Citation Nr: 1326759 Decision Date: 08/21/13 Archive Date: 08/29/13 DOCKET NO. 10-48 559 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Phoenix, Arizona THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD M. Donohue, Counsel INTRODUCTION The Veteran served on active duty from December 1944 to November 1946. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In that decision, the RO granted service connection for PTSD and assigned a 10 percent evaluation effective from May 12, 2009. Jurisdiction of the case was subsequently transferred to the RO in Phoenix, Arizona. During the pendency of the appeal, the RO issued a rating decision in May 2012 which granted the Veteran an increased evaluation of 30 percent for his PTSD effective as of February 27, 2011. The Veteran testified at a hearing before the undersigned Veterans Law Judge in March 2013. A transcript of the hearing has been associated with the claims file. The Board remanded the Veteran's appeal for additional development in May 2013. Following the Board's remand, in a June 2013 rating decision, the RO granted an increased rating for the Veteran's PTSD. Specifically, the 10 percent rating that was in effect prior to February 27, 2011, was increased to 30 percent. As a result, a 30 percent rating is currently in effect for the entire appeal period. While the Veteran has been granted a 30 percent disability rating throughout the appeal period, applicable law mandates that, when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). Thus, the issue of entitlement to an increased evaluation remains on appeal. Following the June 2013 supplemental statement of the case, the Veteran submitted additional evidence and written argument. The RO has not considered this evidence, however, the Veteran has waived consideration of such evidence by the agency of original jurisdiction. See 38 C.F.R. § 20.1304 (2012). Please note this appeal has been advanced on the Board's docket pursuant to 38 U.S.C.A. § 7107(a)(2) (West 2002); 38 C.F.R. § 20.900(c) (2012). The issue to entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. FINDING OF FACT The Veteran's PTSD has been productive of no more than 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 conversation normal). CONCLUSION OF LAW The criteria for an initial evaluation in excess of 30 percent for PTSD have not been met or approximated. 38 U.S.C.A. §§ 1155, 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 FINDING AND CONCLUSION After the evidence has been assembled, the Board is responsible for evaluating the entire record. 38 U.S.C.A. § 7104(a) (West 2002). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. See 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.102 (2012). Indeed, in Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. The Board notes that it has reviewed all of the evidence in the claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate the issue adjudicated herein and what the evidence in the claims file shows, or fails to show, with respect to this claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). I. The Veterans Claims Assistance Act of 2000 (VCAA) Upon receipt of a substantially complete application for benefits, VA must notify the claimant what information or evidence is needed in order to substantiate the claim and it must assist the claimant by making reasonable efforts to get the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A (West 2002); 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice required must be provided to the claimant before the initial unfavorable decision on a claim for VA benefits, and it must (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1); Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. With regard to claims for increased disability ratings for service-connected conditions, the law requires VA to notify the claimant that, to substantiate a claim, the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded sub nom. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant Diagnostic Codes, which typically provide for a range in severity of a particular disability from noncompensable to as much as 100 percent (depending on the disability involved), based on the nature of the symptoms of the condition for which disability compensation is being sought, their severity and duration. Finally, the notice must provide examples of the types of medical and lay evidence that the Veteran may submit (or ask the VA to obtain) that are relevant to establishing her or his entitlement to increased compensation. However, the notice required by section 5103(a) need not be specific to the particular Veteran's circumstances; that is, VA need not notify a Veteran of alternative diagnostic codes that may be considered or notify of any need for evidence demonstrating the effect that the worsening of the disability has on the particular Veteran's daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The notice must be provided prior to an initial unfavorable decision by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Nevertheless, the Veteran in this case is challenging the initial evaluation assigned following the grant of service connection for PTSD. In Dingess, the Court held that, in cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Id. at 490-91. See also VAOPGCPREC 8- 2003 (December 22, 2003). Thus, VA's duty to notify has been satisfied with respect to the issue of entitlement to a higher initial evaluation for his PTSD. In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records as well as all identified and available post-service medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the claim. The Veteran has not identified any outstanding records that are available and relevant to the issue being decided herein. The Veteran was also provided an opportunity to testify at a hearing before the Board in March 2013. During that hearing, the undersigned Veterans Law Judge identified the issue on appeal. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony and questioning by his representative, demonstrated his actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that VA complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). As noted above, the Board remanded the Veteran's claim for additional development in May 2013. In particular, the Board requested that additional treatment records be obtained and that the Veteran be afforded an additional VA examination. The record reveals that the Appeals Management Center (AMC) sent the Veteran a letter in May 2013 requesting that identify or submit any additional records that he might have in his possession, to include the records from Dr. B. (initials used to protect privacy) that he identified during the hearing. In response, the Veteran submitted an additional VA treatment record, but he did not provide or authorize VA to obtain his treatment records from Dr. B. The duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). VA is only obligated to obtain records that are adequately identified and for which necessary releases have been submitted. 38 C.F.R. § 3.159(c)(1). The Veteran was also provided with the requested VA examination in June 2013. Upon review, this examination complied with the Board's remand instructions, as the examination report contains all findings necessary under the rating criteria. In addition, the AMC mailed a supplemental statement of the case to the Veteran's in June 2013. Thus, there has been compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance); see also Dyment v. West, 13 Vet.App. 141, 146-47 (1999) (although under Stegall VA is required to comply with remand orders, substantial compliance, not absolute compliance, is required). Moreover, as the Board will discuss in its analysis, the Veteran was provided with VA examinations in June 2009, February 2011, and June 2013. The reports from these examinations reflect that the examiners reviewed the Veteran's medical history, recorded his current complaints, conducted appropriate clinical examinations, and provided the findings necessary under the rating criteria. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board therefore concludes that the examinations are adequate for rating purposes. See 38 C.F.R. § 4.2 (2012). There is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disability since he was last examined. 38 C.F.R. § 3.327(a). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. VAOPGCPREC 11- 95. Thus, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). The Board further observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has been accorded the opportunity to present evidence and argument in support of his claim. He exercised the option of a personal hearing and was afforded one in March 2013 as previously discussed. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and that no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claim. II. Law and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the "present level" of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending. Hart v. Mansfield, 21 Vet. App. 505 (2007). Similarly, where a veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. In this case, the Veteran's service-connected PTSD is currently rated under 38 C.F.R. § 4.130 Diagnostic Code 9411 (posttraumatic stress disorder). In this case, the Board has considered whether another rating code is "more appropriate" than the one used by the RO, Diagnostic Code 9411. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Upon review, Diagnostic Code 9411 is deemed by the Board to be the most appropriate code primarily because it pertains specifically to the diagnosed disability in the Veteran's case (PTSD). In any event, with the exception of eating disorders, all mental disorders are rated under the same criteria in the rating schedule. Therefore, rating under another diagnostic code would not produce a different result. Accordingly, the Board concludes that the Veteran is appropriately rated under Diagnostic Code 9411. Under the general rating formula for mental disorders, a 30 percent evaluation is contemplated 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 conversation 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). A 50 percent evaluation is for assignment when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereo-typed speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability evaluation is contemplated for 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. A 100 percent evaluation is warranted when there is evidence of 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; memory loss for names of close relatives, own occupation, or own name. The symptoms listed in the rating schedule are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." A Global Assessment of Functioning (GAF) score is highly probative because it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). 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 FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), p. 32]. GAF scores ranging between 41 and 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 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). GAF scores ranging from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV for rating purposes). III. Analysis In this case, the Veteran's service-connected PTSD is currently rated as 30 percent disabling. For the reasons explained in greater detail below, the Board finds that a disability rating in excess of 30 percent is not warranted at any time during the appeal period. As noted above, the assignment of a 50 percent disability rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and, difficulty in establishing effective work and social relationships. However, the Board's inquiry is not necessarily strictly limited to the criteria found in the VA rating schedule. See Mauerhan, supra. During an April 2009 initial VA outpatient psychiatric history and assessment, the Veteran stated that he has been experiencing nightmares and is easily startled. He denied experiencing depression, lack of concentration, panic attacks, anxiety, and suicidal or homicidal ideations. He reported that he checks "things faithfully every night" and avoids large crowds. A mental status examination revealed that the Veteran was neatly dressed and groomed. His behavior was cooperative, and he was alert and oriented in all spheres. The Veteran's speech was normal, and his mood was "fine." His affect was euthymic, and his thought process was linear. The Veteran denied having suicidal ideation, homicidal ideation, and auditory or visual hallucinations. The April 2009 VA psychiatrist diagnosed the Veteran with PTSD. On Axis IV, the psychiatrist indicated that the Veteran's stressors were "moderate" but assigned a GAF score of 65. During a June 2009 VA examination, the Veteran complained of difficulty sleeping and being easily startled. He acknowledged having an exaggerated startle response and hypervigilance. The Veteran reported having difficulty with anger and described engaging in "verbal altercations"; however, he denied having a history of violence. While the Veteran stated that he avoids large crowds, he reported having "lots" of friends and that he "enjoys having lunch, dinner, going to concerts and plays with them." He also reported frequent attendance at church and at weekly bible studies. It was noted that the Veteran had been retired for approximately 12 years and volunteers part-time at a veterans home. He denied "any lost time from work related to mental health struggles." A clinical examination conducted at that time revealed that the Veteran was alert and fully oriented. His grooming was good, and his mood was euthymic. The Veteran's affect was described as appropriate, and his speech was normal in rate or tone. His judgment and thought process were described as normal, and the Veteran denied suicidal or homicidal ideations. His judgment and insight were satisfactory, and his impulse control was described as appropriate. The June 2009 VA examiner diagnosed the Veteran with PTSD and assigned a GAF score of 65. He reported that the Veteran symptomatology was in the "mild range." It was noted that the Veteran "continues to volunteer part-time as well as be involved in many extra activities including church and working out. He maintains a relationship with his wife as well as friends." In a February 2010 statement, the Veteran reported that his symptoms had been changing and inquired why his GAF score had not changed as well. Specifically, the Veteran stated that his concentration, memory, confusion, nightmares, depression, and temper had all worsened. However, he also reported that he had hope for the future and was content. While receiving VA outpatient treatment in August 2009, the Veteran reported that he "has been doing well." His mood was described as "good," and he denied experiencing depression, manic symptoms, paranoia, hallucinations, and suicidal or homicidal ideations. It was noted that he had been attending PTSD groups and found it to be helpful. He reported that he spends time with his grandchildren and exercises three times a week. A mental status examination conducted at that time revealed that the Veteran was neatly dressed and groomed and cooperative, and his speech was of normal rate and rhythm. The Veteran's thought process was linear, and there was no thought content impairment, to include paranoia, hallucinations, thought broadcasting, and suicidal or homicidal ideation. He was diagnosed with PTSD and assigned a GAF score of 65. In January 2010, the Veteran reported that his wife was not doing well and that he "almost lost her." He reported that his mood has been more irritable and that he had an increase in his PTSD symptoms. While the Veteran's mood was described as "stressed" and his affect was described as "anxiety," the treating clinician continued the assigned GAF score of 65. While receiving VA treatment in June 2010, the Veteran reported that he had recently tripped and fell, but was "doing ok" mentally. He reported that his medication was helping and denied experiencing depression, hopelessness, lack of concentration, suicidal or homicidal ideation, manic symptoms, anxiety, and panic attacks. The Veteran reported that he volunteers as a chaplain, occasionally hikes, and enjoys spending time with his grandchildren. A clinical examination noted that the Veteran was appropriately groomed and fully oriented with no speech impairments. His mood was "ok," and he displayed a normal range of affect. A VA mental health note from November 2010 documented that the Veteran had been under increasing family stress, including his daughter being diagnosed with breast cancer "several years ago." It was noted that this stress had exacerbated his PTSD symptoms to the point that his wife now slept in another room. The Veteran stated that he continued to have difficulty sleeping and would scream in his sleep. A clinical examination revealed that the Veteran was alert and oriented. His speech was of normal rate and rhythm, and his mood was stable with an anxious affect. His recent and remote memory was described as intact. His judgment and insight were good, and his thought content and processes were appropriate. The treating psychologist diagnosed the Veteran with PTSD and assigned a GAF score of 50. The Veteran was afforded an additional VA examination in February 2011. During the examination, the Veteran reported that his symptoms have improved under his current medication regimen and specifically noted that his anger, irritability, and anxiety had all decreased in severity. He reported that he experiences nightmares twice a week and still had angry, verbal outbursts. The Veteran reported that engages in hypervigilant behaviors and experiences intrusive thoughts and an exaggerated startle response. He reported that he gets along well with his wife and has frequent contact with his children. He continued to be active in his church and volunteered six to seven hours per week. It was noted that the Veteran "continues to have a number of friends that he socializes with," but did indicate that he had an occasional verbal outburst and irritability. A clinical examination revealed that the Veteran's immediate, recent, and remote memories were intact. He was oriented in all spheres, and his speech was normal, but with a noticeable increase in the level of emotionality when discussing his active duty stressors. The Veteran's thought process was spontaneous and sometimes overabundant with detail. His continuity of thought "contained considerable rambling," but could be goal-directed and relevant when refocused. His thought content did contain some preoccupation with his past military experiences. The examiner noted that the Veteran did not express any suicidal or homicidal ideation, and there were no delusions, ideas of reference, or feelings of unreality. His mood was anxious and his range of affect was broad. It was noted that the Veteran was pleasant and had a talkative demeanor accompanied by a sense of humor. He was alert, responsive, and cooperative. His judgment was described as adequate. The February 2011 VA examiner diagnosed the Veteran with PTSD and provided a GAF score of 55. He reported that there had not been a permanent increase in severity of his PTSD as a result of the recent family stressors. "In fact, the Veteran's own subject[ive] report is that there has been recent improvement with his medication regimen." The examiner opined that the Veteran's "current symptomatology relevant to [PTSD] is in the moderate range." The claims folder contains a May 2012 apology letter from the Veteran. This letter indicates that the Veteran was staying at a hospital overnight when a nurse or security guard woke him up between three and four in the morning. The Veteran apparently responded to the situation with anger and apologized. He assured the employee that he never had any intention to cause physical harm and explained that he has problems controlling his emotions as a result of active-duty stressors which occurred at night. During the March 2013 hearing, the Veteran testified that he experiences night terrors where he will scream in his sleep. See the hearing transcript, page 4. He stated that he experiences panic attacks several times a week. Id at 6. While the Veteran will have dinner at his daughter's house every Sunday and participates in a weekly Bible study group, he reported that he feels isolated due to his PTSD. The Veteran also complained of short-term memory loss and reported that he will lose his temper six times per week. The Veteran's wife testified that the Veteran has problems with his mood and motivation. During a June 2013 VA PTSD examination, the Veteran reported experiencing nightmares, irritability, and anxiety. It was noted that he remained active, babysits his grandchildren, and attends church and a Bible study group. He holds weekly family dinners with his wife and runs errands and does chores. The VA examiner stated that the Veteran's PTSD symptoms include anxiety, suspiciousness, chronic sleep impairment, and mild memory loss. It was noted that he had not been hospitalized for his PTSD and that his "symptom presentation, his function, and impairments are similar" to those reported during the February 2011 VA examination. The examiner stated that the Veteran's condition is "moderate in severity" and indicated that his condition requires continuous medication and the Veteran has to fight irritability. He opined that the Veteran's symptomatology results in "occupational and social impairment with occasional decrease in work efficiency and intermittent period of inability to perform occupational tasks, although generally functioning satisfactory with normal routine behavior, self-care and conversation." A GAF score of 55 was assigned. In support of his claim, the Veteran submitted a June 2012 VA neurology psychology consultation note. This treatment record indicates that the Veteran's wife has noticed a gradual decline in the Veteran's memory, increased sadness, isolation, and an inability to read "nonverbal social cues," but these symptoms might be "at least partially due to his poor hearing." Upon observation and clinical examination, the VA psychologist noted that the Veteran's speech was normal, but his thought process was "often tangential and over-inclusive." There was no evidence of delusion, hallucinations, or paranoia, and the Veteran displayed full affect. Testing revealed "impairments in attention, phonemic fluency, visual memory, immediate and delayed recall of rote auditory information, executive functioning, verbal, abstract reasoning, and aspects of visuoconstructional/visuospatial skills." It was noted that these test results likely represented a decline from his previous functioning. The record indicates that the Veteran has been married to his wife for more than 50 years. In a May 2009 statement, the Veteran's spouse indicated that, shortly after they were married, she woke up to find the Veteran in the kitchen. When she went to check on him, he became angry, accused her of sneaking up on him, and threw a chair into a wall. The Veteran's spouse indicated that her husband has continued to experience nightmares and noted that his temper has been getting shorter. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an initial evaluation in excess of 30 percent at any time during the appeal period. A 30 percent rating is warranted where the Veteran demonstrates 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 conversation normal). To warrant a 50 percent rating, the evidence must demonstrate occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. Under Mauerhan, supra, an analysis of the Veteran's PTSD symptoms is not limited to those mentioned in the ratings criteria, and the Board has considered factors outside of the specific ratings criteria, such as the Veteran's irritability, isolation, and hypervigilance. The Board recognizes that the Veteran has demonstrated some of the symptoms specified in the 50, 70 and 100 percent rating criteria, such as some memory impairment, an impaired affect, panic attacks, and disturbances of mood and motivation. However, the presence of certain symptoms is not necessarily determinative. These symptoms must also cause the occupational and social impairment in the referenced areas. See Vazquez-Claudio, supra. Upon review of the evidence, the Board finds that the Veteran's PTSD symptoms more closely approximate the rating criteria for a 30 percent evaluation. As to work, the record indicates that the Veteran retired in 1997. See a June 2012 treatment record. He has asserted that he would be unable to work due to his PTSD, yet he volunteered as a chaplain in a veterans home for 10 years. He later stopped because he could no longer drive. There is no indication that his PTSD prevented him from volunteered or otherwise interfered with such activity. See the March 2013 hearing transcript, page 11. While the VA examinations reveal that the Veteran has memory problems and concentration problems and is startled by loud noises, he reported during the June 2009 VA examination that he did not lose any time from work due to his PTSD. Thus, the evidence suggests that the Veteran did not have reduced reliability or productivity in his occupation due to his PTSD symptoms. As to social impairment, the Veteran testified during the March 2013 hearing that he does not have friends because most of them have passed away. However, he indicated that he attends a Bible study class every week and has weekly dinners with his family. The record also indicates that the Veteran babysits his grandchildren and has been married to his wife for more than 50 years. While he experiences irritability, the Veteran reported to the June 2013 VA examiner that he and his wife get along well. Thus, while the Veteran may have had some social impairment, the evidence shows that he was able to establish and maintain social relationships. Moreover, during the June 2013 VA examination, the VA examiner stated that the Veteran's psychiatric symptoms resulted in "occupational and social impairment with occasional decrease in work efficiency and intermittent period of inability to perform occupational tasks, although generally functioning satisfactory with normal routine behavior, self-care and conversation." Such findings correspond to a 30 percent evaluation under the rating criteria. After considering the evidence of record, the Veteran's symptoms more closely approximate the criteria for the currently assigned 30 percent disability rating. Overall, the Veteran has not demonstrated a level of impairment consistent with the 50 percent criteria, nor have the Veteran's symptoms caused occupational and social functioning in most of the areas referenced by the criteria referenced in the 50 percent evaluation. Mauerhan, supra; Vazquez-Claudio, supra. The evidence also shows that the Veteran had normal speech, panic attacks no more than once a week, fair insight, good judgment, normal thought processes, and no homicidal or suicidal ideation. While cognizant that the record indicates that the Veteran once threw a chair at a wall, the Veteran's spouse indicated that this happened shortly after they were married. VA treatment records also indicate that this happened "years ago." See an April 2009 VA Mental Health Treatment note. The record does not indicate that the Veteran has displayed any similar behavior during the appeal period. The criteria for the next higher rating of 50 percent have not been met or approximated for any period in this appeal. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board does observe that the Veteran has been assigned a Global Assessment of Functioning (GAF) score between 50 and 65. These GAF scores reflect mild to severe symptoms. See 38 C.F.R. §§ 4.125, 4.130 (incorporating the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, of the American Psychiatric Association in the rating schedule). While the Board has considered the degree of functioning as evidenced by these reported scale scores, they are but one factor for consideration in assigning a rating in this case. As outlined above, the Board finds that, when all of the evidence and findings contained therein are considered, including the degree of functioning as evidenced by these reported scales, the Veteran has not been shown to have occupational and social impairment occupational and social impairment with reduced reliability and productivity. Accordingly, the Board finds that the schedular criteria for the next higher 50 percent disability evaluation have not been met. Therefore, the Board finds that the preponderance of evidence is against an initial evaluation in excess of 30 percent for PTSD. In reaching this decision, the potential application of various provisions of Title 38 Code of Federal Regulations have been considered, whether or not they were raised by the Veteran. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In particular, the Board has considered the provisions of 38 C.F.R. § 3.321(b)(1). However, in this case, the Board finds that the record does not show that the Veteran's service-connected PTSD is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extraschedular referral is required. Id; see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extraschedular regulation (38 C.F.R. § 3.321(b)(1) ) as "governing norms" (which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected disability are inadequate. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology, which includes anxiety, sleep impairment, irritability, hypervigilance, memory loss, and impairment in mood and motivation. Indeed, the 30 percent evaluation contemplates the overall effect of all of his symptomatology on his occupational and social functioning. As discussed above, there are higher ratings available under the diagnostic code, but the Veteran's disability is not productive of such manifestations. Based on the foregoing, the Board finds that the requirements for an extraschedular evaluation for the Veteran's service-connected PTSD under the provisions of 38 C.F.R. § 3.321(b)(1) have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to an initial rating in excess of 30 percent for PTSD is denied. REMAND The Court has held that, if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted. Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, during the March 2013 hearing, the Veteran testified that the severity of his service-connected PTSD would prevent him from sustaining full-time employment. See the hearing transcript, page 11. Therefore, the RO/AMC should develop a claim for TDIU in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) The RO/AMC should consider whether the Veteran is entitled to TDIU under the provisions of 38 C.F.R. § 4.16, based on impairment attributable to his service-connected disabilities, in accordance with Rice v. Shinseki, 22 Vet. App. 447 (2009). In so doing, the RO/AMC may decide to pursue further development of the Veteran's employment history or to obtain additional medical evidence or medical opinion, as is deemed necessary. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court 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). ______________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs