Citation Nr: 1333233 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 12-22 841 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent prior to April 25, 2011 and after June 30, 2011 for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disability. REPRESENTATION Appellant represented by: Daniel Smith, Attorney ATTORNEY FOR THE BOARD Jonathan Tracy, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1999 to July 2006. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board notes the November 2011 rating decision issued by the RO that denied initial increased ratings for the Veteran's service-connected hearing loss and right hip disorder. Those issues were not appealed and are therefore not before the Board. In February 2013, attached to the Veteran's Brief, the Veteran's attorney included VA treatment records from July 2012 that were not considered by the RO. In an attached letter, the Veteran's attorney waived the consideration of the evidence by the RO. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim for total disability rating based upon individual unemployability (TDIU) is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. The Court further held that when evidence of unemployability is submitted during the pendency of a claim for an increased evaluation, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. In the Veteran's Brief dated in February 2013, the Veteran's attorney made a claim for TDIU. Accordingly, the issues listed above have been amended to include the issue of whether a TDIU rating is warranted. However, such claim has not been developed or considered by the RO in the first instance. The TDIU issue is addressed in the REMAND portion of the decision below and is REMANDED to the RO. The Board notes that, in addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals most of the documents are either duplicative of the evidence in the paper claims file or irrelevant to the issues on appeal. The only non-duplicative and relevant documents included in the Virtual VA file are VA treatment records from the Bay Pines VA Healthcare System (HCS) dated from March 2010 to February 2012. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim herein decided has been accomplished. 2. The Veteran's service-connected PTSD is manifested by no worse than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), and chronic sleep impairment until February 21, 2011 and after June 30, 2011. 3. The Veteran was admitted into Bay Pines VA Healthcare System (HCS) from February 22, 2011 to March 2, 2011 for treatment for alcohol dependence and his service-connected PTSD, the symptoms of which escalated. 4. The Veteran was admitted into Bay Pines VA HCS Domiciliary/Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) from March 21, 2011 to April 18, 2011 (more than 21 days) for treatment for alcohol dependence and his service-connected PTSD. 5. The Veteran was admitted into Bay Pines VA HCS Domiciliary Residential Treatment Program (DRTP) from April 25, 2011 to June 10, 2011 (more than 21 days) for treatment for alcohol dependence and his service-connected PTSD, during which time his PTSD was rated as 100 percent disabling by the RO. CONCLUSION OF LAW The criteria for an initial evaluation of 30 percent, but not higher, prior to February 22, 2011; of 70 percent, but not higher, from February 22, 2011 to March 20, 2011; of 100 percent from March 21, 2011 to June 30, 2011; and of 30 percent, but not higher, from July 1, 2011 have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.29, 4.130 Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim, VA is required to notify the claimant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In rating cases, a claimant must be provided with information pertaining to the assignment of disability ratings (to include the criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the Veteran pre-adjudication notice by a letter dated in August 2010. The content of the notice letter complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). With respect to the Dingess requirements, the letter included notice of what type of information and evidence was needed to establish a disability rating, as well as notice of the type of evidence necessary to establish an effective date. Accordingly, the duty to notify has been fulfilled. VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to a claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this instance, the claims file contains the Veteran's service treatment records, VA treatment records, and the Veteran's own assertions in support of his claim. The Board has reviewed the file for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim for which VA has a duty to obtain; therefore appellate review may proceed without prejudicing him. See Bernard v. Brown, 4 Vet. App. 384 (1993). In addition, the RO arranged for a VA PTSD examination in October 2010. The Board finds that the examination obtained in this case was adequate, as it provides findings relevant to the criteria for rating the Veteran's PTSD. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The claims file was reviewed and the examiner considered the full mental history of the Veteran. The Board finds that the examination was adequate to allow proper adjudication of the issue on appeal. VA has substantially complied with the notice and assistance requirements and the claimant is not prejudiced by a decision on the claim at this time. II. Legal Criteria, Factual Background, and Analysis A. Criteria of Disability Evaluations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the appellant has expressed dissatisfaction with the assignment of an initial rating following an initial award of service connection for that disability, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The pendency of the issue in this instance dates to the original rating decision granting service connection. Id. Consequently, the Board will evaluate the Veteran's PTSD as a claim for a higher evaluation of the original award. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). B. Increased Rating for Psychiatric Disorder The Veteran was assigned a 30 percent rating for PTSD, effective from July 30, 2010 to April 24, 2011 and from July 1, 2011, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411. Diagnostic Code 9411 provides that a 30 percent rating is warranted for occupational and social impairment with an 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). 38 C.F.R. § 4.130. A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted where there is objective evidence demonstrating occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to 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, or 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 the inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The Global Assessment of Functioning (GAF) scale is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). A GAF score of 31 to 40 indicates 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 younger children, is defiant at home, and is failing at school). A GAF score of 41 to 50 indicates serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of between 51 and 60 indicates that the Veteran has moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 61 and 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. A GAF score of 71 to 80 indicates, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). See DSM-IV. While the Rating Schedule indicates that the rating agency must be familiar with the DSM -IV, VA does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. Rather, GAF scores are but one factor to be considered in conjunction with all the other evidence of record. C. Analysis The Board considered the Veteran's service treatment records, VA treatment records, the VA PTSD examination, the Veteran's own assertions in support of his claim, and the argument in support of the claim provided by the Veteran's representative. Each piece of evidence will be discussed below. The service treatment records are negative for complaints, treatment, or diagnosis of any mental health problems. The Veteran was administratively discharged due to 2 DUI offenses and received an examination and a mental health evaluation in January 2006 as part of that process. A psychiatric clinical evaluation at the examination resulted in normal findings. The mental health status evaluation indicated there was "no evidence of an emotional or mental disorder of psychiatric significance to warrant disposition through medical channels." There are no other relevant service treatment records. The claims file includes VA treatment records from Fayetteville (October 2006), Tampa (February 2008), and Bay Pines (November 2006 to February 2012). The records from Fayetteville and Tampa are negative for complaints, treatment, or diagnosis of any mental health problem. The first indication of any treatment for a mental health problem is in the records from Bay Pines VA HCS beginning in February 2010. At that time, the Veteran was admitted into the Depression Care Management (DCM) program. He was in that program from February 2010 to August 2010. During that time, he was treated for depression through therapy and medication. The main stressor discussed in those records was the Veteran's repeated employment problems. On several occasions the mental healthcare provider indicated that the Veteran suffered from 2 PTSD symptoms (nightmares and hypervigilance). During a visit in June 2010, the Veteran was given a provisional PTSD diagnosis. His GAF score was 60. The Veteran underwent a VA PTSD examination in October 2010. The examiner reviewed the Veteran's treatment records and noted that there had been a good response to medication and the limited therapy the Veteran had undergone to date. The prognosis looked good to the examiner. The Veteran reported suffering from a few panic attacks since early 2010. The examiner noted that the attacks sounded minor and that the Veteran reported he had improved with medication. The examiner took the Veteran's history. The Veteran served as a truck driver during Operation Iraqi Freedom. He experienced combat in Balad, Iraq in 2004. He described being involved in a firefight in which a small boy was killed. After the deployment he had some disciplinary infractions. He had 2 DUI offenses, one of which occurred while he was on duty. This led to a general discharge under honorable conditions in July 2006. The Veteran reported heavy alcohol use after separation. After service, he went to school to become a medical assistant and then went to school to become a pharmacy technician. He told the examiner he received good grades. At the time of the examination, the Veteran was working as a pharmacy technician. The Veteran also reported being in a good marriage and having a good relationship with his step-children. He also indicated he has "few friends" but gets along well with peers and teachers. He reported no history of suicidal attempts or having a history of violence. In describing the Veteran's psychosocial functional status, the examiner said the Veteran appears to have relatively mild psychosocial impairment, but appears to be "doing well with family and academic pursuits." The Veteran reported having several nightmares a week, but did not experience day time effects from sleep impairment. He reported not experiencing hallucinations. He also reported not having suicidal or homicidal ideation. The examiner noted that the Veteran had good impulse control. The Veteran is also reported to have had good insight and to have related well with the examiner. The Veteran's memory was noted to be normal. The examiner noted the following PTSD symptoms: recurrent distressing dreams about the combat event; difficulty falling or staying asleep; hypervigilance; and clinically significant distress or impairment in social, occupational, or other areas of functioning. Also, the Veteran was reported to prefer to avoid large crowds and to have some difficulty modulating emotions during stressful times. The examiner diagnosed the Veteran with generally mild PTSD. The Veteran was also diagnosed with alcohol abuse, and the examiner could not exclude the possibility of adjustment disorder. The Veteran's GAF score was 66. The examiner noted that the Veteran "appears to just meet [the] criteria for PTSD." The level of psychosocial impairment appeared fairly mild. The examiner noted that the Veteran was employed, appeared to be fully sober, and had a good relationship with his family. After this examination, the RO granted service connection with an evaluation of 30 percent disabling. The Veteran continued outpatient treatment and therapy at the Bay Pines VA HCS through the end of 2010 and into 2011 with the description of his symptoms remaining the same as those provided at the VA examination. On February 22, 2011, the Veteran was admitted into Bay Pines HCS. He was brought to the hospital by his wife due to escalated "drinking as well as increased anxiety, irritability and problems with others." The Veteran reported that his symptoms had worsened. He complained of experiencing a depressed mood, decreased sleep due to daily nightmares, daily flashbacks, and increased irritability. He said that when he is very depressed he cannot function. He also expressed having issues with anger. He explained that he avoids crowded places and believes other people want to hurt him. He also explained that he does not like to leave his house unless he is armed with a knife. He said he started using alcohol more during the previous few weeks to help himself. In a mental health assessment that day, the Veteran was described as alert, being able to relate well and maintain good eye contact, as having coherent speech, and as having no psychomotor abnormalities. The Veteran's mood was described as depressed. He denied any delusions or hallucinations. He also denied suicidal or homicidal thoughts. He was oriented to all spheres. His memory and cognition were grossly intact. He also had good insight and judgment. His diagnosis was PTSD and alcohol abuse and his GAF score was 35. In a later session, the Veteran expressed that he is hypervigilant, including when he drives. He said he changes lanes a lot while driving to avoid things that look like IEDs. A social worker wrote an entry on the following day. The note indicates that the Veteran presented for admission under escort from the police. The social worker wrote that the Veteran "seems to be suffering from exacerbated symptoms of PTSD and has relapsed with alcohol and substances (Xanax and methadone). The symptoms include nightmares, flashbacks, anxiety, panic attacks, and irritation. The social worker also wrote that the Veteran "had a car accident while he was under the influence prior to his hospitalization. His wife reports that he has several serious legal issues stemming from this incident." At a group therapy session on the day after his admission, the Veteran stated that he is constantly in a state of fear. Consequently, he reported having no relationships outside his family and does not trust others. However, he mentioned that he does feel support when he participates in programs with other Veterans. In an assessment on the day after his admission, the Veteran appeared alert and oriented. The assessment further provided that the Veteran "has a constricted and isolated affect. Thought processes are linear and goal driven. Speech and communication are of normal rate and tone." The Veteran underwent individual and group therapy while he was admitted. In one session, the Veteran reported that his PTSD symptoms were out of control and that led to his drinking. On March 2, 2011, the Veteran was discharged from the hospital. On the next day, he was given a psychological evaluation to determine his entry into the residential program. He reported abusing his wife's Xanax. In regards to alcohol, he reported having periods of sobriety lasting between 7 to 10 months followed by relapses. His mood was calm and his eye contact was good. Psychomotor activity was within normal limits. His thought processes appeared linear and goal directed/future oriented. Thought content focused on current psychosocial stressors including his job responsibilities, pending legal charges, and difficulty in his current relationship with his wife. The volume, rate, and tone of his speech were within normal limits. Although not formally assessed, his concentration and memory appeared intact. There was no evidence of psychosis noted. Judgment and insight appeared good. He appeared oriented to time, place, person, and situation. When directly asked, the Veteran denied any current suicidal or homicidal ideation, plan, or intent. He indicated that he previously had access to firearms but asked his wife to make them inaccessible to him. Overall, the Veteran appeared to be experiencing significant psychological distress. The therapist wrote that individuals "with this profile type tend to be anxious, tense, angry, irritable, and easily agitated. It is likely that [the Veteran] is experiencing sleep disturbances and intrusive thoughts." Further, the Veteran is described as feeling on edge and to experience difficulty concentrating. He continued to have feelings of insecurity. His GAF score was 45. On March 21, the Veteran was admitted into the Domiciliary/Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) at Bay Pines VA HCS until April 18, 2011. The records from that time indicate that the Veteran underwent treatment for substance abuse as well as PTSD. He participated in individual and group therapy sessions. His GAF scores on repeated assessments, ranged between 50 to 60 during this time. On April 25, 2011, the Veteran was admitted into the Domiciliary Residential Treatment Program (DRTP) at Bay Pines VA HCS until June 10, 2011. The Veteran was again treated for substance abuse and PTSD through individual and group therapy. The RO awarded a rating of 100 percent for this period of hospitalization. At the end of June, the Veteran's GAF score was 55 at a psychiatric assessment. He was described as attentive and oriented to person, place, and time. Immediate and remote memories were intact. The Veteran was appropriately groomed and dressed and maintained eye contact. His general behavior did not include any involuntary movements. His speech had a normal rate, volume, and tone. His language was productive, relevant, coherent, and logically organized. His thought process was linear and goal oriented. The Veteran was not suffering from delusions or hallucinations. He denied paranoid, persecutory, erotomaniac, grandiose, somatic, or jealous preoccupations. His mood was described as normal. He had full range of affect. The same description and assessment were given in August 2011 and February 2012. Again, the GAF score was 55 on both occasions. In support of the Veteran's claim for a higher rating, the Veteran's attorney submitted records from Bay Pines VA HCS dated in July 2012. The Veteran's wife brought the Veteran to Bay Pines to have a psychiatric consult because the Veteran told his wife, "I am overwhelmed and feel like hurting myself." The Veteran's attorney argued in the February 2013 Brief that this record supports a higher rating. The history provided at that assessment indicates that the Veteran was released from Pinellas County Detention Center the week before after serving 3 months for driving under the influence and a probation violation. The Veteran indicated that he had not taken any of his medication since before his incarceration. He indicated that he felt overwhelmed by the schedule ahead of him. He clarified his statement that he made to his wife. He denied any desire to die or to injure himself. He also denied homicidal ideation. The psychiatrist indicated that there was no evidence of psychosis or delusional thinking. The Veteran had a pleasant and cooperative attitude and behavior and maintained good eye contact. No tremors were noted and the Veteran had a normal gait. He was anxious and near tearful. His thought process was mostly linear, organized, logical, goal directed, and relevant. His orientation was alert and his attention was intact. His abstract reasoning was intact and concrete. His memory was normal and his insight and judgment were fair. The psychiatrist assigned a GAF score of 52. Also, the Axis IV diagnosis was criminal legal issues, unemployment, and non-compliance with medications. The psychiatrist described the Veteran's condition at the end of the evaluation as rather unremarkable and noted that the Veteran was in no apparent distress. The Veteran was ordered to restart medication and treatment. There is no other relevant medical evidence of record. The Board also considered the Veteran's assertions. The Board acknowledges that lay testimony is competent regarding features or symptoms of injury or disease when the features or symptoms are within the personal knowledge and observations of the witness. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Other than the Veteran's written statement regarding his in-service stressor, which is not at issue here, the Veteran has not provided any other substantive statements to the RO or the Board. His only lay statements come in the form of providing his history to the various VA medical personnel. Those statements, which do not purport to offer any diagnoses, have all been considered by VA medical personnel and are reflected in the diagnoses provided at Bay Pines VA HCS. The Board also considered the arguments presented by the Veteran's attorney. The medical evidence from July 2012 Bay Pines VA HCS and all of the entries that the attorney mentioned in the February 2013 Brief were reviewed and considered by the Board, as mentioned above. The Board finds that the Veteran's diagnosis from the VA examination and the treatment records from July 30, 2010 to February 21, 2011 support a disability rating of no higher than 30 percent. The Veteran did not present occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Nor did he have occupational and social impairment with reduced reliability and productivity due to any symptoms not listed in the rating criteria. However, on February 22, 2011, it is clear from the clinical evidence and diagnoses the Veteran received at Bay Pines VA HCS that his condition worsened. His GAF score lowered from the 55-60 range to 35. As discussed above, he was admitted into Bay Pines VA HCS and was complaining of experiencing a depressed mood, decreased sleep due to daily nightmares, daily flashbacks, and increased irritability. From the evidence in the treatment records discussed above, the Board finds that the Veteran was experiencing more than weekly panic attacks, an increased social impairment, impaired judgment as evidenced by his documented paranoia and hypervigilance. The Veteran was admitted into Bay Pines VA HCS on February 22, 2011 and released March 2, 2011. The Board finds that he is entitled to a 70 percent disability rating from February 22, 2011 to March 20, 2011. On March 21, 2011, the Veteran was readmitted to Bay Pines VA HCS and remained there until April 18, 2011. This was longer than 21 days. Under 38 C.F.R. § 4.29, if a Veteran is hospitalized for more than 21 days for a service-connected disability, a temporary 100 percent evaluation is assigned from admission to the last day of the month of discharge. The RO did not grant a 100 percent rating because the RO found that the Veteran was admitted for substance abuse. While the Board notes that the Veteran was brought to Bay Pines VA HCS by his wife due to alcohol abuse and a recent DUI, the treatment records from that stay indicate that the medical professionals treating the Veteran believed his PTSD symptoms played a role in his recent problems and he was treated for PTSD while he was admitted. Therefore, the Board finds that the Veteran is entitled to a 100 percent disability rating beginning March 21, 2011. The Veteran was released on April 18, 2011. However, he was readmitted to Bay Pines VA HCS on April 25, 2011 and released on June 10, 2011. The RO granted the Veteran a 100 percent rating for that hospitalization because he was treated for PTSD. Therefore, under 38 C.F.R. § 4.29, the Veteran is entitled to a 100 percent rating from March 21, 2011 until June 30, 2011. Beginning July 1, 2011, a 30 percent rating, but no higher, is warranted. As the treatment records discussed above indicate, the Veteran's mental health improved throughout his hospitalizations. By the end of June 2011, his GAF scores returned to the 55-60 range and the assessments made by his treating mental healthcare providers correspond to the criteria of a 30 percent rating. In regards to the July 2012 suicide consult, the Board finds that the Veteran is not entitled to a rating in excess of 30 percent. The assessment made by a VA psychiatrist at Bay Pines VA HCS at that time does not indicate that the criteria for a 50 percent rating or higher were met. The Veteran's GAF score was 52 and the psychiatrist noted that the Veteran had an unremarkable mental health evaluation. D. Extraschedular Consideration Finally, an extraschedular evaluation is for consideration where service-connected disabilities present an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the Veteran's service-connected disabilities. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected PTSD. The Veteran's disability is manifested by impairment in social and occupational functioning; the rating criteria contemplate these impairments. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to an initial disability rating of 70 percent, but not higher, from February 22, 2011 to March 20, 2011; of 100 percent from March 21, 2011 to June 30, 2011 is granted. To this extent only, the appeal is allowed. REMAND Once a Veteran submits evidence of a medical disability, makes a claim for the highest possible rating, and submits evidence of unemployability, then an informal claim of TDIU has been raised. See Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In the Veteran's Brief dated in February 2013, his attorney raised a claim for TDIU when he sought the highest possible rating and claimed that the Veteran's service-connected PTSD causes the Veteran severe and probably total occupational impairment. Further, the medical records show that the Veteran has told his VA treatment providers that he has had extended periods of unemployment during the last several years. The claim for TDIU was not adjudicated by the RO. Accordingly, the Board must remand the Veteran's TDIU claim for adjudication by the RO in the first instance, to include consideration of whether TDIU is warranted at any time during the pendency of the Veteran's claim. Accordingly, the case is REMANDED for the following action: 1. Issue a notice letter for the TDIU issue in accordance with 38 U.S.C.A. §§ 5102, 5103, and 5103A; 38 C.F.R. § 3.159, and applicable legal precedent. Take all necessary action to develop and adjudicate such claim, as appropriate. 2. The RO should contact the Veteran and request that he identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who have treated him for his service-connected disabilities. The RO should attempt to obtain copies of pertinent treatment records identified by the Veteran that have not been previously secured and associate them with the claims folder. 3. Only upon completion of the above, schedule the Veteran for a VA examination. The entire claims folder, to include a complete copy of this remand, must be made available to and reviewed by the examiner in conjunction with the examination. All indicated studies, tests, and evaluations, if any, should be performed as deemed necessary by the examiner. The results of any testing must be included in the examination report. The examiner must elicit from the Veteran and record for clinical purposes a full work and educational history. Based on his/her review of the case, the examiner must provide an opinion on whether it is at least as likely as not (50 percent or greater degree of probability) that the Veteran's service-connected disabilities alone preclude him from securing and following substantially gainful employment consistent with his education and occupational experience. The examiner is requested to provide a rationale for any opinion provided. 4. After undertaking any other development deemed appropriate, the RO should re-adjudicate the issue on appeal. If any benefit sought is not granted, the Veteran and his agent should be furnished with a supplemental statement of the case and afforded an opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters 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). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs