted. He tended to ramble and get off topic, but he denied hallucinations. He indicated a vague suicidal ideation, but no current intent to kill himself. He did not appear psychotic, his concentration was adequate, his short term memory impairment was mild, and his remote memory was intact. The Veteran's PTSD symptoms included re-experiencing stressful service experiences, nightmares two to three times per week, daily unwanted memories, and flashbacks. He indicated that he would react emotionally and physically when reminded of the event, perspiring or getting clammy hands. The Veteran endorsed avoiding thoughts and feeling about the war, including movies, books, news and memorials. He also indicted that he was less interested in activities that he used to enjoy, including fishing, keeping neat, and socializing. He stated that he enjoyed talking to his counselor at the Vet Center and that he loved his daughter. The examiner opined that the Veteran had avoidance symptoms in the moderate range. The Veteran was also noted to have sleep impairment for which he took medication, and irritability when he was provoked. The examiner noted some concentration issues, and startle response to loud noises. The Veteran was diagnosed with PTSD, chronic, delayed onset, and depressive disorder, NOS. He was assigned a GAF score of 55. The Veteran was again examined by VA in August 2008. The Veteran's claims file, and service, VA, and private medical records were reviewed in connection with the examination. The Veteran endorsed symptoms of depression. He was noted to have been divorced six times, had two friends, and liked to watch movies and read. He had no history of suicide attempts, violence/assaultiveness, or issues associated with alcohol or substance abuse. On examination, the Veteran was clean, neatly groomed, and appropriately and casually dressed. His psychomotor activity was unremarkable and his speech was spontaneous, clear, and coherent. He was attentive, his affect was full, and he was oriented times 3. His thought process and content were unremarkable, and he had no delusions. He was indicated to be of average intelligence and understood the outcome of his behavior. The Veteran was noted to have sleep impairment, but no hallucinations, or inappropriate or obsessive/ritualistic behavior. He was noted to have panic attacks, but no homicidal or suicidal thoughts, or episodes of violence. The Veteran's impulse control was indicated to be fair, he was able to maintain minimum personal hygiene, and his memory was normal times three. His PTSD symptoms included recurrent and intrusive distressing recollections and dreams (nightmares), avoidance of thoughts feelings, and conversations associated with the trauma (detachment/restricted range of affect), sleep disturbance, irritability, anger, hypervigilance, and flashbacks. The examiner diagnosed the Veteran as having PTSD, chronic, and assigned a GAF score of 55. The examiner found that there was no total occupational and social impairment due to PTSD signs and symptoms, and that PTSD symptoms did not result in deficiencies in judgment, thinking, family relations, work, mood, or school. There was however, reduced reliability and productivity due to PTSD symptoms. His PTSD symptoms, including hypervigilance and detachment, were described as moderate social impairment. In this regard, the examiner indicated that the Veteran had two friends at present, compared to six friends before service. The examiner stated that the Veteran was not unemployable due to PTSD. The Veteran stated that he had not worked since a head injury in 1991 and added that he had applied for numerous jobs without success. The Veteran was again examined by VA in September 2010. The examiner indicated that the Veteran's claims file had been reviewed in connection with the examination and report. The Veteran reported use of medication and therapy for treatment of his PTSD symptoms. He advised that he was chronically depressed, but the examiner indicated that the Veteran's test results show he was over-reporting his affective symptoms. Again, he reports that he has been divorced six times and had a daughter, but stated that they are no longer close. He also stated that he had no friends for the past 8-10 years. He reported staying home or watching TV. The Veteran denied suicide attempts and he has no current issues with alcohol or substance abuse, but he indicated that he has slapped 2-3 people. On examination, the Veteran was clean, neatly groomed, and appropriately and casually dressed. His psychomotor activity was unremarkable and his speech was spontaneous, clear, and coherent. He was attentive, his affect was full, and he was oriented times three. His thought process and content were unremarkable, and he had no delusions. He was indicated to be of average intelligence and understood the outcome of his behavior. The Veteran was noted to have sleep impairment, but no hallucinations, or inappropriate or obsessive/ritualistic behavior. He was not found to have panic attacks, and there was no homicidal ideation. The Veteran indicated suicidal thoughts, and some episodes of violence (slapping 2-3 people). The Veteran's impulse control was indicated to be fair, he was able to maintain minimum personal hygiene, and his memory was normal times three. His PTSD symptoms included recurrent and intrusive distressing recollections and dreams (nightmares), avoidance of thoughts feelings, and conversations associated with the trauma, sleep disturbance, irritability, anger, hypervigilance, and exaggerated startle response. The Veteran was diagnosed with PTSD, chronic. The examiner opined that there was no total occupational and social impairment due to PTSD signs and symptoms, and that PTSD symptoms did not result in deficiencies in judgment, thinking, family relations, work, mood, or school. There was also no reduced reliability and productivity due to PTSD symptoms, nor was there occasional decrease in work efficiency or intermittent ability to perform occupation tasks. The Veteran was most recently afforded a VA examination in November 2011. The examiner indicated that the Veteran's claims file had been reviewed in connection with the examination and report. The Veteran was noted to have a diagnosis of PTSD with a GAF score of 60. No other psychiatric disorder was diagnosed. The examiner opined that the Veteran had occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. The Veteran's family history was noted and he indicated that he had current no friends, but an occasional girlfriend. There were no suicide attempts noted and no issues with alcohol or substance abuse, but the Veteran was indicated to have a history of violence and assaultiveness. The Veteran advised that he has not worked since 1995, when he began receiving SSA disability. The examiner noted the Veteran's psychiatric history, including diagnoses and treatment for PSTD and depressive disorder. A GAF score of 40 was assigned in March 2004. The Veteran's PTSD symptoms included recurrent and distressing recollections and dreams, including physiological reactions, avoidance of thoughts, feelings, conversations, and activities, detachment from others, sleep disturbance, irritability and ager, hypervigilance, and exaggerated startle response. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The examiner described the Veteran's symptoms as mild to moderate in nature. In this regard, the examiner stated that the Veteran's subjective complaints during the examination appeared to be out of proportion to the objective examination findings. A review of the Veteran's Vet Center and outpatient treatment records indicates continued treatment for PTSD and depression. Overall, he has been assigned GAF scores ranging from 40 to 60, with most scores in the 50-55 range. The Veteran's records indicate that his symptoms have been worse than those reported on the VA examinations. Treatment records indicate continued PTSD symptoms, particularly at night, and continued nightmares. He indicated on a number of occasions that he does not want to go to sleep, because of nightmares. Treatment records also note isolation, irritability, heightened startle reflex, avoidance of news, and depressed symptoms. Some treatment records indicate that the Veteran's PTSD was found to be severe to disabling, and others indicated that the Veteran had become increasingly non-functional, so that he could no longer keep his occupational licenses or keep a job. In an April 2010 VA treatment record, the Veteran indicated that his estrangement from his daughter is due to her drinking. He also attributed a lot of his low mood to worsening, chronic pain in his left elbow and right hand. In this case, the Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran's disability in his favor. The Board concludes, however, that the symptoms and manifestations of his PTSD as shown during the numerous VA examinations and the course of outpatient treatment, as well as based on statements by the Veteran do not demonstrate a degree of disability that warrants assignment of a rating greater than 50 percent at any point during the appeal period. See 38 C.F.R. § 4.7 (2012). Furthermore, the symptoms and manifestations shown throughout the Veteran's treatment are generally consistent throughout the pendency of the applicable appellate time period. For this reason, further staged ratings are not applicable. See Fenderson, 12 Vet. App. at 119. Initially, the Board acknowledges the assigned GAF scores during this period range from 40 to 60, which suggests up to a serious impairment of functioning. That said, 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 rating is to be based on all the evidence that bears on occupational and social impairment. 38 C.F.R. § 4.126 (2012); VAOPGCPREC 10-95 (1995); 60 Fed. Reg. 43186 (1995). In this case, the Veteran's manifestations included anxiety, depression, flashbacks, nightmares, intrusive memories, avoidance, sleep impairment, irritability, anger outbursts, concentration problems, hypervigilance, startle response, panic attacks, lack of motivation, loss of interest, and some memory problems. However, the Veteran did not exhibit suicidal ideation, display obsessional rituals which interfere with routine activities, spatial disorientation, exhibit illogical, obscure, or irrelevant speech, exhibit neglect for personal appearance or hygiene, or near continuous panic attacks. The Board acknowledges that the Veteran's reported signs and symptoms included some panic attacks, occasional suicidal ideation, and depression and that he tends to stay at home due to his symptoms. The Board notes, however, that the Veteran's symptoms otherwise did not prevent him from functioning independently or, as will be discussed in greater detail below, otherwise result in occupational and social impairment with deficiencies in most areas during the timeframe on appeal. In addition, and as instructed by the January 2013 JMR, the Board has considered the Veteran's report of severe symptoms in relation to his occupational and social impairment due to his PTSD. The Board acknowledges the Veteran's competency to report his symptoms, but concludes that the medical evidence of record during the appellate time period that universally finds the Veteran to experience moderate symptoms related to his PTSD of significantly greater probative value. Additionally, there is evidence showing that the Veteran has exaggerated his symptoms upon examination. The Board notes that when considering the Veteran's overall level of social and occupational impairment, the medical professionals have a presumed greater level of training and expertise in evaluating the severity of PTSD symptoms. See Sklar v. Brown, 5 Vet. App. 140 (1993). Moreover, even if the Board were to concede that the Veteran's PTSD symptoms are sometimes severely disabling, there is no evidence to indicate that such problems adversely affected his social and occupational functioning to a significant degree as to warrant a higher evaluation. As noted above, the Board acknowledges that a Veteran need not demonstrate the presence of all, most, or even some, of the symptoms listed as examples in the rating criteria. See Mauerhan, 16 Vet. App. at 442; however, as the Court held in Mauerhan, without the examples noted in the rating criteria differentiating a 50 percent rating from a 70 percent rating, evaluation of the psychiatric disability for rating purposes would be extremely ambiguous. The Board is to consider all symptoms of a Veteran's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. If the evidence demonstrates that a Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the Diagnostic Code, the appropriate equivalent rating should be assigned. Id. In this case, however, the Board concludes that the Veteran's PTSD symptoms did not cause occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, as contemplated by a 70 percent rating. Nor did the Veteran exhibit total occupational and social impairment as contemplated for a 100 percent rating. With respect to the Veteran's occupational functioning and impairment, the Board observes the Veteran most recently worked part-time repairing pumps. It is well-documented that the Veteran's well business became unprofitable and he had to quit this job. Although the Veteran reported that his psychiatric symptoms prevented him from pursuing other employment opportunities and seriously affected his ability to perform his most recent job, the record clearly demonstrates that the Veteran performed at least at the minimally acceptable standard for retaining his most recent employment. Moreover, the evidence of record shows the Veteran's reports of trying to find employment, but because of his lack of success, he quit trying. Thus, the Veteran's PTSD did not result in marked or substantial occupational impairment during the timeframe on appeal. As such, although the Veteran may have some level of occupational impairment due to his PTSD symptoms, the Board finds that based on the Veteran's work history he did not have deficiencies in work functioning as contemplated for a 70 percent rating or total occupational impairment as contemplated for a 100 percent rating. In this regard, the Board notes that the 50 percent rating assigned is recognition of significant industrial impairment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). As to the Veteran's social functioning and impairment, the Board recognizes that the Veteran has self-limited his social activities due to his psychiatric symptoms. Moreover, he has had 6 failed marital relationships and does not have a current relationship with his only daughter. That being said, the Veteran has admitted that he does not have a relationship with his daughter because of her drinking problem, and not because of his PTSD symptoms. The Veteran has described difficulty participating in romantic relationships, because once they become stressful, he cannot handle it. There is some indication that during the timeframe on appeal, the Veteran has been actively dating. Although the Veteran has certainly experienced problems due to his PTSD symptoms, such problems are contemplated in the current 50 percent rating. Moreover, while he may have limited his social interaction and had a relatively few number of friends, the record demonstrates that the Veteran did have two friends and was able to somewhat function in a public setting. As such, although the Veteran may have significant social impairment due to his PTSD symptoms, the Board finds that based on the lay and medical evidence of record he did not have deficiencies in social functioning as contemplated for a 70 percent rating or total social impairment as contemplated for a 100 percent rating. In summary, during the entire timeframe on appeal, Veteran did not have the degree of deficiencies in social or occupational functioning as contemplated for a 70 percent rating or total social and occupational impairment as contemplated for a 100 percent rating. He certainly did have deficiencies in these areas, but the greater weight of evidence demonstrates that it was to a degree no more than contemplated by the 50 percent rating currently assigned. Furthermore, even resolving any reasonable doubt in the Veteran's favor, the Board finds that he did not meet the requirements for an evaluation greater than the current 50 percent schedular rating. Although the Veteran had some of the criteria for a 70 percent rating, see Mauerhan, 16 Vet. App. at 442, the Board concludes his overall level of disability did not exceed his current 50 percent rating. Some of the GAF scores, in this case, could support a higher rating if taken alone. However, the actual reported symptoms and manifestations repeatedly noted in the record were commensurate with the degree of social and industrial impairment required for the assignment of the current 50 percent disability evaluation. The Veteran's speech was not illogical, obscure or irrelevant. He was not in a near-continuous state of panic or disorientation. He did not experience hallucinations. He did exhibit some concentration and memory problems, but his thought processes and communication were overall logical and coherent. He did not exhibit inappropriate behavior and his personal hygiene was appropriate. He had some social impairment, but he did have a few friends. Although his socializing was self-limited, it is clear from the evidence of record that he did maintain a social relationship with a few individuals in a social setting. Again, in determining that a rating in excess of 50 percent is not warranted, the Board has considered the Veteran's complaints regardless of whether they are listed in the rating criteria, but concludes that the Veteran's level of social and occupational impairment does not warrant a rating in excess of the currently assigned 50 percent rating at any time during the appeal period. The Board has considered the Veteran's claim and the lay and medical evidence, but concludes the preponderance of the evidence is against granting a higher rating for PTSD, and thus, the benefit-of-the-doubt rule does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Extraschedular Considerations The Board also has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1) (2012). An exceptional case is said to include such factors as marked interference with employment or frequent periods of hospitalization as to render impracticable the application of the regular schedular standards. See Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD disability with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. Specifically, the Veteran primarily reports anxiety, depression, flashbacks, nightmares, intrusive memories, avoidance, sleep impairment, irritability, anger outbursts, concentration problems, hypervigilance, startle response, obsessive thoughts, and some short- and long-term memory problems. As discussed above, the current 50 percent rating is adequate to fully compensate for these symptoms and are contemplated by the rating criteria. In short, the rating criteria reasonably describe the Veteran's disability level and symptomatology. The Board, therefore, has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER An initial rating in excess of 50 percent for PTSD is denied. REMAND In the Board's July 2012 remand, the issue of entitlement to a TDIU was remanded for further development. Namely, a request to initiate and develop a TDIU claim pursuant to Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Since the July 2012 remand, there has been no action taken with respect to the Veteran's TDIU claim. As noted before, the Veteran's treatment records indicate that the Veteran is unemployed, and has been on Social Security Administration disability due, in part, to his service-connected disability. The VA examination reports do not show that the Veteran has severe occupational impairment. Some treatment records indicate that his PTSD is severe to disabling, and others indicated that the Veteran had become increasingly non-functional, so that he could no longer keep his occupational licenses or keep a job. The Veteran was denied Vocational Rehabilitation because it is not feasible for him to benefit from a program designed to return him to gainful employment. The Board found that the evidence of record has reasonably raised the issue of entitlement to a TDIU. As not action has been taken yet with respect to the TDIU claim, it must again be remanded for the requested development from the July 2012 remand. Accordingly, the case is REMANDED for the following action: 1. The RO or the AMC should provide all required notice in response to the Veteran's most recent claim of entitlement to a TDIU. 2. The RO or the AMC should undertake appropriate development to obtain a copy of any outstanding records pertinent to the Veteran's claims. 3. The RO or the AMC should also undertake any other development it determines to be warranted. 4. When the development requested has been completed, the case should again be reviewed by the RO or the AMC, to include expressly addressing whether the Veteran is entitled to a TDIU rating, to include consideration of whether the Veteran's claim should be submitted to the Director of Compensation and Pension Service pursuant to the provisions of 38 C.F.R. § 3.321(b) for consideration of whether an extraschedular rating is warranted. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case, and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the Veteran until he is otherwise notified but he 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). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs