Citation Nr: 1333383 Decision Date: 10/23/13 Archive Date: 10/24/13 DOCKET NO. 09-49 135 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Providence, Rhode Island THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating based upon individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Massachusetts Department of Veterans Services WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D.J. Drucker, Counsel INTRODUCTION The Veteran had active military service from June 1980 to June 1983 and from June 1989 to June 1993. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from February and April 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Providence, Rhode Island, that, in pertinent part, granted service connection for PTSD and assigned an initial 10 percent rating, effective from October 16, 2008. In November 2011, the Veteran, sitting at the RO, testified during a hearing conducted via video conference with the undersigned, sitting at the Board's main office in Washington, D.C. A transcript of the hearing is of record. In February 2012, the Board remanded the Veteran's case to the RO via the Appeals Management Center (AMC) in Washington, D.C., for further development. Then, in a July 2012 rating decision, the RO denied entitlement to a TDIU. In a September 2012 decision, the Board again remanded the claim to the AMC for additional development. In March 2013, the Board remanded the Veteran's case to the AMC for further development. Then, in a July 2013 rating decision, the AMC granted a 30 percent rating for the Veteran's service-connected PTSD, effective from October 16, 2008. The matter of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the AMC. FINDING OF FACT Resolving all doubt in the Veteran's favor, since October 16, 2008, his service-connected PTSD has been manifested by moderate occupational and social impairment with reduced reliability and productivity throughout the appeal period, without deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. CONCLUSION OF LAW Since October 16, 2008, the criteria for an initial 50 percent rating, but no higher, for PTSD, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act (VCAA), 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. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). In Bryant v. Shinseki, 23 Vet App 488 (2010), the United States Court of Appeals for Veterans Claims (court) held that 38 C.F.R. 3.103(c)(2) (2009) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, this Veterans Law Judge outlined the issues on appeal and asked questions aimed at substantiating the claim and identifying any outstanding evidence. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2); they have not identified any prejudice in the conduct of the Board hearing. Proper notice from VA must inform the claimant of any information and medical or lay 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. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Here, the Veteran was sent letters in October and December 2008 and May 2010 that provided information as to what evidence was required to substantiate the claim on appeal and of the division of responsibilities between VA and a claimant in developing an appeal. The October 2008 letter provided notice as to how VA assigns an appropriate disability rating or effective date, and the matter was subsequently readjudicated, curing any timing defect. Accordingly, no further development is required with respect to the duty to notify. Next, VA has a duty to assist the Veteran in the development of his claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All reasonably identified and available VA and non-VA medical records were obtained. A review of the Veteran's Virtual VA electronic file does not reveal any additional evidence regarding the claim for an increased initial rating for PTSD on appeal. The Veteran was afforded VA examinations in March 2009, September 2010, July 2012, and July 2013, and the examination reports are of record. The VA examination reports are adequate for rating purposes as the claims file was reviewed, the examiners reviewed the pertinent history, provided clinical findings and diagnoses, and offered etiological opinions with rationales from which the Board can reach a fair determination. The records satisfy 38 C.F.R. § 3.326 (2013). The Board's February 2012 remand, in large part, was ordered to obtain recent VA treatment records and schedule the Veteran for a VA examination. There was substantial compliance with this remand, as he was scheduled for VA examinations in July 2012 and July 2013. VA treatment records, dated to March 2012, were obtained. In September 2012 and March 2013, the Board remanded the case to the RO to obtain records of his treatment at the Vet Center in Brockton, Massachusetts. There has been substantial compliance with these remands, as the Veteran's Vet Center treatment records, dated from April 2006 to July 2011, were obtained. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and non-VA treatment and examinations. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records 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 the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Factual Background and Legal Analysis Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2013). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). In Fenderson v. West, 12 Vet. App. 119, 126 (1999), the court noted that where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" is required. Id. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Where there is a question as to which of two evaluations is to be applied, 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 (2013). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2013). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also mean statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). The Veteran's statements describing the symptoms of his service-connected PTSD are deemed competent. These statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. The April 2009 rating decision granted service connection for PTSD, and assigned an initial 10 percent rating under Diagnostic Code 9411, effective October 16, 2008. In the July 2013 rating decision, the RO assigned a 30 percent rating for the Veteran's service-connected PTSD from that date. He seeks a higher initial rating. During his November 2011 Board hearing, the Veteran complained of having difficulty holding a steady job. See Board hearing transcript at page 2. He no longer lived with his girlfriend and was socially isolated. Id. at 3. The Veteran preferred to be at home while his girlfriend preferred to go out and his symptoms affected their relationship. Id. at 9. He went to church but avoided crowds. Id. at 4. He did not receive clinical treatment for PTSD but planned to return to The Vet Center. Id. The Veteran reported sleep difficulty due to nightmares and awoke easily. Id. at 7-8. His memory was pretty good but he startled easily. Id. at 8. The Veteran further stated that he was more depressed than usual. Id. at 10. His concentration was good and he was able to take care of his personal hygiene. Id. at 11. His anger or irritability affected his ability to obtain employment. Id. at 9-10. The General Rating Formula for Mental Disorders, including Diagnostic Code 9411, that evaluates PTSD, at 38 C.F.R. § 4.130, provides the ratings for psychiatric disabilities. A 30 percent evaluation is provided 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, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted if the disability is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating contemplates occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating contemplates 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 ability 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. Also of relevance, 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 Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also 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), page 32). 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 51 to 60 indicates the examiner's assessment of moderate symptoms (e.g., a 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). A GAF score of 61 to 70 denotes mild symptoms (e.g. depressed and mild insomnia) or some difficulty in social and occupational functioning but generally functioning pretty well, with some meaningful interpersonal relationships. Id. While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it 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. When it is not possible to separate the effects of a non- service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service- connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); see also 38 C.F.R. § 3.102; Mauerhan v. Principi, 16 Vet. App. 436 (2002) (factors listed in the rating formula are examples of conditions that warrant a particular rating and are used to help differentiate between the different evaluation levels.). VA and non-VA medical records, dated from 2006 to 2012, indicate that the Veteran's PTSD was treated with outpatient VA individual and group psychotherapy (stress management group therapy primarily in 2009) and outpatient counseling at The Vet Center. Records from The Vet Center, dated from April 2006 to July 2011, describe the Veteran's treatment for chronic PTSD. According to a January 2008 Vet Center Intake History, the Veteran experienced sleep difficulty, irritability, anger outbursts, concentration difficulty, exaggerated startle response, and panic attacks. He had a very difficult time functioning socially or interpersonally since his discharge. He had several different jobs and was married briefly. On examination, the Veteran had no delusions or hallucinations. He had some suicidal ideation, but no attempts or plan. His appearance was neat and he was aware of his surroundings. The Veteran's judgment was good, his memory was normal, and his speech was appropriate. His affect was that of one who was anxious, agitated, and angry. The Axis I diagnoses were PTSD and major depression without psychotic features. A GAF score of 45 was assigned. A January 2009 Vet Center report from a counselor shows that the Veteran had become increasingly irritable and isolative. The Veteran reported a spike in nightmares, intrusive memories, hypervigilance, exaggerated startle, panic attacks, and avoidant symtoms, that markedly elevated his stress. There was no evidence of delusions and he denied hallucinations of any kind. His interpersonal relations were very restricted and social activities were a result of his debilitating symtoms. A GAF score of 48 was assigned. Subsequent Vet Center records, dated throughout 2009 and 2010, reveal that the Veteran was treated for chronic PTSD and that there was no evidence of suicidal or homicidal ideation. In March 2009, he reported that he was not living with his significant other and was in a brawl at work. Also in March 2009, the Veteran underwent VA examination. It was noted that he received individual counseling at The Vet Center and planned to start group therapy twice a month. The Veteran was unmarried and not working. He last worked in the construction field in 2000 and was not currently working due to lack of construction work due to the failing economy. He and his significant other of three and one half years broke up several weeks earlier. The Veteran had good relationships with his family and friends and the examiner noted that the degree and quality of his social relationships appeared good. In his free time, the Veteran walked and rode his mountain bicycle. He had a couple of beers per week and denied any history of violence or assaultiveness. He denied any history of suicide attempts or criminal behavior. His concentration was generally good but sometimes became scattered. The Veteran had combat-related nightmares approximately once a week and tried to avoid thoughts, feelings, and conversations associated with military service. He had a loss of interest in activities he once enjoyed and was sometimes emotionally numb. He sometimes felt as if his future might be cut short. On examination, the Veteran said he felt "all right" and felt "good." He reported a recent breakup with his girlfriend that he found upsetting, and believed that this might have contributed to an increase in his symptoms, along with lack of work and poor finances. His sleep was disturbed by having a few nightmares. The Veteran was casually attired, adequately groomed and had good eye contact. There were no apparent motor abnormalities. His speech was normal, he was fully oriented, and his memory appeared fully intact. His mood was euthymic and his affect was full range and appropriate. There was no abnormal thought content, process, or perception noted. Insight and judgment were adequate and the Veteran denied suicidal or homicidal ideation. He was able to maintain personal hygiene and other basic activities of daily living. The Axis I diagnoses were mild PTSD and a depressive disorder, more likely than not related to PTSD. A GAF score of 61 was assigned indicative of mild difficulty in social and occupational functioning. The VA examiner commented that the Veteran should be considered mildly impaired in both social and occupational domains. He was able to work, intended to continue trying to find work, and should be encouraged to work. There was nothing to indicate that the Veteran would be incapable of obtaining and maintaining gainful employment on the basis of PTSD alone. The PTSD should not be considered as disabling regarding the Veteran's ability to obtain and maintain employment. A May 2010 Vet Center record reveals that the Veteran's symptoms included anger, with a history of explosive, aggressive outburst out of proportion to any precipitating stressors triggering his PTSD. According to a July 2010 written update from the Veteran's Vet Center counselor, since November 2008, the Veteran was seen monthly for individual psychotherapy for PTSD symptoms that included great difficulty sleeping, relationship issues, hypervigilance, difficulty concentrating, and anger issues. There was no evidence of delusions and the Veteran denied hallucinations. He endorsed difficulty with relationships, was extremely isolated and highly avoidant and had impaired personal relations. It was also noted that the Veteran experienced problems with employment due to PTSD. The Axis I diagnosis was PTSD and a GAF score of 50 was assigned. In September 2010, the Veteran underwent VA examination. He reported that he was "about the same" but was "doing better lately" as he attended church weekly. The Veteran was staying busy doing construction jobs and volunteer work at his church. His girlfriend called the police related to a "spat" and he was arrested for domestic assault, for which he received unsupervised probation. The Veteran said they had a fair relationship. He was friendly with some people from his church and had "a couple (of) buddies" with whom he discussed personal things. The Veteran enjoyed playing golf and riding his bicycle, which he did regularly. He drank approximately six beers per week. The Veteran had some difficulties with irritability and anger and had frequent conflicts with his girlfriend when they lived together (he was vague about the details). The Veteran stated that they got along much better now that they lived separately. He was self-employed in the construction business, said he was a "good worker," and missed no time from work in the past year. The examiner noted that the Veteran engaged in social activities, was capable of basic activities of daily living, and was able to meet work demands and responsibilities. On examination, the Veteran was casually and appropriately dressed and had good hygiene. His speech was rapid and he chewed gum throughout the interview. There was no impairment of thought process or communication and no delusions. His behavior was appropriate and his mood was anxious and irritable. He had no suicidal or homicidal ideations. The Veteran was able to maintain personal hygiene and basic activities of daily living. He was oriented and there was no memory loss or presence of obsessive or ritualistic behavior, panic attacks, depression or anxiety, impaired impulse control, or sleep impairment. His speech was normal. The VA examiner commented that the Veteran had mild psychiatric symptoms, with occasional nightmares but did not have intrusive memories or flashbacks. He had some irritability and startle response. The VA examiner observed that the Veteran did not endorse significant distress related to these symptoms and was able to maintain social and occupational functioning in terms of employment and social relationships. His relationships were mildly to moderately affected by his PTSD symtoms. The Axis I diagnosis was an anxiety disorder, not otherwise specified (NOS), with features of PTSD and a GAF score of 60 was assigned. The examiner explained that the Veteran's anxiety symtoms exerted a mild negative impact on his social and occupational functioning. In December 2010, The Vet Center records reflect the Veteran's reports that he was doing well and, in July 2011, he denied having suicidal or homicidal ideations. In July 2012, the Veteran underwent VA examination. He stated that he experienced some anxiety. He had one brief marriage and had a girlfriend for six years and said they were "more like friends." He tried to stay busy, had four or five friends, and was active in his church. The Veteran was unable to find full-time work but was actively looking, and worked four to five hours a day, four to five days a week. He denied receiving any mental health treatment since last examined and did take any psychiatric medications. He drank six beers at a time, one to three days a week. The examiner noted that the Veteran's records showed he experienced a traumatic event but he denied persistently experiencing it. He made efforts to avoid certain activities that reminded him of it, but there was no persistent avoidance or numbing and no persistent symtoms of increased arousal. According to the VA examiner, the Veteran appeared calm, and relaxed, and was smiling often, but some of his responses were often vague or contradictory. For example, he stated that he was anxious that he could not find a job and that he was actively looking for one, but he later stated that he worked several hours a day several days a week. The Veteran's psychiatric symptoms had no negative impact on his ability to obtain and maintain physical or sedentary employment. He was clearly employable. The examiner commented that the Veteran's symptoms were not severe enough to either interfere with his occupational and social functioning or to require continuous medication. A GAF score of 65 was assigned. In July 2013, the Veteran underwent another VA examination. He continued to experience PTSD symtoms and was not open to taking psychotropic medication due to fear of negative side effects. He used alcohol to alleviate PTSD symptoms. The Veteran worked part-time and on an as-needed basis for a fence company and tried to obtain employment but was unsuccessful to date. The examiner noted that the Veteran used alcohol as needed to modulate PTSD symtoms. The Veteran's symptoms included depressed mood, anxiety, mild memory loss, such as forgetting names, directors or recent events, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. A GAF score of 58 was assigned. After reviewing the record and the relevant rating criteria, it is concluded that a 50 percent rating, but no more, is warranted for the Veteran's PTSD since he filed his initial service connection claim in October 2008. Clinicians who evaluated him assigned GAF scores that ranged from 45 (indicative of serious occupational and social impairment) to 65 (commensurate with mild impairment). Notably, his Vet Center counselor, who regularly treated him, particularly noted the Veteran's sleep and concentration difficulty, irritability, anger outbursts, an exaggerated startle response, avoidant symtoms, concentration difficulty, and panic attacks. VA examiners noted good concentration that was scattered, combat-related nightmares, some irritability, and loss of interest in previously enjoyable activities but evidently only considered the Veteran mildly impaired (in March 2009 and September 2010). Significantly, in November 2011, the Veteran provided credible testimony to the effect that he had worsening nightmares and irritability, difficulty finding work, and was socially isolated. A depressed mood, anxiety, mild memory loss, disturbances of motivation and mood, and difficulty establishing and maintaining work and social relationships were noted by the July 2013 VA examiner who assigned a GAF score of 58, commensurate with moderately severe disability. As noted above, a global assessment of functioning score is a scale reflecting a patient's psychological, social, and occupational functioning on a hypothetical continuum of mental health and illness. Carpenter, 8 Vet. App. at 242. It is wholly appropriate for adjudicators to look to these scores in evaluating psychiatric disability since, as noted above, the evaluation of such disabilities involves the application of a rating schedule that in turn is based on average impairment of earning capacity. The January 2008, January 2009, and July 2010 reports from Vet Center, and July 2013 VA examination report, reflect symptoms consistent with a 50 percent evaluation under Diagnostic Code 9411. The other medical evidence, including the March 2009, September 2010, and July 2012 VA examination reports, further demonstrates that the Veteran reported irritability, anxiety, sleep difficulty and combat-related nightmares, avoidant behavior, and social isolation. In view of the foregoing, the Board concludes that the evidence is at least in relative equipoise as to whether the disability picture more nearly approximates the criteria for a 50 percent evaluation. See 38 C.F.R. § 4.7 Although a 50 percent evaluation is supported in the record, the weight of the evidence is against a finding persistent symptoms that equal or more nearly approximate the criteria for a rating in excess of 50 percent. Indeed, symptoms such as spatial disorientation, near-continuous panic, or other symptoms set out for the 70 percent rating are not shown. Although suicidal ideation, without plan or intent, was noted by The Vet Center counselor in January 2008, such was not noted by the 2009, 2010, 2012, or 2013 VA examiners. In fact, the most recent Vet Center record, in July 2011, shows that the Veteran denied suicidal and homicidal ideation. Further, the March 2009 VA examiner described the Veteran as adequately groomed and the September 2010 VA examiner stated that he was appropriately dressed and no clinician has stated that he is unable to maintain his personal hygiene. Additionally, there have been no clinical reports that the Veteran had panic attacks that occurred more than once a week, illogical speech, obsessional rituals, or presented a danger of hurting himself or others. Moreover, while examiners have repeatedly found the Veteran oriented, the July 2013 VA examiner noted symptoms of disturbances of motivation and mood. But no clinician who has evaluated the Veteran has ever reported evidence of psychotic thought, grossly inappropriate behavior or persistent delusions or hallucinations. Most importantly, despite the symptoms demonstrated in the record, the evidence fails to establish occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood disorder to suggest that a higher 70 percent rating might be for consideration. Indeed, although the Veteran reported some irritability in his relationship with his girlfriend, he said that he had good relationships with family members and several friends with whom he was able to talk. The Board acknowledges that the absence of specific symptoms noted in the criteria for the next-higher 70 percent rating are not fatal to the claim. The primary consideration is the overall level of impairment, as due to any symptoms. In Claudio-Vazquez, the Federal Circuit held that the deficiencies that would warrant a 70 percent rating must be due to symptoms that are the equivalent in severity to those listed as examples in the 70 percent criteria. Such symptoms or their equivalent have not been demonstrated in this case. Indeed, the record indicates that the Veteran was employed to the extent that work was available- in many examination reports he indicated working several hours several days a week- although he had engaged in a brawl at work in March 2009, there is no other indication that his psychiatric symptoms interfered with his work. The latest VA examination in July 2013 indicates that he was unemployed, but there is no indication that this is specifically due to his psychiatric symptoms. Indeed, prior examinations had noted a lack of full time work in his field. Moreover, the Veteran had been in a relationship with a girlfriend which, although troubled, demonstrates his desire to pursue some form of social contact. He also had reportedly good relationships with his family and had a few friends that he discussed his problems with. Given the above, the level of impairment shown is not commensurate with deficiencies in most areas and an inability to establish and maintain effective relationships. As such, a rating in excess of 50 percent is not warranted at any time since the Veteran filed his initial claim in October 16, 2008. In sum, resolving reasonable doubt in the Veteran's favor, an initial 50 percent rating, but no higher, is granted for PTSD, but the preponderance of the objective medical and other credible evidence of record is against a rating in excess of 50 percent. The benefit of the doubt has been resolved in the Veteran's favor to this limited extent. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, supra. The Board has also considered whether the Veteran's PTSD disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2013); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "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) (2013). The question of an extraschedular rating is a component of a claim for an increased rating. See Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). When it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. at 182. Here the Board has considered Mittleider and attributed all potentially service-connected symtoms to his service-connected PTSD disability before considering if the Veteran is entitled to an extra-schedular rating. If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). The manifestations of the Veteran's disability include irritability, social isolation, anxiety, and depressed mood. The rating schedule contemplates these symptoms. Diagnostic Code 9411. The rating schedule is meant to compensate for average impairment in earning capacity and for considerable time lost from work commensurate with the percentage evaluations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Thus, the Board finds that the threshold test is not met for referral for extraschedular consideration. Id.; see also Thun v. Peake, 22 Vet. App. at 111. In addition, the Board notes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for a higher rating is whether a TDIU as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The matter of the Veteran's claim for a TDIU is addressed in the remand infra. Further, in view of the holding in Fenderson, and, based upon the record, the Board finds that at no time since the Veteran filed his most recent claim for service connection has the disability on appeal been more disabling than as currently rated under the present decision of the Board. ORDER An initial 50 percent rating, but no higher, for PTSD is granted from October 16, 2008, subject to the laws and regulations governing the award of monetary benefits. REMAND The Veteran also seeks entitlement to a TDIU. In his June 2012 formal application for a TDIU (VA Form 21-8940), he reported that he earned a general equivalency diploma (GED) and had work experience as a floor installer and framer. A TDIU may be assigned where the schedular rating is less than total, where it is found that the disabled person is unable to secure or follow substantially gainful occupation as a result of a service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, providing at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 4.16(a) (2013). Service connection is currently in effect for dermatitis, evaluated as 60 percent disabling and PTSD, evaluated by the Board herein as 50 percent disabling. Thus, he meets the minimum percentage requirements for a TDIU set forth in 38 C.F.R. § 4.16(a). The remaining question is whether he is rendered unemployable by his service-connected disabilities. Here the record is unclear, as a recent VA examiner indicated that the Veteran was unable to work when he had a flare up of his skin disability, that occurred three times a year. See e.g., Hart v. Mansfield, 21 Vet. App. 505 (2007) (to the effect that staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified). The record reflects that, in July 2012, a VA nurse practitioner evaluated the Veteran's skin disability and opined that his dermatitis did not prevent him from rendering gainful employment both physical and sedentary. The examiner stated that the Veteran was physically capable of working but did not provide a rationale for her opinion. Specifically, she did not provide a basis as to why the Veteran was physically capable of working. Also in July 2012, a VA clinical psychologist opined that the Veteran's psychiatric symptoms had no negative impact on his ability to obtain and maintain physical or sedentary employment. The examiner stated that the Veteran's "thought processes and communication skills are (interfering) with his social functioning. The Veteran is clearly employable." The examiner's rationale is unclear; specifically, he did not provide a basis as to why the Veteran was capable of sedentary work. Next, in July 2013, a VA clinician evaluated the Veteran's service-connected skin disability and stated that it impacted his ability to work. The examiner explained that the Veteran did fence work, part-time, stated that his eczema flared up about three times a year "and he is unable to work when he has a flare-up." The examiner noted that, based on current VA examination findings and "outcomes, [the Veteran's] eczema does limit his ability to work when he has flare-ups. However, [the V]eteran's [eczema] does not preclude him from substantial gainful employment." This opinion suggests that the Veteran was periodically rendered unemployable by his skin disability. See e.g., Hart v. Mansfield, supra. Also in July 2013, the VA psychologist opined that the Veteran's PTSD alone did not render him unable to obtain and maintain gainful employment. The examiner did not provide a rationale for his opinion. Thus, further clarification is warranted prior to appellate consideration of the Veteran's TDIU claim. Accordingly, the case is REMANDED for the following action: 1. Refer the Veteran's claims file and a copy of this remand to a VA dermatologist (physician) to obtain an opinion as to whether the Veteran's service-connected disabilities (dermatitis and PTSD) render him unable to obtain and maintain substantially gainful occupation. (A clinical evaluation should be scheduled only if deemed warranted by the examiner.) The examiner should be advised that: a. service connection is currently in effect for dermatitis, evaluated as 60 percent disabling, and PTSD, evaluated as 50 percent disabling; b. the Veteran earned a (GED); and c. has work experience as a construction worker (framer) for four years and a floor installer. d. The examiner should render an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's service-connected disabilities render him unable to obtain and maintain substantially gainful employment, considering his education level (GED) and work background. The examiner is particularly requested to address the July 2013 VA skin's examiner's opinion (to the effect that the Veteran was unable to work during flare-ups that occurred three times a year). e. In rendering an opinion, the examiner is requested to consider the post-service treatment records, the Veteran's medical history, his June 2012 TDIU claim (VA Form 21-8940); and the July 2012 and July 2013 VA examination reports. f. The opinion should include a rationale that addresses whether the Veteran could secure and maintain an occupation requiring only sedentary work. 2. Then, readjudicate the Veteran's claim for a TDIU. If the claim remains denied, furnish the Veteran and his representative with a supplemental statement of the case, and afford a reasonable opportunity for response before returning the record 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. 2013). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs