Citation Nr: 1331640 Decision Date: 10/01/13 Archive Date: 10/07/13 DOCKET NO. 06-39 559 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to an initial disability rating in excess of 10 percent for the period from June 20, 2003, through April 17, 2005; in excess of 30 percent for the period from April 18, 2005, through March 29, 2012; and in excess of 50 percent for the period from March 30, 2012, onward for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD A.E.H. Gibson, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1967 to September 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama, which assigned an initial disability rating of 10 percent for PTSD. The Veteran timely appealed for a higher rating, and during the pendency of his appeal, the RO assigned higher ratings of 30 percent for the period from April 18, 2005, through March 29, 2012, and 50 percent for the period from March 30, 2012, forward. See Fenderson v. West, 12 Vet. App. 119 (1999). These increases during the appeal did not constitute a full grant of the benefit sought. Therefore, the Veteran's claim for an increased rating for the PTSD remains on appeal. See AB v. Brown, 6 Vet. App. 35 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). This matter was remanded by the Board in October 2010 and March 2013, each time for the purpose of scheduling the Veteran for a personal hearing before a member of the Board. He failed to report to the hearing that was scheduled pursuant to the March 2013 Remand, and has not since offered any reason for missing it, nor has he asked for it to be rescheduled. His hearing request, therefore, is deemed withdrawn. See 38 C.F.R. §§ 20.702(d); 20.704(d) (2012). Review of the Virtual VA paperless claims processing system reveals additional medical records that are pertinent to the Veteran's claims. During the pendency of this claim, evidence was received that the Veteran's PTSD prevented him from obtaining and maintaining gainful employment. See, e.g., VA Form 9 received December 2006. When evidence of unemployability is presented in cases such as this, the issue of whether a TDIU will be assigned should be handled during the determination of the initial disability rating assigned at the time disabilities are determined to be service connected, considered part and parcel of the claim for benefits for the underlying disability. See Rice v. Shinseki, 22 Vet. App. 447, 452-53 (2009). However, the issue of whether he is entitled to a TDIU requires further development, and is addressed in the REMAND portion of the decision below. That issue is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran's PTSD is manifested by depression, anger, social isolation, difficulty in following the orders of superiors, substance use and abuse, hypervigilant behavior, mild disturbances in thought, and cognitive impairments. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 50 percent, but not higher, for the period from June 20, 2003, through March 29, 2012, for PTSD have been met. 38 C.F.R. §§ 3.102, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an evaluation in excess of 50 percent for the period from March 30, 2012, forward, for PTSD have not been met. 38 C.F.R. §§ 3.102, 4.7, 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, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. See Gonzales, 218 F.3d at 1380-81. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. Id. The Board must assess the competency and credibility of all evidence, including the medical 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 Veteran. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). 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. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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 a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. Veterans Claim Assistance Act (VCAA) The Veterans Claims Assistance Act (VCAA) provides that VA has a duty 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 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of what is needed to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2011); 38 C.F.R. § 3.159(b) (2012). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and, (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). All notice under the VCAA should be provided prior to an initial 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) (Pelegrini II). The issuance of a fully compliant VCAA notification followed by readjudication of the claim is sufficient to cure a timing defect. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370 (2006). A service connection claim consists of five elements: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006); 38 U.S.C. § 5103(a) (West 2002 & Supp. 2011). Compliance with the first Quartuccio element requires notice of these five elements. See Dingess/Hartman, 19 Vet. App. at 486. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, notice under section 5103(a) is no longer required because the purpose that the notice is intended to serve has been fulfilled. See Dingess, 19 Vet. App. at 490-91. Thus, because service connection for PTSD was granted, VA's notice obligation with respect to the issue of entitlement to a higher initial evaluation for this disability is fully satisfied, and any defect in the notice is not prejudicial. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) (where a claim has been substantiated, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). In any event, the record reflects that the originating agency provided the Veteran with the notice required under the VCAA and under Dingess by letters mailed in July 2003, February 2005, and March 2006 (to include for a TDIU). VA also has a duty to assist the claimant in the development of the claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). This duty includes assisting him in obtaining service treatment records (STRs) and other pertinent treatment records, as well as providing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See id. In this case, the Veteran's STRs and post-service medical records have been obtained and associated with the file. He has also been afforded four VA examinations, in October 2003, November 2004, July 2005, and March 2012. The Board finds that these examination reports contain findings that are adequate to adjudicate the Veteran's appeal for a higher initial disability rating. Accordingly, the Board finds that VA's duty to assist with respect to development of the claim has been met. 38 C.F.R. § 3.159(c)(4) (2011); Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board will address the claim on the merits. Entitlement to Increased Initial Disability Ratings Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes (DCs) identify the various disabilities. 38 C.F.R. Part 4 (2012). If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2012). Pyramiding, the evaluation of the same disability under various diagnoses, is to be avoided. 38 C.F.R. § 4.14 (2012). Consistent with the facts found, the rating may be higher or lower for periods of the time under review on appeal, that is, the rating may be "staged." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Veteran's disability rating for PTSD is currently staged. For the period from June 20, 2003, to November 17, 2005, the Veteran has been assigned a 10 percent disability rating. For the period from November 18, 2005, to March 29, 2012, the Veteran has been assigned a 30 percent disability rating. And, for the period from March 30, 2012, forward, the Veteran has been assigned a 50 percent disability rating. The criteria for evaluating PTSD are found at 38 C.F.R. § 4.130, DC 9411 (2012). A 10 percent evaluation is warranted for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. Id. A 30 percent evaluation is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily), with routine behavior, self-care, and conversation normal, due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). Id. A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands, impairment of short and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and, difficultly in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id. A 100 percent evaluation requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and, memory loss for names of close relatives, own occupation, or own name. Id. Symptoms listed in VA's general rating formula for mental disorders serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). The examples are not all inclusive or exhaustive, but they do provide guidance as to the effect and severity of symptomatology contemplated for each rating. The nomenclature employed in the rating formula is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. § 4.130 (2012). Contained within the DSM-IV are Global Assessment Functioning (GAF) scale scores ranging from 1 to 100, which reflect "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown , 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). The Board notes that an examiner's classification of the level of psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage rating to be assigned. See VAOPGCPREC 10-95. GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). GAF scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co- workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which 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., a depressed patient who avoids friends, neglects family, and is unable to do work). According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. See 38 C.F.R. § 4.126(a) (2012). In addition, the evaluation must be 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. See Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. See 38 C.F.R. § 4.126(b) (2012). Turning to the evidence, in October 2000, the Veteran complained of depression. He said he was sleeping all the time and having a hard time concentrating. He said he had been on Antabuse for more than 20 years. He reported he was working as a painter. In February 2002, the Veteran reported that he stopped taking Prozac. He said he had no symptoms of depression, had a good energy level, was in a good mood, was sleeping fine, and eating enough. He denied suicidal and homicidal ideation. He was taking Antabuse, but said he drank once a year at his army reunion. He also reported that he attended Alcoholics Anonymous meetings. An undated Intake and Treatment Summary, received in March 2005, described the Veteran's symptoms and treatment he received at the Vet Center from June 2003 through August 2004. He complained of intrusive thoughts, flashbacks, angry outbursts, social isolation, sleep disturbance, and depression. He reported that he attempted suicide in February 2003 by taking pills. He had trouble maintaining employment because he did not respond to authority figures. He said that taking orders from others was very hard for him, and was the biggest obstacle in finding employment. He also said that he took up painting because he could do that on his own. He and his first wife divorced two years after he returned, and he was also divorced from his second wife. The Vet Center's assessment found that he had moderate to severe symptoms of PTSD, which was based on his substance abuse, social isolation, multiple failed marriages, poor job history, intrusive thoughts, and flashbacks. At the October 2003 VA examination, the Veteran reported that he was working clearing land, for which he was paid $400 a month and provided a place to live. Before that, he said he was a self-employed painter. He told the examiner that he drank heavily in the 1970's, but was currently a social drinker. He complained of intermittent trouble sleeping, and occasionally had dreams. He said he was not social. He denied suicidal or homicidal ideation. He said that he was receiving treatment at the Vet Center, which he thought was helping him. As an example, he said that he now felt more comfortable sitting with his back to the door, but that he preferred having his back to the wall. He often looked for hiding places, but said he was getting over this. He described feelings of detachment. He was oriented to time, place, person, and circumstance, made good eye contact, and was cooperative. His appearance was disheveled. His thought process was coherent, and negative for suicidal or homicidal ideation. His insight and judgment were adequate. His GAF was 76. In a July 2004 statement, the Veteran's friend submitted a statement in which he emphasized the extreme and disturbing anger the Veteran was capable of expressing. He categorized it as "homicidal and suicidal anger," or rage, and he said that the Veteran made threatening remarks against the VA when his claim was denied. He said that he had seen the Veteran for the first time since service, and did not recognize him due to his changed personality. He was silent and withdrawn, angry, and depressed. He also said the Veteran could not remember incidents from Vietnam that he was a part of, but that he also has flashbacks. At the November 2004 VA examination, the examiner noted the Veteran was upset over the findings and diagnoses made in his October 2003 VA examination, which was conducted by the same examiner. During the November 2004 examination, the Veteran reported being very angry about how the VA was handling his claim, although he knew the denial was not a personal attack. He said that he lived alone, and his personality chased people away. He was alert and oriented to time, place, person, and circumstance. His thought processes were coherent and content was negative for suicidal or homicidal ideation. His GAF was 70. At a May 2005 mental health intake, the Veteran reported feeling depressed for many years. He said that he had crying spells, poor concentration, sleep difficulties, loss of interest in pleasurable activities, and fatigue. He also had intrusive thoughts and memories, and that he avoided thoughts, conversations, and activities that remind him of traumatic events. He had consumed alcohol (a quart of whiskey or more) 3 or 4 times in the preceding 9 months, but denied drug use. He denied suicidal or homicidal ideations. During the examination, he appeared nervous. He did not exhibit psychotic, manic, or hypomanic features. He did not have any mental content symptoms, perceptual disturbances, or gross cognitive confusion, and was oriented to time, place, person, and circumstance. His abilities to work with abstractions appeared intact. His GAF was 59. At the July 2005 VA examination, the Veteran reported that he last worked 3 to 4 years before the examination, and that he stopped working due to body aches and fatigue. He said he addressed his mental health for 35 years by self-medicating with alcohol. He said he was still drinking occasionally, but not using marijuana. He reported intrusive thoughts of Vietnam, flashbacks, angry outbursts, social isolation, sleep disturbances, and depression. During the examination, he was alert and oriented to time, place, person, and circumstance. He made fair eye contact, and his mood was mildly anxious. His thought process was coherent. He had no suicidal or homicidal ideations, and no overt psychosis. His insight and judgment were adequate, except for his occasional alcohol use. The examiner assigned him a GAF of 63, and indicated that the Veteran's PTSD symptoms would not preclude him from obtaining employment. In a February 2006 statement, the Veteran said that he last worked in 1990, as a self-employed painter. He said he had difficulty getting along with people. He also said he has memory loss, particularly short-term. He said he has a hard time remembering information that he has read. He had no social life, except for time spent with family. In a December 2006 statement, the Veteran said that his PTSD prevents him from working at his usual occupation, painting. He also said that he has no social life. In an April 2007 statement, the Veteran's former military Chaplain explained that he would see the Veteran from time to time at funerals or reunions. He said that he saw the Veteran's symptoms of PTSD, including social withdrawal, anger, and alternating between involvement and detachment. He said that the Veteran is easily provoked to the point of extreme agitation. He also said the Veteran contemplated suicide from time to time. He said the Veteran has told him that he feels overwhelmed by guilt, and has recurring nightmares and intrusive flashbacks of his time in Vietnam, all of which cause him to be depressed. He indicated that he has seen these signs and symptoms in the Veteran and in other veterans. He also indicated that he understood the Veteran's symptoms caused him problems in employment situations, especially in dealing with authority figures. In the fall of 2007, the Veteran submitted paperwork to establish his common law wife as his dependent. They had been living together and acting as a married couple since 1990. An administrative decision acknowledging their common law marriage was issued in early 2008. In August 2009, the Veteran reported that he had significantly reduced his alcohol consumption, and that he had only had one beer that day. He reported that there was an outstanding warrant for his arrest, and he appeared to be handling it fairly well. His GAF was 55. At a November 2009 psychotherapy session, the Veteran denied suicidal and homicidal ideation, and was viewed as a low-risk for self-harm. He was in psychological distress, however, there were no indications of perceptual disturbances or gross cognitive confusion. His thinking and speech were within normal limits. His GAF was 50. In March 2011, the Veteran reported he had started drinking again, and he had a two-week binge. At the time of the appointment, he had been abstaining for 7-8 days. He was attending NA meetings. He said that he was very depressed while he was drinking, but feeling better since he stopped. He reported continued difficulties sleeping. His GAF was 55. In April 2011, the Veteran reported that he was doing better than he was at his last appointment. He indicated that he was eager to enroll in the compensated work therapy (CWT) program, and was hopeful that he could find an apartment for him and his wife. He was cheerful. In July 2011, the Veteran's treating psychotherapist noted that his mental health appears to be stable. There were financial and housing concerns. He was staying at a shelter for homeless veterans, but said that he thought he and his wife would be able to find an apartment within the month. He reported recently completing forklift training, but was doubtful that he would be able to find a job. He denied suicidal and homicidal ideation, intent, or plan. He appeared to be at low-risk for self-harm. His therapist noted no mental content symptoms, perceptual disturbance, or gross cognitive confusion. His thinking and speech were within normal limits. His GAF was 55. Also in July 2011, the Veteran reported to his treating psychiatrist that he was feeling anxious and not sleeping well. He also reported completing the forklift training, and said that his previous occupation, painting, is too hard on his body. He also thought that painting would lead him to relapse. At that time, he was in substance abuse recovery. The Veteran was medically cleared to attend compensated work therapy (CWT) in July 2011. It was noted that his mental status was alert, no active disease was noted, and he was calm and cooperative. There was no evidence of intoxication or withdrawal, and no evidence of hallucinations or delusions. He denied suicidal or homicidal ideation. The only indicated special accommodations were physical. At the March 2012 VA examination, the VA examiner diagnosed the Veteran with PTSD, noting his symptoms are mild but chronic. She opined that he had mild psychosocial impairments as a result of his PTSD. He reported that he rarely had combat-related dreams, and was rarely confronted by intrusive thoughts and memories of Vietnam, and attributed his progress to group therapy he participated in 4 to 5 years previous. He also reported that his hypervigilance had decreased, and that he was able to eat out at restaurants or go to the store without significant distress. He was still avoiding crowds, and did not attend sporting events, which was an activity he had enjoyed prior to Vietnam. He denied having significant emotional distress over the conflict in Iraq, but reported psychological distress and physiological reactivity to unexpected loud noises and certain scenes from movies. He was also diagnosed with depressive disorder NOS and polysubstance dependence. He had a depressed affect, reduced interest in activities, poor motivation, lack of energy, frequent fatigue, and occasional suicidal ideation without plan or intent. The examiner opined the bulk of his current impairments stem from his depression. His depressive symptoms resulted in moderate impairment in functioning, however, the examiner opined that his depressive symptoms were related to current stressors-his housing situation, his unemployment, his wife's health problems, and his own health problems-rather than related or secondary to his PTSD. It was noted that he attended the outpatient substance abuse clinic (OSAC) from March through July 2011. The Veteran was evasive about his current pattern of substance use, but admitted to occasional drinking, and occasional use of prescription painkillers. The March 2012 VA examiner opined that his symptoms cause occupational and social impairment with reduced reliability and productivity. However, she indicated that he reported minimal symptoms of reexperiencing, avoidance behaviors, and hyperarousal. She said his PTSD GAF ranged from a 60 to 70. She said that he reported moderate depressive symptoms, and was still using substances, which increase his level of impairment, and lead her to assign an overall GAF of 52. At the time of the examination, he and his common law wife of 22 years were not living together because they were unable to find housing. He reported little contact with his daughters, and few friends. He was not working, and said that his last steady employment was in 2001 or 2002. He said that he feels very weak and fatigued, which he attributed to his liver problems, and that when he works for a few days and then is tired for two weeks. The examiner observed that the Veteran was medically cleared to attend Compensated Work Therapy (CWT), which would help him find employment, but the Veteran responded that he was advised that he should not take part in that program while his appeal for disability was pending. He denied being hospitalized for his mental health since the last VA examination in 2005. He said he spends his days sleeping a lot and "piddling around," which leaves him "bored to death." He had no motivation to do things because of the fatigue that results from even minor exertion. He reads frequently. He helps care for his wife, and works at the soup kitchen once a week. He occasionally fishes or goes to church. He does not watch television. He reported infrequent panic attacks. The examiner noted that his hygiene was not good, and that he appeared to be in pain. His speech was mildly slurred and dysarthric, but he did not appear to be under the influence of alcohol. His thought processes were circumstantial and tangential, and he required frequent redirection, but there was no overt evidence of perceptual disturbance or cognitive confusion. His judgment was limited, and impulse control was fair. He was able to spell "world" backwards, and perform mental calculations with only one error. He remembered 2 out of 3 words immediately, but only 1 of those three words after a delay. He complained of having a hard time concentrating, and said that he often forgets where he puts things. He had no hallucinations or delusions. Based on the foregoing, and in resolving any doubt in the Veteran's favor, the Board finds that the criteria have been met for a 50 percent disability rating for the entire period under review. In this regard, the evidence shows the Veteran has symptoms that are associated with occupational and social impairment with reduced reliability and productivity, including: his mood disturbances (i.e., depression and anger); his difficulty in establishing new social or professional relationships (i.e., social isolation, a difficulty in following the orders of superiors, angry outbursts); his impaired judgment (i.e., continuing substance use and abuse); his hypervigilant behavior, which the Veteran has consistently reported as improving (i.e., in October 2003, he reported he was becoming more comfortable with having his back face the door, and in March 2012, he reported he was able to eat at restaurants or go to the store without significant distress); mild disturbances in thought (i.e., intrusive memories, flashbacks); and, cognitive impairments (i.e., difficulty in concentrating, no memory of some incidents that took place in Vietnam). The actual impact of the Veteran's symptoms on his occupational function is difficult to ascertain, as he has been in and out of employment and generally self-employed. He has asserted, and the other evidence confirms, that he has difficulty in getting along with people and taking orders from others, which would likely negatively impact his ability to find customers willing to pay for his services. His social functioning is clearly limited, for the reasons above. His GAF scores have generally ranged between 50 and 60, showing moderate impairment, which further supports an assignment of a 50 percent rating. The Board acknowledges that the VA examiner that conducted the October 2003 and November 2004 examinations assigned GAF scores of 76 and 70 (mild or transient impairment); however, the Board also notes that the Veteran's most prominent symptoms-mood disturbance, impaired judgment, and difficulty in establishing relationships-cause continuous impairment, rather than occasional or intermittent, and support a 50 percent rating over a 30 percent rating. The Board has considered whether application of a 70 percent rating, which requires occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, is warranted at any time during the appellate period. Although he has been shown to be angry and to have made threatening remarks, he has not been shown to have impaired impulse control or violent reactions to stressors. Although he has indicated he has no social life and says that his personality "chases people away," he has been with his common law wife for over 20 years, he attends Army reunions, he has friends that are willing to support his application for VA benefits, and he helps at the local soup kitchen. He has said that he has little motivation to do things, but he also said that is because of physical aches and pains that have not been attributed to his mental health disabilities. He has recently shown circumstantial and tangential thought processes, but was able to be redirected. Overall, his thought processes and content have been within normal limits, and they have not ever reached the level of having perceptual disturbance or cognitive confusion. There is evidence of one suicide attempt, in February 2003, however, it is not clear that this attempt was clinically significant, and there is no evidence that this had a significant impact on his social or occupational functioning. Moreover, during the period under review, he has asserted to treatment providers that he did not have suicidal or homicidal ideation, intent, or plan, and the Board places more weight on this evidence than on his statement to VA asserting otherwise. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the veteran). In sum, while the Veteran does have some symptoms that are frequently associated with a 70 percent rating, he does not have sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency, or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation. His thought process has been coherent and his judgment adequate. His thinking has been reported as within normal limits. Again, while he recently showed circumstantial and tangential thought processes, he was able to be redirected. Accordingly, the preponderance of the evidence is against entitlement to a rating in excess of 50 percent at any time during the appellate period. Extraschedular considerations The Board has considered whether the claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2012). Because the ratings under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun v. Peake, 22 Vet. App. 111, 114 (2008). In exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these cases is a finding that the disability presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2012). The determination of whether a veteran is entitled to an extraschedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115 (2008). First, there must be a finding that the evidence of record presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. In this regard, the Board must compare 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. See id. If the rating criteria reasonably describe the veteran's disability level and symptomatology, then the veteran's disability picture is contemplated by the rating schedule, in which case the assigned schedular evaluation is adequate and no referral is required. Id. Second, if the schedular criteria are found to be inadequate to evaluate the disability, the Board must determine whether the exceptional disability exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. Id. If so, then the third step requires the case to be referred to the Under Secretary for Benefits or the Director of Compensation and Pension Services to determine whether the disability requires the assignment of an extraschedular rating. Id. The Board finds that referral for extraschedular consideration is not warranted in this case. The Veteran's reported symptoms (such as depression, anger, social isolation, a difficulty in following the orders of superiors, substance use and abuse, hypervigilant behavior, mild disturbances in thought, and cognitive impairments) are contemplated by the rating criteria, as discussed above. There are no symptoms left uncompensated or unaccounted for by the assignment of a schedular rating. The evidence does not indicate that his PTSD presents "such an exceptional or unusual disability picture... as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b) (2012). The fact that circumstances specific to a particular claimant may cause the effects of a service-connected disability to be more profound in that veteran's case does not ordinarily provide a basis for extraschedular consideration. Id. Rather, the impairment must be one that is so unusual as to be unanticipated by the rating criteria. See id. Because the Board finds that the symptoms and functional limitations caused by the Veteran's PTSD are contemplated by the rating criteria, there is no need to consider whether it causes marked interference with employment. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, the Board finds that the available schedular evaluations are adequate to rate this disability, and therefore referral for extraschedular consideration is not warranted. See 38 C.F.R. § 3.321(b) (2011); Thun v. Peake, 22 Vet. App. 111, 115 (2008). ORDER Entitlement to an initial rating of 50 percent, but no higher, for the period from June 20, 2003, through March 29, 2012, for PTSD is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to an initial rating in excess of 50 percent for the period from March 30, 2012, forward for PTSD is denied. REMAND After careful consideration, and for the reasons set forth below, the Board finds that additional development of the record is necessary before the remaining issues on appeal may be decided. The Board sincerely regrets the delay a remand of these claims may cause, but the additional development requested will ensure procedural due process and that there is a complete record upon which to decide the claims so the Veteran is afforded every possible consideration. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. As mentioned above, there is also a derivative claim for a TDIU. While the Board has jurisdiction over such issue as part and parcel of the Veteran's disability rating claim, further development is necessary for an appropriate adjudication of the TDIU aspect of such claim. The most recent VA examination did not specifically address the impact of all of the Veteran's service-connected disabilities, including PTSD, on his ability to obtain and maintain gainful employment. Further, he has alleged that his liver, which has not been examined since 2007, has a negative impact on his ability to work. On remand, the Veteran should be provided with an examination to determine whether any of his service-connected disabilities, alone or in aggregate, render him unemployable. Any recent VA treatment records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. Make arrangements to obtain copies of the Veteran's updated treatment records from the Birmingham VAMC, dated since March 2012. Efforts to obtain these records should also be memorialized in the Veteran's claims file. 2. Schedule the Veteran for an appropriate VA examination. The entire claims file and a copy of this remand must be made available to and reviewed by the designated examiner. All necessary tests and studies, including appropriate psychological studies (if determined to be necessary by the examiner), should be conducted in order to identify the degree of occupational impairment attributable to his service connected disabilities. The examiner should take a detailed history regarding the Veteran's employment, education, and vocational attainment in connection with the claim for TDIU. The examiner is requested to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's service-connected disabilities, either individually or in the aggregate, render him unable to secure or follow substantially gainful employment consistent with his education and occupational experience. Service connection is currently in effect for PTSD; hepatitis C; and, a scar on the left leg. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached. 3. After the requested examination has been completed, the report should be reviewed to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, it should be returned to the examiner for corrective action. 4. Finally, readjudicate the claim on appeal. If the claim is not granted to the Veteran's satisfaction, send him and his representative an SSOC and give them an opportunity to respond before returning the file to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs