Citation Nr: 1324998 Decision Date: 08/06/13 Archive Date: 08/13/13 DOCKET NO. 11-01 592 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to a disability evaluation in excess of 30 percent for the Veteran's posttraumatic stress disorder (PTSD) for the period prior to May 21, 2013. 2. Entitlement to a disability evaluation in excess of 70 percent for the Veteran's PTSD for the period on and after May 21, 2013. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel INTRODUCTION The Veteran is the appellant in the instant appeal. He had active service from April 1962 to April 1965. This matter came before the Board of Veterans' Appeals (Board) on appeal on appeal from a May 2010 rating decision of the Wichita, Kansas, Regional Office (RO) which denied service connection for PTSD, bilateral hearing loss, and tinnitus. In December 2010, the RO granted service connection for PTSD; assigned a 30 percent evaluation for that disability; and effectuated the award as of October 23, 2009. In November 2012, the Veteran submitted a Motion to Advance on the Docket. In November 2012, the Board granted the Veteran's motion. In December 2012, the Board remanded the Veteran's appeal to the RO for additional action. In July 2013, the Appeals Management Center (AMC) granted service connection for bilateral hearing loss; assigned a noncompensable evaluation for that disability; effectuated that award as of October 23, 2009; granted service connection for tinnitus; assigned a 10 percent evaluation for that disability; increased the evaluation for the Veteran's PTSD from 30 to 70 percent; and effectuated those awards as of May 21, 2013. The action requested by the December 2012 Board remand was accomplished and the case subsequently returned to the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board's duty to "insure [the RO's] compliance" with the terms of its remand orders). The Board has reviewed both the physical claims file and the "Virtual VA" file so as to insure a total review of the evidence. FINDINGS OF FACT 1. For the period prior to May 21, 2013, the Veteran's PTSD was manifested by occupational and social impairment due to recurrent nightmares and intrusive thoughts; anxiety; depression, suicidal ideation; obsessional rituals; and Global Assessment of Functioning (GAF) scores of between 35 and 55. 2. On and after May 21, 2013, the Veteran's PTSD has been shown to be productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as a depressed mood; a flattened affect; anxiety; panic attacks which occur "weekly or less often;" chronic sleep impairment; mild memory loss; disturbances of motivation and mood; difficulty in adapting to stressful circumstances including work or a work-like setting; and a GAF score of 49. CONCLUSIONS OF LAW 1. The criteria for a 70 percent evaluation for the Veteran's PTSD for the period prior to May 21, 2013, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an evaluation in excess of 70 percent for the Veteran's PTSD for the period on and after May 21, 2013, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473(2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. VA has issued several VCAA notices to the Veteran including a March 2010 notice which informed him of the evidence generally needed to support a claim of service connection and the assignment of a rating and effective date for an initial award of service connection; what actions he needed to undertake; and how VA would assist him in developing his claim. The March 2010 VCAA notice was issued to the Veteran prior to the May 2010 rating decision from which the instant appeal arises. The issue was readjudicated in the May 2011 statement of the case (SOC) and the July 2013 supplemental statement of the case (SSOC). Therefore, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Moreover, because this appeal arises from the Veteran's disagreement with initial evaluation following the grant of service connection for PTSD, no additional notice is required regarding this downstream element of the service connection claim for PTSD. In reference to the downstream element of the initial evaluation, 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. No additional notice is 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) (noting that, once an initial VA decision awarding service connection and assigning a disability evaluation and effective date has been made, 38 U.S.C.A. § 5103(a) notice is no longer required); 38 C.F.R. § 3.159(b)(3) (no VCAA notice required because of filing of NOD). Regarding the duty to assist in this case, VA has secured or attempted to secure all relevant documentation required by the VCAA. In accordance with the Board's December 2012 Remand instructions, the Veteran was afforded a May 2013 VA examination. When VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The May 2013 VA examination report reflects that all relevant records were reviewed and the opinion requested was advanced. All identified and available relevant documentation has been secured and all relevant facts have been developed. There remains no question as to the substantial completeness of the Veteran's claim. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). For these reasons, the Board finds that the VCAA duties to notify and to assist have been met. II. Historical Review The report of a December 2010 VA psychiatric examination for compensation purposes conveys that the Veteran was diagnosed with PTSD as the result of his in-service traumatic experiences. A GAF score of 50 was advanced. In December 2010, the RO granted service connection for PTSD; assigned a 30 percent evaluation for that disability; and effectuated the award as of October 23, 2009. In July 2013, the AMC increased the evaluation for the Veteran's PTSD from 30 to 70 percent and effectuated that award as of May 21, 2013. III. Evaluation Disability evaluations are determined by comparing a veteran's current symptomatology with the criteria set forth in the Schedule For Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. A 30 percent evaluation is warranted for PTSD which is productive of occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although the individual is generally functioning satisfactorily with routine behavior and normal self-care and conversation) due to symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). A 50 percent evaluation requires occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks occurring 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 or forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. A 100 percent rating requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting herself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: 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 as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). A. Period prior to May 21, 2013 The Veteran asserts that the record supports assignment of at least a 70 percent evaluation for his PTSD for the period prior to May 21, 2013, as the disability was manifested by recurrent suicidal ideation and obsessive behavior. Treatment records from T. Bettis, R.N./L.C.S.W., dated in October 2009 and November 2009 convey that the Veteran complained of depression. He reported that he was retired after having worked for Hallmark Cards for 41 years. The Veteran was observed to be well-groomed; appropriate; and oriented to person, place, and time. On mental status examination, the Veteran exhibited an appropriate and blunted affect; an anxious, depressed, and irritable mood; logical and relevant though processes; intact memory; fair insight, reliability, and judgment; and "OK" abstraction and concentration. The Veteran was diagnosed with major depression, "[ruleout]" adjustment disorder, and an obsessive compulsive personality disorder. A GAF score of "45+" was advanced. A November 2009 written statement from Mr. Bettis conveys that the Veteran complained of increasing PTSD symptoms including intrusive thoughts and dreams with associated impaired sleep; road rage; social isolation; trust issues; and the need for psychotropic medication to function. The Veteran was noted to be depressed. A June 2010 written statement from V. Kirubakaran, M.D., reports that he had treated the Veteran since June 2006. The doctor stated that the Veteran experienced severe anxiety, flashbacks, "significant mood swings," and "memory problems." The Veteran was diagnosed with PTSD and a depressive disorder. A GAF of 35 was advanced. At the December 2010 VA examination for compensation purposes, the Veteran complained of PTSD symptoms including nightmares; intrusive thoughts; depression; anxiety; excessive worry; irritability; social withdrawal; feelings of hopelessness and helplessness; suicidal ideation; and sleep, memory, and concentration problems. He reported that he was married and currently retired. It was noted that the Veteran worked at Hallmark Cards for over 40 years before retiring in 2000. After retirement he worked part-time in security at a casino for 3 1/2 years and resigned after injuring his back on the job. It was noted that over the previous 12 months he had not experienced absence or loss of employment related to mental health symptoms. Veteran was observed to be alert, cooperative, and oriented times three and to have "OK" personal hygiene. On mental status examination, the Veteran exhibited a "tired" mood and affect; "evidence of depression and anxiety;" goal-directed thought processes; impaired memory; and no hallucinations or suicidal or homicidal ideation. The Veteran was diagnosed with PTSD. A GAF score of "50 due to PTSD" was advanced. In his January 2011 notice of disagreement (NOD) and June 2011 Appeal to the Board (VA Form 9), the Veteran advanced that an initial evaluation in excess of 30 percent was warranted for his PTSD as he experienced suicidal ideations which he did not discuss with doctors "for fear of what might happen;" frequent "horrible night terrors;" and depression and anxiety with associated "lost relationships with my family." A June 2011 VA psychiatric evaluation states that the Veteran complained of "ongoing recurrent and prominent dreams/nightmares of wartime activity;" depression; anxiety; and impaired sleep. He was observed to be in "moderate distress" and periodically tearful and able to maintain good personal hygiene. On mental status examination, the Veteran exhibited a dysphoric mood; a blunted affect; linear, logical and goal-directed thought processes "devoid of obsessions, compulsions, phobias or thoughts of self-harm;"spontaneous and relevant speech; and impaired memory. The Veteran was diagnosed with PTSD; a "depressive disorder NOS secondary to PTSD;" and a "cognitive disorder NOS." A GAF score of 50 was advanced. A July 2011 VA mental health clinic treatment record states that the Veteran complained of anxiety and depression. On mental status examination, the Veteran was noted to be depressed and to deny any current suicidal or homicidal ideation. The Veteran was diagnosed with PTSD with depression. A September 2011 VA mental health clinic treatment record states that the Veteran complained of recurrent dreams; financial concerns; and difficulty "talking to my wife about anything 'personal' in my past." The Veteran was observed to be casually dressed with good hygiene and oriented times three. On mental status examination, the Veteran exhibited a dysphoric mood; a congruent affect; "grossly intact" cognition; and no psychotic symptoms or suicidal or homicidal ideation. The Veteran was diagnosed with PTSD; a "depressive disorder NOS secondary to PTSD;" and a "cognitive disorder NOS." A GAF score of 50 was advanced. VA mental health clinic clinical documentation dated in November 2011 and December 2011 states that the Veteran complained of anxiety and depression. He reported that he "still has suicidal thoughts" and "some [suicidal ideation]." The Veteran was found to have a depressed mood and no homicidal ideation. The Veteran was diagnosed with "PTSD with depression." A January 2012 VA psychiatric evaluation conveys that the Veteran complained of depression and sadness. The Veteran was observed to be casually dressed with good hygiene and oriented times three. On mental status examination, the Veteran exhibited a dysphoric mood; a congruent affect; "grossly intact" cognition; well-organized thoughts; and no psychotic symptoms or suicidal or homicidal ideation. The Veteran was diagnosed with PTSD; a "depressive disorder NOS secondary to PTSD;" and a "cognitive disorder NOS." A GAF score of 50 was advanced. A February 2012 VA mental health clinic treatment record states the Veteran complained of anxiety; depression; obsessive counting rituals; beliefs that the "world is going to blow up;" moodiness; irritability; headaches; and excessive worry thoughts. On mental status examination, he exhibited an anxious and depressed mood and denied any current suicidal or homicidal ideation. The Veteran was diagnosed with PTSD with depression. At an April 2012 VA psychiatric evaluation, the Veteran complained of estrangement from a granddaughter and financial concerns. The Veteran was observed to be casually dressed with good hygiene and oriented times three. On mental status examination, the Veteran exhibited a sad mood; a congruent affect; "grossly intact" cognition; well-organized thoughts; and no psychotic symptoms or suicidal or homicidal ideation. The Veteran was diagnosed with PTSD; a "depressive disorder NOS secondary to PTSD;" and a "cognitive disorder NOS." A GAF score of 55 was advanced. At an August 2012 VA psychiatric evaluation, the Veteran reported that he had been diagnosed with leukemia. The Veteran was observed to be casually dressed with good hygiene and oriented times three. On mental status examination, the Veteran exhibited a "down, but I am not giving up" mood; a congruent affect; "grossly intact" cognition; well-organized thoughts; and no psychotic symptoms or suicidal or homicidal ideation. The Veteran was diagnosed with a "mood disorder due to leukemia;" PTSD; a "depressive disorder NOS secondary to PTSD;" and a "cognitive disorder NOS." A GAF score of 55 was advanced. At an October 2012 VA psychiatric evaluation, the Veteran complained of "struggling with probably facing the end of my life." The Veteran was observed to be casually dressed with good hygiene and oriented times three. On mental status examination, the Veteran exhibited a "down, but I am not giving up" mood; a congruent affect; "grossly intact" cognition; well-organized thoughts; and no psychotic symptoms or suicidal or homicidal ideation. The Veteran was diagnosed with a "mood disorder due to leukemia;" PTSD; a "depressive disorder NOS secondary to PTSD;" and a "cognitive disorder NOS." A GAF score of 52 was advanced. In his November 2012 Informal Hearing Presentation, the accredited representative asserted that the Veteran's documented suicidal ideation and obsessional rituals warranted assignment of a 70 percent evaluation for his PTSD. The Board has reviewed the probative evidence of record including the Veteran's written statements on appeal. Prior to May 21, 2013, the Veteran's PTSD was manifested by a disability picture with symptoms such as recurrent nightmares and intrusive thoughts; anxiety; depression; suicidal ideation; obsessional rituals; and GAF scores of between 35 and 55. The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994). A GAF score of between 31 to 40 indicates impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score of between 41 and 50 denotes 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 score of between 51 to 60 reflects moderate difficulty in social, occupational, or school functioning. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). During the relevant period, the Veteran reported having retired in 2000 after maintaining longstanding employment with the same company and fair relationships with his wife and family during the relevant time period. His PTSD symptomatology, including recurrent suicidal ideation, was shown to be productive of significant occupational and social impairment most closely approximating the criteria for a 70 percent evaluation. Given the absence of objective evidence of symptoms of total occupational and social impairment such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; a persistent danger of hurting himself or others; an intermittent inability to perform activities of daily living; disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name, the Board finds that a 70 percent evaluation and no higher is warranted for the Veteran's psychiatric disability for the period prior to May 21, 2013. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411. B. Period on and after May 21, 2013 At a May 21, 2013, VA psychiatric examination for compensation purposes, the Veteran complained of PTSD symptoms which were "heightened" by his leukemia and associated medical treatment. He reported that he lived with his wife and was retired. On mental status examination, the Veteran exhibited a depressed mood; a flattened affect; anxiety; panic attacks which occurred "weekly or less often;" chronic sleep impairment; mild memory loss; disturbances of motivation and mood; and difficulty in adapting to stressful circumstances including work or a work-like setting. The Veteran was diagnosed with PTSD; a not otherwise specified depressive disorder secondary to PTSD; and a mood disorder due to leukemia. A GAF score based on the "PTSD diagnosis in isolation" of 49 was advanced. The examiner concluded that the Veteran's psychiatric disabilities were productive of occupational and social impairment with reduced reliability and productivity. On and after May 21, 2013, the Veteran's PTSD has been shown to be productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as a depressed mood; a flattened affect; anxiety; panic attacks which occurred "weekly or less often;" chronic sleep impairment; mild memory loss; disturbances of motivation and mood; difficulty in adapting to stressful circumstances including work or a work-like setting; and a GAF score of 49. Such a GAF score reflects serious impairment in occupational or social functioning. Given the Veteran's significant PTSD disability picture and the absence of objective evidence of symptoms of total occupational and social impairment such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; a persistent danger of hurting himself or others; an intermittent inability to perform activities of daily living; disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name, the Board finds that the current 70 percent evaluation adequately reflects the Veteran's PTSD symptomatology for the period on and after May 21, 2013 and the criteria for a 100 percent evaluation are neither met nor more nearly approximated. 38 C.F.R. §§ 4.3, 4.7. C. Extra-schedular Consideration The Board has also evaluated whether the Veteran's claim should be referred for consideration of an extra-schedular rating for PTSD under 38 C.F.R. § 3.321(b)(1). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extra-schedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. Second, if the schedular rating 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 extra-schedular rating. Thun v. Peake, 22 Vet App 111 (2008). With respect to the first prong of Thun, the evidence in this instant appeal does not establish such an exceptional disability picture as to render the schedular evaluation inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria found in 38 C.F.R. § 4.130, Diagnostic Code 9411, reflects that the diagnostic criteria reasonably describes the Veteran's disability level and symptomatology. The diagnostic criteria convey that compensable ratings will be assigned for PTSD which is manifested by various levels of occupational and social impairment. The Veteran's disability picture has been shown to encompass significant occupational and social impairment and symptoms which falls squarely within the diagnostic criteria for a 70 percent evaluation for all relevant periods. The Secretary of VA, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C.A. § 1155; see 38 U.S.C.A. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 psychiatric disorders, there can be no doubt that the Secretary of VA anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128(1997). See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant 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 will be assigned. Mauerhan, 16 Vet. App. at 443. The Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326(Fed. Cir. 2004). Prior to May 21, 2013, the Veteran's PTSD was manifested by occupational and social impairment due to recurrent nightmares and intrusive thoughts; anxiety; depression, suicidal ideation; obsessional rituals and GAF scores of between 35 and 55. On and after May 21, 2013, the Veteran's PTSD has been shown to be productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as a depressed mood; a flattened affect; anxiety; panic attacks which occur "weekly or less often;" chronic sleep impairment; mild memory loss; disturbances of motivation and mood; difficulty in adapting to stressful circumstances including work or a work-like setting; and a GAF score of 49. All the impairment and symptoms are either explicitly part of the schedular rating criteria or like or similar to examples or symptoms in the schedular rating criteria. In addition, the GAF score, which is incorporated into the schedular rating criteria as part of the DSM-IV, assesses the degree of overall occupational and social impairment. For these reasons, the Veteran's PTSD has not been shown to be productive of an exceptional disability picture. Therefore, the Board determines that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not merited. A claim for entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU) is part of an increased rating issue when such claim is raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). As indicated above, the evidence associated with the claims file shows that the Veteran is retired without any indication that PTSD caused unemployability. Therefore a TDIU claim is not raised by the record. (CONTINUED ON NEXT PAGE) ORDER A 70 percent evaluation for the Veteran's PTSD for the period prior to May 21, 2013, is granted subject to the law and regulations governing the award of monetary benefits. An evaluation in excess of 70 percent for the Veteran's PTSD for the period on and after May 21, 2013, is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs