Citation Nr: 1333517 Decision Date: 10/24/13 Archive Date: 10/24/13 DOCKET NO. 12-33 516 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability (TDIU).due to PTSD. REPRESENTATION Appellant represented by: Missouri Veterans Commission ATTORNEY FOR THE BOARD Sarah Plotnick, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1968 to November 1969. This appeal to the Board of Veterans' Appeals (Board) arose from an August 2010 rating decision in which the RO granted service connection for PTSD and assigned a 30 percent rating, effective February 25, 2010. In October 2010, the Veteran filed a notice of disagreement (NOD). A statement of the case (SOC) was issued in October 2010, which continued the Veteran's 30 percent rating for PTSD. The Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in November 2012. A supplemental statement of the case (SSOC) was issued in March 2013, which, again, continued a 30 percent rating for PTSD. Because the Veteran has disagreed with the initial rating assigned following the award of service connection for his PTSD, the Board has characterized this issue in light of Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disabilities). The Board notes that the issue of entitlement to a TDIU was not certified for appeal. However, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). February 2013 VA treatment notes show that the Veteran stated he was not currently working and that "his anger forced him to retire early because he was afraid of losing his job." The evidence of record suggests that the Veteran may be unemployed due, primarily, to symptoms of his service-connected PTSD. As such, the Board finds that the issue of entitlement to a TDIU due to PTSD, has been raised during the appeal period. Therefore, as the Board has jurisdiction over such issue as part and parcel of the Veteran's higher rating claim, it has been listed on the first page of this decision. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's appeal. The evidence within the virtual file has been carefully reviewed by the Board. The Board's decision on the for claim for higher rating for PTSD is set forth below. The claim for a TDIU is addressed in the remand following the order; this matter is being remanded to the RO, via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran when further action, on his part, is required. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the matter herein decided have been accomplished. 2. Since the February 25, 2010 effective date of the award of service connection, the Veteran's PTSD has been manifested by occupational and social impairment with reduced reliability and productivity due to symptoms such as insomnia and frequent waking, frequent nightmares, hypervigilance, irritability, social isolation, anxiety, dissociative symptoms, and disturbances of motivation and mood, including flattened and depressed affect. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, the criteria for an initial 50 percent, but no higher, rating for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). The notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA 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; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353-23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction. Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. An April 2010 pre-rating letter provided pertinent notice to the Veteran in connection with what was then a claim for service connection for PTSD. That letter indicated what information and evidence was needed to substantiate the claim, as well as what information and evidence must be submitted by the Veteran and what information and evidence would be obtained by VA. Furthermore, although no additional notice for the downstream issues was required under 38 U.S.C.A. § 5103A (see VAOPGCPREC 8-2003, 69 Fed. Reg. 25180 (May 5, 2004)), in this case, after the award of service connection and the Veteran's disagreement with the initial rating assigned, the October 2012 SOC set forth the criteria for higher ratings for PTSD (the timing and form of which suffices, in part, for Dingess/Hartman). The Veteran was afforded appropriate opportunity to respond to the additional information provided before the claims file was returned to the Board. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file includes the Veteran's VA treatment records and the reports of VA examinations. Also of record and considered in connection with the appeal are various written statements provided by the Veteran. The Board finds that no additional RO action to further develop the record in connection with the claim for higher rating, prior to appellate consideration, is required. The evidence of record demonstrates that the Veteran is currently receiving retirement benefits from the Social Security Administration. The Board need not obtain these records because they do not involve disability benefits. The Board has not received notice of any additional relevant evidence that is available but has not been obtained. In summary, the duties imposed by the VCAA have been considered and satisfied. The Veteran has been notified and made aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006) (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Factual Background Pertinent medical evidence associated with the claims file includes VA treatment records and the reports of August 2010 and February 2013 VA examinations. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). VA treatment records dated from February 2010 through February 2013 reflect that the Veteran received mental health counseling at a VA medical facility approximately once per month. The Veteran was treated by Dr. D.S., a clinical psychiatrist, and Dr. J.S., an M.D. who managed the Veteran's medication. In February 2010, the Veteran was seen for a crisis walk-in appointment. He reported that his cousin had been killed the previous week. He complained of nightmares and depression and that he had been sleeping approximately two hours each night for the past month. The clinician reported that the Veteran had a flat affect. The Veteran reported that he was "profoundly depressed" and rated his depression as a 7/10. His appetite was poor; he experienced anhedonia, had crying spells and felt worthless, helpless, and hopeless. March 2010 treatment notes reflect that the Veteran reported that he had experienced passive ideation of suicide, but did not currently have a plan or intent to commit suicide. He reported that he talked to his sister on a regular basis and had a few friends. He stated that he had been feeling more detached and nervous. Dr. J.S. noted that the Veteran's mood was depressed or anxious, and his speech was clear, coherent, relevant, and goal oriented, but painfully slow. A GAF score of 55 to 60 was assigned. April 2010 treatment notes show that the Veteran did not want to go to the movies with his girlfriend because of his anxiety in crowds. His PTSD symptoms included sleep disturbances, intrusive thoughts, nightmares, flashbacks, hyper-vigilance, hyper-startle reaction, detachment from self and world, hyper-arousal symptoms, anger issues, and avoidance behaviors. The clinician further noted that the Veteran had survivor guilt. The Veteran's symptoms of depression included anhedonia, dysphoria, sleep disturbances, concentration problems, and recurrent thoughts of death. His mood and affect were slightly depressed. He stated that he had no male friends and avoided close relationships. In August 2010, the Veteran was afforded a VA examination. The Veteran reported that he had difficulty sleeping and experienced frequent nightmares about his service in Vietnam. He reported that he avoided activities that would remind him of military service. He stated that he did not like to go out in public and did not like to be around crowds. He stated that he was uncomfortable in new places until "he checks them out." He reported a depressed mood and that he sometimes did not have interest or motivation to engage in activities. He was currently working part-time and did not give a specific reason why he was working part-time instead of full-time. The Veteran reported that during the day he either went to work or did work around his house. He reported that he did his own housekeeping, yard work, household shopping, and meal preparation. He was not involved in any clubs, groups, or organizations. He occasionally would watch television or read. He reported that he and his girlfriend would go out to eat once every two weeks and that they liked to "look for Indian artifacts." He also visited his mother in a nursing home approximately three times each week. The examiner noted that the Veteran tended to avoid eye contact or avert his eyes during the examination. The Veteran appeared despondent and his affect was flat. He exhibited a little modulation in his voice. There were no problems noted on the language portion of the exam and no mental trends involving delusions or hallucinations were evident. The examiner assigned a score of 55 on the PTSD - Military Edition (PCL-M) instrument. The examiner diagnosed the Veteran with PTSD and Depressive Disorder, not otherwise specified. He assigned a GAF score of 62-65. In February 2011, Dr. D.S. noted that the Veteran continued to have panic attacks in crowds or when he was required to make a decision. The Veteran reported that he had "difficulty telling his daughters that he has loving feelings for them." May 2012 treatment notes show that the Veteran had little contact with anyone except for his girlfriend, and social isolation was his solution to his PTSD. In August 2012, Dr. D.S. assigned the Veteran a GAF score of 53. The Veteran rated his depression as 7/10. In November 2012, the Veteran reported to Dr. D.S. that his nightmares had increased to four times per week. The Veteran had intrusive thoughts about the navy. Dr. D.S. noted that the Veteran's "inability to get close and problems with his girlfriend are directly related to his PTSD." His mood and affect were mildly depressed. In December 2012, the Veteran reported that his girlfriend ended their relationship because he could not control his emotions and she could not handle his irritability anymore. The Veteran reported that his girlfriend wanted to be more intimate with him but "he could not do it because of his PTSD." Dr. D.S. noted that the Veteran's PTSD had caused clinically significant impairment in social functioning, and the Veteran was socially isolated because he uses avoidance to cope with his PTSD. Dr. D.S. administered the PTSD Checklist (PCL), and the Veteran's score was 85 (the highest possible score). He was also given the Beck Depression Test and scored "in the clinically significant range consistent with a diagnosis of Major Depression." The Veteran's PTSD symptoms included: sleep disturbance, intrusive thoughts, nightmares, flashbacks, hyper-vigilance, hyper-startle, detachment from self and world, avoidance of relationships, hyper-arousal symptoms, anger issues, avoidance behaviors, dissociative symptoms, and survivor guilt. Dr. J.S. noted that the Veteran had poor comprehension, a depressed mood, and was somewhat reluctant or noncooperative. Dr. J.S. assigned a GAF score of 55. In February 2013, Dr. D.S. noted that the Veteran had a dissociative experience related to his PTSD. The Veteran reported that he ended up in a mall in St. Louis, Missouri, with a bag of recently purchased clothing. He had no memory of driving to St. Louis from Jackson, Missouri, and no recollection of buying anything. He stated that this experience frightened him. Dr. D.S. noted that the Veteran uses avoidance to cope and had "three marriages breakup secondary to his PTSD." Dr. D.S. stated that he could not opine on the Veteran's current occupational dysfunction because the Veteran was no longer working. However, the Veteran reported that he had trouble at work in the past and had difficulty getting along with others. He stated that "his anger forced him to retire early because he was afraid of losing his job." The Veteran was also treated by Dr. J.S., who assigned a GAF score of 59. In February 2013, the Veteran was afforded another VA examination. He described a positive relationship with his two daughters. He reported that he was employed until 2009, when he retired. He did not report having any difficulties with obtaining or maintaining employment. He denied suicidal and homicidal ideation. He reported experiencing nightmares approximately three times per week and was only able to sleep for three to four hours each night. He reported experiencing flashback episodes two to three times per week, which he stated were related to his dreams. He described having an avoidance of places or people that reminded him of his military service and occasionally avoided people, places, or conversations about his military service. He had a diminished interest or participation in significant activities, a detachment and estrangement from others, and a restricted range of affect. He had persistent symptoms of increased arousal manifested by difficulty falling or staying asleep, irritability and anger outbursts, difficulty concentrating, hypervigilance, and an exaggerated startle response on occasion. The Veteran described an incident in which he woke up in a mall in St. Louis and did not know how he got there. He stated that he had not driven very much since the incident. He also explained that his girlfriend left him after he engaged in a verbal altercation with another driver. The examiner found that there was "occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication." He assigned the Veteran a GAF score of 68. III. Applicable Law The Veteran seeks an initial disability rating in excess of 30 percent for his service-connected PTSD, contending that his currently assigned disability rating does not adequately reflect the severity of his disorder. Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is entitlement to a higher initial rating, evaluation of the medical evidence since the grant of service connection to consider the appropriateness of "staged ratings" (assignment of different ratings for distinct periods of time, based on the facts found) is required. Fenderson, 12 Vet. App. at 126. The Veteran has been assigned a 30 percent rating for PTSD under Diagnostic Code 9411. However, the actual criteria for evaluating psychiatric disorders other than eating disorders are set forth in a General Rating Formula. See 38 C.F.R. § 4.130. Pursuant to the General Rating Formula, a 30 percent disability rating is assigned when there is 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). A 50 percent disability rating is warranted for PTSD if it 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. A 70 percent disability 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. A 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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. Use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran and disorder, and the effect of those symptoms on a Veteran's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th Ed.) (DSM-IV) (1996), GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. There is no question that the GAF score and interpretations of the score are important considerations in evaluating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). IV. Analysis At the outset the Board's In addition to his PTSD, VA treatment records show the Veteran has additional Axis I diagnoses, including an anxiety disorder and major depression. Where it is not possible to distinguish the effects of nonservice-connected conditions from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181 (1998). As there is no indication here that it is possible to distinguish the symptoms from the Veteran's various psychiatric disorders, the Board has considered all of his psychiatric symptoms in evaluating his service-connected PTSD. Considering the pertinent evidence in light of the applicable criteria and affording the Veteran the benefit of the doubt, the Board finds that a 50 percent but no higher, rating for PTSD is warranted from the February 25, 2010 effective date of the award of service connection-the entire period under consideration, The above-described evidence reflects that the Veteran exhibits the level of occupational and social functioning impairment contemplated by a 50 percent rating. Treatment records show that the Veteran's affect consistently has been described as flat or depressed. The Veteran has experienced disturbances of mood manifested by anxiety, hypervigilance, irritability, and depression. He also experienced a dissociative episode, noted by Dr. D.S. as related to the Veteran's PTSD. As a consequence, the Veteran subsequently drove much less frequently. These symptoms have impaired the Veteran's ability to establish social relationships. As noted by Dr. D.S., the Veteran has had multiple marriages "secondary to his PTSD." The Veteran reported that he has no male friends. The evidence of record shows that the Veteran also has difficulty establishing and maintaining work relationships. He currently is unemployed and reported that he stopped working because of his anger. The Veteran also has exhibited symptoms not listed under the criteria for a 50 percent rating, such as insomnia and frequent nightmares. Collectively, the evidence shows that the Veteran's symptoms result in occupational and social impairment with reduced reliability and productivity. As such, the Board finds that the Veteran's PTSD has most nearly approximated the criteria for an initial 50 percent rating. While the Veteran has not demonstrated all of the symptoms associated with the 50 percent rating criteria, the Board acknowledges that not all of the demonstrative symptoms must be shown to warrant a higher rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In this case, the Board finds that the Veteran's overall symptomatology picture, including symptoms of flattened affect, frequent nightmares, disturbance of motivation and mood, and difficulty in establishing and maintaining social relationships, supports the assignment of a 50 percent rating. Notwithstanding the above, however, the Veteran has not manifested the type and extent or severity of psychiatric symptoms meeting the criteria for the next higher, 70 percent rating. As noted above, a 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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 inability to establish effective relationships. Here, the objective medical evidence does not show symptoms sufficient to approximate the level of impairment contemplated in the 70 percent rating. March 2010 treatment notes reflect that the Veteran experienced passive suicidal ideation. However, he did not have a plan or intent to commit suicide. The evidence of record reflects that after March 2010, the Veteran consistently denied any suicidal or homicidal ideation. The medical evidence of record shows that the Veteran's judgment and thinking generally have been noted to be normal and logical. In December 2012 VA treatment records, Dr. J.S. reported that the Veteran's comprehension was poor. However, Dr. J.S. did not note any deficiencies in the Veteran's judgment. The Veteran has shown no illogical, obscure, or irrelevant speech, and no signs of obsessive rituals. The Veteran did report experiencing a dissociative event, which Dr. D.S. opined was related to the Veteran's PTSD. However, the Veteran has not reported any other symptoms of spatial disorientation or memory impairment. While the Veteran demonstrated intermittent depression and anxiety, his symptoms have not affected his ability to function independently, appropriately, and effectively. The Veteran consistently has been described as having good personal hygiene and appearance. While the Veteran has had multiple marriages, he has been able to establish and maintain some effective relationships. He has maintained a relationship with his two daughters and with his sister. The Veteran has exhibited some symptoms demonstrating impairment in his ability to work. However, he has not shown impairment in "most areas" as is required for a 70 percent disability rating. The Board also notes that the Veteran's assigned GAF scores are consistent with the assignment of no more than a 50 percent rating for PTSD. According to the DSM-IV, GAF scores from 61 to 70 reflect 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 indicate that the individual is functioning fairly well and has some meaningful interpersonal relationships. Scores from 51 to 60 are indicative of 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 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 from 31 to 40 indicate 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). The Veteran's assigned GAF scores ranging from 51 to 68 are indicative of overall moderate symptoms/impairment. Although the Veteran was occasionally assigned a GAF score higher than 61, indicating mild symptoms, the majority of his GAF scores were below 60. Accordingly, the Board finds that a 50 percent, but no higher, rating for PTSD is warranted. In reaching this conclusion, the Board has applied the benefit-of-the-doubt doctrine, but finds that the preponderance of the evidence is against assignment of a higher rating. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). The Board notes that the Veteran's symptomatology has been relatively stable throughout the period under consideration. Therefore, a rating of 50 percent for PTSD should be assigned from for since the entire appeal period, with no need for "staged rating." See Fenderson, supra. The above-noted determinations are based on consideration of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no pertinent point has the disability under consideration been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extra-schedular consideration is a finding on the part of the RO or the Board that the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability at issue are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). See also 38 C.F.R. § 3.321(b)(1); VA Adjudication Procedure Manual, Pt. III, Subpart iv, Ch. 6, Sec. B(5)(c). 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 this 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 rating is therefore adequate, and no referral for extra-schedular consideration is required. See VAOGCPREC 6-96 (Aug. 16, 1996); Thun v. Peake, 22 Vet. App. 111 (2008). If the rating schedule 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" (including marked interference with employment and frequent periods of hospitalization). 38 C.F.R. § 3.321(b)(1). If so, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step: a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun, supra. In this case, the Board finds that the applicable schedular criteria are adequate to rate the disability under consideration at all points pertinent to this appeal. The rating schedule fully contemplates the described symptomatology. Significantly, there is no medical indication or argument that the applicable criteria are otherwise inadequate to rate the disability. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial 50 percent rating for PTSD is granted, subject to the legal authority governing the payment of VA compensation. REMAND The Board's review of the claims file reveals that further RO action on the claim remaining on appeal is warranted. Under the applicable criteria, a TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where a veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned-pursuant to specifically prescribed procedures-upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Therefore, in the case of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the schedular percentage standards, the case should be submitted to the Director, Compensation and Pension Service, for extra-schedular consideration. The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. See 38 C.F.R. § 4.16(b). The Board notes that the Veteran does not meet the objective minimum percentage requirements, set forth in 38 C.F.R. § 4.16(a). However, as noted, entitlement to a TDIU, on an extra-schedular basis (per 38 C.F.R. § 4.16(b)), may nonetheless be established, if the Veteran is shown to be unemployable by reason of his service-connected disability. The Board notes that, although raised by the record, the RO has not adjudicated a claim for TDIU, to include on an extra-schedular basis pursuant to 38 C.F.R. § 4.16(b). Under these circumstances, the RO should, after giving the Veteran an opportunity to file a formal claim for a TDIU, and completing the other actions noted below, adjudicate the matter of the Veteran's entitlement to a TDIU due to PTSD, to include on an extra-schedular basis pursuant to 38 C.F.R. § 4.16(b), in the first instance, to avoid prejudice to the Veteran. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993). On remand, the RO should also obtain and associate with the claims file all outstanding VA medical records, as more recent treatment records may now be available. The RO should also give the Veteran another opportunity to provide information and/or evidence pertinent to the claim remaining on appeal, explaining that he has a full one-year period for response. See 38 U.S.C.A. § 5103(b)(1) (West 2002); but see also 38 U.S.C.A. § 5103(b)(3) (West Supp. 2012) (amending the relevant statute to clarify that VA may make a decision on a claim before the expiration of the one-year notice period). The RO should specifically request that the Veteran provide, or provide appropriate authorization for it to obtain, any outstanding, pertinent private medical records. Thereafter, the RO should attempt to obtain any additional evidence for which the Veteran provides sufficient information, and, if needed, authorization, following the current procedures prescribed in 38 C.F.R. § 3.159 (2013). The actions identified herein are consistent with the duties to notify and assist imposed by the VCAA. See 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AMC of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AMC should also undertake any other development and/or notification action deemed warranted by the VCAA (to including arranging for and examination and/or opinion, if appropriate) prior to adjudicating the matter remaining on appeal. In adjudicating the claim, the RO should specifically consider whether the procedures for award of an extra-schedular TDIU, pursuant to 38 C.F.R. § 4.16(b), are invoked. Accordingly, this matter is hereby REMANDED for the following action: 1. Furnish to the Veteran a VA Form 21-8940, to enable him to file a formal application for a TDIU due to service-connected PTSD. 2. Obtain all outstanding records of VA mental health evaluation and/or treatment, following the procedures of 38 C.F.R. § 3.159 as regards requesting records from Federal facilities.. 3. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information, and if necessary, authorization to enable it to obtain any additional evidence pertinent to the claim for a TDIU due to PTSD that is not currently of record. The letter should specifically explain how to establish entitlement to a TDIU, to include on an extra-schedular basis pursuant to 38 C.F.R. § 4.16(b). Also, clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claim within the one-year period). 4. After completing the requested actions, and any additional notification and/or development deemed warranted (to include arranging for the Veteran to undergo examination, if appropriate), the RO should adjudicate the claim for a TDIU due to PTSD in light of all pertinent evidence and legal authority (to include 38 C.F.R. § 4.16(b)). 5. If the benefit sought on appeal remains denied, the RO must furnish to the Veteran and his representative an appropriate supplemental SOC that includes citation to and discussion of all additional legal authority considered-to include 38 C.F.R. § 4.16(b)-along with clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The purpose of this REMAND is to afford due process and to accomplish additional development and adjudication; it is not the Board's intent to imply whether the benefits requested should be granted or denied. The Veteran need take no action until otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999); This claim must be afforded expeditious treatment. The law requires that all claims 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). ______________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs