Citation Nr: 1327864 Decision Date: 08/30/13 Archive Date: 09/05/13 DOCKET NO. 07-25 039 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to an initial disability rating (evaluation) of greater than 50 percent for psychological disabilities, to include posttraumatic stress disorder (PTSD), bipolar disorder, and major depressive disorder. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney ATTORNEY FOR THE BOARD J. Schulman, Associate Counsel INTRODUCTION The Veteran, who is the appellant, had active service from October 1963 to October 1967. This matter comes before the Board of Veteran's Appeals (Board) on appeal from a December 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California, which granted service connection and assigned an initial 30 percent rating for PTSD, effective February 7, 2005. In March 2009, a 50 percent rating was assigned fot the period from February 2005. In a May 2012 decision, the Board denied the Veteran's appeal for a higher inial rating, and that same month a joint motion for remand back to the Board was filed with the United States Court of Appeals for Veterans Claims (Court) by the Veteran and VA. In December 2012, the Court granted the joint motion for remand, and remanded the matter to the Board for action consistent with the motion. The Veteran raised the issue of entitlement to TDIU and, in a rating decision of September 2011, the RO denied the TDIU on the basis that unemployability is due to non-service-connected disabilities. In Rice v. Shinseki, 22 Vet App. 447 (2009), the Court held that TDIU is not a separate claim, but is part and parcel of any claim for increased or initial evaluation, although the Court also recognized that a veteran could file a claim for TDIU without having a pending rating claim. For reasons explained in greater detail below, the September 2011 rating decision did not become final, and the claim for TDIU is still now before the Board as a part of the Veteran's appeal for a higher initial disability rating for the service-connected psychiatric disorder. FINDINGS OF FACT 1. Psychological disabilities, including bipolar disorder and major depressive disorder, are related to service or the service-connected PTSD. 2. Throughout the entire initial rating period on appeal from February 7, 2005, psychological disabilities have been characterized by occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood, due to such symptoms as suicidal ideation, near-continuous depression affecting the ability to function independently, appropriately and effectively, impaired impulse control, difficulty managing anger, nightmares and other sleep disturbances, and an inability to establish and maintain effective relationships. 3. The September 2011 rating decision denying TDIU did not become final. 4. The Veteran's service-connected disabilities preclude him from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for an initial rating of 70 percent for psychological disabilities have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.14, 4.130, Diagnostic Code 9411 (2012). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for a TDIU have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim and of the relative duties of VA and the claimant for procuring that evidence. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). The Veteran's appeal arises from an appeal of the initial evaluation following the grant of service connection for PTSD. Once service connection is granted the claim is substantiated, additional notice is not required. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3)(i) (no duty to provide VCAA notice upon receipt of a notice of disagreement); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims). Based on the foregoing, adequate notice was provided to the Veteran prior to the transfer and certification of this case to the Board and complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), and no further notice is needed under VCAA. The Board also notes that in a July 2013 statement from the Veteran's representative, the Veteran waved "any VCAA notice errors." Next, VA has a duty to assist a veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; see Golz v. Shinseki, 590 F.3d 1317, 1320-21 (2010) (stating that the "duty to assist is not boundless in its scope" and "not all medical records . . . or all [Social Security Administration] disability records must be sought - only those that are relevant to the veteran's claim"). In this case, service records have been obtained, as have records of private and VA treatment as well as records from the Social Security Administration (SSA). These pertinent records have been associated with the Veteran's claims file and reviewed in consideration of the issues before the Board. The Board finds that the record as it stands includes adequate competent evidence to allow the Board to decide the case, and no further action is necessary. See 38 C.F.R. § 3.159(c). The Veteran was afforded VA examinations in December 2007, July 2011, and August 2011 to address the severity of PTSD and associated psychological symptoms. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Board notes that the VA examiners were provided with accurate histories, the Veteran's histories and complaints were recorded, the examination reports set forth detailed examination findings in a manner that allows for informed appellate review under applicable VA laws and regulations, and the examiners offered the necessary findings. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012); Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of their opinion). With regard to the Veteran's claim for a TDIU, the Board is granting, in full, the benefits sought; accordingly, VA has no further duty to notify or assist with regard to this issue. Initial Rating for Psychological disabilities Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2012). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 3.102, 4.3. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran's appeal for a higher initial rating for psychological disabilities is an appeal from the initial assignment of a disability rating. When a claimant is awarded service connection and assigned an initial disability rating, separate disability ratings may be assigned for separate periods of time in accordance with the facts found. Such separate disability ratings are known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (noting that staged ratings are assigned at the time an initial disability rating is assigned). Here, as the evidence discussed below shows, the psychological disabilities have not significantly changed and a uniform evaluation is warranted. In the December 2005 rating decision on appeal, the Veteran was awarded service connection for PTSD and granted an initial evaluation of 30 percent effective February 7, 2005. In a subsequent rating decision of March 2009, the Veteran was granted an initial evaluation of 50 percent, effective February 7, 2005. The Veteran's psychological disabilities are rated under General Rating Formula for Mental Disorders, found at 38 C.F.R. § 4.130, which provides that for a 50 percent rating on evidence of: 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. A 70 percent rating is warranted for evidence of: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Finally, a 100 percent rating is warranted for 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. 38 C.F.R. § 4.130. In evaluating the Veteran's level of disability, the Board has considered the Global Assessment of Functioning (GAF) scores as one component of the overall disability picture. GAF is a scale used by mental health professional and reflects psychological, social, and occupational functioning on a hypothetical continuum of mental health illness and is relevant in evaluating mental disability. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). The GAF Scale score is based on all of the Veteran's psychiatric impairments. A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or a major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., avoids friends, neglects family, and is unable to work). A GAF score of 41-50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51-60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with coworkers). A GAF score of 61-70 indicates 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. The VA Secretary, acting within his authority to "adopt and apply a schedule of ratings," chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501 (West 2002); 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002) (holding that "the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment"). The Board finds that both bipolar disorder and major depressive disorder are related to service or service-connected PTSD. When it is not possible to distinguish the effects of a non-service-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to a veteran's service-connected disability. See 38 C.F.R. § 3.102 (2012); Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (holding that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so); but see Mittleider, 11 Vet. App. at 182 (holding that the Board may not ignore distinctions between symptomatology attributed to a non-service-connected disability and a service-connected disability where they appear in the medical record). Evidence in the record showing that bipolar disorder and major depressive disorder are related to service or service-connected PTSD includes VA examination in December 2007, discussed in greater detail below. Following a thorough examination and review of the Veteran's symptoms, the December 2007 VA examiner opined that major depressive disorder was secondary to PTSD. Furthermore, with regard to bipolar disorder, the Veteran's VA psychologist, who has been treating the Veteran since 2005, stated in an April 2012 letter that although the Veteran does have a co-morbid psychiatric condition of bipolar disorder II, this in no way diminishes the impact of the PTSD symptoms. Further, it is this clinician's opinion that the high level of combat exposure [the Veteran] experienced very likely contributed to the manifestation of this psychiatric condition, as high levels of physiological arousal and lack of sleep often precipitate manic episodes in individuals. Because the Board finds that the Veteran's acquired psychiatric disorders other than PTSD are service connected, delineating which symptomatology is related to which mental health disability is unnecessary. The rating for all service-connected psychiatric disorders will be provided based on all psychological symptoms and impairments, without differentiation. Additionally, to the extent that 38 C.F.R. § 4.14 prohibits the assignment of evaluations for the same symptoms of disability under more than one Diagnostic Code, the Board considers all of the Veteran's psychological disabilities together under the same Diagnostic Code so as to avoid prohibited pyramiding of symptoms. The Board has reviewed all the lay and medical evidence in the claims folder and finds that the Veteran is competent to report many of the symptoms and impairments associated with the psychological disabilities on appeal including symptoms which are observable such as feelings of anxiety, depression, difficulty sleeping, nightmares, poor concentration, memory problems, irritability, anger, and disturbance of motivation and mood. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (holding that lay statements may serve to support a claim by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability that are susceptible to lay observation). The Board has not discounted any lay evidence regarding the severity of psychological disabilities merely because it is lay evidence or because it was reported by the Veteran. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005) (holding that a history given by a veteran that has not been found by the Board to be inaccurate is not a basis for discounting an opinion based on that history). That being said, the Board has an obligation to determine the credibility of all evidence, lay and medical. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the duty to assess the credibility and weight to be given to the evidence). The Veteran contends that psychologic symptoms and impairment warrant a rating of higher than 50 percent. He further contends that he is totally disabled, which he feels is due to PTSD symptoms such as severe anxiety and depression, which make it impossible for him to work. After reviewing the entire claims file, the Board finds that the Veteran's psychological disabilities have more nearly approximated the criteria for a 70 percent rating for the entire initial rating period on appeal. The Board finds that psychological disabilities have been productive of occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, due to such symptoms as suicidal ideation; near-continuous depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; difficulty managing anger; nightmares and other sleep disturbances; and an inability to establish and maintain effective relationships. By way of history, VA treatment records reflect that the Veteran was seen in August 1994 with complaints of having a "reaction" to prednisone, which he had been taking for two weeks due to a neck disability. He described leg swelling, facial flushing, insomnia, nightmares and "hallucinations." On examination he was alert and oriented and appeared anxious and agitated. In September 1994, the Veteran was admitted to a VA hospital for treatment of his neck disability and psychiatric symptoms. Affect was mildly constricted and mood appeared sad. The Veteran was assessed as having a psychiatric disorder or personality disorder with possible neurotic features, possible schizoaffective disorder, and rule out PTSD. The examiner noted that the effects of hypersensitivity to steroids were resolving, but provisionally diagnosed a possible organic etiology. In a subsequent evaluation in 1994, the Veteran reported constant visual hallucinations which he described as alterations in the "hues" of objects, as well as strange, vivid dreams. He said that he was having "mental difficulties" while taking steroids but noted that he felt better since the drugs (steroids) were discontinued. The Veteran described himself as an anxious person but denied nightmares or flashbacks of combat and did not feel he had PTSD. The examiner noted that the Veteran had pressured speech, labile affect, and "ok" mood. The Veteran complained of racing thoughts and decreased sleep, and denied suicidal or homicidal ideation. Insight and judgment were impaired. The examiner suspected a history of manic depressive illness and felt that the Veteran was in a hypomanic state. The examiner assessed manic depression and anxiety, and recommended anxiety medication and follow up psychiatric treatment. In December 1994, the Veteran reported a past history of alcohol problems, but had recently stopped drinking completely. He denied most symptoms of PTSD, including intrusive thoughts, flashbacks, and nightmares, but endorsed insomnia and anger. The examiner assessed PTSD and alcohol dependence in remission. VA progress notes reflect that in January 1995 the Veteran reported taking medications from his mother and medications that were not on the prescription list, and was requesting prescriptions for medication. The history/problem list reported by the Veteran included symptoms that the examiner thought were possible personality disorder, perhaps with neurotic features, or possibly a schizoaffective disorder. On VA outpatient treatment in March 2005, the Veteran denied a history of any functional affective or psychotic disorders or symptoms. The Veteran stated that he had been on no medications, and reported a 40 year history of alcohol abuse prior to stopping one and a half years prior. The Veteran was reported to be nonpsychotic, euthymic, and motivated to follow up with treatment. During a subsequent appointment the same month, the Veteran reported poor sleep and difficulty controlling his anger. It was noted that the Veteran was oriented and had normal speech and pleasant demeanor. Mood was mildly dysphoric and affect was broad. Thought process was logical, goal directed, and coherent. Thought content showed no evidence of psychosis or suicidal or homicidal ideation. Insight and judgment were fair. The assessment was PTSD, alcohol dependence in remission, and a mood disorder was ruled out. A March 2005 diagnosis of PTSD was made on the basis of findings of logical and coherent thought process, fair judgment, and no evidence of psychosis, suicidal or homicidal ideation. During continued assessment by VA in April 2005, the Veteran endorsed a high degree of symptomatology associated with PTSD, including anxious arousal, anger/ irritability, intrusive experiences, and defensive avoidance. The Veteran described dissociative experiences such as feeling of being outside his body, mind going blank, not feeling like his real self, absent-mindedness, and daydreaming. Depressive symptoms were also clinically elevated and included sadness, feeling hopeless and worthless, and avoiding people because of depression. Test scores indicated chronic difficulties with identity, self awareness, and tendencies to rely on acting-out behaviors to deal with internal stress. The evaluating medical provider opined that the overall profile suggested severe symptoms of PTSD and insufficient self resources to manage disruptive internal distress. The score on the Mississippi Scale, which is designed to assess combat-related PTSD, was well above the required score for a diagnosis of PTSD. On VA treatment in May 2005, it was noted that the Veteran continued to have significant PTSD symptomatology related to combat traumas. PTSD symptoms were identified including marked distressing intrusive thoughts of trauma, nightmares, night sweats, and marked exaggeration of startle at minor noises. On evaluation, the Veteran showed hypervigilance, and anxiety escalated severely when talking about experiences in Vietnam. The Veteran was non-psychotic and euthymic, alert and oriented, without suicidal or homicidal ideation. The Veteran's GAF score was 40. VA outpatient treatment records reflect that the Veteran attended PTSD group therapy regularly through December 2005. During a December 2005 VA psychiatric evaluation, PTSD and panic disorder with agoraphobia were diagnosed, and the GAF score was 49. Mood was euthymic and there were no hallucinations or delusions, and no suicidal or homicidal ideations. The Veteran declined to use any psychotropic medications, and reported that he was on a leave of absence from a telemarketing firm, The claims file contains a California disability insurance application that was completed by the Veteran's treating VA psychologist in May 2006. She diagnosed the disabilities as PTSD, and ruled out bipolar disorder and panic disorder. She described symptoms as intrusive recollections, avoidance, chronic physiological arousal which promotes irritability and inattentiveness, and anxiety. The level of disability varied due to stress but was currently serious. The examiner estimated that the Veteran would be unable to work for at least six months due to psychiatric symptoms, both from PTSD and others. In July 2006, the Veteran underwent a psychiatric evaluation by the California Department of Social Services, in which chronic PTSD was diagnosed and the GAF score was 60. The Veteran described nightmares and flashbacks of experiences in service, as well as severe anger and anxiety. The Veteran reported a history of bipolar disorder, but did not describe periods of depression or manic symptoms, and the examiner could not confirm the diagnosis. On examination, the Veteran was cooperative and had no obvious psychomotor agitation or retardation. Thought process was somewhat circumstantial but coherent and organized. The examiner noted that the Veteran was non-delusional and did not have bizarre or psychotic thought content, but sometimes heard voices during anxiety attacks. Mood and affect were euthymic, and speech was normal; however, the examiner stated that insight and judgment may be impaired due to emotional response. The Veteran endorsed homicidal ideas but stated that no intention of carrying them out. In July 2006, the Veteran submitted a series of statements describing experiences in Vietnam. The Veteran reported that he "sustained major personality changes" after service because of guilt and anxiety relating to combat experiences. The Veteran stated being able to suppress feelings about these incidents until 1994, when he had a severe reaction to steroid medication which made him unable to sleep and "completely insane." The Veteran contended that VA physicians told him he had had "a nervous breakdown," and since that time has experienced ongoing PTSD symptoms, including violent nightmares, flashbacks, and anger. In an August 2006 letter to VA, the Veteran repeated the assertion of having suffered a "nervous breakdown" as a result of steroid use and thereafter developing a "nervous condition" characterized by severe anxiety. In August 2006, the Veteran's VA Vocational Rehabilitation Counselor completed a form letter indicating that the Veteran suffered from PTSD manifested by insomnia, poor attention and concentration, mood and emotional issues related to PTSD, as well as physical symptoms relating to respiratory disease, and that the Veteran was not ready to work on a full-time basis. VA outpatient treatment records reflect that the Veteran participated regularly in PTSD group therapy sessions from September 2006 through September 2007. The Veteran was occasionally described as irritable or anxious but was mostly euthymic and cooperative. The Veteran was consistently noted to be free of hallucinations, delusions, suicidal ideation, and homicidal ideations. The diagnoses included PTSD, panic disorder, and anxiety, and the Veteran was prescribed psychotropic medications. Speech, thought processes, and affect were consistently normal. In January 2007, the Veteran reported that he had returned to work, but only during evening shifts. The Veteran reported in June 2007 that he had stopped working when the evening shift was eliminated because he experienced increased pressure and anxiety during the day shift. A VA outpatient psychology treatment note dated in July 2007 indicates that the Veteran had recently become depressed and had suicidal thoughts. The examiner related the symptoms of depression, and associated suicidal thoughts, to bipolar disorder rather than PTSD. The Veteran reported that he was overwhelmed by personal issues unrelated to PTSD, including the loss of his job, health problems that he could not afford to treat, and the potential loss of his home, which further reflects etiologies of non-PTSD psychiatric symptoms. The Veteran's mood was moderately depressed and he reported increased irritability and impatience. His affect was broad, thought process was logical and coherent, and no psychosis was noted in thought content. The examiner diagnosed PTSD and bipolar disorder II, depressed. In a July 2007 letter to his VA psychiatrist, the Veteran reported that experiencing "strange visions" of committing suicide, as well as aural hallucinations which tell him to kill himself. The Veteran wrote that he had not reported these symptoms to the psychiatrist before because they are difficult to discuss. The Veteran stated that, when he becomes depressed, he feels physically sick and weakened, and becomes unable to concentrate, to go to appointments, to work, or to get out of bed for several days at a time. The Veteran believed that depression and "hearing voices" were related to spending several days at a time in the jungle in Vietnam, at which time the Veteran would "see things that were not there." While the Veteran is competent to report these symptoms, and to relate the content of the auditory hallucinations, the Veteran is not competent to relate the symptoms of auditory hallucinations to his service-connected PTSD. Jandreau, 492 F.3d 1372. Nonetheless, the Board has found that the evidence is in equipoise as to the question of whether bipolar disorder is related to the Veteran's service-connected psychological disabilities. Accordingly, the Board has associated symptoms and impairment attributable to bipolar disorder as part of service-connected psychological disabilities, without differentiation. All the Veteran's psychiatric disorders are considered service connected, and will be rated together under the schedular rating criteria at 38 C.F.R. § 4.130. On VA examination in December 2007, the Veteran reported recurrent distressing dreams of experiences in Vietnam which occurred once per month, with flashbacks of these events once per week. The Veteran described panic attacks marked by trembling, heart flutters, and rapid breathing, which occurred daily. The Veteran stated that he tried to avoid thoughts and activities which aroused recollection of the traumatic events in service. The Veteran reported markedly diminished interest in significant activities and felt estranged from other people. The Veteran also reported frequent sleep disturbance, irritability, anger, difficulty concentrating, and that he was hypervigilant. The Veteran endorsed depressed mood off and on for 40 years and was depressed most of the time. The Veteran described aural hallucinations and paranoia, but denied other psychotic or manic symptoms. On examination, the Veteran was alert and oriented with normal intellectual functioning, although recent memory was impaired. Judgment and insight were intact, and the VA examiner diagnosed PTSD, major depressive disorder secondary to PTSD, and alcohol abuse in remission. The GAF score was 58. In a December 2007 statement, the Veteran reported that he was totally disabled and unable to work because of PTSD symptoms, which the Veteran described as including anxiety attacks, impaired thought process and communication, poor judgment, memory loss, depression, hallucinations, flashbacks, and "feeling sick." The claims file contains a PTSD assessment completed by the Veteran's VA treating psychologist in February 2008, in which she indicated that the Veteran experiences occupational and social impairment, with deficiencies in most areas, as described in the rating criteria for a 70 percent disability rating. In a November 2008 letter, the same psychologist described the Veteran's traumatic service experiences and PTSD symptoms as noted during the initial mental health assessment in March 2005. The VA psychologist stated that, although the Veteran had participated in a PTSD therapy group and anger management training, the Veteran "continues to manifest serious symptoms of the disorder, which have chronically impeded his occupational and social functioning." It was noted that the Veteran had recently had an exacerbation of depression and anxiety requiring new medication. The VA psychologist diagnosed chronic PTSD and recurrent depression versus bipolar disorder II, and assessed that the GAF score was 45. In an April 2008 determination from the Social Security Administration, the Veteran was found to be disabled since March 2006 for purposes of receiving Social Security Disability, due to physical and mental disabilities, which included PTSD and panic disorder, with a secondary disorder of bipolar disorder. VA outpatient treatment records reflect that the Veteran continued to participate in PTSD group therapy through March 2009. In December 2008, the Veteran presented with complaints of increased depression, forgetfulness, and a "buzzing" in his body. Later that month, the Veteran complained of racing thoughts, increased goal-directed behavior, and irritability. It was noted that the Veteran's symptoms were related to bipolar disorder weighted in favor of elevated mood. In an August 2010 letter, a VA nurse practitioner who treated the Veteran from June 2008 through March 2010 stated that the Veteran had "mental health issues" which remain chronic despite aggressive medication management and outpatient therapy. The VA nurse practitioner noted that recent exacerbations of the Veteran's condition included feeling sick, difficulty sitting still, and a feeling of "buzzing" throughout the body. Finally, it was noted that the Veteran is unable to work or attend classes due to episodes of emotional lability and feelings of stress and pressure. On VA examination in July 2011, the Veteran reported using psychiatric medication which the examiner felt may cause side effects similar to Parkinson's disease. The Veteran experienced the sensation of "having an engine inside" of himself and endorsed being jumpy and agitated, and reported nightmares at least once per week. The Veteran also reported hearing voices and making involuntary "little noises" when in a crowd or other anxiety-provoking situation. The Veteran reported getting angry or irritable once per month, that concentration and attention were poor, and he endorsed trouble following simple instructions. The Veteran appeared to forget things from both the recent and the distant past. The Veteran reported having friends and being active in a church, and that he was also close with his sister. During the July 2011 VA examination, the Veteran was well-groomed but manifested a blunted affect and impoverished speech. Mood was agitated and dysphoric, and thought content included obsessions, phobias, and hyper religiosity. The Veteran reported persistently hearing voices which provoked him to make noises. Judgment and insight were normal, but with impaired sleep, and the Veteran had severe problems with motivation and mood regulation. The Veteran reported panic attacks two to three times per month, and endorsed suicidal ideation once per month, although the Veteran had no intention of harming himself. The VA examiner stated that symptoms associated with PTSD included persistent re-experiencing the traumatic event by intense psychological distress and physiological reactions at exposure to cues that symbolize or resemble the traumatic event. PTSD symptoms also included persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, which included markedly diminished interest or participation in significant activities and feelings of detachment or estrangement from others. The VA examiner also identified symptoms of increased arousal due PTSD, including difficulty falling or staying asleep, irritability, outbursts of anger, difficulty concentrating, and hypervigilance. The VA examiner in July 2011 diagnosed PTSD, bipolar II disorder with psychotic symptoms, and ruled out mood disorder secondary to a medical condition. The GAF score was 50. The VA examiner described the PTSD symptom of guilt as "severe" and "daily," while diminished interaction with others was "moderate, every day." The symptoms of hypervigilance and hearing voices were moderate and "once per week 3-4 years." The examiner identified the bipolar II symptoms as mood instability, irritability, anger management problems, and psychotic symptoms intermittently. The VA examiner differentiated psychiatric symptomatology attributable to bipolar disorder, opining that bipolar II disorder "may be accounting for a great deal of his impairment" including intermittent suicidality, anger management problems, irritability, sense of "an engine" constantly running inside his body, and hearing voices. The VA examiner in July 2011 stated that the Veteran's PTSD symptoms were combined with bipolar II symptoms and psychotic symptoms, such as hallucinations, as well as chronic insomnia and side effects from medications. Cognitive symptoms, such as slow response and bradykinesia, were of unknown origin and could be attributable to either medication used for treatment or an underlying idiopathic disorder. The VA examiner assessed that the Veteran appeared to have experienced a steady decline in function since becoming unemployed in 2005. The Veteran's PTSD and bipolar disorder impaired social and occupational functioning, causing the Veteran to be unable to concentrate and do activities with consistency. The examiner differentiated the guttural noises or tics that the Veteran described from PTSD, opining these may be etiologically related to medication, or could represent a compulsive behavior in response to the auditory hallucinations. On VA outpatient treatment in July 2011, the Veteran exhibited mood instability and endorsed intermittent suicidal ideation. The Veteran also reportedly maintained regular, positive social contacts. In a July 2011 treatment note, the treating VA psychiatrist stated that bipolar disorder and PTSD frequently coexist and form a complex entity with considerable overlap and reciprocal augmentation of symptoms. The Veteran was afforded a VA neurobehavioral assessment in August 2011, in order to determine the severity and likely etiology of his cognitive impairments. The Veteran described a sensation of having a "machine inside" which caused him to produce guttural sounds. During these episodes, the Veteran experiences black-and-white hallucinations. The evaluating physician opined that these symptoms appeared to be consistent with a tic, but that it is rare for a tic to develop so late in life. Although the Veteran reported memory problems, overall memory function was assessed as good, and the evaluating physician reported that the Veteran was "not particularly bothered by forgetfulness" as the Veteran had developed coping strategies to mitigate memory problems. The Veteran did not meet the criteria for a diagnosis of dementia or even minimal cognitive impairment, although there were some problems with concentration and focus. The evaluating physician stated that it is possible these symptoms arise from the combination of psychiatric conditions, medical conditions, and medication, and the lack of focus was "certainly" exacerbated by anxiety and PTSD symptoms. In an April 2012 letter, the Veteran's primary treating VA psychologist stated that the Veteran experiences a high level of anxiety that causes considerable distress. The Veteran reported that he had some casual friendships but "really has no intimate relationships." The psychologist went on to state that, given the "chronicity and severity of [the Veteran's] symptoms, and after several years of providing psychological treatment, it is clear to [the Veteran's psychologist] that [the Veteran] is unable to work." The Veteran's treating psychologist opined that while the Veteran does have a comorbid psychiatric condition - bipolar disorder - "this in no way diminishes the impact of the PTSD symptoms." The GAF score was 45. In June 2013, the Veteran underwent examination by a private clinical psychologist. The psychologist began by eliciting from the Veteran comprehensive pre-military, and military histories. The Veteran reported currently having "some friends," which are mostly through the two churches that he attends, but the Veteran did not appear to have any close friendships. The Veteran reported trying to date and wanting "to be with somebody," but that relationships inevitably are destroyed due to the Veteran's difficulties with anger and rage. The psychologist noted some psychotic type symptoms, including involuntarily making noises, and experiencing marked paranoia regarding the motives of others. The Veteran endorsed hallucinations in the past, which the evaluating psychologist indicated were possibly related to PTSD, but may also be suggestive of a separate psychotic process. On mental status evaluation in June 2013, the Veteran suffered from chronic and severe depression and anxiety which were "quite disabling," and the Veteran endorsed being "anxious all the time." The Veteran endorsed that memory was "ok," however the psychologist stated that the "disrupted attentional/concentrational processes" are such that memory, especially short term memory, is often impaired. The Veteran reported being constantly on guard, and admitted to significant ongoing intrusive thoughts and memories of traumatic war experiences including experiencing flashbacks and nightmares. The Veteran was hypervigilant, but indicated that regular treatment had helped to decrease this symptom. The Veteran reported difficulty sleeping, indicating that that without sleep medications, he would be unable to sleep at all. When the Veteran was able to sleep, sleep was poor and included night sweats. The Veteran denied suicidal ideation on the day of the examination, however the psychologist stated that the Veteran "clearly had entertained suicide on many occasions." Anger was marked, and the Veteran stated wanting to hurt or kill people in the past, but always stopping himself. The psychologist in June 2013 concluded that the Veteran "clearly evidences marked deficits" in the major areas of work, school, family relations, judgment, thinking, and mood. With regard to work, the private psychologist noted that the Veteran had a long history of "numerous job losses" due to difficulties in getting along with others. Deficits in schooling were evidenced by the Veteran's inability to obtain required teachers certifications despite having three years to complete the certifications. The Veteran's family relations had historically been poor, and only very recently had he reconnected with his sister. The Veteran's judgment, thinking, and mood had been marked by anger, impulsive actions, paranoia, intrusive thoughts, and a "quite depressed" mood. The private psychologist recognized diagnoses of bipolar disorder and severe depression, but opined that "PTSD remains the primary and most important diagnosis." After reviewing all the evidence, lay and medical, the Board finds that, for the entire initial rating period on appeal, the Veteran's psychological disabilities, to include PTSD, bipolar disorder, and major depressive disorder, have been characterized by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; near-continuous depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (demonstrated by difficulty controlling anger and evidence of hyperstartle response); difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. Such impairment and symptoms more nearly approximate the criteria for a 70 percent rating under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. The Board finds that the criteria for next-higher 100 percent rating for service-connected psychological disabilities have not been met or more nearly approximated for any period during the initial rating period on appeal. The criteria for a 100 percent rating are met on 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 behaviour; 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. Id. During the rating period on appeal, the evidence has shown the Veteran to have difficulty maintaining social and family relationships, but has not precluded such relationships entirely. For example, the Veteran has reported that he attends church on a somewhat regular basis, socializes with individuals met through his church and that he is close with his sister. Although the Veteran has endorsed delusions and hallucinations, these have been reported sporadically, and the Veteran has demonstrated that he has some control over these symptoms, given enough effort. Finally, the Veteran's thought processes have not been grossly impaired and, as reported on private evaluation in July 2013, the Veteran is "basically oriented" in all four spheres. The Veteran has not manifested obsessional rituals which interfere with routine activities, though at times there have been significant symptoms that pertain to combat, including anxiety, distressing intrusive thoughts/recollections, nightmares, hyperstartle, and hypervigilance; however, such symptoms have not been noted to cause obsessional rituals which interfere with routine activities, but rather have resulted in irritability, inattentiveness, and anxiety, as noted in May 2006. Further evidencing that the Veteran's psychological disabilities have not been 100 percent disabling are GAF scores throughout the appeal period which have been between 40 and 60 - indicative of symptoms ranging from merely moderate symptoms, to symptoms resulting in impairments in reality testing or major impairments in several areas, such as work or school, family relations, judgment, thinking, or mood. Nonetheless, the GAF scores have not indicated a level of severity resulting in serious impairment in communication or judgment, or an inability to function in almost all areas (as indicated by GAF scores from 30-21). In total, symptomatology manifested by service-connected psychological disabilities is encompassed by the 70 percent disability rating criteria, and does not more nearly approximate the criteria for the next higher 100 percent disability rating for any portion of the initial rating period on appeal. Accordingly, resolving reasonable doubt in the Veteran's favor, the Board concludes that the Veteran's psychological disabilities have been 70 percent disabling throughout the entire initial rating period on appeal. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. Extraschedular Consideration The Board has also considered whether referral for an extraschedular rating is warranted for service-connected psychological disabilities. 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. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran'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 veteran's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Here the schedular rating criteria used to rate the Veteran's service-connected psychological disabilities above, reasonably describe and assess the Veteran's disability level and symptomatology. The schedular rating criteria described in the General Rating Formula for Mental Disorders specifically provides for disability ratings based on a combination of history and clinical findings. In this case, the evidence adequately reflects the symptoms of the Veteran's psychological disabilities including nightmares, sleep impairment, intrusive thoughts, anger, irritability, social and family isolation, hypervigilance, hyperarousal, excessive startle response, decreased concentration, anxiety, depressed mood, suicidal and homicidal ideation, and hallucinations. These symptoms are part of or similar to symptoms listed under the schedular rating criteria. The schedular rating criteria include occupational and social impairment, as indicated by reduced reliability and productivity, and as caused by specific psychiatric symptoms. The schedular rating criteria also include analogous symptoms that are "like or similar to" listed schedular rating criteria. Mauerhan, 16 Vet. App at 442 ; see also 38 C.F.R. § 4.21 (2012). Additionally, the Board has considered GAF scores, which are incorporated through the DSM-IV as part of the schedular rating criteria, as reflective of the degree of severity of psychiatric symptoms or overall functional impairment caused by the acquired psychiatric disorder. For these reasons, the Board finds that the schedular rating criteria is adequate to rate the Veteran's service-connected psychiatric disabilities, and referral for consideration of an extra-schedular evaluation is not warranted. TDIU A total disability ratings for compensation based on individual unemployability (TDIU) may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.34l, 4.16(a) (2012). Where the combined rating percentage requirements are not met, entitlement to the benefits may be nonetheless considered when a veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). Marginal employment shall not be considered substantially gainful employment, and generally shall be deemed to exist when a veteran's earned income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. Marginal employment may also be held to exist, on a facts-found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Consideration shall be given in all claims to the nature of the employment and the reason for termination. 38 C.F.R. § 4.16(a). The central inquiry is, "whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19 (2009); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Board observes that a claim for TDIU is, in essence, a claim for an increased rating. Norris v. West, 12 Vet. App. 413, 420-21 (1999). A TDIU claim is an alternate way to obtain a total disability rating without recourse to a 100 percent evaluation under the rating schedule. Evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b) (2012). See Charles v. Shinseki, 587 F.3d 1318 (Fed. Cir. 2009) (holding that, because evidence relevant to a claim had been received within one year of the rating decision, that decision was non-final for VA purposes under 38 C.F.R. § 3.156(b)). The Board finds that a September 2011 rating decision denying TDIU did not become final, and the issue of TDIU is still before the Board as an integral part of the Veteran's claim for an increased rating. As stated above, in a September 2011 rating decision the RO denied TDIU. However, in a February 2012 statement, received within one year of the rating decision denying TDIU, the Veteran's representative continued to submit arguments in favor of a grant of TDIU. Furthermore, a letter from the Veteran's treating VA psychologist received in April 2012, also within one year of the rating decision, presented new and material evidence of the Veteran's unemployability. As new and material evidence was received within one year of the September 2011 rating decision, the rating decision did not become final. 38 C.F.R. § 3.156(b); see Charles, 587 F.3d 1318. The Board finds the evidence to be in equipoise with regard to whether the Veteran is unemployable due to service-connected psychological disabilities. As a threshold matter, the Board notes that in the immediate decision, the Veteran's only service-connected disability has been evaluated as 70 percent disabling, meaning that the Veteran meets the schedular criteria for TDIU by having at least a single service-connected disability ratable at 60 percent or more. 38 C.F.R. § 4.16(a). The record includes multiple assessments of the Veteran's unemployability due to his current psychological disabilities. The evidence indicates that in December 2012 the Veteran was on a leave of absence from a telemarketing firm, which the Veteran went on voluntarily according to a July 2006 statement. In January 2007, the Veteran reported that he had returned to work on the evening shift; however, in June 2007 the Veteran reported that he stopped working the evening shift when it was eliminated, and that he would not "cope with the activity, pressure and social demands of the day shift," and as a result decided not to return to work. An August 2010 letter from a VA nurse practitioner who had been treating the Veteran from June 2008 through March 2010 indicated that the Veteran was unable to work or attend classes due to episodes of emotional lability and feelings of stress and pressure. These symptoms have been associated with service-connected psychological disabilities. Especially probative is the April 2012 opinion of the Veteran's VA treating psychologist in which it was stated that, given "the chronicity and severity of [the Veteran's] symptoms, and after several years of providing psychological treatment, it is clear to [the VA psychologist] that [the Veteran] is unable to work." Because this opinion was based in part on sufficient opportunities for observation, and was offered by a trained clinical psychologist, the Board finds the opinion to be highly probative. Furthermore, the opinion is consistent with the July 2013 opinion of a private clinical psychologist who opined, following examination and review of the Veteran's records, that the Veteran was "unable to secure and follow substantially gainful employment solely as a result of his service-connected PTSD without regard to his non-service-connected conditions." While the Board finds that the Veteran is currently unemployable, the record is unclear regarding when the Veteran became unable to secure and follow substantially gainful employment, though the record shows a pattern of periods of actual unemployment and intermittent employment during the claim period. In particular, the Veteran reported employment at a telemarketing firm; however the record does not establish dates of such employment, and whether such employment amounted to substantially gainful employment under 38 C.F.R. 4.16(a). Regardless, it the purview of the RO to assign the effective date for TDIU in the first instance. Resolving all reasonable doubt in the Veteran's favor, TDIU is warranted. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER An initial rating of 70 percent, and no higher, for psychological disabilities, to include PTSD, bipolar disorder, and major depressive disorder, is granted. TDIU is granted. ____________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs