Citation Nr: 1323148 Decision Date: 07/19/13 Archive Date: 07/24/13 DOCKET NO. 98-18 522 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to a rating higher than 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Sean A. Ravin, Attorney-at-law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The Veteran served on active duty from September 1942 to October 1944. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 1998 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2000, a Board hearing was held before a Veterans Law Judge who is no longer with the Board; a transcript of that hearing is included in the claims file. [The claims file was reassigned to the undersigned Veterans Law Judge, and the Veteran was offered the opportunity to testify at a new hearing, yet he declined the offer in an August 2012 statement.] In June 2007, the Board denied the claim for a higher initial rating for PTSD. In November 2008, the Court vacated the June 2007 Board decision and remanded the matter for readjudication consistent with its decision. In May 2009, the Board remanded the matter pursuant to the Court's decision for further development. 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 entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. The Veteran's PTSD has not resulted in sever impairment of the ability to establish and maintain effective or favorable relationships with people; the psychoneurotic symptoms have not been of such severity and persistence to result in severe impairment in the ability to obtain or retain employment. 2. Since November 7, 1996, the Veteran's PTSD has not been manifested by 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 work like setting); inability to establish and maintain effective relationships; or symptoms of similar severity. CONCLUSION OF LAW The criteria for entitlement to a disability evaluation in excess of 50 percent for the Veteran's service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.130, Diagnostic Code 9411 (1996); Diagnostic Code 9411 (2012) REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Notify Upon receipt of a complete or substantially complete application, 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. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) Veteran status; 2) existence of a disability; (3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the appellant with notice in August 2005, subsequent to the initial adjudication. VCAA had not been enacted when the Veteran filed his claim. While the notice was not provided prior to the initial adjudication, the claimant has had the opportunity to submit additional argument and evidence, and to participate meaningfully in the adjudication process. The claim was subsequently readjudicated in numerous supplemental statements of the case, most recently in May 2012, following the provision of notice. The appellant has not alleged any prejudice as a result of the untimely notification, nor has any been shown. As the rating decision on appeal granted service connection and assigned a disability rating and effective date for the award for PTSD, statutory notice had served its purpose, and its application was no longer required. See Dingess, supra, aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). An October 1998 statement of the case (SOC) provided notice on the "downstream" issue of entitlement to an increased rating; while a May 2012 supplemental SOC (SSOC) readjudicated the matter after the appellant and his representative responded and further development was completed. 38 U.S.C.A. § 7105. The Veteran has had ample opportunity to respond/supplement the record. He has not alleged that notice in this case was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (holding that "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 the downstream issues"). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (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, supra. Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Assist VA has obtained service treatment records; assisted the appellant in obtaining evidence; afforded the Veteran VA examinations in February 1994, February 1998, November 2001, January 2002, March 2002, January 2006, March 2010 (with June 2011 addendum), and April 2012; obtained medical opinions as to the etiology and severity of disabilities; and afforded the appellant the opportunity to give testimony before the Board. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (VA must provide an examination that is adequate for rating purposes). All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file, and the appellant has not contended otherwise. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. B. Legal Criteria, Factual Background, and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file (including via Virtual VA), 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. See Gonzales v. West, 218 F, 3d, 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the evidence as appropriate, and the Board's analysis will focus on what the evidence shows, or fails to show, as to the claim. Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. 38 C.F.R. § 4.7. Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected PTSD has been rated by the RO under the provisions of Diagnostic Code 9411. Under the rating schedule in effect prior to November 7, 1996, a 50 percent evaluation is warranted under the General Rating Formula for Psychoneurotic Disorders when the evidence demonstrates that the ability to establish or maintain effective or favorable relationships with people is considerably impaired. By reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels must be so reduced as to result in considerable industrial impairment. A 70 percent evaluation under the same rating schedule is warranted when the evidence demonstrates that the ability to establish and maintain effective or favorable relationships with people was severely impaired. The psychoneurotic symptoms must have been of such severity and persistence that there was severe impairment in the ability to obtain or retain employment. Under the current regulatory provision in effect since November 7, 1996, a 50 percent rating is warranted if the Veteran experiences 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. A 70 percent rating is warranted if the Veteran experiences occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of closest relatives, own occupation, or own name. The Veteran has been assigned various Global Assessment of Functioning (GAF) scores for his PTSD. 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). Scores ranging from 31 to 40 reflect 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; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. Lesser scores reflect increasing severe levels of mental impairment. See 38 C.F.R. § 4.130 [incorporating by reference VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes]. The Board recognizes that the Court in Mauerhan v. Principi, 16 Vet. App. 436 (2002), stated that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). On February 1994 VA examination, the Veteran reported that he had been taking medication for anxiety. It was noted that a July 1993 impression included mild PTSD and dysthymia. The examiner noted nothing unusual about the Veteran's behavior except he was a bit on the underactive side. He reported trouble sleeping and being extremely nervous. He spent his time gardening and walking; he had never had any hobbies although he did used to fish and hunt. He socialized with a few people and felt close to them, and he reported that crowds bothered him. He did not want his back to the door or window in a restaurant. He reported having nightmares approximately five to six times per year. He reported having hallucinations although only when he was drowsy and falling asleep, which the examiner opined was a hypnogogic phenomena rather than a hallucination; there was no evidence of delusions. The examiner noted PTSD symptoms including avoidance of war movies, fear of water, having flashbacks about once per month, startling at the sound of a gunshot, difficulty making close friends, and intrusive thoughts. On mental status examination, the Veteran was tense and preoccupied. His speech was normal, and his mood included periodical depression. He reported having some crying spells about once per week for the past few years. His thought processes were normal and his memory was fair. His insight was superficial but his judgment was good. There was no evidence of suicidal ideation; there were some homicidal feelings that depended on the circumstances but there had been no attempts. The diagnosis was chronic delayed PTSD. In an October 1997 VA medical opinion letter, Dr. Kelly stated that the Veteran had symptoms indicative of PTSD including intrusive thoughts, nightmares related to combat experiences, hyperarousal (increased startle and social avoidance due to increased anxiety), depressed mood, sleep difficulties, and irritability. Dr. Kelly stated that the Veteran carried a diagnosis of PTSD and he believed the Veteran would be appropriate for full compensation for what he believed is a service connected disorder. He opined that the Veteran's PTSD is chronic in nature. On February 1998 VA examination, the Veteran showed some preoccupation and complained of trouble sleeping, being nervous, flying off the handle, and being bothered by certain television shows. He avoided discussing the war. He spent his time traveling around the country with his wife and one other couple, and he also gardened and took care of his lawn and fished. He socialized very little and had a couple of friends. Crowds bothered him, and he did not want to be cooped up with anybody. He had sleep difficulties and nightmares, the most recent occurring about nine months earlier. He reported sometimes hearing voices when falling asleep, which sounded to the examiner like either hypnogogic phenomena or flashbacks. He may have had some delusional material, but the examiner did not get any gross material. His PTSD symptoms included avoiding war movies, fear of water, and occasional flashbacks. He reported having some guilt feelings and survivor guilt. He had difficulty making close friends. On mental status examination, the Veteran was tense and underactive. His speech was normal. His mood showed some depression that came and went depending on the circumstances. He had crying spells about every six weeks. His thought processes were normal. His memory was fair and he reported some decrease in his memory over the previous 20 years. He was well oriented to time, place, and person and quite alert. There was no evidence of gross delusions or schizophrenic trends. His insight was superficial and his judgment was fair. There was no suicidal ideation, and he did have some homicidal feelings but controlled it without difficulty. The impressions included chronic delayed PTSD and recurrent dysthymia and a GAF score of 45 was assigned. On April 1998 psychological evaluation, the Veteran showed no odd or unusual behaviors or mannerisms. He reported continuing symptoms including nightmares and flashbacks, hostile reactions to Asians, chronic intrusive thoughts, and avoidance of war scenes in the media. Based on his test results, Dr. Moneypenny opined that the Veteran presented with symptoms of delayed onset PTSD, with chronic tension and arousal, and frequent intrusive and disturbing thoughts regarding aspects of his service. He had managed to repress many of his combat memories for many years but had become increasingly aware of them in recent years and was now quite distressed and affected and his range of activities had been substantially limited. An increasing number of stimuli seemed to trigger his memories and thoughts of the disturbing events. At the December 2000 Board hearing, the Veteran testified that he had trouble sleeping because of intrusive thoughts and he avoided war coverage on television. He testified that his PTSD symptoms had increased since he had retired in 1972 [due to physical disability following a motor vehicle accident] and had affected his relationships to other people. He testified that he often took trips with his wife and another couple. In February 2001, the Board remanded the matter for additional development. On November 2001 VA examination, the Veteran reported nightmares occurring two to three times per month and getting less than six hours of sleep per night. He reported intrusive thoughts about the war, but he was less likely to have them if he avoided other veterans or watching television. He was not easily startled by noises. He preferred to be by himself and not in crowds. He went out to restaurants with his wife but preferred to sit with his back to the wall. He reported being close to his wife but had difficulty being short tempered. He spent the majority of his time sitting around but he liked to walk when possible and visiting with some friends. On mental status examination, the Veteran was fully cooperative with minimal eye contact and some anxiety. His speech was within normal limits for rate and rhythm. The predominant mood was of anxiety and his affect was appropriate to content. His thought processes and associations were logical and tight with no loosening of associations or confusion. No gross impairment in memory was observed, and he was oriented in all spheres. He complained of no hallucinations and no delusional material was noted. His insight and judgment were adequate. He denied any suicidal or homicidal ideation. The diagnosis was chronic PTSD and a GAF score of 48 was assigned. On January 2002 VA examination, the Veteran reported that his status was generally about the same as it was on the previous examination. He believed he was doing a little bit worse than he was in 1998 and perhaps than in 1991 and 1993 as well. He felt his nightmares and flashbacks were worse and he found it more upsetting to continue having the symptoms and to hear people talking about the war or asking questions about the war. The impression was chronic PTSD and a GAF score of 48 was assigned. The examiner opined that, in spite of the Veteran's contention that he was doing somewhat worse, he suspected that the GAF rating assigned was a good representation of the Veteran's functioning throughout the decade of the 1990s. The examiner noted that the Veteran did not provide evidence of unemployability based on his PTSD symptomatology. On March 2002 VA examination, the Veteran was noted to have a long history of PTSD, and the examiner opined that there was no question regarding the nature of the PTSD. The Veteran had a long history of nightmares, intrusive thoughts, crying, preference for being alone, and tendency to avoid watching war movies. He was limited in his activity level and his socialization with others. The examiner opined that the symptom picture was rather clear and consistent throughout much of the previous decade. The examiner noted that the Veteran also had a depressive disorder, most likely a major depression, which appeared to be in part secondary to the PTSD. The examiner opined that the Veteran was very frustrated with the nature of his life and limitations imposed by his PTSD. The examiner noted that the Veteran did not provide any evidence that his PTSD precluded his ability to work; the examiner opined that it might make work assignments difficult but id dit not make working impossible. The examiner noted a GAF score of 45-51 assigned upon hospitalization in May 1994 but opined again that the most appropriate GAF rating is 48 based on the extent of the Veteran's depression and his PTSD symptoms. The examiner opined that the PTSD and depression were severe and there was impairment in social functioning, and there would likely be impairment in vocational functioning, although the Veteran was not necessarily unemployable on the basis of either of the two psychiatric conditions. The examiner opined that the GAF rating of 48 was appropriate both for his present functioning and for much of the 1990s. On January 2006 VA examination, the Veteran reported that he loved to spend time with his grandchildren and the family relationship was very warm. He reported having a very harmonious marriage. The examiner noted one psychiatric hospitalization in 1994 when the diagnoses included PTSD and major depression. The Veteran reported that his depressive condition was very frequent, and he frequently cried and felt very sad. On mental status examination, the Veteran was well oriented and had good contact with outside reality. He reported frequent nightmares occurring more than once per week and sleep disturbances of about the same frequency, awakening with heavy sweating and being unable to go back to sleep. He reported frequent crying but did not know why; the examiner opined that this came with the Veteran's personality structure and his emotional reaction had something to do with losing his mother at an early age under tragic circumstances. However, the examiner opined that at least a part of the depression might be part of his PTSD and this was a natural phenomenon often seen together, so the examiner was unable to say the proportion on each side. The diagnoses included PTSD and emotional instability with frequent crying, feeling depressed, and hopelessness lasting a few hours or part of a day. A GAF score of 50 was assigned, and the examiner opined that the current PTSD rating was about appropriate although the Veteran wanted it increased. In a January 2009 VA medical opinion letter, Dr. Kimbrell stated that the Veteran's report of symptoms was consistent with chronic PTSD and he reported worsening clinical status over the last several years. The Veteran scored an 82 on the PTSD checklist, indicating a self-report of severe PTSD symptoms. He contended that he medically retired from police work in 1972 secondary to worsening of chronic PTSD symptoms. From the record, his current history included significant/severe difficulty interacting with others, anxiety in public places, periods of severe depression, nightmares, and intrusive thoughts. He was also noted to have a dementing process that impacted his concentration and memory. Dr. Kimbrell opined that the Veteran had a straightforward diagnosis of PTSD and his current severe symptom report and early inability to not be employed secondary to his severe PTSD indicated that he had been disabled from PTSD to a significant degree. On March 2010 VA examination, the Veteran reported having nightmares at least twice per week and frequent and almost constant intrusive thoughts. He could sometimes get seven hours of sleep per night. He reported getting very uncomfortable at the sound of guns. He would go out to eat but would not have his back to the door. He would go to large stores but did not enjoy doing so because of the crowds. He watched the news but avoided war movies. He reported that it bothered him to see Asian people and had no contact with them. He reported getting along well with his wife of 46 years. He reported that he worked as a policeman until 1972 when he was injured by a vehicle. He enjoyed driving around with his wife, watching television, and listening to the radio, and he had a lot of neighbors with whom he would visit. On mental status examination, the Veteran was fully cooperative and his speech was within normal limits for rate and rhythm. His mood was somewhat dysphoric and his affect was appropriate to content. His thought processes and associations were logical and tight, with no loosening of associations or confusion noted. His memory was grossly intact, he was oriented in all spheres, and no hallucinations or delusions were noted. His insight and judgment were adequate. He denied any suicidal or homicidal ideation. The diagnosis was chronic PTSD and a GAF score of 52 was assigned. The examiner commented that he had seen the Veteran multiple times since 1994. He stated that the Veteran clearly appeared to meet the criteria for a diagnosis of PTSD, and the reports from 1994 suggested that the disorder had been persistent for many years. The examiner noted that the Veteran was given a GAF rating of 55 at his most recent medication management visit in November 2009, when he was also diagnosed with dysthymia and mild cognitive development. The examiner noted that the Veteran underwent neuropsychological testing in the past which was suggestive of cognitive difficulties, although the examiner did not find the cognitive difficulties to be related to the PTSD symptoms. The examiner opined that the etiology of the Veteran's depression was somewhat unclear although he believed it was not specifically related to his PTSD symptoms. The examiner believed the Veteran's PTSD symptoms occurred several days or more per week, were moderate, and had persistent virtually continuously since 1994. The examiner saw no evidence that there would be a marked change in the Veteran's functioning over the next 6 to 12 months. The examiner noted that the GAF ratings had remained relatively unchanged during the period between 1994 and 2010. The examiner found no evidence that the Veteran's PTSD symptoms precluded employment or negatively impacted employment. On examination, the Veteran did not report social isolation and in fact regularly visited with several neighbors, although he gave contradictory information as he initially stated that he did not want to talk to anyone. The examiner found no impairment in thought processing, no communication impairment, and some memory impairment. The examiner found no evidence that the Veteran's PTSD symptoms precluded his activities of daily living. On June 2011 addendum opinion, the March 2010 VA examiner noted that he located treatment records from 1993 that described the Veteran's "mild" symptoms involving primarily some sleep issues and irritability. Overall, the examiner opined that there was evidence of PTSD symptomatology beginning in 1993 and it is more likely than not that those symptoms remained moderate between 1993 and 2011. The examiner noted that the Veteran's GAF scores in the intervening years had remained relatively unchanged and were suggestive of moderate impairment and functioning using the GAF criteria. Because there was little documentation of symptom severity other than the "mild" description, the examiner found it unclear what symptoms led to that description. However, the examiner opined that it appeared the Veteran had moderate difficulty in social, occupational or school functioning with few hobbies and just a few occasional visits with acquaintances. On April 2012 VA examination, the Veteran reported that he had a supportive and pleasant family life, he had friends, and he visited people. He reported that he retired from being a police officer due to injuries sustained when he was rear-ended by another vehicle in the early 1970s; he did not contend that his job came to an end due to the effects of a mental disorder, and in fact he reported receiving multiple awards during his period of employment. He reported having nightmares and intrusive memories of the war and he avoided things that may remind him of it. He was frequently depressed with crying spells. The examiner noted that the Veteran was suffering from a dementing process influencing his short term memory and his executive functioning; he was bright and conversation but tangential. The examiner noted that the records reflect an awareness of developing dementia as far back as 2009. The Veteran reported symptoms [pertaining to all diagnoses] including depressed mood; anxiety; chronic sleep impairment; impairment of short and long term memory, such as retention of only highly learned material, while forgetting to complete tasks; circumstantial, circumlocutory or stereotyped speech; difficulty in understanding complex commands; impaired abstract thinking; and difficulty in establishing and maintaining effective work and social relationships. The examiner opined that the Veteran was not capable of managing his financial affairs due to his developing dementing disorder. The Veteran's diagnoses included PTSD, dysthymia, and dementia not otherwise specified; a GAF score of 48 was assigned. The examiner opined that the Veteran's dysthymia symptoms included depressed mood with insomnia, low energy, poor concentration, and feelings of hopelessness; and his dementia symptoms included multiple cognitive deficits manifested by memory impairment and disturbance in executive functioning. The examiner opined that the Veteran's occupational and social impairment level with regards to all mental diagnoses resulted in occupational and social impairment with reduced reliability and productivity, differentiating the impairment at 33 percent each to the PTSD, dysthymia, and dementia. The examiner opined that the Veteran's dysthymic disorder was partly secondary to his PTSD, but that the dementia was not caused by or a result of service. The examiner further opined that the declining GAF score is mostly a function of the Veteran's [non-service-connected] dementia, and his PTSD did not appear to have worsened appreciably since the last examination. The examiner opined that the Veteran could not be considered unable to secure and maintain gainful employment based on his PTSD alone since he did not lose his last job due to mental health factors but medical injuries; he did not contend that mental health factors played a role in his unemployment. VA and private treatment records through 2012 reflect findings largely similar to those noted above. In addition to the medical evidence, the Veteran has submitted several lay statements regarding the nature of his symptoms, including from himself and his wife. The Board finds all the lay evidence to be both competent and credible. As noted earlier, the rating criteria for PTSD changed effective November 7, 1996. Since the Veteran's claim which gives rise to the present appeal was received prior to that date, the Board will consider whether a higher rating is warranted under the old criteria at anytime during the appeal period, as well as whether a higher rating is warranted under the new criteria from November 7, 1996. It is readily clear that the Veteran has suffered from PTSD during the appeal period. However, after reviewing the entirety of the evidence, the Board is compelled to conclude that the preponderance of the evidence is against a rating in excess of 50 percent under current or the old rating criteria. Under the old rating criteria, there must be a showing of severe impairment in the ability to establish and maintain effective or favorable relationships; the symptoms must have been of such severity and persistence to result in severe impairment in the ability to obtain or retain employment. The evidence simply does not show either severe social impairment of severe occupational impairment. Although the Veteran on occasion would give a history of having social fears and impairment, he more consistently reported that he had ongoing family relationships as well as a number of friends. As for occupational impairment, the totality of the evidence shows that medical care providers have for the most part found no more than moderate impairment. The October 1997 opinion by Dr. Kelly is simply inconsistent with the overall medical evidence and the Board assigns the opinion minimal weight. There has been some occupational impairment to be sure. However, the evidence shows such impairment to be essentially moderate in nature, not severe. As such the criteria for a 70 percent rating under the old criteria have not been met. The Board acknowledges the Court's decision with respect to addressing the GAF scores. For the most part, the Veteran's GAF scores have been in the upper 40's to low 50's. These scores reflect serious symptoms, but the Board declines to assign a rating solely based on these GAF scores since they should be considered in the context of the overall evidence. In this case, the Veteran has been shown to have some ongoing social relationships with family and friends. In a June 2011 opinion, the March 2010 VA examiner opined that the overall evidence showed that the PTSD symptoms had essentially remained moderate from 1993. The examiner further commented that the GAF scores had remained relatively unchanged and were suggestive of moderate impairment using the GAF criteria. There has been no persuasive showing of severe social impairment due to the PTSD, nor has there been a showing of severe occupational impairment due to this disability. The record also reflects that he remains married, he has a close relationship with his grown children and his grandchildren, he travels regularly with his wife and another couple, and he visits with his neighbors often. As such, he is clearly able to establish and maintain effective relationships. There does not appear to have been any deficiencies in the Veteran's judgment or thinking. The Veteran has not exhibited suicidal ideation at any time. The Board also finds that the current criteria for a rating in excess of 50 percent have not been met in this case. The Board finds that at no time has the Veteran's PTSD caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to the types of symptoms set out as examples in Code 9411. There is no persuasive showing of suicidal ideation. There is no evidence of obsessional rituals which interfere with routine activities. His speech has not been reported to be intermittently illogical, obscure or irrelevant. The symptoms of panic and depression do not affect his ability to function independently, appropriately and effectively. There is also no showing of impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene. For the same reasons addressed under the discussion of the old criteria, the Board finds that there is no resulting inability to establish and maintain effective relationships. The April 2012 examiner reported the Veteran's PTSD symptoms as those in keeping with the current criteria for a 50 percent rating, not the 70 percent rating. The examiner adequately reported the functional impairment resulting from the PTSD. For purposes of this decision, although the more recent evidence shows that dementia has also been detected in addition to the PTSD and depression, the Board notes that the April 2012 examiner nevertheless opined that the occupational and social impairment due to all mental diagnoses resulted in reduced reliability and productivity. As such, the current 50 percent rating contemplates all of the Veteran's mental health symptoms. In sum, the Board finds that the preponderance of the evidence is against a rating in excess of 50 percent under either the old or current rating criteria. The potential application of various provisions of Title 38 of the Code of Federal Regulations has also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards". 38 C.F.R. § 3.321(b)(1). Rather, as discussed above, the evidentiary record in this case persuasively shows that the Veteran's PTSD symptoms squarely match the type and degree of the examples set forth under the criteria for the current 50 percent schedular rating. Consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) is not appropriate in such a case where the rating criteria reasonably describe the Veteran's disability level and symptomatology. See generally Thun v. Peake, 22 Vet. App. 111 (2008). The Board therefore finds that referral for extraschedular consideration under 38 C.F.R. § 3.321(b)(1) is not warranted in this case. ORDER Entitlement to a rating in excess of 50 percent for PTSD is not warranted. To this extent, the appeal is denied. REMAND A June 2012 rating decision denied the Veteran's claim seeking entitlement to TDIU. In a May 2013 letter, the Veteran's representative reports that a notice of disagreement was filed and that the Veteran had elected the DRO process. The representative asks that a statement of the case be issued so that the Veteran may perfect his appeal to the Board. A review of Virtual VA revealed a July 2012 letter from the RO acknowledging having received the Veteran's notice of disagreement with the June 2012 rating decision. The representative has requested a statement of the case, and the Board finds that a remand for such is appropriate under these circumstances. Manlincon v. West, 12 Vet. App. 238 (1999). Although the Board is cognizant of the judicial holding in Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009), it appears that the Veteran is advancing the TDIU issue separately at the RO level. Accordingly, the case is REMANDED for the following actions: (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. The RO should reexamine the TDIU claim and determine whether additional development is warranted. If so, such development should be accomplished. 2. The RO should then review the record and determine if TDIU is warranted. If the claim remains denied, the Veteran and his representative should be furnished a statement of the case and be afforded an opportunity to respond. If a timely substantive appeal is received, the case should be returned to the Board for appellate review. The appellant 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). ______________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs