Citation Nr: 1320311 Decision Date: 06/24/13 Archive Date: 07/02/13 DOCKET NO. 08-09 226 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L.M. Yasui, Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from January 1964 to February 1967, to include in-country service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In a June 2012 decision, the Board increased the disability rating for PTSD to 50 percent, but denied an evaluation in excess of 50 percent. The Veteran appealed this matter to the Court. VA's General Counsel and the Veteran, through his attorney, filed a Joint Motion for Partial Remand (JMR) regarding the PTSD issue listed above. By Order dated in February 2013, the Court granted the JMR, and the portion of the decision that denied entitlement to an initial rating in excess of 50 percent for PTSD was remanded to the Board for action consistent with the JMR. In evaluating this case, the Board has not only reviewed the Veteran's physical claims file, but has also reviewed the Veteran's file on the "Virtual VA" system to ensure a complete assessment of the evidence. In a May 2013 statement, the Veteran's attorney raised the issue of entitlement to service connection for ischemic heart disease. That claim was not been adjudicated and it is referred to the RO for the appropriate action. The May 2013 statement of the Veteran's attorney contains additional argument with regard to the increased rating claim, with attached duplicate copies of the JMR and the April 2013 VA Form 21-22a, Appointment of Individual as Claimant's Representative. No new or pertinent evidence was submitted with that statement and there is no requirement for waiver of initial RO consideration of this statement with attachments. See 38 C.F.R. § 20.1304. Please note 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). The issue of 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. For the entire initial rating period under appeal, the Veteran's PTSD has been manifested by symptomatology more nearly approximating occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood, and difficulty in establishing and maintaining effective social relationships. 2. For the entire initial rating period under appeal, the Veteran's PTSD has been not been manifested by symptomatology more nearly approximating 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; spatial disorientation; neglect of personal appearance and hygiene; and inability to establish and maintain effective relationships. CONCLUSION OF LAW For the entire initial rating period, the criteria for an initial rating in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.125, 4.126(a), 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 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(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative of any information, and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to initial adjudication. July 2004 and March 2006 letters explained the evidence necessary to substantiate the claim, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. The March 2006 notice letter also informed the Veteran as to how disability ratings and effective dates are assigned. Concerning the appeal for a higher initial rating, because it is an appeal that arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for PTSD, no additional notice is required. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Court have held that, once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App.112 (2007). With regard to the duty to assist, VA has obtained the Veteran's VA and private treatment records, and Social Security Administration (SSA) records to assist with the claims. The Board notes that the Veteran's service treatment records are missing from the claims file. In April 2006, VA issued a formal finding of unavailability, indicating that the service treatment records could not be located and that any further attempts to locate them would be futile. As a result, the Board has heightened obligation to consider carefully the benefit of the doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365 (1991). The Board will not simply deny the Veteran's claim because the service treatment records are missing, but will decide these claims based on the totality of the evidence, to include the credibility of the Veteran's statements. The case law does not lower the legal standard for proving a claim for service connection, but rather increases the Board's obligation to evaluate and discuss in its decision all the evidence that may be favorable to the Veteran. Russo v. Brown, 9 Vet. App. 46 (1996). In August 2007 and May 2011, respectively, VA provided the Veteran with VA psychiatric examinations to determine the severity of the Veteran's PTSD. The Board notes that the August 2007 VA examiner did not review the claims file; however, the August 2007 VA psychiatric examination report will only be utilized in this decision as evidence of the Veteran's contemporaneous PTSD symptomatology. In addition, the Board notes that the Veteran was capable of informing the August 2007 VA examiner of his psychiatric history and current PTSD symptomatology, in fact did so, and that such history was specifically noted in the VA examination report. See, e.g., Kowalski v. Nicholson, 19 Vet. App. 171 (2005) (holding that VA cannot reject a medical opinion simply because it is based on a history supplied by a veteran, but the strength of the opinion depends rather upon the accuracy of the facts asserted by the veteran). As the Veteran was capable of supplying the information regarding his current PTSD symptomatology, the August 2007 VA examiner's failure to review the claims file does not render the August 2007 VA medical examination report inadequate on the relevant question of the current level of PTSD disability symptomatology, specifically including the psychiatric symptomatology and GAF scores noted at that examination, which are valid measures independent of any history. See VAOPGCPREC 20-95 (stating that the determination as to whether review of prior medical records is necessary in a particular case depends largely upon the scope of the examination and the nature of the findings and conclusions the examiner is requested to provide). The Board notes that the May 2011 VA examiner also did not have a copy of the claims file to review prior to providing the May 2011 VA psychiatric examination report; however, the May 2011 VA examiner later provided a June 2011 addendum to the May 2011 VA psychiatric examination report after a review of the claims file. As the respective VA psychiatric examination reports and addendum were written after interviews with the Veteran and contain specific findings regarding the extent of the Veteran's psychiatric disability at the times of the examinations, the examinations are adequate for VA purposes, and there is no duty to provide an additional examination or medical opinion regarding the claim of a higher initial rating for PTSD. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). As such, VA has provided assistance to the Veteran as required under 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c), as indicated under the facts and circumstances in this case. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal. Mayfield, 444 F.3d at 1328. Hence, no further notice or assistance is required to fulfill VA's duty to assist the Veteran in the development of the claim. Disability Rating Criteria Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as staged ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). In Hart v. Mansfield, 21 Vet. App. 505, 511 (2007), the Court extended entitlement to staged ratings to claims for increased disability ratings where "the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings." VA is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. See Mittleider, 11 Vet. App. at 181. PTSD is evaluated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula for Mental Disorders, a 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of 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. 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 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. 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; difficulty in establishing effective work and social relationships. The Court has held that Global Assessment of Functioning (GAF) scores are 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); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.) (DSM-IV), p. 32). GAF scores ranging between 61 to 70 reflect 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 has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect 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). Id. The Court in Mauerhan v. Principi, stated that "when evaluating mental health disorders, the factors listed in the rating criteria are simply examples of the type and degree of symptoms, or their effects, that would justify a particular rating; analysis should not be limited solely to whether a Veteran exhibited the symptoms listed in the rating scheme. Rather, the determination should be based on all of a Veteran's symptoms affecting his level of occupational and social impairment." See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive. Id. In rendering a decision on appeal, the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno, 6 Vet. App. 465. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Initial Rating Analysis for PTSD For the entire initial rating period under appeal, the Veteran essentially contends that his PTSD has caused greater symptomatology than that contemplated by the 50 percent rating currently assigned under 38 C.F.R. § 4.130, Diagnostic Code 9411. Specifically, the Veteran indicates that his PTSD has caused constant feelings of discouragement, depression, and anger, resulting in difficulty in establishing and maintaining effective social relationships. After a review of the evidence of record, lay and medical, the Board finds that, for the entire initial rating period under appeal, the Veteran's PTSD has been manifested by symptomatology more nearly approximating occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships, consistent with a 50 percent rating under Diagnostic Code 9411, and that an initial rating in excess of 50 percent is not warranted. 38 C.F.R. § 4.130. In a May 2004 VA nursing assessment treatment record, the Veteran reported having a history of problems with relationships. The Veteran indicated that he had been married eight times. The Veteran stated that he had a short temper and could assault others if provoked. The Veteran admitted feelings of depression and stated that he was seeking treatment for his depression. In an October 2004 VA treatment record, a VA examiner noted that the Veteran appeared noticeably angry and agitated upon reporting to the VA hospital. When asked why he was upset, the Veteran stated that he did not want to see a "foreign doctor." Upon examination that same day, as noted in an additional October 2004 VA treatment record, the Veteran stated that the antidepressants he had been prescribed were having beneficial effects. The VA examiner noted that the Veteran's mood was discouraged, but not without hope. In a February 2005 VA treatment record, the VA examiner noted that the Veteran's mood was grumpy and discouraged, but not without hope. The Veteran's appearance and affect were noted to be appropriate in the situation. In a September 2005 VA treatment record, the Veteran reported being demoralized with the VA bureaucracy as the original file regarding his claims for service connection had been lost. The VA examiner noted that the Veteran was discouraged, grumpy, and frustrated, but not hostile. The VA examiner indicated that the Veteran's affect was appropriate to the situation. In a December 2006 VA treatment record, the Veteran reported that the antidepressants he had been prescribed were no longer helping him so he had stopped taking them. The Veteran stated that he had depression, anxiety, insomnia, and nightmares related to service in Vietnam. The VA mental health professional prescribed different medications for the Veteran's PTSD. At that time, the VA mental health professional assigned a GAF score of 35 for the Veteran's psychological profile. In an August 2007 VA psychiatric examination report, the Veteran reported experiencing continuous problems with his temper. The Veteran indicated that he fidgeted and would easily get into fights. The Veteran indicated that such fights were not violent, suggesting that they were verbal confrontations. The Veteran stated that he was depressed because he was emotionally disordered and that he felt as if he could not get ahead. The Veteran reported having few leisure pursuits. The VA examiner noted that the Veteran had feelings of detachment and estrangement from others. The VA examiner also noted moderate depression with anxiety or depressed mood. He indicated severe impairment in the Veteran's impulse control. The VA examiner assigned a GAF score of 60 for the Veteran's psychological profile. He also stated that the Veteran's PTSD was manifested by reduced reliability in productivity and that the PTSD required continuous medication. In a May 2011 VA psychiatric examination report, the VA examiner noted that the Veteran's affect was appropriate to the content of the discussion in both intensity and direction. The Veteran reported being married either eight or nine times, and that his most recent divorce occurred five or six years prior to the interview. The Veteran stated that his wife could not handle his "dreams and stuff." The Veteran stated that his daughter was "here" with her two children. The Veteran also indicated that he saw his daughter and her children one to two times per month, and that he enjoyed spending time with his grandchildren. He indicated that the only leisure activity he enjoyed was cutting metal designs with a plasma cutter. The Veteran reported that he had a "short fuse," and would yell a lot, but had not fought anyone in 10 years. He stated that his memory was getting bad, as he would forget why he went outside or conversations he had just had with his daughter. The Veteran rated his depression symptomatology as a six on a scale of 10. The VA examiner noted no impaired impulse control on the part of the Veteran. The Veteran reported some hallucinations, such as flashes of "stuff" coming around him when nothing was really there. He also indicated being frightened by planes and helicopters and reported chronic sleep impairment. The VA examiner stated that the Veteran's symptoms caused significant distress or impairment in social, occupational, or other important areas of functioning. The VA examiner also noted depressed daily moods, diminished interest and pleasure in activities, insomnia, and fatigue/loss of energy related to the Veteran's PTSD. The VA examiner reported irritability or outbursts of anger and, despite the comments made in his report, that the Veteran displayed a restricted range of affect. The VA examiner assigned a GAF score of 55 for the Veteran's psychological profile. In a June 2011 addendum to the May 2011 VA psychiatric examination report, the May 2011 VA examiner stated that the Veteran experienced occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The May 2011 VA examiner reported seeing no evidence that the Veteran's psychological symptomatology had improved or deteriorated over the initial rating period. The VA examiner stated that the Veteran did not appear motivated to improve through treatment and that he doubted that the Veteran had complied with treatment. In weighing this evidence, the Board finds that for the entire initial rating period under appeal, the Veteran's PTSD has been manifested by disturbances of motivation and mood, and difficulty in establishing and maintaining effective social relationships, which more closely approximates a 50 percent disabling rating. The Veteran's PTSD has been noted to be uniformly manifested in symptoms of depression, discouragement, and anger for the entire rating period under appeal. Moreover, the Veteran's PTSD has resulted in difficulties in establishing social relationships due to feelings of estrangement and detachment from others, as noted in the August 2007 VA psychiatric examination report. In the May 2011 VA psychiatric examination report, the examiner indicated that the Veteran's PTSD was manifested by significant impairment in social functioning. The evidence suggests that he does not have any friends and had been divorced many times, partly as a result of symptoms related to his PTSD. The May 2011 VA psychiatric examination report also indicated that the Veteran had a restricted range of related to his PTSD. The Board notes that a December 2006 VA staff psychiatrist assigned a GAF score of 35 for the Veteran's psychological profile, suggesting a more severe disability picture. Subsequently, however, in the August 2007 VA psychiatric examination report, the August 2007 VA psychiatric examiner assigned a GAF score of 60 for the Veteran's psychological profile. Thereafter, in a May 2011 VA psychiatric examination report, the May 2011 VA examiner assigned a GAF score of 55. As noted above, a GAF score must be considered in light of the actual symptoms of a veteran's disorder, which provide the primary basis for the rating assigned. A GAF from 51 to 60 is defined as moderate symptoms or moderate difficulty in social, occupational, or school functioning. By contrast, a GAF Scale score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or a 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). The GAF score of 35, assigned by a VA staff psychiatrist in December 2006, is the lowest GAF score assigned during the initial rating period. Significantly, the December 2006 VA treatment record is brief, consisting of only a single written paragraph of text with notes regarding medications. The December 2006 VA staff psychiatrist did not indicate that he met with the Veteran to determine the full severity of the Veteran's psychological symptomatology, but instead indicated that he was contacted to assist the Veteran in changing his medication. The December 2006 VA staff psychiatrist did not report meeting with the Veteran at length and did not diagnose any particular symptoms during the meeting. In contrast, the August 2007 and May 2011 VA examiners reported meeting with the Veteran, discussing his symptomatology at length, and writing complete profiles of the Veteran's psychological symptomatology based on their interviews. Therefore, considering the more thorough and comprehensive nature of the August 2007 and May 2011 VA examination reports, which both include references to the symptoms related to the Veteran's PTSD, the Board finds the GAF scores reported in the August 2007 and May 2011 VA psychiatric examination reports are more probative in their indications of the severity of the Veteran's PTSD. In this regard, the GAF scores of 60 and 55 are consistent with the criteria for a 50 percent rating. The Veteran has reported disturbances of mood, specifically symptoms of depression, and anger, and a noted lack of motivation, throughout the initial rating period, resulting in difficulty establishing and maintaining effective social relationships. He has indicated that he experienced great difficulty in establishing relationships with either partners or friends, as noted by his many divorces, and only appears to have a strong relationship with his daughter and grandchildren. In addition, in the August 2007 VA psychiatric examination report, the August 2007 VA examiner indicated that the Veteran's PTSD symptomatology more nearly approximated reduced reliability in productivity, which meets the criteria for a 50 percent rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. Of note, the May 2011 VA examiner also reported seeing no evidence that the Veteran's status had improved or deteriorated over the initial rating period. Therefore, the May 2011 VA examiner found that the Veteran's PTSD symptomatology had not changed since the August 2007 VA examiner indicated that it more nearly approximated the criteria for a 50 percent rating under Diagnostic Code 9411. As such, the Board finds that the Veteran's PTSD symptomatology more nearly approximates the criteria required for a 50 percent rating under Diagnostic Code 9411. 38 C.F.R. §§ 4.3, 4.7. The weight of the evidence demonstrates that the criteria for an initial rating in excess of 50 percent for the Veteran's service-connected PTSD have not been met for the entire initial rating period under appeal. Specifically, during the appeal period, the Veteran's PTSD has not been manifested by symptomatology more nearly approximating 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; spatial disorientation; neglect of personal appearance and hygiene); or an inability to establish and maintain effective relationships, as required for a next higher 70 percent disability rating under Diagnostic Code 9411. 38 C.F.R. § 4.130. In reviewing the criteria for the next higher 70 percent rating and determining whether an evaluation in excess of 50 percent is warranted, the Board notes that the Veteran exhibited impaired impulse control related to his PTSD during the initial rating period, as stated in the August 2007 VA psychiatric examination report. Impaired impulse control is one criterion listed for a next higher 70 percent rating under Diagnostic Code 9411. Id. However, on VA examination in May 2011, the examiner indicated that there was no impairment of impulse control. The Board notes that the Veteran has near-continuous depression symptomatology; however, this disorder has not been shown to affect the Veteran's ability to function independently, appropriately and effectively. Throughout the entire rating period under appeal, the Veteran was able to care for himself despite his depression. The Veteran also specifically denied experiencing suicidal ideation. The record also contains no report of obsessional rituals which interfered with routine activities; speech intermittently illogical, obscure, or irrelevant; spatial disorientation; or neglect of personal appearance and hygiene. Although the Veteran has difficulty in his social relationships due to his PTSD, the evidence indicates that he is able to maintain a relationship with his daughter and grandchildren; therefore, the evidence weighs against a finding that the Veteran's PTSD is manifested by an inability maintain effective relationships. Based on the above, the Board finds that the Veteran's symptomatology does not more approximately meet the criteria for the next higher 70 percent rating for PTSD under Diagnostic Code 9411 for any period. 38 C.F.R. §§ 4.3, 4.7. After careful review of the evidence of record, lay and medical, the Board does not find evidence that the 50 percent rating assigned should be increased for any other separate period based on the facts found during the appeal period. As such, an initial evaluation in excess of 50 percent disabling for PTSD is not warranted. See Fenderson, 12 Vet. App. at 119; Hart, 21 Vet. App. at 509. Hence, the claim for an initial rating in excess of 50 percent disabling for PTSD must be denied. The evidence in this case is not so evenly balanced as to allow application of the benefit-of-the-doubt rule. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). Extraschedular Considerations The Board has considered whether referral for extraschedular consideration is warranted. 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. 38 C.F.R. § 3.321(b)(1) (2012); 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 claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the VA Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether the Veteran's disability picture requires the assignment of an extraschedular rating. The Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria (General Rating Formula for Mental Disorders at 38 C.F.R. § 4.130), and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provide for disability ratings based on a combination of history, symptoms, and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has been manifested restricted effect, feelings of discouragement, depression, anger, a number of divorces with the ability to maintain a relationship with his daughter and grandchildren, indicting such symptoms as flattened affect; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. The GAF scores in the DSM-IV are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Moreover, all the Veteran's PTSD symptomatology is contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155 (2012). "Generally, the degrees of disability specified [in the rating schedule] are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability." 38 C.F.R. § 4.1 (2012). In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with PTSD, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial disability rating in excess of 50 percent for PTSD is denied. REMAND VA regulations provide that where the Veteran is unemployable by reason of service-connected disabilities and fails to meet the percentage standards under 38 C.F.R. § 4.16(a), the case must be submitted to the Director of Compensation and Pension Service for extraschedular consideration. See 38 C.F.R. § 4.16(b) (2012); Barringer v. Peake, 22 Vet. App. 242 (2008); see also Rice v. Shinseki, 22 Vet. App. 447 (2009) (Since the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the Veteran or is reasonably raised by the evidence of record.). The Veteran does not meet the percentage standards under 38 C.F.R. § 4.16(a). In light of the evidence of record regarding the effect of his service-connected disabilities, particularly his PTSD, on his employment during the applicable time period, and directly addressing the arguments made by the parties of the JMR, the Board finds that the issue of entitlement to a TDIU under 38 C.F.R. § 4.16(b) should be referred to the Director of the Compensation and Pension Service for appropriate development. In this regard, the Veteran stated in the May 2007 notice of disagreement that he was unable to hold a job for more than a year after Vietnam due to his PTSD. The record also reflects that the Veteran is in receipt of SSA benefits. Remand of the claim for a TDIU is also warranted for additional medical inquiry. The VA examination reports of record do not adequately address whether the Veteran's service-connected disabilities, alone, render him unemployable under VA guidelines. See 38 C.F.R. §§ 3.321, 4.16 (2012). Accordingly, the issue of a TDIU is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Issue the appropriate VCAA notice regarding the issue entitlement to a TDIU. 2. Request that a VA health care provider review the claims file and provide a medical opinion. The claims file, including a copy of this Remand, must be made available to, and be reviewed by, the examiner. The examiner should note such review in the examination report (another examination of the Veteran is not required). If the examiner determines that an additional examination of the Veteran is necessary to provide a reliable opinion as to the service-connected disabilities' impact on employability, such examination should be scheduled. However, the Veteran should not be required to report for another examination as a matter of course, if it is not found to be necessary. The examiner should offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's service-connected disabilities, either individually or in concert, render him unable to secure and following a substantially gainful occupation? The opinion should consider the Veteran's education, special training, and previous work experience, but should not consider his age or the effect of any non-service-connected disorders. The service-connected disabilities are PTSD, tinnitus, and bilateral hearing loss. The term "at least as likely as not" does not mean merely within the realm of possibility, but that the evidence for and against a conclusion is so evenly divided that it is as sound to find in favor of causation as it is to find against it. A rationale should be given for all opinions and conclusions rendered. The opinion should address the particulars of this Veteran's medical history and the relevant medical science as applicable to this claim. If an opinion cannot be rendered without resorting to speculation, the examiner should state whether the inability to provide an opinion was due to a need for further information (with said needed information identified) or because the limits of medical knowledge had been exhausted regarding the etiology of the disorder. 3. Refer the TDIU issue to the VA Under Secretary for Benefits or the VA Director of the Compensation and Pension Service for adjudication of entitlement to a TDIU under 38 C.F.R. § 4.16(b). 4. After completion of the above and any additional development deemed necessary, entitlement to a TDIU under 38 C.F.R. § 4.16(b) should be adjudicated in light of all the evidence of record. If the benefit sought on appeal is not granted, the Veteran and his representative should be provided with a supplemental statement of the case and afforded the appropriate time period within which to respond thereto. The Veteran has the right to submit additional evidence and argument on the matter 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). ______________________________________________ K.J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs