Citation Nr: 1327442 Decision Date: 08/27/13 Archive Date: 09/05/13 DOCKET NO. 07-13 275A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to July 30, 2007, and in excess of 70 percent from July 30, 2007, to February 21, 2010. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J.A. Flynn, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1969 to December 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio that granted service connection for PTSD and assigned an initial 30 percent rating effective June 16, 2005. An April 2009 rating decision granted a 70 percent disability rating for PTSD effective July 30, 2007. This case was previously before the Board in January 2013, at which time the Board remanded the Veteran's claim in order to obtain outstanding treatment records and provide the Veteran with an additional examination. Additional treatment records were obtained, and the Veteran received an additional VA examination in February 2013. The Board finds that there has been substantial compliance with the remand instructions. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). A March 2013 rating decision granted a 100 percent disability rating for PTSD effective February 22, 2010. The issue of an increased rating for PTSD remains on appeal as to the period prior to February 22, 2010, because the increased rating does not represent the highest possible benefit for this period. AB v. Brown, 6 Vet. App. 35 (1993). The issue of entitlement to a TDIU is REMANDED to the RO via the Appeals Management Center, in Washington, D.C. FINDINGS OF FACT 1. Prior to May 22, 2007, the Veteran's PTSD is manifested by symptoms producing no more than occupational and social impairment with reduced reliability and productivity due to disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships. 2. From May 22, 2007, to February 21, 2010, the Veteran's PTSD was manifested by symptoms producing no more than occupational and social impairment with deficiencies in most areas due to suicidal ideation, obsessional rituals, near-continuous depression affecting the ability to function effectively, neglect of appearance and hygiene, and difficulty in adapting to stressful circumstances. CONCLUSIONS OF LAW 1. Prior to May 22, 2007, the criteria for an initial rating of 50 percent, but not greater, for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 2. From May 22, 2007, to July 30, 2007, the criteria for a rating of 70 percent, but not greater, for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 3. From July 30, 2007, to February 21, 2010, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim decided herein. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. Timberlake v. Gober, 14 Vet. App. 122 (2000) (Board must address reasons for rejecting evidence favorable to the veteran). The Board must assess the credibility and weight of all evidence to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Duty to Notify and Assist VA has a duty to notify a Veteran as to the information and evidence necessary to substantiate claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012). VA also has a duty to assist Veterans in the development of claims. 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2012). Upon receipt of a substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence that (1) is necessary to substantiate the claim; (2) VA will seek to provide; and (3) the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The issue of a higher initial disability rating is a downstream issue. Once a decision awarding service connection, a disability rating, and an effective date has been made, the notice has served its purpose, and its application is no longer required because the claim has already been substantiated. Sutton v. Nicholson, 20 Vet. App. 419 (2006). Because the issue on appeal relates to a claim for a higher initial rating for service-connected PTSD, the Board concludes that the notice requirements have been satisfied . VA has done everything reasonably possible to assist the Veteran with respect to his claims for benefits in accordance. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). The service medical records have been associated with the claims file. All identified and available treatment records have been secured, which includes VA treatment records, Vet Center records, and VA examination reports. The duty to assist includes, when appropriate, the duty to conduct a thorough and contemporaneous examination of the veteran. Green v. Derwinski, 1 Vet. App. 121 (1991). More specifically, a VA examination must be conducted when the evidence of record does not show the current state of the Veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 3.327(a) (2012). When VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran was provided with VA psychiatric examinations in October 2005, August 2007, October 2009, and February 2013. The examination reports indicate that the examiners recorded the Veteran's current complaints, conducted appropriate evaluations, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board concludes that the examination reports are adequate to make a decision in this appeal. 38 C.F.R. § 4.2 (2012); Barr v. Nicholson, 21 Vet. App. 303 (2007). In July 2006, the Veteran testified during a hearing before RO personnel, and a transcript of that hearing is associated with the claims file. The Veteran declined the opportunity to present testimony before a Veterans Law Judge. The Board observes that all due process concerns have been satisfied. 38 C.F.R. § 3.103 (2012). Accordingly, the Board will proceed to a decision. Schedular Rating of PTSD Disability ratings are determined by the application of a schedule of ratings, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). Separate diagnostic codes identify the various disabilities. 38 C.F.R. Part 4 (2012). When there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2012). In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to compensate entitlement to a higher rating during any period during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). The assignment of a particular diagnostic code is completely dependent on the facts of a particular case. Butts v. Brown, 5 Vet. App. 532 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, diagnosis, and demonstrated symptomatology. Any change in diagnostic code by a VA adjudicator must be specifically explained. Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Separate disabilities arising from a single disease entity are to be rated separately. 38 C.F.R. § 4.25 (2012); Esteban v. Brown, 6 Vet. App. 259 (1994). However, pyramiding, or rating the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating service-connected disabilities. 38 C.F.R. § 4.14 (2012). Under the General Rating Formula for Mental Disorders, a 30 percent rating is assigned for occupational and social impairment with occasional decreases 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for 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 establishing effective work and social relationships. A 70 percent rating is assigned 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 that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; memory loss for names of close relatives, own occupation or name. 38 C.F.R. § 4.130, Diagnostic Code 9413 (2012). When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency must assign a rating 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. When rating the level of disability from a mental disorder, the rating agency must consider the extent of social impairment, but cannot assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126 (2012). The Board notes that the specified factors for each incremental rating are examples, rather than requirements, for a particular rating. The Board will not limit its analysis solely to whether the Veteran exhibited the symptoms listed in the rating criteria. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Also relevant to the Board's analysis is the Global Assessment of Functioning (GAF) score assigned to the Veteran, which is a scale that indicates the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Carpenter v. Brown, 8 Vet. App. 240 (1995); Richard v. Brown, 9 Vet. App. 266 (1996); American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV); 38 C.F.R. § 4.130 (2012). While the veteran's GAF score is not itself determinative of the most appropriate disability rating, the Board must consider it when assigning the appropriate disability rating for the veteran. VAOPGCPREC 10-95 (1995), 60 Fed. Reg. 43186 (1995). GAF scores ranging from 51 to 60 indicate 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 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning. Scores ranging from 31 to 40 indicate 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). American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994); 38 C.F.R. § 4.130 (2012). The Board now turns to an evaluation of the relevant medical evidence. In an April 2005 intake form, a Vet Center counselor noted that the Veteran's appearance was neat, his manner was friendly and cooperative, his judgment was good, and his speech and affect were appropriate. The Veteran was relaxed and oriented to time, place, and person. The Veteran's memory was impaired. The Veteran showed no evidence of a thought disorder. He had no delusions, disorganized thinking, or hallucinations. The Veteran's appetite was average, and he had not recently experienced a change in weight. The Veteran indicated that he had experienced a sleep disturbance and a change in his sex drive. The Veteran's energy level was low. The Veteran had suicidal and homicidal thoughts, but he indicated that he did not intend to follow through on those thoughts. The Veteran wore latex gloves in order to avoid getting sick. In October 2005, a VA examiner noted that the Veteran was not currently involved in a romantic relationship, and had no children. The examiner observed the Veteran to be a thin male, dressed casually. The Veteran wore latex gloves, which the Veteran indicated helped him to stay clean. The Veteran was cooperative with the examination, and he spoke in a straightforward manner. The Veteran's thoughts were logical and coherent. The Veteran indicated that he had occasional problems with depression. The Veteran indicated that he spent most of the day in bed reading and did not feel like socializing. The Veteran reported having difficulty in the past with sleep, but he felt that his sleep was returning to normal. The Veteran's appetite was normal but his energy level was low. The Veteran denied experiencing crying spells. The Veteran had difficulty enjoying activities, and he reported experiencing occasional periods of irritability. The Veteran reported having suicidal thoughts in the past, but not recently. The Veteran reported having difficulty concentrating, and he reported that he had little to look forward to and no plans for the future. The Veteran denied experiencing psychosis, and he appeared to be of average intelligence. The Veteran felt detached from others and had a restricted range of affect. The examiner assigned a GAF score of 60. In July 2006, the Veteran stated that he spent most of his time either sleeping or reading in bed. The Veteran indicated that his personal hygiene had been "awful," and he often went seven to ten days without showering. The Veteran reported that he had been married and divorced twice, and he had a number of other romantic relationships that did not work out. The Veteran indicated that he was a loner without close friends. The Veteran often lost interest in activities, and he indicated that he did not care about anything. The Veteran lacked energy and motivation. The Veteran indicated that he experienced irritability and outbursts of rage. In a July 2006 hearing before RO personnel, the Veteran indicated that he spent most of his time in bed. The Veteran indicated that he had a couple of friends but did not often socialize. The Veteran reported having one friend who occasionally stopped by his house to talk, and he had another friend whom he felt he could confide in. The Veteran reported that he occasionally visited storage units to play cards with his friend. In a July 2006 treatment record, a VA clinician noted that the Veteran was well-groomed. The Veteran's speech was normal, but his mood was "down" and his affect was mildly blunted. The Veteran denied experiencing current suicidal or homicidal ideation or plan. The Veteran reported sleeping excessively and he endorsed feelings of anhedonia. The Veteran's appetite, concentration, and motivation were "not a problem." The Veteran's thought process was linear, organized, goal-directed, and without delusional content. The Veteran preferred to be alone, and he had a history of many previous jobs and failed relationships. The Veteran felt detached from people, and he had few friends. The Veteran's insight and judgment were good, with intact recent and remote memory. The Veteran resisted taking drugs in order to treat his depressed mood. In an April 2007 VA treatment record, the Veteran reported that he slept often. The Veteran had no television and did not play the radio. The Veteran had no motivation, and he reported feelings of anhedonia, detachment, irritability, and hypervigilance. The Veteran was not suicidal or homicidal. Instead, he was open and cooperative with a depressed mood and constricted affect. The Veteran had no hallucinations and his judgment was appropriate. On May 22, 2007, the Veteran stated that he no longer worked as a volunteer at a storage facility because he spent most of his days in bed. The Veteran had no ambition to do things around his house. The Veteran indicated that his sleep patterns were worsening rather than improving. The Veteran thought he was worthless and useless, and he indicated that he did not socialize with or date any women. The Veteran indicated that his personal hygiene had dropped to "near zero," and he did not care how he appeared. The Veteran reported wearing the same clothes and underwear for many days at a time. The Veteran reported having a compulsive habit of hand-washing, and he indicated that his house was a mess. The Veteran indicated that he had trouble concentrating, but he frequently thought of suicide. In June 2007, the Veteran's mood was sad, he was oriented in all three spheres, his affect was flat and dulled, his judgment was impulsive, his attitude was guarded, and he had little insight. The Veteran indicated that he was "jumpy," and sounds of fire crackers in his neighborhood sent him into deeper isolation. The Veteran was unshaven, and he experienced nightmares four to five times weekly, with nightly sleep disturbances. In a July 30, 2007, treatment record, a VA clinician reiterated the findings of the October 2005 examiner, but the clinician assigned a GAF score of 40 rather than the GAF score of 60 that had been assigned in October 2005. The Veteran underwent a VA examination in August 2007. The Veteran indicated that his depression was one of his most troubling symptoms, with the examiner noting that the Veteran experienced anhedonia. The Veteran denied any consistent sleep patterns, stating that the time that he spent in bed had increased dramatically since the time of his last examination. The Veteran indicated that he did not care about anything, and he had a heightened startle response. The Veteran indicated that he could not get close to anyone, and he spent most of his time alone. The Veteran indicated that he stopped drinking nine months prior to the examination at the suggestion of his primary care physician. Before that time, the Veteran went twice a week to a bar to socialize. The Veteran indicated that he bathed approximately once a week as a result of spending much of his time alone. The Veteran had no interest in pursuing a romantic relationship. The Veteran reported that he played card games on the computer for entertainment. The Veteran complained of a heightened startle response, and he indicated that he bathed himself less frequently than previously. The Veteran occasionally spoke with his brother on the phone, and he saw his sister occasionally. The Veteran characterized his relationship with his brother and sister as good. The Veteran reported that though he typically saw his mother weekly, but he had not seen her in a couple of months. Though the Veteran indicated that he frequently thought about suicide, he denied any suicide attempts. The Veteran denied experiencing auditory hallucinations. With respect to visual hallucinations, the Veteran stated that he occasionally saw something "running across the bedroom" in his peripheral vision. The Veteran was oriented in all three spheres. The Veteran endorsed homicidal ideation, although he stated that he did not think he would act on those thoughts. The Veteran denied experiencing panic attacks. With respect to compulsive behavior, the Veteran stated that he washed his hands all the time. The Veteran reported that his concentration was poor. The Veteran reported experiencing a lack of interest in significant activities, an inability to experience a full range of feelings, and a feeling of detachment from others. In an August 2007 treatment record, the Veteran's mood was sad, he was oriented in all three spheres, his affect was flat and dulled, his judgment was impulsive, his attitude was guarded, and he had little insight. The Veteran had been isolating and he stayed busy on the computer. A VA clinician made the same notation in a November 2007 treatment record, and added that the Veteran had been sleeping for long periods of time, and he otherwise had low levels of energy. In August 2009, the Veteran's mood was depressed, but he was oriented in all three spheres. The Veteran's affect was flat and dulled, his judgment was impulsive, his attitude was guarded, and he had little insight. The Veteran complained of nightmares and intrusive thoughts. The Veteran felt depressed and isolated in his home. The Veteran underwent a VA examination in October 2009. The Veteran appeared on time for his appointment and cooperated with the examiner. The Veteran was well-groomed and casually dressed. The examiner noted that the Veteran was twice-divorced. The examiner noted that treatment records suggested that the Veteran's condition had remained stable during the past few years, and the examiner noted that there was no indication that the Veteran's PTSD had worsened. Psychological testing was exaggerated and suggested that the Veteran over-endorsed deviant items. The examiner noted that the Veteran was depressed, but he was not taking any medication to alleviate his symptoms. In December 2009, the Veteran's mood was depressed, but he was oriented in all three spheres. The Veteran's affect was flat and dulled, his judgment was impulsive, his attitude was guarded, and he had little insight. The Veteran complained of nightmares and intrusive thoughts. The Veteran felt depressed and isolated in his home. The Veteran was not bathing, in part because of his psoriasis. On February 22, 2010, the Veteran stated that he had difficulty performing simple tasks such as washing dishes, washing clothes, and cleaning his house. The Veteran indicated that his personal hygiene was terrible. The Veteran indicated that he did not care about anything. The Veteran indicated that he did not enjoy the company of other people, and the only social activity that he enjoyed was seeing his psychiatric counselor. The Veteran described having erratic sleep habits. The Veteran described having a diminished appetite, and he indicated that he occasionally stopped eating for days at a time. The Veteran received a VA examination in February 2013. The examiner noted that the Veteran lived alone and lacked social support. The examiner assigned the Veteran a GAF score of 50. The examiner indicated that the Veteran had occupational and social impairment with reduced reliability and productivity. The examiner noted that the Veteran was twice-divorced and currently lived alone. The Veteran reported that he communicated occasionally with his former spouse. The Veteran had previously been married once, at the age of 26, for one year and eight months. The Veteran had no children. The Veteran reported that he had one good friend who "used to be [the Veteran's] drinking buddy," but that friend was now sober. The Veteran reported that he attempted to commit suicide once in the 1980s, but the Veteran could not remember why he wished to do so. The Veteran otherwise had frequent thoughts of suicide, but indicated that he knew that he would not do it. The Veteran indicated that he stopped attending group counseling in 2010. The Veteran refused to take psychiatric medications. The examiner noted that the Veteran had a depressed mood, chronic sleep impairment, suicidal ideation, and an intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner also noted that the Veteran had difficulty in establishing and maintaining effective work and social relationships, more so in his social life than his work life. The examiner otherwise noted that the Veteran was able to maintain steady employment for 25 years at a steel mill. The examiner noted that the Veteran had disturbances in motivation and mood. The Veteran was unable to complete simple household chores like dishes and laundry. The Veteran reported that he often spent the whole day in bed. The examiner noted a neglect of personal appearance and hygiene, specifically noting that the Veteran was malodorous and that the Veteran reported that he could go for weeks without a shower. The examiner noted that the Veteran had depressive symptoms of sadness, pessimism, punishment feelings, self-dislike, a lack of interest in activities, tiredness, a lack of interest in sex, feelings of failure, indecisiveness, worthlessness, low energy, a change in appetite, concentration problems, feelings of guilt, and crying. The Veteran's mood was depressed and his affect was flat. The Veteran's thoughts were logical and goal-oriented. The Veteran showed no signs of homicidal thoughts, hallucinations, or delusions, though he reported experiencing weekly passive suicidal thoughts. The Veteran moved slowly but was cooperative and showed no signs of aggression or anger. Prior to May 22, 2007 After a thorough review of the evidence, the Board finds that prior to May 22, 2007, the totality of the evidence indicates that the impact of the Veteran's PTSD on his social and industrial functioning during this time was most congruent with a 50 percent rating. Although the Veteran does not have all the symptomatology consistent with the assignment of a 50 percent rating, the Board finds that the impact of the Veteran's PTSD on his social and occupational functioning sufficiently approximates the degree of impairment contemplated by a 50 percent rating. 38 C.F.R. § 4.7 (2012). The Board acknowledges that the record contains evidence of certain elements of a 70 percent rating prior to May 22, 2007. However, the Board concludes that the Veteran's overall disability picture does not more nearly approximate a 70 percent rating . A 70 percent rating is assigned where the evidence shows occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. While the Board acknowledges that the record contains evidence of occupational and social impairment, it does not find that the Veteran suffered from "deficiencies in most areas," prior to May 22, 2007, as is required for a 70 percent rating. While mindful that the symptoms listed in the General Rating Formula for Mental Disorders are not meant to be used as an exhaustive list, the Board observes that the Veteran has met or approximated two of the symptoms listed as demonstrative of a 70 percent rating. The Veteran showed depression occasionally affecting his ability to function effectively, and difficulty adapting to stressful circumstances. The Veteran has not otherwise demonstrated the symptoms associated with a 70 percent rating. The Veteran denied experiencing current suicidal ideation in October 2005, July 2006, and April 2007. While the Veteran reported engaging in obsessional behaviors such as hand-washing, the evidence does not suggest that activity interfered with routine activities. The Veteran did not display illogical, obscure, or irrelevant speech. In October 2005, the Veteran's speech was "straightforward," and in July 2006, the Veteran's speech was "normal." Though the Veteran indicated that he experienced irritability, that did not result in impaired impulse control. To the contrary, an April 2007 clinician characterized the Veteran's judgment as "appropriate." The Veteran was consistently oriented in all three spheres. The Board finds that the weight of the evidence does not indicate that the Veteran generally neglected his personal hygiene or appearance prior to May 22, 2007. The October 2005 examiner observed the Veteran to be a "thin male dressed casually." In July 2006, the Veteran self-reported that his personal hygiene had been "awful," but a later July 2006 treatment record indicated that the Veteran was well-groomed. Furthermore, while the Board acknowledges the Veteran's statements that he spent much of his time alone, the Board does not find that the Veteran's desire for solitude to constitute an inability to establish or maintain effective relationships. Though the Veteran reported in July 2006 that he was a "loner" without close friends, he also indicated at his July 2006 hearing before RO personnel that he had a couple of friends, including at least one friend in whom he felt that he could confide. Also in July 2006, the Veteran reported that he preferred to be alone. The Board finds that while the record contains a few symptoms associated with a 70 percent rating, a 70 percent rating of the Veteran's PTSD is not appropriate prior to May 22, 2007, because the evidence does not show occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Similarly, the Board concludes that the Veteran's overall disability picture prior to May 22, 2007, does not more nearly approximate the criteria for a 100 percent rating . A 100 percent rating is assigned for total occupational and social impairment. The Veteran did not present a persistent danger of hurting himself or others. The record shows no evidence of gross impairment in thought processes or communication, persistent delusions or hallucinations, or grossly inappropriate behavior. The Veteran did not show an intermittent inability to perform activities of daily living, disorientation to time and place, or memory loss for the names of close relatives, his own occupation, or his own name. Therefore, the Board finds that while the record contains a few elements of a 100 percent rating, a 100 percent rating of the Veteran's PTSD was not appropriate prior to May 22, 2007. In making this determination, the Veteran's GAF score has been considered. Prior to May 22, 2007, the Veteran was assigned a GAF score of 60 during his October 2006 VA examination. The Board finds that score, which is indicative of symptoms of "moderate" severity, best approximates a 50 percent rating. Consideration has also been give to the Veteran's personal assertions in support of his claim. The Veteran is competent, as a layperson, to report on that as to which he has personal knowledge, such as feelings of sadness associated with depression. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a)(2) . However, as a layperson, without the appropriate medical training and expertise, he is not competent to provide a competent and persuasive opinion on a medical matter, especially the severity of his psychiatric disability in terms of the applicable rating criteria and its effect on his ability to work. King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). Rather, that necessarily requires appropriate medical findings regarding the extent and nature of his psychiatric disorder. The Board finds that the preponderance of the evidence is against the assignment of a rating greater than 50 percent for PTSD prior to May 22, 2007. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). From May 22, 2007, to February 21, 2010 After a thorough review of the evidence, the Board finds that from May 22, 2007, to February 21, 2010, the totality of the evidence indicates that the impact of the Veteran's PTSD on his social and industrial functioning more nearly approximated the criteria for a 70 percent rating. The Board has changed the effective date of the Veteran's 70 percent rating from July 30, 2007, to May 22, 2007. The Board finds that date more accurately reflects when the Veteran's social and industrial functioning contained deficiencies in most areas. The Veteran stated at that time that his personal hygiene had dropped to "near zero," and he indicated that he did not socialize. The Veteran indicated at that time that he frequently thought of suicide. Similarly, in June 2007, a VA clinician noted that the Veteran was unshaved, his mood was sad, he was impulsive, and his affect was guarded. Although the Veteran does not have all the symptomatology demonstrative of the assignment of a 70 percent rating, the Board finds that the impact of the Veteran's PTSD on his social and occupational functioning sufficiently approximates the degree of impairment contemplated by a 70 percent rating from May 22, 2007, to February 21, 2010. 38 C.F.R. § 4.7 (2012). The Board concludes that the Veteran's overall disability picture prior to February 21, 2010, does not more nearly approximate the criteria for a 100 percent rating. A 100 percent rating contemplates total occupational and social impairment. The Veteran did not present a persistent danger of hurting himself or others. The record shows no evidence of gross impairment in thought processes or communication. Although the Veteran indicated in July 2007 that he occasionally saw things in his peripheral vision, the Board does not find that experience amounts to having "persistent" delusions or hallucinations. The record shows no evidence of grossly inappropriate behavior. The Veteran has not shown an intermittent inability to perform activities of daily living, disorientation to time and place, or memory loss for the names of close relatives, his own occupation, or his own name. Furthermore, the evidence does not otherwise demonstrate total occupational or social impairment prior to February 21, 2010. Therefore, the Board finds that while the record contains a few elements of a 100 percent rating, a 100 percent rating of the Veteran's PTSD is not appropriate at during this period. In making this determination, the Veteran's GAF score of record has been considered. The Veteran was assigned a GAF score of 40 in July 2007, which is indicative of some impairment of reality testing or communication. The Board finds that score best approximates a 70 percent rating based on occupational and social impairment with deficiencies in most areas. Consideration has also been give to the Veteran's personal assertions in support of his claim. The Veteran is competent, as a layperson, to report on that as to which he has personal knowledge, such as feelings of sadness associated with depression. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a)(2) . However, as a layperson, without the appropriate medical training and expertise, he is not competent to provide a competent and persuasive opinion on a medical matter, especially the severity of his psychiatric disability in terms of the applicable rating criteria and its effect on his ability to work. King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). Rather, that necessarily requires appropriate medical findings regarding the extent and nature of his psychiatric disorder. The Board finds that the preponderance of the evidence is against the assignment of a rating greater than 70 percent for PTSD prior to February 21, 2010. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Ratings The Board has considered whether the Veteran is entitled to a greater level of compensation on an extraschedular basis. Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors that render application of the schedule impractical. 38 C.F.R. § 3.321(b) (2012); Fisher v. Principi, 4 Vet. App. 57 (1993). To determine whether to refer a claim for consideration of assignment of an extraschedular rating, first, the Board must determine whether the evidence presents such an exceptional disability picture that the schedular ratings for that service-connected disability are inadequate. Second, if the schedular rating does not contemplate the Veteran's level of disability and symptomatology and is found to be inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. 38 C.F.R. § 3.321(b) (2012); Thun v. Peake, 22 Vet. App. 111 (2008). The Board finds that the rating criteria are not inadequate, and it does not appear that the Veteran has exceptional or unusual disabilities. He merely disagrees with the assigned ratings for his level of impairment. He does not have any symptoms from his service-connected PTSD that are unusual or are different from those contemplated by the schedular rating criteria. Therefore, the available schedular evaluations are adequate. The Board finds that referral for extraschedular consideration is not warranted. ORDER Prior to May 22, 2007, an initial 50 percent disability rating, but not higher, for PTSD is granted. From May 22, 2007, to July 30, 2007, a 70 percent disability rating, but not higher, for PTSD is granted. From July 30, 2007, to February 21, 2010, a rating in excess of 70 percent for PTSD is denied. REMAND A claim for TDIU is part of an increased rating claim when a request for a TDIU is reasonably raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009). Before February 22, 2010, the Veteran was in receipt of a disability rating for his service-connected disabilities that was less than total. The Board finds that possible entitlement to a TDIU has been raised by the record, and the claim must be remanded for additional evidentiary development. Among other evidence, in August 2007, a VA clinician noted that the Veteran was "potentially unemployable" as a result of his psychiatric disabilities. An additional opinion from a physician should be obtained on remand. Accordingly, the case is REMANDED for the following actions: 1. Forward the Veteran's claims file to a psychologist or psychiatrist . After a complete review of the Veteran's claims file, the examiner is requested to offer an opinion as to whether the Veteran's service-connected disabilities precluded his obtaining or retaining substantially gainful employment consistent with his education and occupational experience before February 22, 2010. The opinion should be offered irrespective of age and any nonservice-connected disabilities. The examiner should provide a complete rationale for the opinion. 2. Then readjudicate the claim. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. The Veteran has the right to submit additional evidence and argument on the matter that 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 the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2012). ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs