Citation Nr: 1326143	
Decision Date: 08/16/13    Archive Date: 08/26/13

DOCKET NO.  07-19 368	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Denver, Colorado


THE ISSUES

1.  Entitlement to an initial rating greater than 50 percent for posttraumatic stress disorder (PTSD), prior to March 19, 2008.

2.  Entitlement to an increased rating greater than 70 percent for PTSD during the period from March 19, 2008 to November 20, 2010 and on and after February 1, 2011.

3.  Entitlement to a total disability evaluation for compensation based on individual unemployability (TDIU) prior to November 21, 2010.

4.  Entitlement to service connection for a chronic respiratory disability, claimed as a chronic cold, to include as due to an undiagnosed illness.


REPRESENTATION

Appellant represented by:	The American Legion

ATTORNEY FOR THE BOARD

M. Katz, Counsel


INTRODUCTION

The Veteran served on active duty from July 1990 to August 1990 and from October 1990 to May 1991.  

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision by the Department of Veterans Affairs (VA) Regional Office in Denver, Colorado (RO) and Board remand.

The Veteran requested a hearing in conjunction with his appeal of the above-captioned issues; he was notified in November 2009 that one was scheduled for him in December 2009, but he did not appear for the hearing.  As the Veteran has not explained his absence at the hearing or requested an additional hearing, the Board finds that his hearing request is withdrawn.  38 C.F.R. § 20.704(d) (2012).

The Veteran's appeal was remanded by the Board in February 2011.  In pertinent part, the Board directed the RO to obtain copies of the Veteran's VA treatment records from March 2009 to the present and to provide the Veteran with a VA examination to determine the current severity of his service-connected PTSD.  Review of the claims file reflects that the RO has substantially complied with those remand directives, such that an additional remand to comply with such directives is not required.  See Stegall v. West, 11 Vet. App. 268 (1998).  As discussed in the Remand section below, additional development is warranted regarding the Veteran's claim for entitlement to service connection for a respiratory disability.

While the Veteran's appeal was in remand status, his claims for entitlement to service connection for chronic diarrhea and entitlement to service connection for tinea pedis interdigitalis (claimed as jungle rot of the feet) were granted in a June 2012 rating decision.  This action constitutes a full grant of the benefit sought on appeal with respect to those issues, and they are no longer before the Board.

In a May 2013 brief, the Veteran's representative raised the issues of entitlement to service connection for hypertension, entitlement to service connection for diabetes mellitus, entitlement to service connection for a traumatic brain injury, and entitlement to service connection for tinnitus and dizziness.  These issues have not yet been adjudicated by the Agency of Original Jurisdiction (AOJ).  Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action.

A 100 percent rating for PTSD has been assigned from November 21, 201 to February 1, 2011.  Therefore, that period of the claim is not on appeal with respect to entitlement to an increased rating for PTSD since the Veteran is receiving the maximum rating during that period of time.

The issues of entitlement to service connection for a respiratory disability and entitlement to a TDIU are addressed in the REMAND portion of the decision below, and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC.


FINDINGS OF FACT

1.  Prior to March 19, 2008, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity.

2.  From March 19, 2008 to November 20, 2010, the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas such as school, work, family relations, judgment, thinking, and mood.

3.  On and after February 1, 2011, the Veteran's PTSD was manifested by total occupational and social impairment.

CONCLUSIONS OF LAW

1.  The criteria for an initial rating greater than 50 percent for PTSD, prior to March 19, 2008, have not been met.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012).

2.  The criteria for a rating greater than 70 percent for PTSD from March 19, 2008 to November 20, 2010 have not been met.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012).

3.  The criteria for an increased rating of 100 percent for PTSD on and after February 1, 2011 have been met.  38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

VA has met all statutory and regulatory notice and duty to assist provisions.  See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012).  Letters dated in May 2005, June 2005, March 2006, February 2008, and June 2008 satisfied the duty to notify provisions.  38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). 

The Veteran's service treatment records, VA medical treatment records, and identified private treatment records have been obtained.  38 U.S.C.A. § 5103A, 38 C.F.R. § 3.159.  The Veteran was most recently provided with a VA examination to assess the severity of his PTSD in January 2012.  In a May 2013 brief, the Veteran's representative argued that the January 2012 VA examination was inadequate because the examiner indicated that the Veteran had depression due to his PTSD, but that it was not clear that the depression was considered, as the examiner also asserted that the depression and PTSD symptoms could be separated.  The representative requested that the Veteran's claim for PTSD be remanded to clarify his PTSD symptoms.  Although the Veteran's representative believes that the January 2012 VA psychiatric examination is inadequate, the Board does not agree.  The January 2012 VA examiner diagnosed both major depressive disorder and PTSD, and clearly identified the symptoms associated with each diagnosis.  However, the examiner concluded that the Veteran's major depressive disorder was part of his PTSD diagnosis, and secondary to the PTSD.  Accordingly, the Board will consider the Veteran's depressive symptoms in determining the appropriate rating for his service-connected PTSD.  See Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009) (holding that in order to be entitled to separate ratings for two psychiatric disabilities, there must be evidence that differentiates the symptoms and manifestations and attributes them to different disabilities).  A remand for clarification of the symptoms associated to depression and PTSD would not be helpful in this instance, as the Board construes the VA examiner's report to indicate that the Veteran's depressive symptoms are part of his service-connected PTSD.  Thus, the Board finds that the January 2012 VA psychiatric examination is adequate in this case, as it describes the symptoms associated with the Veteran's PTSD, to include the depressive symptoms associated with PTSD, in sufficient detail to assess the current severity of that disability under the pertinent rating criteria.  38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). 

There is no indication in the record that any additional evidence, relevant to the issue of entitlement to an increased rating for PTSD, is available and not part of the claims file.  See Pelegrini v. Principi, 18 Vet. App. 112 (2004).  As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless.  See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009).

The Veteran contends that he is entitled to a higher disability rating for his service-connected PTSD.
Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity.  Separate diagnostic codes identify the various disabilities.  38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012).  Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases.  38 C.F.R. § 4.21 (2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). 

The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability.  Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings.  Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply.  Fenderson v. West, 12 Vet. App. 119 (1999).  Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports.  Id.  VA has a duty to consider the possibility of assigning staged ratings in all claims for increase.  See Hart v. Mansfield, 21 Vet. App. 505 (2007).

The Veteran's PTSD is rated as 50 percent disabling prior to March 19, 2008, 70 percent disabling beginning on March 19, 2008, 100 percent disabling beginning on November 21, 2010, and 70 percent disabling beginning on February 1, 2011, under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012).  Under the rating criteria, a 50 percent rating is warranted where the disorder is manifested by 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 for example, 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.  38 C.F.R. § 4.130, Diagnostic Code 9411 (2012)
A 70 percent rating is for application 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; difficult in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships.  Id.

A maximum 100 percent evaluation is warranted when there is total occupational and social impairment due to such symptoms as: gross impairment in thought process 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; and memory loss for names of close relatives, own occupation, or own name.  Id.

Global Assessment of Functioning (GAF) scores are a scale reflecting the 'psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness.'  See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), p. 32).

GAF scores ranging between 81 and 90 reflect absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).  GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).  GAF scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships.  Scores ranging from 51 to 60 reflect more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers).  Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job).  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 which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas.  A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute).  A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death.  See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV, for rating purposes).

When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, length of remissions, and a veteran's capacity for adjustment during periods of remission.  38 C.F.R. § 4.126(a) (2012).  The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination.  However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment.  38 C.F.R. § 4.126(b).  Ratings are assigned according to the manifestation of particular symptoms, but the use of a term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase 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 rating.  Mauerhan, 16 Vet. App. 436.

VA treatment records beginning in January 2005 reveal complaints of and treatment for PTSD.  In January 2005, the Veteran presented for a Gulf War physical.  He complained of depression.  He noted that he was engaged and had one child from an earlier relationship, but that the child was put up for adoption.  He reported that he was treated for depression in 2000, but that he felt that the depression started when he came back from Iraq in 1991.  He indicated that he was treated with Depakote.  The diagnoses included depression.  In April 2005, the Veteran was referred for evaluation of PTSD and depression.  He complained of feeling depressed, anergia, anhedonia, decreased concentration, episodes of irritability and tearfulness, depressed mood, and flat affect.  He also reported terrorizing nightmares, intrusive thoughts, flashbacks, avoidance of trauma-related stimuli, hyperstartle response, hyperalert state, emotional numbing, sense of foreshortened future, and sense of valuelessness to life.  He reported that he was attending school with the hopes of attaining a welding degree.  He stated that he was divorced with one adopted child, and noted that he was engaged to be married the following month and that his fiancé was pregnant with their child.  Mental status examination revealed the Veteran to be dressed in clean clothes.  He was cooperative and communicated his thoughts in a logical and coherent manner without any pressuring of speech or gaps in responses.  He denied experiences or perceptions consistent with psychosis, including hallucinations and delusional or paranoid thinking.  His affect was variable with content and his mood was depressed.  He denied suicidal and homicidal ideation.  The diagnoses were PTSD and major depression and a GAF score of 55 was assigned.

Another April 2005 record reflects that the Veteran complained of trouble sleeping and heightened anxiety.  The diagnosis was PTSD, and a GAF score of 55 was assigned.  In May 2005, the Veteran indicated that he recently married his wife and that they were having a baby together.  He complained of intrusive memories, nightmares, flashbacks, and dissociation.  The diagnosis was PTSD and a GAF score of 55 was assigned.  

VA treatment records from July 2005 through May 2006 reflect diagnoses of PTSD and major depression with GAF scores of 55.  A July 2005 record notes the Veteran's complaints of sleep disturbance and nightmares, as well as intrusive recollections.  He indicated that he was working as a welder.  In September 2005, the Veteran reported an increase in quality of sleep and ability to not react with as much anger.  He noted that he was very glad that he had a job and that he had options opening up to him with regard to employment.  An August 2005 record reflects that the Veteran denied nightmares but struggled with a sense of increased irritability.  In November 2005, he stated that he experienced stress with the c-section birth of his baby girl and the subsequent influx of family members into his home.  He indicated that he marginally managed his anger during that time.  A December 2005 record reflects that the Veteran complained of hypervigilance and irritability when in traffic.  He also noted depression.  He stated that he was glad for work and was investing himself in school to get further certificates for welding.  He also reported enjoying being a father to his 8-week old baby girl.  In January 2006, the Veteran reported having retaliatory fantasies related to Iraqis that were very disturbing.  He consistently reported that he was not at risk of acting on those thoughts, but was ashamed of having them.  He also noted that he struggled to avoid news of the Iraq war as it aggravated his symptoms.  He reported symptoms of irritability, anger, and depression.  A March 2006 record notes that the Veteran reported improved mood but irritability in the early afternoon.  

In March 2006, the Veteran underwent a VA psychiatric examination.  The Veteran complained of depression and anxiety.  He also noted depressed mood for two weeks or more at a time, periodic suicidal thoughts, anhedonia, poor concentration, poor sleep, anergia, fluctuating appetite, tearfulness, and hopelessness.  He described recurrent intrusive recollections and dreams, intense psychological distress at exposure to reminders of the traumatic event, avoidance of trauma-related stimuli, inability to recall important aspects of the trauma, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, restricted range of affect, difficulty sleeping, irritability or outbursts of anger, hypervigilance, and exaggerated startle response.  He described a very loving and happy family environment with no mistreatment.  

Mental status examination revealed the Veteran to be clean, neatly groomed, and appropriately dressed.  His psychomotor activity revealed persistent mannerisms.  Speech was unremarkable and attitude was cooperative.  Mood was anxious and affect was flat.  Attention was intact and the Veteran was alert and fully oriented.  Thought process and thought content were unremarkable.  There were no delusions and insight and judgment were intact.  The examiner noted that the Veteran had moderate sleep impairment which interfered with daily activity, as it caused him fatigue which affected work performance in the mornings.  He denied hallucinations and there was no inappropriate behavior.  There was no obsessive or ritualistic behavior.  The Veteran described panic attacks with the last episode in 2004.  Impulse control was good and there were no episodes of violence.  The Veteran described occasional suicidal ideation with no homicidal ideation.  The Veteran was able to maintain minimum personal hygiene and had no problems with the activities of daily living.  Memory was fully normal.  The diagnoses were PTSD and major depressive disorder, and a GAF score of 55 was assigned.  The examiner noted that the Veteran reported many somatic complaints, including withdrawal from almost all social contact except close family, episodic conflict with co-workers, irritability with family members, and enjoying leisure time in solitary activities.  The examiner also stated that the Veteran's depression was related to his PTSD, and that his PTSD caused moderate and frequent decreased efficiency, severe and frequent decreased productivity, mild or transient and occasional decreased reliability, moderate and frequent inability to perform work tasks, and moderate and frequent impaired work, family, and other relationships.

In a November 2005 statement, R.L. noted that the Veteran had emotional and mental problems including severe and debilitating depression, uncontrollable and unexplainable outbursts of rage, anxiety, extreme mood swings, nightmares, and multiple sleep disturbance issues.  She also indicated that the Veteran struggled to maintain healthy relationships.  In a December 2005 statement, the Veteran's brother reported that the Veteran was depressed, distant, and sometimes volatile.

VA treatment records from April 2006 through February 2008 reflect diagnoses PTSD and major depression and GAF scores of 55.  In April 2006, the Veteran complained of irritability.  He noted that he and his wife were struggling in their relationship, and that she verbalized a fear that the Veteran would leave.  A May 2006 record states that the Veteran continued to struggle with nightmares.  The Veteran returned to work following shoulder surgery in June 2006.  He stated that he was very happy to be working.  The physician noted that his ability to take care of himself and his health was complicated by his PTSD and depression.  Another June 2006 record indicates that the Veteran was having more irritability.  He also reported nightmares.  In July 2006, the Veteran was struggling with anergia and emotional distance from his family.  He was back at work with the potential for developing greater self-esteem and respect.  An August 2006 record notes that the Veteran's wife sent a message that the Veteran needed a medication change or he would be looking at divorce.  She indicated that the Veteran's symptoms of isolation from family, emotional distance, and sense of indifference about most things were intolerable to his wife.  In September 2006, the Veteran reported a recent conflict with his wife involving his contact with another woman by mail, but he assured his wife that he stopped the relationship.  He noted that he was studying hard for his classes and working full-time.  In November 2006, the Veteran and his wife reported that their relationship was stronger.  The Veteran's affect was bright.  A January 2007 record indicates that the Veteran felt able to manage his irritation and frustration.  He also noted decreased libido.  In April 2007, the Veteran's wife reported that he was irritable.

In May 2007, the Veteran complained of depression and irritability.  He also noted feeling apprehensive about his future vocation, noting that he was graduating from community college the following day.  He stated that he was often barely able to accomplish his assigned work at welding shop due to one to three panic attacks per week, hyperstartle responses to loud noises, and irritability and frustration with co-workers and supervisors.  He related that he was angered by the accommodations that his boss made for him on account of his PTSD, as he felt that it set him apart from other employees.  He noted that he would have likely been fired had his boss not looked the other way.  He also reported that he felt anxious and ashamed that, while his family came to celebrate his welding degree, he preferred not to have so many people in his house.  In June 2007, the Veteran stated that he enjoyed time with his wife and daughter, but that otherwise he wished to stay to himself.  An August 2007 record notes that the Veteran reported a resurgence of irritability and depression with the reduction of psychiatric medication.  In October 2007, the Veteran reported a relatively stable mood.  He expressed continued relief from terrorizing nightmares most nights with the addition of a new medication, but found that he must avoid all conversations and activities that have any content of combat.  A January 2008 record indicates that the Veteran avoided news and movies with combat content.  He also noted that he had a more harmonious relationship with his wife since he quit smoking.  

In February 2008, the Veteran and his wife described a recent emotional explosion where the Veteran became extremely angry with his wife and spoke about leaving their relationship, the area, and his job.  The Veteran reported having difficulty tolerating frustration at home and at work, and saw himself as very irritable at work to the point that his supervisor spoke with him about his anger and inability to work well with others.  The Veteran and his wife both reported that the Veteran did not have difficulty managing his anger with their two-year old child, but that it took every effort to control his anger.  The Veteran noted becoming abrupt and rude with co-workers asking about his war experience, and indicated that he felt tempted to strike others, but has refrained.  He indicated that he isolated himself at home and at work due to a fear of becoming angry.  He also reported feeling tearful at least three times per week.  He denied suicidal and homicidal ideation, but reported fleeting thoughts of suicide three weeks before.

In a June 2007 substantive appeal, the Veteran stated that he experienced symptoms including nightmares several times per week as well as social and occupational impairment.  He noted that his employer made concessions at work for him as a result of his PTSD symptoms.

In March 2008, the Veteran underwent another VA psychiatric examination.  The Veteran complained of low mood most of every day, markedly diminished interest and pleasure in previously enjoyed activities, weight gain, insomnia, psychomotor agitation and retardation, constant fatigue, difficulty concentrating, and recurring thoughts of death.  He noted a strained relationship with his wife and two-year old daughter.  He reported that he spoke with his parents once per week.  He indicated that he had one close friend and described difficulty establishing and maintaining friendships.  He noted that he used to go fishing and camping, but had no desire to do that anymore.  His only reported leisure activity was playing videogames.  He denied a history of suicide attempts as well as violence or assaultiveness.  He stated that he struggled to maintain composure in his daily life, and that everything was hard work.

Mental status examination revealed the Veteran to be clean, neatly groomed, and appropriately dressed.  Psychomotor activity was unremarkable, but speech was slow.  Attitude was attentive, mood was agitated and depressed, and affect was appropriate.  Attention was intact, and the Veteran was fully oriented.  Thought process was unremarkable, but thought content was positive for suicidal and homicidal ideation.  There were persecutory delusions, but none were persistent.  Insight and judgment were intact, and intelligence was normal.  The Veteran described sleep impairment and nightmares.  He reported auditory and olfactory hallucinations, but stated that they were not persistent.  There was no inappropriate behavior.  The Veteran reported some obsessive and ritualistic behavior, described as checking the locks and lights at home or at work at the end of the day.  He noted that he had knives located at strategic locations around the house and in the car.  He also described panic attacks any time he is in a crowd of four people or more, or any time he is in a car for extended periods of time.  He admitted to homicidal thoughts, noting that he has been losing it a lot lately over stupid things,  He stated that he will experience vivid homicidal fantasies which he initially enjoys, and is then repulsed by.  He reported that he has never acted on them.  He stated that he became very hostile towards his wife over a comment from her that he had not done enough dishes.  He denied current homicidal intent.  He also acknowledged suicidal thoughts frequently, but denied intent.  Impulse control was reported as poor, but there were no episodes of violence.  However, the Veteran indicated that he has become increasingly verbally aggressive at slight provocations.  The Veteran had the ability to maintain minimum personal hygiene.  He experienced some difficulty with activities of daily living, including slight difficulty with household chores and dressing; moderate problems engaging in sports and exercise as well as other recreational activities and driving; and severe problems shopping and traveling.  Remote and recent memory were normal.  

With regard to the Veteran's PTSD symptoms, the examiner noted that the Veteran had recurrent and intrusive distressing recollections; recurrent and distressing dreams; acting or feeling as if the traumatic event were recurring; intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; psychological reactivity on exposure to internal or external cues; avoidance of trauma-related stimuli; markedly diminished interest in significant activities; feelings of detachment or estrangement from others; restricted range of affect; sense of foreshortened future; difficulty sleeping; irritability or outbursts of anger; difficulty concentrating; hypervigilance; and exaggerated startle response.  The Veteran reported that he was isolative, had frequent suicidal and homicidal thoughts, difficulty concentrating and remembering, feeling depressed a majority of the time, and having low energy.  The examiner noted that the Veteran was employed full-time as a welder, but that his PTSD caused problems with occupational functioning, including decreased concentration, inappropriate behavior, increased absenteeism, increased tardiness, memory loss, and poor social interaction.  The diagnosis was PTSD with major depressive disorder, and a GAF score of 45 was assigned.

The VA examiner stated that the Veteran did not have total occupational and social impairment due to PTSD, and that his PTSD signs and symptoms did not result in deficiencies in judgment, thinking, family relations, work, mood, and school.  The examiner acknowledged that there was reduced reliability and productivity due to PTSD symptoms, such as missing more than two weeks of work in a 12-month period; engaging in verbal arguments with his wife at minimal provocation; feeling barely able to control violent impulses towards his daughter; reduced reliability to work due to poor memory and concentration; and minimal socialization outside of the home and pursuit of solitary leisure activities.
In support of his claim, the Veteran submitted several buddy statements in March 2008.  J.D. stated that he worked as the supervisor at the Veteran's place of employment, and that the Veteran had worked for him for three years.  J.D. reported that he observed the Veteran go from being pleasant to upset to the point that he had to excuse himself for a short time.  J.D. noted that the Veteran was a very good employee, and because of that, he made concessions to accommodate him.  The Veteran's wife reported that his PTSD affected his life, work relationships, and personal relationships.  She noted that the Veteran became angry with his co-workers on numerous occasions for minor things; he yelled and confronted his co-workers; he was reprimanded by his supervisors and warned that his behavior could not continue; and he told her that he became upset at work to the point of crying.  She stated that the Veteran used to have a passionate love for the outdoors, but no longer desired to go fishing and camping.  She indicated that, at times, it was difficult for her to get the Veteran to leave the house, noting that he would often spend an entire weekend in bed.  She stated that the Veteran had difficulty opening up about his feelings.  The Veteran's wife also reported that the Veteran had very few friends, as he was afraid of what others will think of him.  She noted that the Veteran occasionally had very angry reactions to the point where she feared for her safety and the safety of her family.  She indicated that the Veteran suffered from night terrors and sleep disturbance.

VA treatment records from March 2008 through March 2011 reveal continued diagnoses of and treatment for PTSD and major depressive disorder, with GAF scores of 55.  In March 2008, the Veteran reported struggling with irritability and noted that he was going to start taking anger management classes.  He denied suicidal and homicidal ideation, but acknowledged fleeting thoughts of suicide.  A September 2008 record reflects that the Veteran was very concerned about his level of irritability.  In October 2008, he stated that his irritability was a bit reduced with medication.  He indicated that work was stressful and physically exhausting.  In November 2008, the Veteran stated that he was struggling with anhedonia and not feeling interested in the family from time to time.  In February 2009, the Veteran stated that he had increased depression, as he was laid off two weeks before.  A March 2009 record indicates that the Veteran and his wife noticed an improvement in the Veteran's mood and level of irritability with the addition of a new psychiatric medication.  In May 2009, the Veteran complained of moderate anger and frustration.  In June 2009, the Veteran stated that he was very concerned about worsening nightmares as well as transient visual hallucinations in peripheral vision.  He also noted that he was tearful at times.  A July 2009 record indicates that the Veteran's medication was helpful in decreasing depression.  He noted continued hallucinations in his peripheral vision.  He denied suicidal and homicidal ideation.  In August 2009, the Veteran noted continued peripheral visual hallucinations.  A September 2009 record indicates that the Veteran felt more depressed when he did not have enough exposure to sunshine.  In October 2009, he indicated that he found light therapy to be helpful in increasing mood and quality of sleep.  He noted continued peripheral visual hallucinations and now some auditory hallucinations.  A November 2009 record reflects that the Veteran was alert and fully oriented.  He denied confusion or disorganization.  His affect was congruent with conversation and mood was described as stable.  He denied psychotic thinking as well as suicidal or homicidal ideation.  

In January 2010, the Veteran complained of an increase in nightmares.  Mental status examination showed him to be alert and fully oriented.  Affect was congruent with conversation, and mood was stable.  The Veteran denied psychotic thinking as well a suicidal or homicidal ideation.  A February 2010 VA treatment record indicates that the Veteran's nightmares were reduced with medication.  He indicated that he was trying to quit smoking, but that he had difficulty moderating anger at times.  Mental status examination showed the Veteran to be alert and fully oriented.  He denied confusion and disorganization.  His affect was congruent with conversation and his mood was stable.  He denied psychotic thinking and suicidal or homicidal ideation.  Another February 2010 record reflects that the Veteran reported that he trusted very few people and became frustrated with his wife because she asked too many questions about his wartime experiences.  In March 2010, the Veteran complained of flashbacks, nightmares, and exaggerated startle response.  He stated that he enjoyed spending time with his four-year old daughter.  Mental status examination was unchanged from the prior examination.  In April 2010, the Veteran indicated that he felt vulnerable regarding not being armed.  Mental status examination as unchanged.  In May 2010, the Veteran stated that he experienced an episode which sounded like a panic attack, and described symptoms of ringing in the ears, hyperventilating, and pounding heart.  Mental status examination was unchanged.  In June 2010, the Veteran stated that he was struggling with depression related to being laid off from his job and being denied money for schooling through vocational rehabilitation.  He expressed feelings of worthlessness and inadequacy related to his unemployment.  He noted that it was often difficult for him to trust and open up to his wife, but that he believed she was an advocate and cared for him.  Mental status examination was unchanged.

In June 2010, the Veteran reported feeling anxious, especially when in crowds or in crowded traffic.  A July 2010 record notes that the Veteran requested an urgent appointment due to losing his temper to an increasing degree around the house over the prior two weeks.  Mental status examination was unchanged.  Another July 2010 record reflects that the Veteran complained of increased agitation and anger.  He reported losing his temper with his daughter and subsequent feelings of guilt and shame.  An August 2010 record notes that the Veteran stated that he hadn't yet become physically abusive due to his anger, but that he was afraid that it could happen because he had little control.  He complained of irritability, anger outbursts, depression, nightmares, hypervigilance, and the need to keep knives on or near him all of the time.  He also reported flashbacks and hallucinations, and that he avoided fireworks on the 4th of July.  Mental status examination revealed the Veteran to be clean and well-groomed.  Mood was euthymic and verbalizations were logical and clear.  The Veteran was alert and fully oriented and there was no evidence of psychosis.  The Veteran denied suicidal and homicidal ideation.  Another August 2010 record notes that the Veteran's irritability had improved, but that he was struggling with depression, as evidenced by anergia, anhedonia, diminished concentration, irritability, tearfulness, diminished appetite and libido, and sense of worthlessness.  Mental status examination showed the Veteran to be alert and fully oriented.  He denied confusion or disorganization, and his affect was congruent with conversation.  His mood was described as stable.  He denied psychotic thinking.

In September 2010, the Veteran noted continued irritability and depression.  Mental status examination showed the Veteran to be alert and fully oriented.  He denied confusion and disorganization.  Affect was congruent with conversation, but mood was reported as unstable and irritable.  The Veteran denied psychotic thinking.  The diagnoses included PTSD and major depression, and a GAF score of 45 was assigned.  Another September 2010 record reveals complaints of anger.  He reported a long string of failed relationships, including his first marriage, due to his anger since returning from service.  He noted that his wife and daughter caught the brunt of his anger, and that he was grateful that he had not become physically abusive, but noted that he was afraid that it could happen.  He stated that he did not like being touched by anyone, including his wife and daughter.  Mental status examination showed the Veteran to be clean and well-groomed.  Mood was euthymic and verbalizations were logical.  The Veteran was alert and fully oriented and there was no evidence of psychotic material.  The Veteran denied suicidal and homicidal ideation.  A GAF score of 45 was assigned.

In October 2010, the Veteran complained of depression and survivor guilt.  Another October 2010 record reflects that the Veteran had a return of nightmares, poor sleep, and increased irritability and depression.  Mental status examination showed the Veteran to be alert and fully oriented.  Affect was congruent with conversation and mood was unstable and irritable.  The Veteran denied psychotic thinking.  The diagnoses were PTSD and major depression, and a GAF score of 45 was assigned.

From November 2010 to January 2011, the Veteran participated in a PTSD rehabilitation treatment program through VA.  A November 2010 pre-admittance screening notes the Veteran's symptoms, including fear, anxiety, avoidance of crowds, anger, depression, intrusive thoughts, hypervigilance, and emotional numbing.  He reported feeling down, depressed, and hopeless, but denied any thoughts of hurting or killing himself.  The diagnoses included PTSD and major depression.  A GAF score of 45 was assigned.  A November 2010 psychiatric examination reflects the Veteran's complaints of anger.  Mental status examination showed the Veteran to be neat and clean.  His attitude was pleasant.  Speech was logical and conversational.  Speech rate was normal.  Posture was relaxed.  Mood was pleasant and joking.  There were no delusions expressed and no signs of paranoia.  Thoughts were organized.  Diagnoses included PTSD and depression.  Another November 2010 psychiatric intake report reveals that the Veteran reported minimal libido and short attention span.  He reported that he lost 15 or more jobs in the past 10 years due to his anger.  He noted that he was unemployed and could not find work.  Mental status examination showed the Veteran to be cooperative and polite with good eye contact.  He gave off an aura of depression.  His affect was constricted.  He endorsed vivid auditory hallucinations, and sometimes command hallucinations.  He also noted some visual hallucinations.  The diagnoses included PTSD and major depression, and a GAF score of 45 was assigned.  A January 2011 discharge report reflects that the Veteran made very good progress on his goal of reducing anger and depression and increasing safety.  He was very active in family therapy and described much less hopelessness.

In February 2011, the Veteran stated that he completed PTSD treatment in January 2011, which was very helpful to him.  He indicated that he and his wife were attending marital therapy, and that he very much wanted to achieve full reconciliation.  He noted that his auditory hallucinations were back, and that they were often giving commands.  Mental status examination revealed the Veteran to be clean and well-groomed.  Mood was sad and guilty.  Verbalizations were logical and clear.  He was alert and fully oriented.  No psychotic material was noted, and he denied suicidal and homicidal ideation.  The diagnoses included PTSD and major depression, and a GAF score of 55 was assigned.  A March 2011 record shows that the Veteran was concerned about his anger, noting that he was having anger outbursts frequently.  He stated that he was getting short-tempered with his daughter.  He described sleep disturbance.  Mental status examination was unchanged from the last examination.

In March 2011, the Veteran underwent a VA PTSD examination.  He stated that he just finished a residential PTSD program at VA.  He complained of fatigue, low mood, anger, road rage, constant depression, angry outbursts, withdrawal from others, and difficulty getting out of bed.  He stated that he was married and had a daughter, and indicated that he was in marriage counseling with his wife.  He stated that he was active with The American Legion, and that most of his social contact was there.  He also indicated that his hobbies included motorcycle riding and welding.  He reported a history of suicide attempts, but denied any attempts since 2008.  The Veteran denied a history of violence or assaultiveness.  Mental status examination revealed the Veteran to be clean and casually dressed.  Psychomotor activity and speech were unremarkable.  The Veteran was cooperative and guarded.  His mood was anxious and dysphoric and his affect was appropriate and constricted.  Attention was intact and the Veteran was fully oriented.  His thought process was racing, illogical, and blocking.  Thought content was positive for suicidal and homicidal ideation as well as obsessions.  The examiner explained that the Veteran had worries of losing his family.  He endorsed some homicidal thoughts with limited planning regarding people who were making him mad, but noted that his family relationships kept him from doing anything.  He reported suicidal feelings, but that he would not act on them due to his daughter.  He denied delusions and his judgment was impaired.  Intelligence was average and insight was intact.  The Veteran reported symptoms of sleep impairment with nightmares.  He denied hallucinations.  He noted obsessive and ritualistic behavior, described as checking the doors at least three times per night.  He stated that he was very preoccupied with being orderly and had to put everything away.  He noted that he had panic attacks three to four times per week.  Impulse control was reported to be poor, but there were no episodes of violence.  The Veteran stated that he became depressed after a temper outburst.  The examiner noted that the Veteran had the ability to maintain minimum personal hygiene.  The Veteran had problems with the activities of daily living.  His PTSD prevented him from shopping, caused moderate impairment in traveling and driving, caused slight impairment in household chores, and no impairment in toileting, grooming, self-feeding, bathing, dressing, engaging in exercise, and other recreational activities.  Remote memory was normal, but recent and immediate memory were mildly impaired.  

The examiner reported that the Veteran's symptoms included recurrent and intrusive recollections and dreams, acting or feeling as if the event were reoccurring, intense psychological distress and avoidance of trauma-related stimuli, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, restricted range of affect, sense of foreshortened future, difficulty sleeping, irritability and outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response.  He also endorsed feelings of guilt, avoidance of others, and socialization only with other veterans who had wartime experience.  He reported anxiety and frequent panic attacks as well as fatigue.  The diagnosis was PTSD, and a GAF score of 40 was assigned.  The examiner also stated that the Veteran's PTSD seriously impacted his ability to work, noting that he had poor concentration, poor memory, and angered easily.  The examiner further noted that the Veteran avoided social activities except for participation with The American Legion, that his marriage was troubled by angry outbursts, and that he had depression and fatigue.  The examiner concluded that the Veteran had total occupational and social impairment due to such symptoms as gross impairment in thought process; grossly inappropriate behavior evidenced by social withdrawal, chronic fatigue, and angry outbursts; persistent danger of hurting himself or others; intense reexperiencing of the trauma; and memory loss for dates and appointments.

In January 2012, the Veteran underwent a neuropsychological evaluation.  The Veteran reported a decline in attention and concentration, a decline in short-term memory, mood swings, general impulsivity, daily headaches, lightheadedness, and hearing a high-pitched which noise.  Neuropsychological tests were performed, which revealed severe impairments in short-term memory; significant impairments in attention, concentration, and impulsivity; and intense struggle with timed tasks requiring visual attention.  Mental status examination revealed the Veteran to be adequately groomed and dressed.  His behavior was courteous and compliant.  He was alert and fully oriented and affect was stable and depressed.  Speech was softer than normal in volume and tone, moderately organized, relevant, and goal-directed.  Speech was characterized by brief, quiet statements indicating cooperation.  Memory was intact for distant events, poor for recent events, and variable overall.  Insight was good, judgment was good, and concentration was adequate.  Suicidal and homicidal ideation were denied and there was no evidence of a formal thought disorder.  The examiner stated that the Veteran would likely have significant difficulty in work environments requiring a great deal of pressure under quick deadlines, visual processing without "hands-on" opportunities to work with the material, short-term memory for names/faces of customers met quickly and infrequently, and memory for appointments and events without frequent reminders.  There was evidence of normal judgment; social interaction was routinely appropriate; and the Veteran was always oriented; but there was evidence of moderately severely impaired visual-spatial orientation.

In January 2012, the Veteran underwent another VA PTSD examination.  The Veteran stated that he was married and had one daughter.  He reported that he had one long-term friend and one newer friend who was also a veteran.  He stated that he enjoyed riding motorcycles once per month with a group, but typically rode by himself.  He indicated that he used to be active in The American Legion, but that he stopped two months before when he started his newest job.  He explained that he began a new job as a welder two months before, and that his job did not require much interaction with others.  He indicated that he was reprimanded earlier that week for poor welds and was placed on probation.  He reported that he felt that the mistake was a result of difficulty with sustained concentration and focus.  He stated that his attendance at his job was good, but that he was hypervigilant at work and kept an eye on what was going on behind him.  He indicated that he had to investigate any loud noise, and that he once broke down crying and had to take a break at work.  He noted that his last job prior to his current job was in 2008, and that he was laid off due to absenteeism.  Before that, he worked at an auto parts store and was terminated due to interpersonal conflicts with customers, co-workers, and supervisors.  In an update section of the examination report, the examiner reported that he just learned that the Veteran was fired from his most recent job, and that it was likely due to problems caused by PTSD.

The examiner stated that the Veteran's PTSD symptoms included depressed mood; suspiciousness; panic attacks weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; and suicidal ideation.  Mental status examination showed the Veteran to be alert and fully oriented.  Grooming was good and he was casually dressed.  Affect was somber and mood was dysphoric.  There was no evidence of formal thought disorder.  The diagnoses included PTSD, major depressive disorder, and cognitive disorder.  GAF score of 41 was assigned.  The examiner indicated that the Veteran's depression was part of his PTSD diagnosis.  PTSD symptoms were reported to include re-experiencing traumatic memories, avoidance, and hyperarousal.  Major depression symptoms were noted to be pervasive sadness, poor motivation, guilt, and thoughts of death.  Cognitive disorder symptoms included deficits in visual short-term memory and visual processing speed.

The examiner concluded that the Veteran's symptoms of PTSD and depression caused very significant occupational impairment and very significant social impairment, explaining that the Veteran could not keep a job in environments requiring much interaction with others, had difficulty with sustained concentration, was emotionally detached from others including his own family, did not desire or enjoy social interactions, avoided crowds as much as possible, and spent most of his time in a room by himself.  The examiner concluded that the Veteran's diagnosed mental disabilities caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood.  The examiner noted that approximately 80 percent of his occupational and social impairment was attributable to his PTSD and secondary depression, and that 20 percent was attributable to his unrelated cognitive disability.  

VA treatment records from March 2011 through January 2013 reflect continued diagnoses of and treatment for PTSD.  The treatment records show that the Veteran reported symptoms including depression, irritability, anger outbursts, loss of temper, guilt, sleep disturbance, anergia, nightmares, intrusive thoughts, flashbacks, avoidance of trauma-related stimuli, hypervigilance, emotional numbing, sense of foreshortened future, and survivor's guilt.  Mental status examinations showed the Veteran to be alert and oriented.  Mood was unstable, irritable, stable, euthymic, depressed, sad, or guilty.  Affect was congruent with mood or mobile.  He denied confusion or disorientation.  He was clean and well-groomed.  Verbalizations were logical and clear, and speech was normal.  The Veteran was alert and fully oriented.  Thinking was logical and well-organized.  GAF scores of 40, 45, and 55 were assigned.  The Veteran regularly denied suicidal and homicidal ideation.  In March 2011, he reported that he felt guilty for having spanked his daughter when angry.  He denied ever striking his wife.  He reported that he had not worked since June 2010.  He noted that he has had interviews for jobs, but no job offers.  He explained that he has lost his temper in the workplace before and received verbal warnings for throwing objects when angry, yelling, and becoming confrontational.  The diagnoses included PTSD and major depression, and the physician reported that the Veteran's symptoms were moderate and related to recurrent episodes of exacerbation of symptoms, ongoing occupational and social impairment with deficits in work, family, school, marital relations, and a pattern of poor judgment and impaired impulse control resulting in an inability to establish and maintain effective relationships.  In August 2011, the Veteran reported that he got a job.  In September 2011, the Veteran stated that he had been working for three weeks, but that his job was temporary and he hoped that it would become permanent.  In October 2011, the Veteran reported that he lost his job, but that he thought that he might have another job.  He indicated that he was let go due to a reduction in force.  In November 2011, the Veteran stated that he began working at a welding job at a company close to home with a comfortable schedule.  In December 2011, the Veteran reported that he lost his job and felt responsible, although he could not figure out what he was doing wrong.  He stated that he was sleeping all day and night and becoming more depressed.

As noted above, the Veteran is currently assigned a 50 percent evaluation for his PTSD prior to March 19, 2008.  A 50 percent rating contemplates 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 and maintaining effective work and social relationships.  38 C.F.R. § 4.130, Diagnostic Code 9411.

GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness."  Carpenter, 8 Vet. App. at 242.  The Veteran's GAF scores of 55 indicate moderate symptoms or moderate difficulty in social, occupational, or school functioning.  

Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria.  See Carpenter, 8 Vet. App. at 242.  Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment.  Id.; see also 38 C.F.R. § 4.126 (2012); VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995).

Prior to March 19, 2008, the Veteran's PTSD symptoms included depression, anergia, anhedonia, poor concentration, irritability, tearfulness, nightmares, intrusive thoughts and memories, flashbacks, avoidance of trauma-related stimuli, hypervigilance, exaggerated startle response, emotional numbing, sense of foreshortened future, sleep disturbance, anxiety, road rage, poor memory for trauma, diminished interest in significant activities, detachment or estrangement from others, social isolation, conflicts with co-workers, anger outbursts, mood swings, emotional distance, and trouble controlling anger.  The medical evidence shows that the Veteran's grooming and hygiene were fair, his thoughts were logical, and there was no evidence of hallucinations or paranoia.  Mood was depressed and affect was variable or restricted.  The Veteran regularly denied homicidal ideation, but reported occasional suicidal thoughts.  Psychomotor activity reflected persistent mannerisms.  Speech and thought content were unremarkable.  There were no delusions and insight and judgment were intact.  There was no inappropriate behavior and there was no obsessive or ritualistic behavior.  There were panic attacks one to three times per week.  Impulse control was good and memory was normal.

After a thorough review of the evidence of record, the Board concludes that an increased rating greater than 50 percent is not warranted for the Veteran's PTSD prior to March 19, 2008.  Although there is some evidence of suicidal ideation and constant depression, there is no evidence of obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; impaired impulse control; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or inability to establish and maintain effective relationships.  Moreover, the Veteran was regularly employed or attending school prior to March 19, 2008.  Although the evidence of record may demonstrate two of the symptoms contemplated in a 70 percent evaluation, the Veteran's disability picture prior to March 19, 2008 more closely corresponds to the requirements for a 50 percent evaluation.  Thus, although the evidence reflects some difficulties in family relations and mood, the evidence does not establish occupational and social impairment with deficiencies in most areas, such as work, school, judgment, or thinking, sufficient to establish entitlement to a rating greater than 50 percent for PTSD prior to March 19, 2008.  38 C.F.R. § 4.130, Diagnostic Code 9411.

The Veteran is assigned a 70 percent evaluation from March 19, 2008 to November 20, 2010, and on and after February 1, 2011.  A 70 percent disability rating contemplates 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 worklike setting); inability to establish and maintain effective relationships.  Id.

From March 19, 2008 to November 20, 2010, the evidence demonstrates GAF scores of 45 and 55.  The Veteran's GAF score of 45 reflects serious symptoms or any serious impairment in social, occupational, or school functioning.  The GAF score of 55 indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning.  See DSM-IV at 46-47. 

From March 19, 2008 to November 20, 2010, the Veteran's PTSD symptoms included low mood, markedly diminished interest in significant activities, sleep disturbance, psychomotor agitation, fatigue, difficulty concentrating, recurring thoughts of death, diminished interest in previously enjoyed hobbies, nightmares, avoidance of crowds, anger outbursts, irritability, avoidance of trauma-related stimuli, detachment and estrangement from others, sense of foreshortened future, hypervigilance, exaggerated startle response, social isolation, poor memory, constant depression, confrontations at work, emotional numbing, anger, poor impulse control, anergia, anhedonia, tearfulness, and survivor guilt.  The Veteran also expressed a fear of becoming physically abusive due to loss of temper.  He indicated that he had difficulty establishing and maintaining relationships, as he had a strained relationship with his wife and daughter and one close friend.  The medical evidence of record showed good grooming and hygiene, slow speech, and unremarkable psychomotor activity.  The Veteran's mood was agitated, depressed, stable, euthymic, unstable, or irritable, and his affect was appropriate or restricted.  He was alert and fully oriented with intact attention.  The Veteran complained of suicidal and homicidal ideation and reported persecutory delusions which were not persistent.  He also identified visual hallucinations, auditory hallucinations, and olfactory hallucinations.  Insight and judgment were intact.  There was some obsessive and ritualistic behavior reported, but there was no inappropriate behavior.  The Veteran endorsed panic attacks and poor impulse control with no episodes of violence.  He described verbal aggression.  Remote and recent memory were reported to be normal.  A March 2008 VA examiner observed that the Veteran was employed full-time as a welder, but that his PTSD caused problems with occupational functioning.  The examiner indicated that the Veteran did not have total occupational and social impairment due to PTSD, and that his PTSD symptoms did not result in deficiencies in judgment, thinking, family relations, work, mood, and school.  A later treatment record shows that the Veteran was laid of from his job in February 2009, and that he was not employed again before November 2010.

After a thorough review of the evidence of record, the Board concludes that an evaluation greater than 70 percent is not warranted for the Veteran's PTSD from March 19, 2008 through November 10, 2010.  Although some of the symptomatology described for a 100 percent evaluation are shown, including persistent delusions or hallucinations and persistent danger of hurting self or others, there is no evidence of gross impairment in thought processes or communication, grossly inappropriate behavior, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name.  Moreover, the March 2008 VA examiner stated that the Veteran did not have total occupational and social impairment due to PTSD, and that his PTSD symptoms did not result in deficiencies in judgment, thinking, family relations, work, mood, and school.  Although the Veteran was later laid off from his job and exhibited problems with occupational functioning, the evidence does not show total occupational and social impairment.  Thus, as the Veteran's disability picture from March 19, 2008 to November 20, 2010 more closely corresponds to the requirements for a 70 percent evaluation, the evidence does not more nearly approximate an evaluation greater than 70 percent.  Accordingly, an increased evaluation greater than 70 percent is not warranted for the Veteran's PTSD from March 19, 2008 to November 20, 2010.  38 C.F.R. § 4.130, Diagnostic Code 9411.

On and after February 1, 2011, the evidence demonstrates GAF scores of 40, 45 and 55.  The Veteran's GAF scores of 40 and 45 reflect serious symptoms or any serious impairment in social, occupational, or school functioning.  The GAF score of 55 indicates moderate symptoms or moderate difficulty in social, occupational, or school functioning.  See DSM-IV at 46-47. 

On and after February 1, 2011, the Veteran's PTSD symptoms included anger, short temper, sleep disturbance, fatigue, anger outbursts, road rage, constant depression, nightmares, intrusive thoughts and memories, avoidance of trauma-related stimuli, flashbacks, detachment and estrangement from others, sense of foreshortened future, difficulty concentrating, hypervigilance, exaggerated startle response, guilt, anxiety, irritability, anergia, and emotional numbing.  The Veteran reported that he was attending marriage counseling with his wife, and that he enjoyed hobbies such as motorcycle riding and welding.  The medical evidence of record shows that the Veteran was alert and fully oriented, had good grooming and hygiene, and normal speech.  There was evidence of auditory hallucinations; sad, guilty, anxious, dysphoric, unstable, irritable, and depressed mood; appropriate, constricted, restricted, or mobile affect; racing, illogical, blocking, logical, or well-organized thought process; obsessive and ritualistic behavior; impaired judgment, panic attacks; poor impulse control; impaired recent and immediate memory; and problems with the activities of daily living.  The Veteran reported suicidal and homicidal ideation in some instances, but denied it in others.  He denied a history of violence, but reported that he spanked his daughter, reported a fear that he would become violent due to his inability to control his temper, and complained of anger outbursts.  The January 2012 VA examiner found that the Veteran's PTSD and depression caused very significant occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood.  The examiner attributed 80 percent of his occupational and social impairment to his PTSD and depression, and 20 percent to his cognitive disability.  However, the March 2011 VA examiner found that the Veteran's PTSD alone caused total occupational and social impairment due to such symptoms as gross impairment in thought process; grossly inappropriate behavior evidenced by social withdrawal, chronic fatigue, and angry outbursts; persistent danger of hurting himself or others; intense reexperiencing of the trauma; and memory loss for dates and appointments.

After a thorough review of the evidence of record, the Board concludes that, although not all of the symptomatology described under the relevant diagnostic code is demonstrated, the Veteran's symptoms more closely approximate the requirements for a 100 percent evaluation for PTSD on and after February 1, 2011, as there is evidence of persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; and memory loss for dates and appointments.  Moreover, the March 2011 VA examiner found that the Veteran's PTSD alone caused total occupational and social impairment.  Accordingly, affording the Veteran the benefit of the doubt, the Board concludes that a 100 percent rating is warranted for the Veteran's PTSD on and after February 1, 2011.  38 C.F.R. § 4.130, Diagnostic Code 9411.

The Board has also considered the Veteran's symptoms which are not specifically contemplated by the Rating Schedule during all periods on appeal, such as nightmares, hypervigilance, sleep disturbance, poor concentration, exaggerated startle response, loss of interest, irritability, avoidance of crowds, mood swings, exaggerated startle response, and intrusive thoughts and memories.  While those symptoms certainly contribute to the impairment caused by the Veteran's PTSD, they do not show occupational and social impairment sufficient to warrant a 70 percent evaluation prior to March 19, 2008, or a 100 percent evaluation from March 19, 2008 to November 20, 2010.  Mauerhan, 16 Vet. App. 436.
An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability.  Thun v. Peake, 22 Vet. App. 111, 115 (2008).  If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization.  Id. at 115-116.  When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of an extraschedular evaluation.  38 C.F.R. § 3.321(b)(1) (2012).  Otherwise, the schedular evaluation is adequate, and referral is not required.  Thun, 22 Vet. App. at 116.

The schedular ratings in this case are adequate.  Ratings in excess of those assigned are provided for certain manifestations of the service-connected PTSD, but the medical evidence reflects that those symptoms are not present.  The diagnostic criteria also adequately describe the severity and symptomatology of the Veteran's PTSD.  He has not required hospitalization during the time periods on appeal, and any interference with employment has been accounted for in the assigned evaluations.  Moreover, a claim for entitlement to a TDIU is addressed in the Remand portion of this decision, below.  Therefore, the Veteran's disability picture is contemplated by the Rating Schedule; no extraschedular referral is required.


ORDER

Entitlement to an initial rating greater than 50 percent for PTSD prior to March 19, 2008 is denied.

Entitlement to an increased rating greater than 70 percent for PTSD from March 19, 2008 to November 20, 2010 is denied.

Entitlement to a 100 percent rating for PTSD on and after February 1, 2011 is granted.
REMAND

I.  Respiratory Disability

The Veteran alleges that service connection is warranted for a respiratory disability, manifested by chronic cold symptoms.  He claims that his cold symptoms are the result of an undiagnosed illness.  In February 2011, the Veteran's claim was remanded to the RO to obtain a medical opinion regarding the diagnosis and etiology of the Veteran's respiratory symptoms.  The Board requested that the examiner provide an opinion as to whether the Veteran's respiratory symptoms were the result of an undiagnosed illness, or whether they were attributable to a known clinical diagnosis.  If the examiner concluded that the symptoms were the result of a known diagnosis, the Board asked that the examiner provide an opinion as to whether the Veteran's diagnosed respiratory disability was related to his active duty service.

The Veteran underwent a VA respiratory examination in March 2011.  The Veteran reported symptoms including shortness of breath, a sensation of throat closing, and productive cough.  The examiner diagnosed chronic bronchitis with a date of onset in 2010.  In December 2011, the examiner provided a medical opinion finding that it was less likely than not that the Veteran's diagnosed respiratory disability was incurred in or caused by his active duty service, attributing the Veteran's bronchitis to his smoking history and post-service exposure to toxic fumes while working as a welder.

After a thorough review of the evidence in the claims file, the Board does not find the March 2011 VA examination and December 2011 opinion to be adequate in this case.  Review of the record reflects substantial relevant evidence which was not addressed by the examiner in the December 2011 opinion.  Specifically, the Veteran's service treatment records reflect diagnoses of and treatment for various respiratory illnesses and symptoms, including upper respiratory infections and chest pain with dry cough.  In October 1990, the Veteran stated that he was taking cold medication.  In an April 1991 report of medical history, the Veteran indicated a history of hay fever.  Moreover, the post-service medical evidence reflects numerous diagnoses of and treatment for rhinitis, sinusitis, allergies, and possible hay fever as early as 2005 (five years prior to when the examiner stated that the Veteran's bronchitis began) which were not addressed by the VA examiner.  Accordingly, as the VA examiner did not address all of the pertinent evidence in the claims file, the Board does not find the December 2011 opinion to be adequate.  Barr, 21 Vet. App. at 312 (holding that once VA undertakes the effort to provide an examination for a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one).  Therefore, the Veteran must be afforded a new VA examination to determine the etiology of any diagnosed respiratory disability.

II.  TDIU

VA will grant entitlement to a TDIU when the evidence shows that a veteran is precluded, by reason of service-connected disabilities, from securing or following a substantially gainful occupation.  38 C.F.R. § 4.16 (2012).

A TDIU claim is part of an increased rating claim when such claim is raised by the record.  Rice v. Shinseki, 22 Vet. App. 447 (2009).  The Veteran is currently service connected for PTSD, rated at 50 percent disabling prior to March 19, 2008, 70 percent disabling from March 19, 2008 to November 20, 2010, and 100 percent disabling on and after November 21, 2010.  The evidence of record reflects that, despite his continued efforts to find employment, the Veteran has lost many jobs, in part, due to his PTSD symptoms.  The evidence also reflects that his PTSD symptoms interfered with his job performance and relationships with his co-workers and employers.  Thus, the Board finds that the issue of entitlement to a TDIU prior to November 21, 2010 has been raised by the record.  

However, the evidence of record prior to November 21, 2010 is unclear as to whether the Veteran's service-connected disabilities rendered him unemployable.  Accordingly, a VA opinion addressing the Veteran's employability prior to November 21, 2010 is warranted.

Accordingly, the case is REMANDED for the following action:
1.  Schedule the Veteran for a new VA examination to determine the nature and etiology of all diagnosed respiratory disabilities, including bronchitis, rhinitis, sinusitis, allergies, and hay fever.  The claims file and a copy of this Remand must be made available to the examiner in conjunction with the examination.  All pertinent symptomatology and findings must be reported in detail.  Following a thorough review of the claims file, to include the service and post-service treatment records which reflect diagnoses of and treatment for various respiratory disabilities and symptoms, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or more) that any diagnosed respiratory disability began during service or is otherwise related to service.  A complete rationale for all opinions must be provided.

2.  Schedule the Veteran for an examination to determine whether his service-connected disabilities resulted in unemployability prior to November 21, 2010.  The claims file and a copy of this Remand must be made available to and reviewed by the examiner.  Following a review of the service and post-service medical records, the VA examiner must state whether, prior to November 21, 2010, the Veteran was unable to secure or follow a substantially gainful occupation due solely to his service-connected disabilities, consistent with his education and occupational experience, without consideration of his age and any nonservice-connected disabilities.  The opinion must be based on the review of the claims file, to include the multiple VA examination reports of record.  A complete rationale must be provided for any opinions expressed.  

2.  Notify the Veteran that he must report for any scheduled examination and cooperate in the development of the claims.  Failure to report for a VA examination without good cause may result in denial of the claim.  38 C.F.R. §§ 3.158, 3.655 (2012).

3.  After completing the above development, and any other development deemed necessary, readjudicate the issues on appeal.  If any benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board for appellate review, after the Veteran has had an adequate opportunity to respond.

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).



______________________________________________
ROBERT C. SCHARNBERGER
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs