Citation Nr: 1325083 Decision Date: 08/07/13 Archive Date: 08/13/13 DOCKET NO. 09-18 896 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for the period prior to October 10, 2008, and a disability rating in excess of 50 percent for the period beginning October 10, 2008, 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: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD K. Haddock, Associate Counsel INTRODUCTION The Veteran had active naval service from January 1965 to February 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2008 Decision Review Officer (DRO) decision and a December 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. The Board has reviewed the physical claims file and the Virtual VA electronic claims file. The Board notes that in a September 2011 supplemental statement of the case, the Veteran was awarded a 50 percent disability rating for his PTSD effective October 10, 2008. As the increased disability rating does not represent a full grant of the benefit sought on appeal, the Board has limited its consideration accordingly as the claim for increase remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). This case was previously before the Board in May 2011, at which time it was remanded for additional development. The case has now been returned to the Board for further appellate action. The issue of entitlement to a TDIU is addressed in the REMAND following the ORDER section of this decision. FINDINGS OF FACT 1. For the period prior to October 10, 2008, the social and occupational impairment from the Veteran's PTSD more nearly approximated deficiencies in most areas than occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. For the period beginning October 10, 2008, the social and occupational impairment from the Veteran's PTSD has more nearly approximated total than reduced reliability and productivity. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 70 percent, but not higher, for the period prior to October 10, 2008, for PTSD have been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a schedular disability rating of 100 percent for the period beginning October 10, 2008, for PTSD have been met or approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2012), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board also notes that the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant pursuant to the VCAA be provided "at the time" that, or "immediately after," VA receives a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). The record reflects that the Veteran was mailed a letter in June 2007 advising him of what the evidence must show and of the respective duties of VA and the claimant in obtaining evidence. The June 2007 letter also provided the Veteran with appropriate notice with respect to the disability-rating and effective-date elements of his claims. The Board also finds the Veteran has been afforded adequate assistance in response to his claim. The Veteran's service treatment records (STRs) are on file, VA Medical Center treatment notes have been obtained, and the Veteran has been afforded appropriate VA examinations. Neither the Veteran nor his representative has identified any outstanding evidence, to include medical records, which could be obtained to substantiate the claim decided herein. The Board is also unaware of any such evidence. Accordingly, the Board will address the merits of the claim. Legal Criteria Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(a), 4.1 (2012). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified; findings sufficiently characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012). 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. PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411. This diagnostic code uses the general rating formula for mental disorders, which provides that a 30 percent disability rating is warranted for a mental disorder when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversational normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent disability rating is warranted for a mental disorder when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent disability rating is warranted for a mental disorder when there is 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 work-like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. The maximum schedular rating of 100 percent is warranted for a mental disorder when there is total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42 (2012) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. In September 2007, the Veteran was afforded a VA examination. At that time, the Veteran reported that he had begun seeking regular psychiatric treatment approximately three to four months prior because he was having suicidal thoughts. However, he reported prior to beginning regular mental health treatment, he had sought treatment in approximately 1982 because of problems with his temper, abuse of alcohol, and flashbacks. He reported he was given some medication at that time, but that he stopped taking it because he did not like the way it made him feel. The Veteran reported that eventually he quit drinking and took jobs where he worked six to seven days a week for the next 20 years or so. The Veteran reported that on his 60th birthday he began having suicidal thoughts. He reported that his wife had been ill the whole day and had apologized for giving him the worst birthday and he began to think about his time in the Republic of Vietnam and the birthday he spent there. The Veteran reported that since then, he had been experiencing nightmares and flashbacks. He reported that he went out of his way to avoid situations that reminded him of his traumatic events. The Veteran reported that he was constantly on guard, watchful, and easily startled. He reported that if someone came up behind him he would get very startled and he reported that his wife had learned to talk when she was around him to avoid startling him. The Veteran reported that he felt detached from others, activities, and his surroundings. He reported that he did not feel like seeing friends anymore and that as a result, he was losing friends. The Veteran reported that he took little interest or pleasure in doing things he used to enjoy and that he usually felt down, depressed, and hopeless. The Veteran reported that he experienced trouble falling and staying asleep every night and that when he did sleep, it was interrupted by nightmares. The Veteran reported that he was tired, had very little energy every day, and that he often felt bad about himself. The Veteran reported that he had trouble concentrating while reading the paper or watching television. The Veteran reported that his wife often told him he was overbearing and he reported that he had stopped spending time with friends because he did not feel up to it. The Veteran reported that he experienced irritability and that he was easily upset, which caused him to be embarrassed when he overreacted. The Veteran reported that he cried whenever he recalled the faces of the dead individuals he had seen while serving in the Republic of Vietnam. The Veteran reported that at times, he heard voices. The Veteran reported that his mental health treatment provider gave him some medication that helped a little with his symptoms. Upon mental status examination, the Veteran was found to be alert, casually dressed, and oriented x3. The examiner noted that the Veteran was a fair historian with a fair memory. The Veteran denied suicidal and homicidal ideations. The Veteran denied paranoid delusions. The examiner noted that the Veteran was of average intelligence and voiced motivation for treatment. The Veteran's judgment appeared to be fair by objective questioning and insight was voiced. The Veteran's affect was congruent and anxious with moments of crying spells and a tendency to be slow. The Veteran's mood was described as a 6 out of 10, 0 being the worst. The examiner noted that the Veteran experienced recurrent recollections of his traumatic events and that the Veteran felt he had lost every feeling that he should have. The examiner further noted that the Veteran had persistent avoidance and disruption in mood. Based on the history provided by the Veteran and the mental status examination, the examiner diagnosed major depressive disorder and PTSD. The examiner assigned a Global Assessment of Functioning score (GAF) of 65. The examiner noted that the Veteran appeared very depressed which could be a manifestation of a bipolar condition. The examiner further noted that it was likely that as the Veteran's depression symptomatology remitted with treatment, his PTSD symptoms may also decrease as he had been very functional for many years prior to his wife's illness, which had also served to trigger his PTSD symptoms. At this juncture, the Board notes that GAF scores are based on 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); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. The GAF score is based on all of the veteran's psychiatric impairments. A GAF score of 31-40 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). A GAF score of 41-50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51-60 represents 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 coworkers). A GAF score of 61-70 represents 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. While particular GAF scores are not contained in the VA schedule of ratings for mental disorders, 38 C.F.R. § 4.130, they are a useful tool in assessing a veteran's disability and assigning disability evaluations. However, they are just one of many factors considered when determining an evaluation. In October 2011, the Veteran was afforded another VA examination. At that time, the Veteran reported that he remained married, but that his marital relationship had notably suffered as a result of his emotional detachment, anger, irritability, and general worsening of his PTSD symptoms. The Veteran reported that his friendships had dwindled over the past years and that he had ceased to engage in activities with his friends as a result of fear, anxiety, and avoidance of social settings. The Veteran reported that he did not trust himself to behave appropriately in the company of others. The examiner cited to support letters submitted by the Veteran's family, friends, and neighbors in which they described a decline in the Veteran's emotional and social functioning over the past several years. The examiner noted that while the Veteran's neighbors respected him, they were fearful of upsetting him and being on the receiving end of his mood swings. The Veteran reported that he had not engaged in formal employment since his last VA examination. He reported that he had attempted to work on several occasions, but that his anger, irritability, and hypervigilance would interfere with his ability to get along with others on the job. The Veteran reported that he experienced a lot of guilt and a sense of helplessness about his unemployability. The Veteran reported that he continued to seek mental health treatment at the VA Medical Center, but that he was unable to attend group therapy because hearing other veterans discuss their own wartime experiences exacerbated his symptoms. The examiner noted that according to both the Veteran and the mental health treatment notes of record, there had been a substantial decline in the Veteran's psychological functioning over the past several years. The examiner reported that the Veteran had been experiencing a marked increase in his PTSD symptom severity with concomitant medication changes and adjustments and that the Veteran had been prescribed various psychotropic medications with little to no improvement of his symptoms. The Veteran reported that while he had not been arrested or involved in any legal matters since his last VA examination, he did have several occasions of violent behavior. He reported that he had drawn a gun on an individual who came up behind him while in rural Wyoming and he reported that he had gotten into a physical altercation with a younger man and ended up calling the police himself. The Veteran reported that he drank alcohol approximately three to four times per week, but not to the point of intoxication. He reported that he had stopped drinking entirely for 35 years, but that he had resumed alcohol use following his 60th birthday. He reported that the alcohol helped him sleep at night, but that his wife was concerned about his alcohol use. The Veteran experienced both auditory and visual hallucinations of the seven men present at the time of his stressor event during active service. The examiner noted that the Veteran's sentinel event appeared to be a flashback episode on his 60th birthday during which he experienced visual hallucinations of the seven men who were present during his recorded stressor event. The examiner noted that at that time, the Veteran was reportedly found in a closet during the episode and had urinated on himself. The examiner noted that the Veteran described, and the medical records supported, a substantial increase in his PTSD symptoms at that time and further decompensation since. The examiner further noted that the Veteran experienced recurrent and distressing recollections and dreams of his traumatic event, hallucinations and flashbacks of his traumatic event, and intense psychological and physiological distress at exposure to internal or external cues that symbolized or resembled the traumatic event. The examiner noted that the Veteran made an effort to avoid thoughts, feelings, and conversations associated with the traumatic event. The examiner noted that generally, the Veteran's symptoms included avoidance, inability to recall important aspects of his traumatic event, markedly diminished interest or participation in significant events, feelings of detachment and estrangement, restricted range of affect, difficulty falling and staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. Upon mental status examination, the Veteran was found to have a depressed mood and was anxious and suspicious. The Veteran had near-continuous panic or depression that affected his ability to function independently, appropriately, and effectively. The Veteran was found to have mild memory loss, such as forgetting names, directions, or recent events. The Veteran had impairment of short-term and long-term memory in that he had retention only of highly learned material and he forgot to complete tasks. The Veteran had difficulty understanding complex commands. The Veteran's judgment and abstract thinking were impaired. The Veteran had disturbances in motivation and mood. The Veteran was noted to be unable to establish and maintain effective relationships and it was noted that he had difficulty adapting to stressful circumstances, to include work and work like settings. The Veteran was noted to have suicidal ideations and obsessional rituals which interfered with his daily activities. The Veteran had impaired impulse control, such as unprovoked irritability with periods of violence. There was evidence of persistent delusions and hallucinations. There was a persistent danger that the Veteran would hurt himself or others. The examiner diagnosed chronic PTSD and noted that the Veteran appeared to have decompensated significantly during the past several years in terms of the frequency and intensity of his symptoms. The examiner also diagnosed severe major depressive disorder with psychotic symptoms and noted that although the Veteran had some clear symptoms of depression; to include loss of ability to experience pleasure, loss of interest in activities, feelings of worthlessness, loss of energy, irritability, concentration difficulty, indecisiveness, fatigue, loss of interest in sex, pessimism, sadness, guilt, and suicidal ideation; these symptoms appeared to be related to the chronic re-experiencing and/or avoidance associated with trauma. Additionally, the examiner noted that the Veteran's abuse of alcohol over the years appeared to have been associated with PTSD symptoms as a means to cope with traumatic memories and physiological reactivity. The examiner assigned a GAF of 40 and noted that the Veteran's GAF scores during the past year had ranged from 30 to 40. The examiner found that the Veteran had total occupation and social impairment as a result of his PTSD. The examiner noted that the Veteran's PTSD symptoms were the primary reason for his total occupational and social impairment and that all other psychiatric diagnoses were secondary to such. Also of record are letters from the Veteran's various mental health treatment providers at the VA Medical Center. In an October 2009 letter, the Veteran's VA Medical Center treating psychiatrist, Dr. S.K., reported that he had been treating the Veteran for PTSD for approximately three years and that he had watched the Veteran's symptoms worsen over time in spite of multimodal treatment. Dr. S.K. noted that the Veteran had the diagnostic constellation of PTSD symptoms, to include nightmares, flashbacks, intrusive thoughts and images, impulsive anger, physiologic hyper-reactivity, deadening of pleasant emotional experiences, social withdrawal, a pervasive inability to relax, recurrent depressed mood, and a frequent sense of meaninglessness and hopelessness. Dr. S.K. also noted that there were clearly deficiencies in most areas of the Veteran's life and that he was unable to work. Dr. S.K. noted that the Veteran's social relations were strained, distressing, and minimal. The Veteran's marital relationship was noted to have been the victim of the Veteran's emotional detachment and anger. Dr. S.K. noted that the Veteran suffered from near continuous anxiety with panic episodes that required medication usage that often left him fatigued and drained. The Veteran's mood was noted to be depressed on a daily basis and his outlook was noted as rarely optimistic or bright. Dr. S.K. further noted that the Veteran carried an ongoing, ingrained concept and feeling-state that suicide was an option worth considering. It was noted that the Veteran's thought processing had become more prone to detachment from sequence and logic, in that there had been evidence of psychotic decompensation and regression. Dr. S.K. noted that paranoid beliefs were becoming hardened into the Veteran's general view of the world around him. In simple terms, Dr. S.K. noted that the Veteran's PTSD severity ranged from very high to extremely high. In a March 2010 statement from the Veteran's VA Medical Center treating psychologist, Dr. P.T., it was noted that the Veteran continued to suffer from symptoms of PTSD, to include depressed mood, moderately severe anxiety, frequent panic attacks, negative and intrusive memories of his experiences in the Republic of Vietnam, anger and irritability with uncontrolled angry outbursts, severe sleep disturbance as a result of frequent nightmares, flashbacks, hypervigilance, isolative behavior, and severe survivors guilt. Dr. P.T. noted that the Veteran's PTSD was considered to be chronic and severe and further noted that the Veteran's depression was secondary to his PTSD. Dr. P.T. noted that the Veteran's symptoms interfered with his quality of life as well as his social and occupational functioning. It was noted that the Veteran's GAF scores ranged from 40-50 and that he was unable to work as a result of his PTSD. Dr. P.T. reported that in her opinion, the Veteran would never again be capable of competitive employment in his lifetime. In a June 2011 statement from Dr. S.K., it was noted that there was absolutely no doubt that the Veteran should be rated higher for his PTSD. Dr. S.K. noted that this was his opinion based on knowing and treating the Veteran for several years and that the treatment notes and various letters submitted in connection with the Veteran's claim should reflect this belief. In an April 2012 statement from another of the Veteran's VA Medical Center mental health treatment providers, Ms. D.R., it was noted that the Veteran experienced significant symptoms of PTSD. Ms. D.R. reported that the Veteran continued to experience nightmares on a frequent basis; that the Veteran was very lonely, isolated, and "alone" despite the presence of his wife in the home; that the Veteran remained easily angered and at times nearly got into physical altercations as a result; that the Veteran remained very hypervigilant of his environment and that he had visions of the men he saw killed while serving in the Republic of Vietnam; and that the Veteran was avoidant of crowds and had difficulty sitting with his back to a door. Ms. D.R. also noted that the Veteran was often tearful when seen in her office for treatment. Ms. D.R. noted that it was her belief that the Veteran remained severely impacted by his symptoms of PTSD and that he would be unable to interact appropriately with the public in any type of employment setting. It was noted that the Veteran spent the majority of his day avoiding PTSD triggers that would cause him to have angry outbursts, with which he sometimes experienced extreme difficulty. A review of the record shows that the Veteran has received regular mental health treatment and medication management at the VA Medical Center since approximately September 2006. A review of the VA Medical Center mental health treatment notes of record shows that the Veteran regularly complains of symptoms such as nightmares, intrusive thoughts and recollections, isolation, difficulty maintaining social relationships, anger and angry outbursts, irritability, marital difficulties as a result of his symptoms, anhedonia, depression, anxiety, panic attacks, avoidance, and survivors guilt. He has regularly presented with restricted affect and an affected mood and often gets emotional, to include crying, during his mental health treatment appointments. It should be noted that a review of the VA Medical Center treatment notes of record tends to show that the Veteran's PTSD symptoms have gotten progressively worse over time since the commencement of his treatment in September 2006. As noted by the October 2011 VA examiner, also of record are various lay statements from the Veteran's family, friends, and neighbors. A review of those statements shows that the Veteran is reported to be moody, irritable, unpredictable, and tended towards angry outbursts. The Veteran was also noted to be withdrawn and noticeably isolated himself from both his family and his friends. The Board finds that the Veteran is entitled to a 70 percent disability rating for the period prior to October 10, 2008, the date of the Veteran's notice of disagreement in which he first reported his symptoms had increased in severity since his last VA examination. In this regard, the Veteran's PTSD more nearly approximated deficiencies in most areas during that period. The Board notes that at his September 2007 VA examination, the Veteran reported experiencing suicidal ideations and auditory hallucinations. The Veteran was noted to have a restricted affect and a depressed mood and often reported feelings of hopelessness. Further, the Veteran reported significant symptoms of PTSD such as nightmares, irritability, panic, and anxiety. The Veteran was noted to exhibit avoidance and isolative behaviors in addition to disruption of mood. There was evidence that the Veteran experienced some difficulty maintaining social relationships and that he had lost interest in activities he used to enjoy. Further, the Veteran reported some limited difficulties with concentration. Additionally, the Veteran experienced symptoms including significant hypervigilance. The Board notes that the September 2007 VA examiner attributed many of the Veteran's symptoms at that time to depression; however, since that time, the Veteran's depression has been related to his PTSD. Additionally, the Board notes that the Veteran was assigned a GAF score of 65 by the September 2007 VA examiner, which is indicative of mild impairment. However, the Board finds that this GAF score is inconsistent with the symptoms described by the Veteran at that examination and the Veteran's VA Medical Center mental health treatment provider. While the GAF score is indicative of a mild impairment, the symptoms reported and discussed above are indicative of a much more serious impairment. Consequently, the Board assigns the September 2007 VA examination GAF score little probative value. Therefore, the Board finds that the symptoms exhibited by the Veteran for the period prior to October 10, 2008, more closely approximate those contemplated by a 70 percent disability rating. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board acknowledges that the results of the VA examinations and the symptoms described in the VA examination report and the VA Medical Center mental health treatment records do not indicate that the Veteran experiences all of the symptoms associated with a 70 percent disability rating for a psychiatric disability. However, the Court has held that the symptoms enumerated under the schedule for rating mental disorders are 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 disability rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, a finding that there is occupational and social impairment resulting in deficiencies in most areas is sufficient to warrant a 70 percent disability rating for the period prior to October 10, 2008, even though all the specific symptoms listed for a 70 percent rating are not manifested. Consideration has been given to assigning a higher disability rating for the period prior to October 10, 2008. However, the Board finds that there is no reasonable basis for concluding that the social and occupational impairment during this period more nearly approximated total than deficiencies in most areas. In this regard, there is no indication from the evidence of record that the Veteran had total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication, persistent delusions, grossly inappropriate behavior, persistent danger of hurting others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and significant memory loss (i.e. for names of close relatives, own occupation or own name). Further, the evidence of record prior to October 10, 2008, failed to show that the Veteran was not working as a result of his PTSD. Therefore a higher evaluation is not warranted for the period prior to October 10, 2008. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board finds that the Veteran is entitled to a 100 percent disability rating for his service-connected PTSD for the period beginning October 10, 2008, the date of the Veteran's notice of disagreement in which he reported his symptoms had significantly increased in severity since his last VA examination as to render him totally socially and occupationally impaired. In this regard, the Board notes that the Veteran's psychiatric symptoms during this period have been noted to be extremely severe so as to completely prevent him from working and causing him significant social impairment. At his October 2011 VA examination, the Veteran was noted to have near continuous panic and depression which affected his ability to function independently, appropriately, and effectively. Additionally, the Veteran was noted to have memory loss, impaired concentration, and difficulty understanding complex commands. The Veteran's judgment and insight were found to be impaired and he was noted to be unable to establish and maintain effective relationships. The Veteran was noted to have suicidal ideations and it was noted that there was a persistent danger that the Veteran would hurt himself or others. Further, the Veteran was found to exhibit obsessional rituals which interfered with his daily activities and he was noted to have persistent hallucinations and delusions. Additionally, the October 2011 VA examiner and all of the Veteran's VA Medical Center mental health treatment providers have found the Veteran to be incapable of functioning in an employment setting as a result of his PTSD and it has been noted that the Veteran's symptoms have only increased in severity despite the fact that he seeks regular mental health counseling and medication management. Further, the October 2011 VA examiner assigned the Veteran a GAF score of 40, indicative of very serious psychiatric impairment. Therefore, the Board finds that the Veteran's symptoms have produced impairment that more nearly approximates total occupational and social impairment than deficiencies in most areas for the period beginning October 10, 2008. 38 C.F.R. § 4.130, Diagnostic Code 9411. Again, the Board acknowledges that the results of the VA examinations and the symptoms described in the VA examination report and the VA Medical Center mental health treatment records do not indicate that the Veteran experiences all of the symptoms associated with a 100 percent disability rating for a psychiatric disability. However, the Court has held that the symptoms enumerated under the schedule for rating mental disorders are 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 disability rating. See Mauerhan, 16 Vet. App. 436. Thus, a finding that there is total occupational and social impairment is sufficient to warrant a 100 percent disability rating for the period beginning October 10, 2008, even though all the specific symptoms listed for a 100 percent rating are not manifested. The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b)(1) for the period prior to October 10, 2008. The Court has held that the threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). In the case at hand, the record reflects that the manifestations of the disability are contemplated by the schedular criteria. There is no indication from the evidence of record that the Veteran has had frequent hospitalizations or has even received frequent emergency treatment for his PTSD. Additionally, while the Veteran was not working during this period, there is no indication that it was a result of his PTSD symptoms. Regardless, the issue of entitlement to a TDIU is addressed in the remand below. In sum, there is no indication that the average industrial impairment from the disability would be to such a degree as to warrant the assignment of a higher disability rating than that granted herein for the period prior to October 10, 2008. Accordingly, the Board has determined that referral of this case for extra-schedular consideration is not in order. Thun, id. ORDER A 70 percent disability rating for PTSD for the period prior to October 10, 2008, is granted, subject to the criteria applicable to the payment of monetary benefit A 100 percent schedular disability rating for PTSD for the period beginning October 10, 2008, is granted, subject to the criteria applicable to the payment of monetary benefits. REMAND The Veteran submitted a statement in February 2012 that the Board finds to be a timely notice of disagreement with the December 2011 rating decision that denied entitlement to a TDIU. A review of the record shows that the Veteran was not issued a statement of the case in response to that notice of disagreement. Where a notice of disagreement has been filed with regard to an issue, and a statement of the case has not been issued, the appropriate Board action is to remand the issue for issuance of a statement of the case. Manlincon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: Issue a statement of the case on the issue of entitlement to a TDIU. Inform the Veteran of the requirements to perfect an appeal. If the Veteran perfects an appeal, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs