Citation Nr: 1331784 Decision Date: 10/02/13 Archive Date: 10/07/13 DOCKET NO. 10-20 829 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUE Entitlement to an increased rating for service-connected posttraumatic stress disorder (PTSD), currently evaluated 70 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran served on active duty in the United States Marine Corps from June 1990 to June 1994 This matter is before the Board of Veterans' Appeals (the Board) on appeal of a June 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada which granted an increased rating of 70 for PTSD, effective October 2, 2008. The Board notes that the Veteran initially perfected an appeal of the May 2005 rating decision of the San Diego, California RO which granted service connection for PTSD at a 50 disability evaluation, effective August 23, 2004. However, in a December 2007 correspondence, the Veteran withdrew his appeal which disagreed with the initial 50 percent disability evaluation. The Veteran testified at a Travel Board hearing which was chaired by the undersigned Veterans Law Judge at the Las Vegas, Nevada RO in May 2011. A transcript of the hearing has been associated with the Veteran's VA claims folder. In a February 2013 decision, the Board remanded this issue for additional development. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The Board observes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veterans Claims (Court) held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. As the current appeal involves entitlement to a higher rating PTSD and a March 2013 VA examination report, as discussed below, suggests that the Veteran is unemployable due to his psychiatric disability and the Veteran has submitted recent statements asserting unemployability, the Board concludes that the matter of entitlement to TDIU has been raised. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a) (2) (West 2002). FINDINGS OF FACT 1. The Veteran's PTSD has not resulted in total occupational and social impairment due to 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; disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. 2. The Veteran meets the schedular requirements for a TDIU, and his service-connected PTSD precludes him from obtaining and retaining substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 70 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for entitlement to a TDIU have been met. 38 U.S.C.A. § 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). 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 evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice 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. Notice should be sent prior to the appealed rating decision or, if sent after the rating decision, before a readjudication of the appeal. A Supplemental Statement of the Case, when issued following a notice letter, satisfies the due process and notification requirements for an adjudicative decision for these purposes. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In this appeal, the RO provided notice to the Veteran in a November 2008 letter, prior to the date of the issuance of the appealed June 2009 rating decision. The November 2008 letter explained what information and evidence was needed to substantiate a claim for an increased rating, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The letter also provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter on appeal. Pertinent medical evidence associated with the claims file consists of service, VA treatment records and the reports various VA examinations to include recent March 2011 and March 2013 VA examinations. The March 2011 and March 2013 examination reports reflect that the VA examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted an appropriate physical evaluation of the Veteran, and rendered an appropriate diagnosis and opinion consistent with the remainder of the evidence of record. The Board concludes that these examination reports are adequate for purposes of rendering a decision in the instant appeal. See 38 CF.R. § 4.2 (2011); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Also of record and considered in connection with the appeal are the various written statements provided by the Veteran and by the Veteran's representative on his behalf as well as the Veteran's May 2011 hearing testimony. The Board finds that no additional RO action to further develop the record on the claim is warranted. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Increased Rating for PTSD A. Law and Regulations The Veteran essentially contends that his PTSD is more disabling than contemplated by the current 70 percent disability evaluation. Disability ratings are assigned in accordance with the 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 identify the various disabilities. See 38 C.F.R. Part 4. While the Veteran's entire history is reviewed when assigning a disability evaluation, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The Veteran's disability has been evaluated under Diagnostic Code 9411 for PTSD. Under the relevant rating criteria, a 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). A 100 percent evaluation is warranted where there is evidence of total occupational and social impairment due to 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; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association 's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM- IV), p. 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126 (2012); VAOPGCPREC10-95 (Mar. 1995); 60 Fed. Reg. 43186 (1995). According to the DSM-IV, GAF scores ranging between 61 to 70 reflect some mild symptoms [e.g., depressed mood and mild insomnia] or some difficulty in social, occupational, or school functioning [e.g., occasional truancy, or theft within the household], but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect more moderate symptoms [e.g., flat affect and circumstantial speech, occasional panic attacks] or moderate difficulty in social, occupational, or school functioning [e.g., few friends, conflicts with peers or co- workers]. Scores ranging from 41 to 50 reflect serious symptoms [e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting] or any serious impairment in social, occupational or school functioning [e.g., no friends, unable to keep a job]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication [e.g., speech is at times illogical, obscure, or irrelevant] or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood [e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school]. Scores ranging from 21 to 30 reflect behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). GAF scores ranging from 11 to 20 indicate some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasional failure to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). In addition to PTSD, for which service connection has been established, the record shows additional diagnoses of major depressive disorder and anxiety. It is now well-settled 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. See Mittleider v. West, 11 Vet. App. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). As noted below, the March 2013 VA examiner noted that the Veteran's depression was secondary to his PTSD so "all impairment should be ascribed to PTSD". Accordingly, for the purposes of this decision, the Board will attribute all of the Veteran's psychiatric symptoms to his service-connected PTSD. B. Analysis The Veteran's service-connected PTSD is currently rated 70 percent disabling. The Board has reviewed the evidence in order to determine whether the criteria for the assignment of a higher disability rating have been met. The Veteran submitted a claim for an increased rating in October 2008. The Veteran underwent a VA examination in December 2008. He denied any hospitalizations since 2004 but had outpatient care from 2004 to 2007. He currently had sporadic visits to the Las Vegas VA Medical Center (VAMC) both for family care follow-up and for PTSD treatment. He had received treatment in the form of antidepressant medication. He presented with complaints of persistent depression, persistent recurrent nightmares, and flashbacks. He was very anxious, complained of forgetfulness and complained of persisting difficulties with his coworkers and his family. He also had an inability to function well at his job and had been cited several times for his inability to do his work on time. He had family problems with his wife and kids. He was persistently suspicious of people. He was depressed and had episodes of crying spells. He had no legal problems. Over the past 12 months he missed maybe 3 or 4 days of work but had problems with his supervisors. He also did not socialize with his coworkers or other people. He was working with Family Services but was currently in danger of getting fired from his job. He has been married twice and blames the end of the marriage on his nasty behavior. He has been married to his current wife since 2002 and they have 3 children. He also has a daughter that was born out of wedlock. He had very poor social relationships and had no social relations. He denied any leisure pursuits or activities. He had a history of violence with his first marriage but had not had any recent episodes of assaultiveness. He had been verbally abusive and had a history of road rage. He denied any history of suicide attempts although he had suicidal thoughts which he would not carry out because of his children. He had poor performance in his employment but was able to do routine responsibilities of self-care. His family role functioning was impaired and he had constant arguments with his wife. Social and interpersonal interaction had been poor and he had no friends to speak of. He had no recreational activities or leisure pursuits. On examination, he showed no gross impairment of thought process or communication but he did have sudden episodes of crying spells which manifested during the interview. He did not like the fact that he could not stop himself from drinking when he knew that he should not be drinking. He denied any delusions or hallucinations. He had relatively good eye contact and interacted well during the session aside from the inappropriate crying spells. He had suicidal thoughts but no intent. He had no homicidal thoughts although he did anger easily. He was able to maintain minimal personal hygiene and other activities of daily living. He was oriented to person, place and time. He described memory impairment. He did not have any ritualistic behavior although he had some repetitive checking of doors and locks which appeared to get worse when he was anxious. Rate and flow of his speech was relevant and logical and there were no obscure speech patterns. He had a history of panic attacks and reported getting panicky about 3 times a week. He admitted to depression and his mood was depressed during the interview. He had persistent anxiety but denied impulse control problems other than his drinking. He slept poorly and had persistent flashbacks of people he helped bury. He had nightmares and intrusive memories. The examiner noted that the Veteran had reexperiencing symptoms, intrusive recollections, avoidance symptoms, hyperarousal symptoms, poor sleep and irritability at home and at work. He also had difficulty concentrating and exaggerated startle response. The diagnosis was PTSD and alcohol dependence. A GAF score of 40-45 was assigned. The examiner felt that the Veteran was capable of managing his financial affairs. The examiner also opined that the Veteran's PTSD signs and symptoms resulted in deficiencies in work and family relations. He was in danger of losing his job, his 2 brothers no longer talk to him and his current wife is just staying with him because of their children. He felt that his children did not like him because he was mean to them. His judgment was impaired and he was unable to stop drinking. He was distrustful and suspicious of people and his mood was depressed. He had a lot of depressive symptomatologies. The examiner believed that the Veteran's PTSD symptoms were severe enough to require continuous medication. The examiner concluded that the Veteran's PTSD symptoms are severe enough to interfere with occupational and social functioning. In November 2009, the Veteran presented with complaints of suicidal ideation. Specifically, he thought of poisoning himself in his car in a closed garage while his family members were asleep. The physician noted that the Veteran had a well-conceived, lethal, believable plan to act soon and he was at high risk. The Veteran had increased suicidal ideation the past two weeks. He agreed to inpatient hospitalization. The physician also noted that the Veteran was alert and oriented times 3. He was cooperative but his affect and mood were anxious, depressed and tearful. He felt hopeless, helpless and guilty. His speech was spontaneous, coherent and at times tangential. He felt paranoid that his supervisor at work was out to get him. At times he had vague auditory hallucinations that a voice was telling him to end his life. Memory and insight were fair but his judgment tended to be limited. The diagnosis was PTSD with major depression. A November 2009 VA treatment report noted that the Veteran had a previous history of hospitalization after presenting with symptoms of depression with suicidal ideation. He had vague suicidal ideation and required safety monitoring in the unit. The assessment of suicide risk was low to moderate. He was of no significant risk of danger to himself or others. The diagnosis was chronic PTSD, major depression and alcohol abuse. A GAF score of 45 was assigned. A November 2009 VA pharmacy note reported that the Veteran had not been compliant with his medications. The diagnosis was chronic PTSD and major depression. A GAF score of 40 was assigned. A December 2009 VA mental health treatment note reported that the Veteran indicated that his short hospital stay provided a relief as he enjoyed the short break away from home. His work situation was the same as he felt anxious and overwhelmed. He was alert and oriented times three, cooperative and appropriately dressed. His affect was full ranged and his mood was congruent. His speech was within normal limits and there was no delusion, hallucination nor suicidal or homicidal intent planned that was voiced. His memory was fair and his insight and judgment were fair. The physician estimated his risk level as moderate. A May 2010 VA mental health treatment note reported that the Veteran had been hospitalized in November 2009 for an episode of major depression and suicidal ideation. His mood had steadily improved since then with no subsequent episodes of suicidal ideation. The diagnosis was PTSD and depressive disorder in partial remission. A GAF score of 45 was assigned. The Veteran underwent a VA examination in March 2011. The Veteran reported that his psychiatric symptoms included PTSD on a daily basis and severe, paranoid ideation on a daily basis. He also had moderate and anxiety and severe depression. His treatment included medication, one on one counseling and group therapy. He denied legal problems. He reported that he was working for Clark County for 3 years until he quit in 2010 due to a conflict with a supervisor. In May 2010, he became a youth counselor for children through the State of Nevada. He currently worked 40 hours a week and lived with his wife and 3 children. He also saw another child of his periodically. He described a poor relationship with his wife and children. He reported that he did not trust other people and only had one co-worker friend. He described all his other relationships as poor or non-existent. He indicated that he tried to walk and exercise when he could but usually felt too tired and symptomatic to engage in exercise. He denied drug use but did state that he drank "a lot" on weekends for stress. It was noted that he received inpatient care in November 2009 for a week secondary to major depressive disorder and suicidal ideation. He indicated that he had not attempted suicide although he reported intermittent thoughts of suicide due to job stress and marital conflict. He continued to work full time as a youth counselor for the state of Nevada. He reported having a stressful job and a poor relationship with his coworkers but he forced himself to work because his children need health insurance and he needed to provide income for his family. The examiner noted that, overall, the Veteran appeared to be functioning very marginally at the present time as he was hospitalized in 2009 for major depressive disorder and suicidal ideation. On examination, his thought processes were not impaired. No delusions or hallucinations were present but the Veteran exhibited paranoid ideation during the examination. Impersonal behaviors and eye contact were normal. He had no homicidal or suicidal thoughts present although he indicated that he had intermittent thoughts of killing himself but denied a current plan or intent to do so. At the examination, he had rather poor hygiene and grooming. His clothes were stained and he appeared to be functioning rather marginally at this time in terms of self-care. He was fully oriented to person, place, name, date, age and purpose. No difficulties with attention and concentration were noted. There was no impairment to memory for immediate, recent, or remote memories. He had no obsessive or ritualistic behaviors present. His speech was relevant, logical, clear and constant. No panic attacks were present. He continued to report ongoing feelings of depression and anxiety on a daily basis that were moderate to severe in nature. Throughout the examination, he was tearful. His impulse control problems were fair. He reported poor sleep secondary to his PTSD. He had major depressive disorder in partial remission. The symptoms of his PTSD were sleep disturbance with nightmare and intrusive thoughts efforts to avoid thoughts memories or conversations associated with these traumatic events, poor sleep, anger, poor concentration, anxiety and feelings of detachment or estrangement from others including intermittent paranoid ideation. These symptoms occurred daily and were of moderate severity. The diagnosis was PTSD and major depressive disorder in partial remission. The GAF score assigned for PTSD was 50 and the major depressive disorder GAF score was 60. Overall, his GAF score was 50. The examiner noted that the Veteran was fully competent to manage financial affairs. The examiner also noted that the Veteran's depressive disorder was responsible for some degree of his current impairment in psychosocial adjustment and quality of life. The Veteran's prognosis for improvement of his psychiatric condition and impairment in functional status was guarded. The examiner concluded that the Veteran had PTSD signs and symptoms that resulted in deficiencies in most areas of work, school, family relations, judgment, thinking and mood. At his May 2011 hearing, the Veteran testified that he had continued suicidal ideation, daily anxiety and severe depression. He currently worked marginally and had a very difficult time working with people. He also had a difficult time in social situations and experienced marital difficulties. He testified that he worked about 37 to 38 hours per week but that he had no friends. He also reported that if he lost his current job, he would not be able to find a new one. He indicated that while he had not been hospitalized since his November, he did attempt to commit suicide again when he took 10 pills of Trazodone. A June 2012 VA psychiatric admission note reported that the Veteran had checked himself into the emergency room and was admitted with complaints of depression as he was constantly arguing with his wife and had stresses at work as well. He endorsed depressed mood, anhedonia, hopelessness, and thoughts of not wanting to be alive anymore. He also endorsed transient auditory hallucinations, but had none at the present time as he only experienced these hallucinations during the deepest depths of his depression, and when he goes on a drinking binge. He reported being off medication for the past several days during his drinking binge. He was alert, attentive and oriented to person, place time and situation. His thought process and association and thought content were within normal limits. His insight and judgment were good. His affect was blunted/constricted/restricted and his mood was depressed. He had passive suicidal ideation without a plan. The Veteran had a GAF score of 20 and needed acute inpatient care. A June 2012 VA psychiatry inpatient treatment note reported a GAF score of 30. A June 2012 VA treatment record noted that the Veteran presented with depressed mood, passive suicidal ideation and alcohol abuse. The Veteran received psychiatric treatment and he was discharged with "some acute risk of suicide". At discharge his condition was improved and he was oriented times 3. His affect was fuller and brighter and he denied suicidal/homicidal ideation or auditory hallucinations. Insight and judgment were good and he had no thought disorder. A GAF score of 30/45 was assigned. A March 2013 VA treatment note indicated that the Veteran had an assigned GAF score of 45. The treating physician noted that the Veteran had depression and anxiety with disrupted sleep, low energy, negative thinking, nightmares and isolating. Another March 2013 VA treatment note reported that the Veteran's PTSD was "improving with medication". Another March 2013VA treatment report noted that the Veteran's hygiene was adequate and his grooming was consistent with the situation. He was cooperative and reasonable. He was alert, attentive and oriented to person, place time and situation. His thought process and association and thought content were within normal limits. His insight and judgment were good. He had a history of suicidal ideation in the past but no attempts. A GAF score of 48 was assigned. Per the February 2013 Board remand instructions, the Veteran underwent a VA examination in March 2013. The Veteran had an Axis I diagnosis of chronic, severe PTSD; and recurrent, severe major depressive disorder with associated obsessive compulsive symptoms secondary to PTSD. A GAF score of 50 was assigned. The examiner noted that the Veteran's PTSD symptoms included nightmares, intrusive memories, hypervigilance, exaggerated startle response, avoidance of trauma reminders and irritability. His depression symptoms included persistent sadness, suicidal thoughts, hopelessness, reduced energy and motivation, obsessive thinking, and occasional auditory hallucinations. There was some overlap of symptoms such asanhedonia and impaired concentration. The examiner noted that that Veteran's level of occupational and social impairment with regards to all mental diagnoses was best summarized as "occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood." The examiner also noted that the Veteran's depression was secondary to his PTSD so "all impairment should be ascribed to PTSD". The Veteran was on his second marriage which has lasted 7 years and produced 3 children. He reported that his current marriage was badly strained. He also had another child from a previous relationship. He indicated that while he enjoys and cares for his children, his relationship with them is also strained. He had little contact with his mother or two younger brothers. He currently lived with his wife and 4 children. He was currently employed on a part time, on call basis as a teacher assistant. He estimated that he typically worked about 20 hours per week but also estimated that he had not worked for 5 weeks during the last 6 months as a result of depression. He indicated that he was distracted at work and sometimes failed to pay attention to directions. He also complained of difficulty arriving at work on time due to oversleeping and due to time spent obsessively checking his car for sabotage or explosives. He continued to receive psychiatric treatment at the VA and continued to be prescribed medications. He reported being hospitalized last year on a voluntary basis due to suicidal ideation. Throughout the evaluation he periodically expressed fear of harming himself, but denied any current suicidal intent or plan. He had difficulty with his insulin injections as he experienced episodes of severe depression during which he will have obsessive thoughts of blinding himself with his lancet, sometimes accompanied by auditory hallucinations that tell him to blind himself. He denied wanting to act on these thoughts and described them as frightening. He described these episodes as occurring every few weeks. He used to experience nightmares nightly but now had them once a month due to his medications. He had intrusive memories that occurred frequently. He described brief flashback incidents just before going to bed and waking up. He reported hypervigilant behaviors such as repeatedly checking doors and windows at night, and checking his car obsessively for sabotage and explosives. He described experiencing panic-like symptoms if startled. He reported sleeping well or excessively with medications, and being unable to sleep without them. He complained of irritability and angry outbursts that ended his first marriage and have strained his current one. He described occasional violence against property such as kicking furniture or punching walls, but denied recent violence against others. He complained of difficulty concentrating and limited ability to enjoy his life, and stated he sees himself as having no future. During episodes of depressed mood he felt hopeless and helpless, was unmotivated and inactive, isolated himself, and neglected his health. When his mood was improved, he was more active, spent time with his family, and was able to work. He described frequent guilt over family problems and parenting issues. He reported that he had attempted suicide as many as 4 times. The last attempt occurred "about two years ago" when he tried to kill himself by carbon monoxide poisoning before a family member reportedly intervened. After this attempt, he admitted himself to the hospital. He described recent vague thoughts of attempting suicide by walking into traffic, but denied any intent to act on these thoughts and stated family concern would deter self-harm. Such thoughts were described as occurring during episodes of severe depression when the Veteran's functioning declined significantly. He reported hearing auditory hallucinations every few weeks. He reported experiencing minor visual disturbances such as seeming to see movement at the periphery of his vision. He did not report specific delusional beliefs, but complained of frequently feeling misunderstood. On examination, he was casually dressed and groomed with an overweight appearance. Posture and eye contact were appropriate and facial expression was sad. He remained cooperative throughout and expressed gratitude to the VA for the assistance provided to him. Mood was moderately to severely depressed and affect ranged from despondent to agitated. He was preoccupied with depressive themes and fears, and he often had difficulty modulating his emotions and required redirection to calm himself. At times his thoughts had an obsessive and near psychotic quality. Speech was fluent with rate, volume and intonation consistent with affect. He had depressed mood; anxiety, suspiciousness; panic attacks that occurred weekly or less often; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impaired judgment; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; suicidal ideation; obsessional rituals which interfere with routine activities; impaired impulse control; and neglect of personal appearance and hygiene. The Veteran also had neglect of healthcare, excessive use of alcohol and occasional auditory hallucinations. He was capable of managing his financial affairs. The examiner noted that the Veteran continued to work on a part-time basis but that his job performance was poor at times due to distraction by trauma memories or obsessive thoughts, and noted that there are weeks when he was so depressed he did not work at all. The examiner opined that based on the severity of the symptoms, the Veteran struggled to work on part time basis, he did not maintain consistent attendance, and that it would not be possible for him to maintain a living wage given his limitations. The examiner concluded that even though the Veteran worked at times, and should be encouraged to continue to work when able, it was at least as likely as not that he should be considered unemployable under the VA standard. As noted above, to warrant the assignment of a 100 percent disability rating under Diagnostic Code 9411, the Veteran's PTSD must have manifested in 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. See 38 C.F.R. § 4.130, Diagnostic Code 9411. After reviewing evidence of record as a whole, to include the Veteran's ongoing VA treatment reports, his VA examination reports, and his credible lay statements, the Board finds that the assignment of a disability rating greater than 70 percent for the Veteran's service-connected PTSD is not warranted. The Veteran was most recently afforded VA examinations in March 2011 and March 2013. After reviewing the Veteran's medical history and upon interview and examination of the Veteran, the March 2011 and March 2013 VA examiners both pertinently concluded that the Veteran's PTSD symptomatology manifested in "occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood," which corresponds squarely with the schedular requirements for the assignment of a 70 percent disability rating. Indeed, at no point did the March 2011 and March 2013 VA examiners or any other examiner or treating physician find that the Veteran's PTSD causes total occupational and social impairment, as is required for the assignment of a 100 percent rating. In not granting a 100 percent schedular rating for PTSD, the Board is not minimizing the severity of the Veteran's symptoms. The Board notes that the evidence demonstrates that the Veteran experiences significant social impairment as a result of his PTSD. While he remained married to his second wife since 2002, he indicated that his relationship with his wife and children was badly strained. Additionally, he described all his other relationships as poor or non-existent. However, as noted above, a 100 percent rating is applicable if the manifestations of the service-connected psychiatric disorder result in total occupational and social impairment. Here, total occupational impairment is not demonstrated as the Veteran continues to be employed on a part time, on call basis as a teacher assistant. The Board notes that the Veteran reported that he had a stressful job and a poor relationship with his coworkers and he forced himself to work because his children needed health insurance and he needed to provide income for his family. He also noted that there were weeks when he was so depressed he did not work at all and that he described his job performance as poor at times due to distraction by trauma memories or obsessive thoughts. Additionally, the March 2013 VA examiner noted that the Veteran struggled to work on a part time basis, did not maintain consistent attendance, and that it would not be possible for him to maintain a living wage given his limitations. The examiner concluded that it was at least as likely as not that he should be considered unemployable under the VA standard. However, the fact remains that despite these difficulties, the Veteran is gainfully employed on a part time basis. Thus, total occupational impairment has not been demonstrated. Occupational impairment is clearly demonstrated, but such pathology is contemplated in the assignment of a 70 percent rating. Additionally, the Board notes that the March 2013 VA examiner did not indicate that the Veteran experienced total occupational and social impairment which would warrant a 100 percent evaluation. The Board also notes that a June 2012 VA psychiatry inpatient treatment note reported a GAF score of 30 and a June 2012 VA psychiatric admission note assigned a score of 20. As noted above, a GAF score of 30 reflects behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). A GAF score of 20 is indicative of some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasional failure to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). While the GAF scores of 20 and 30 demonstrate major impairment in several areas, the treatment records at the time noted that the Veteran presented with depressed mood, passive suicidal ideation and alcohol abuse which necessitated acute inpatient care. As a result of the inpatient treatment, the Veteran was discharged with "some acute risk of suicide" but it was noted that his condition was improved and he was oriented times 3. A GAF score of 45 was assigned upon his discharge from this treatment. The most recent GAF score of 50 assigned at the March 2013 VA examination also demonstrated this continued improvement. Additionally, VA treatment records and VA examinations show no gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, disorientation to time or place, or memory loss for names of own relatives, own occupation, or own name. The March 2011 and March 2013 VA examiners also determined that the Veteran was capable of managing his financial affairs. Additionally, the Board notes that GAF scores are only one indication of the severity of a given service-connected mental disorder. 38 C.F.R. § 4.130, Diagnostic Code 941; see also Carpenter, supra. Although the Veteran's symptomatology includes past and more recent suicidal ideation as noted by the Veteran's testimony, the evidence of record, to include the Veteran's ongoing VA treatment records and his credible lay descriptions of symptoms, simply does not demonstrate that his PTSD has caused total occupational and social impairment at any time during the appeal period. Based upon the guidance of the Court in Hart v. Mansfield, 21 Vet. App. 505 (2007), the Board has considered whether a staged rating is appropriate. However, in the present case, the Veteran's symptoms remained constant throughout the course of the period on appeal and as such staged ratings are not warranted The Board has also considered whether this case should be referred to the Director of the VA Compensation and Pension Service for extra-schedular consideration under 38 C.F.R. § 3.321(b) (1). The Court has held that the threshold factor for extra-schedular consideration is a finding on part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular evaluations for the service-connected disability at issue are inadequate. Therefore, initially, there must be a comparison between the level of severity and the symptomatology of the claimant's disability with the established criteria provided in the rating schedule for the disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111 (2008). In the case at hand, the record reflects that the Veteran has not required frequent hospitalizations for his PTSD and that the manifestations of his PTSD are not in excess of those contemplated by the schedular criteria. While he was hospitalized in November 2009 and June 2012 for suicidal ideation, the treatment records reflect that after acute inpatient care, the Veteran demonstrated improvement. In sum, there is no indication that the average industrial impairment from the disabilities would be in excess of that contemplated by the assigned ratings, to include the increased rating granted herein. Accordingly, the Board has determined that referral of the issue of entitlement to a higher rating for PTSD for extra-schedular consideration is not in order. As the preponderance of the evidence is against the claim for an increased rating, the benefit-of-the-doubt rule does not apply, and the claim for a schedular rating in excess of 70 percent must be denied. 38 U.S.C.A. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). TDIU A. Law and Regulations Under VA laws and regulations, a TDIU may be assigned upon a showing that a veteran is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his or her service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a veteran's level of education, special training, and previous work experience; however, age and any impairment caused by non-service-connected disabilities are not for consideration in determining whether such a total disability rating is warranted. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Marginal employment, defined as an amount of earned annual income that does not exceed the poverty threshold determined by the United States Department of Commerce, Bureau of the Census, shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). A TDIU may be assigned even where the combined rating for the veteran's service-connected disabilities is less than total if the disabled veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Specifically, if there is only one such disability, this disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability that is ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For the purpose of determining the above, the following will be considered as one disability: 1) disabilities of one or both upper extremities, or of one or both lower extremities, including the bilateral factor set forth under 38 C.F.R. § 4.26, if applicable; 2) disabilities resulting from common etiology or a single accident; 3) disabilities affecting a single body system, e.g., orthopedic, digestive, respiratory, cardiovascular-renal, neuropsychiatric; 4) multiple injuries incurred in action; or 5) multiple disabilities incurred as a prisoner of war. In exceptional cases, an extra-schedular rating may be assigned on the basis of a showing of unemployability alone. See 38 C.F.R. § 4.16(b). B. Analysis The Board notes that the Veteran's disability evaluation for PTSD meets the threshold regulatory requirement for the award of a schedular TDIU under 38 C.F.R. § 4.16(a). The record shows that the Veteran worked for Family Services at the time of his December 2008 VA examination, but was in danger of getting fired from his job. As noted in the March 2011 examination report, he became a youth counselor in May 2010 and currently worked full time at 40 hours a week despite difficulties with coworkers. Similarly, at his May 2011 hearing, he testified that he worked 37 to 38 hours a week. Nevertheless, subsequent records show that he was hospitalized in June 2012 due, in part, to stresses at work. More recently, in March 2013, a VA examiner found that the Veteran, despite working part time had poor job performance due to his psychiatric symptoms. It was noted that, even though he worked occasionally, the Veteran could not maintain consistent attendance and the examiner felt that the Veteran should be considered employable due to his PTSD. In view of the March 2013 opinion, the Board finds that the symptoms associated with the Veteran's service-connected PTSD have rendered the Veteran unable to secure or follow a substantially gainful occupation. The Board finds the evidence in relative equipoise as to the question of whether the Veteran's service connected PTSD currently renders him unemployable. As such, the Veteran is entitled to the benefit of the doubt, and entitlement to TDIU is granted. ORDER An evaluation in excess of 70 percent for service-connected PTSD is denied. A total disability rating due to individual unemployability is granted. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs