Citation Nr: 1333932 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 10-47 383 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to an initial disability evaluation in excess of 10 percent for posttraumatic stress disorder (PTSD), effective May 21, 2007, and in excess of 30 percent, effective October 16, 2008. 2. Entitlement to service connection for a bilateral shoulder disorder. 3. Entitlement to service connection for a low back disorder. REPRESENTATION Appellant represented by: West Virginia Division of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD H. Yoo, Counsel INTRODUCTION The Veteran had active service from November 1966 to October 1970 including service in Vietnam and was awarded the Good Conduct Medal, Combat Air Crew Insignia with three stars, the Air Medal, the National Defense Service Medal, Vietnamese Service Medal with one star, and the Rifle Marksman Badge. This matter came before the Board of Veterans' Appeals (Board) on appeal from a decision of June 2008 by the Department of Veterans Affairs (VA) Cleveland, Ohio, Regional Office (RO) and was subsequently transferred to the Pittsburgh, Pennsylvania, RO. The issue of entitlement to service connection for skin cancer was denied by the RO in June 2008. The Veteran timely appealed and a Statement of the Case (SOC) was issued in November 2010. However, in the substantive appeal, the Veteran indicated he was only appealing the issues listed on the title page herein. As such, the issue of entitlement to service connection for skin cancer is not on appeal and will not be discussed below. In addition, following the November 2010 SOC, the Decision Review Officer decision issued that same month increased the evaluation assigned to the service-connected PTSD from 10 percent to 30 percent, effective October 16, 2008. Despite the grant of an increased rating, a veteran, however, is generally presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). Therefore, the claim for an increased disability rating for PTSD remains on appeal before the Board. In September 2011, the Veteran testified at a hearing before the undersigned Veterans Law Judge at the RO. A transcript of this hearing was prepared and associated with the claims file. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The issues of entitlement to service connection for a bilateral shoulder disorder and a low back disorder are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. Prior to October 16, 2008, the Veteran's PTSD has been manifested by no more than mild symptoms of depressed mood, irritability, occasional nightmares; occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks were not demonstrated. 2. Since October 16, 2008, the Veteran's PTSD is manifested by mild to moderate symptoms including intrusive recollections, nightmares, irritable mood, diminished interest in significant activities, a restricted affect, and feelings of detachment from others, which result in mild occupational impairment and moderate social impairment. CONCLUSIONS OF LAW 1. Prior to October 16, 2008, the criteria for an initial disability rating in excess of 10 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 2. Since October 16, 2008, the criteria for an initial evaluation of 50 percent, but no higher, for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The 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; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. This notice must be provided prior to an initial unfavorable decision on a claim by the AOJ. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006), the U.S. Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. VA has complied with its duty to notify the Veteran through notice letters dated in December 2004 and January 2011, which informed the Veteran of all required elements for service connection. The January 2011 letter also notified the Veteran concerning how VA determines disability ratings and assigns effective dates. Dingess, 19 Vet. App. at 486. VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran 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. The Board finds that all necessary development has been accomplished, and therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records, VA treatment records, and private treatment records. Additionally, the Veteran was provided with VA PTSD examinations in October 2007 and February 2011. With respect to VA examinations, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The most recent VA examination was provided in February 2011. The examination report is based on review of the claims file, taking a relevant history from the Veteran, and clinical evaluation of the Veteran. The examination report is adequate; the information provided by the VA examiner is supported by a thorough history, fully reasoned explanations and clinical findings. A new examination is not required as the examiner's opinions are well-supported and the Veteran has not described a worsening in the severity of his PTSD symptoms. All relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claim. Essentially, all available evidence necessary to substantiate the claim and reach an accurate rating determination has been obtained. The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. There is, therefore, no further notice or assistance to the Veteran required to fulfill VA's duty to assist the Veteran in the development of the claim. See 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. Merits of the Claim Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule). 38 C.F.R. Part 4 (2012). The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2012). Separate diagnostic codes identify the various disabilities. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability 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 the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where there is a question as to which of two evaluations shall 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 (2012). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, a 10 percent rating is warranted when the symptoms exhibited include occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or; when the symptoms are controlled by continuous medication. Id. A 30 percent rating for PTSD will be assigned where 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, and mild memory loss. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating will be assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (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 is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, due to such symptoms as: suicidal ideations; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and the inability to establish and maintain effective relationships. Id. A 100 percent 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; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. Id. However, the symptoms recited in the criteria in the rating schedule for evaluating mental disorders are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The Board is to consider the Global Assessment of Functioning (GAF) scores that have been reported during the rating period for consideration. 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 (4th ed.), p. 32). GAF scores from 91 to 100 represent superior functioning in a wide range of activities. GAF scores from 81 to 90 represent absent or minimal symptoms. GAF scores from 71 to 80 represent no more than slight impairment in social, occupational or school functioning. GAF scores of 61 to 70 represent some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or schooling functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. GAF scores from 51 to 60 represent moderate symptoms, such as flat affect and circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school functioning (such as few friends, conflicts with peers or co-workers). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e. g., largely incoherent or mute). A score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes). The Secretary shall give the benefit of the doubt to the veteran when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although all the evidence has been reviewed, only the most salient and relevant evidence is set forth 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). The Veteran is seeking entitlement to higher initial disability ratings for PTSD, evaluated as 10 percent disabling prior to October 16, 2008, and as 30 percent disabling since October 16, 2008. After a careful review of the record, and for reasons and bases expressed below, the Board finds that an initial increased rating for the Veteran's PTSD prior to October 16, 2008, is not warranted. However, the Board finds that an increased rating since October 16, 2008, is warranted. Evaluation prior to October 16, 2008 The Veteran was afforded a VA PTSD examination in October 2007 where he reported significant physical non-psychiatric illnesses pertaining to his back, left knee, and heart. The Veteran stated he is unable to sleep well because of his experience in Vietnam and thinking of those who were killed in action. He stated he "shakes" about 5 to 10 times per week for minutes to hours when he wakes up and when he is stressed. He stated it is difficult to watch war movies because it increased his dreams of war. He stated he feel brief depression a few times each week that lasts 30 minutes. The Veteran stated that he believes his chronic pain lowers his mood. The Veteran reported he married in December 1969 and has one son and daughter. He described his family life as good and "stayed in harmonious relationships with [his] brothers and sisters." He stated that over the years he had not been interested in parties but gets along fairly well with employees. The Veteran and his wife occasionally socialize with his wife's sister and her husband. He is active as a deacon in his church and participates in church plays. He stated he enjoyed golf, hunting, and fishing. The Veteran's functioning was reasonably good but the quality of life was moderately decreased by chronic pain and sleep disturbance. The examination revealed the Veteran's psychomotor activity, speech, thought process and thought content were unremarkable, his attitude toward the examiner was cooperative, affect was constricted, and mood was depressed. The Veteran's attention was intact and he was able to do serial 7s. The Veteran's orientation was intact to person, time, and place. There was no evidence of delusions. The Veteran was able to understand outcome of behavior and that he has a problem. His intelligence was above average. The Veteran's sleep impairment was described as averaging about six to seven hours sleep a night and is awake 30 to 45 minutes per night because he is awakened by dreams. The Veteran did not have hallucinations. He did not exhibit inappropriate behavior, obsessive/ritualistic behavior, panic attacks, homicidal thought, or suicidal thoughts. He was able to interpret proverbs appropriately. He had good impulse control with no episodes of violence. The Veteran was able to maintain minimum personal hygiene. There were no problems with activities of daily living. The Veteran's remote, recent, and immediate memory were normal. The Veteran's PTSD symptoms included persistent re-experiencing of the stressor by recurrent distressing dreams of the event. He had persistent avoidance with efforts to avoid thoughts, feelings, or conversations associated with the trauma. He avoids activities, places or people that arouse the recollection of the trauma, and restricted the range of affect. The Veteran had increased arousal with difficulty falling or staying asleep and hypervigilance. The Veteran stated that he is unable to sit inside a restaurant if he is unable to see people coming in and out. He refuses to sit in undesirable locations. Normally, he is comfortable around people. The Veteran was diagnosed with chronic mild to moderate PTSD with a GAF score of 63. The Veteran was unemployed and retired in April 2004 due to his physical problems of his back and leg. There was no history of hospitalization due to his PTSD. The Veteran testified at the September 2011 Board hearing that he had difficulty adjusting to civilian life following separation from service. He stated he experienced anxiety and depression consistently since separation and moved from job to job as he was unable to deal with peers. He stated his weight fluctuated significantly. However, the Veteran testified that he "everything was going great" until he was injured at work. He had difficulty dealing with a disability since the injury. Based on the evidence of record described above, the Board finds that the Veteran's PTSD does not result in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss or symptoms otherwise reflective of a 30 percent rating. The Board notes that the evidence of record reflects that the Veteran has additional symptomatology which includes avoidance of thinking or talking about his military experiences, not going out much, and having less interest in hunting. See Mauerhan, 16 Vet. App. 436 (2002). However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 10 percent under the General Rating Formula as they are not of such a severity or frequency to result in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. Additionally, the Board notes that the Veteran was assigned a GAF score of 63. As noted above, GAF scores ranging between 61 to 70 represent some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or schooling functioning (e.g., occasionally truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. This score is reflective of the collective evidence of record prior to October 16, 2008. Therefore, the Board finds that the Veteran's PTSD does not more nearly approximate a rating in excess of 10 percent. The Board has considered whether staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PTSD; however, the Board finds that his symptomatology has been stable during this portion of the appeal period. Again, a 30 percent rating for PTSD will be assigned where 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, and mild memory loss. The Board recognizes that the Veteran testified to his difficulty adjusting to civilian life, particularly occupationally. However, while depressed mood and sleep disturbance were reported, the examiner noted it was in part related to his declining physical health. Overall, the Veteran reported having a satisfactory family life, a moderately active social life and the ability to enjoy leisure time. There was no evidence of panic attacks or memory loss. Therefore, assigning higher staged ratings for such disability from May 21, 2007, to October 15, 2008, is not warranted. From October 16, 2008 In October 2008, the Veteran was treated by a T.M.K., a private counselor for his PTSD. According to the private treatment record of an October 16, 2008 evaluation, the Veteran reported being somewhat anxious, and becoming increasingly less social, easily irritated, and historically had severe difficulty maintaining employment. The Veteran reported frequent flashbacks and nightmares related to the events he witnessed while in Vietnam and recognizes his triggers are news programs or movies related to war. He described extreme difficulty coping with small changes in routine or stressors. The Veteran stated he resides with his wife but that he is distant to her and their children. He has difficulty focusing and "zones out" on others during communication. This has caused problems in relationships with his family. The Veteran stated he had few friends and that he avoids social interactions due to the level of irritability and anxiety. He attends church but does not attend any functions offered through the church. The Veteran stated he enjoys spending time at home with his wife. The Veteran reported that his hands shake almost constantly and that he had frequent feelings of panic during which his heart races during periods of stress. The Veteran arrived to the appointment neatly groomed and his attire was appropriate to situation and weather. His posture was rigid/tense throughout the appointment. He was oriented to all spheres. He was cooperative but visibly anxious and slightly irritable when discussing stressors from war. He reported extreme difficulties sleeping at night and experiences vivid nightmares and frequent flashbacks. His eye contact was very good and speech tone was soft and rate even. His thinking was logical without any apparent preoccupation/bizarre themes. There was no history of hallucinations/delusions or homicidal/suicidal ideation. The immediate, recent, and remote memory appeared intact although he reported significant difficulty maintaining focus. His typical mood was described as hypervigilant and anxious when out of the home. He reported some success over the past few years controlling his irritability though he continues to experience it often. He was diagnosed with PTSD with a GAF score of 60 due to social withdrawal. According to a December 2010 treatment record from T.M.K., the Veteran reported recurring persistent flashbacks. He complained of memories he knows will never cease. He reported nightmares about his time in Vietnam and extreme difficulty sleeping. The Veteran stated he developed "shakes" and that he was told by his physician that nothing could be done about them. He reported intrusive thoughts that can be anywhere from one to four days out of the week and can last for two weeks. He stated he gets along well with his wife and children but is distant with the remainder of his family. He is active at his church and likes to play golf on occasion. He does not enjoy hunting anymore as killing does not appeal to him any longer. He stated he usually goes shopping with his wife during the day but avoids crowds. He spends his time watching sports on TV and avoids war or action movies. He stated he has no triggers to his flashbacks and nightmares of which he was aware but that they come in the middle of the night or while driving. He stated he avoids gathering with friends and lamented that his wife does as well "because of [him]." The Veteran was dressed appropriately to the situation and weather. His gait was normal but his posture varied as he often shifted in his seat and his hands visibly shook. He was shy and quiet but cooperative. He had good eye contact and speech tone was soft and rate normal. His thinking was logical and coherent without any apparent bizarre themes. There were no current hallucinations/delusions or homicidal/suicidal ideation. His intrusive recollection occurred at night which caused difficulty sleeping. His mood was withdrawn and anxious. Most of his issues were internalized which left him feeling panicky. He reported some issues with short term memory but added that in time he is often able to recall. The Veteran was diagnosed with PTSD and a GAF score of 50 due to reported social avoidance and level of anxiety. T.M.K. stated that in her opinion, the Veteran's symptomatology would reflect a 50 or 70 percent disability as evidence by the Veteran's report of daily mood and overall lack of social interaction. Finally, the Veteran was afforded a VA examination in February 2011 where he reported mild depression and frustration due to the VA disability process. He stated he and his wife are getting along. He stated he is no longer close to his extended family. Regarding his other relationships, the Veteran stated he does not have any close friends and while he has some friends at church, they do not do anything together. He stated he did not go to any family reunions until he started going to church. He no longer goes fishing or hunting but plays golf because he can do it by himself. There was no history of suicide attempts and he denied aggressive behavior but reported that a couple of time he "beat people up" in the past. He stated he tends to be isolative with limited interest and enjoyment in things. A psychiatric examination report indicated he was clean and neatly groomed. His psychomotor activity was unremarkable. His speech was at a normal rate, rhythm, tone and volume. His attitude was cooperative with appropriate affect but his mood was a bit apprehensive. The Veteran's attention was mildly impaired, most likely due to anxiety. His orientation was intact to person and place but time was mildly impaired. His thought process and content were unremarkable. There were no delusions but stated he felt paranoid when he was around "Asian people." He understood the outcome of behavior, his intelligence was average, and understood he had a problem. The Veteran expressed sleep disturbances with nightmares frequently waking him and difficulty falling back asleep. He denied insomnia and had occasional tiredness in the afternoon. He reported occasional auditory hallucinations which are brief and infrequent. He denied visual hallucinations. He did not have any inappropriate behavior and interpreted proverbs appropriately. He does have obsessive/ritualistic behaviors such as bathing or washing his hair daily. The Veteran had occasional panic attacks that varied in frequency for a duration of five minutes. He stated breathing exercises and sitting helped. There was no presence of homicidal or suicidal thoughts. The Veteran's impulse control was "fair-good" with no recent episodes of violence. He had the ability to maintain minimum personal hygiene with no problems with activities of daily living with exception to traveling. He stated he is no longer interested in hunting or fishing but attends church every Sunday and plays golf. The Veteran's remote and immediate memory was normal but his recent memory was mildly impaired. The Veteran's PTSD symptoms included daily intrusive thoughts and nightmares about this experience in Vietnam. He reported flashbacks two to three times a week with no specific trigger identified. He was hypervigilent, socially isolative, with decreased interest in things he previously enjoyed. The Veteran avoided conversations about war and he does not tell people about his experience in Vietnam. He preferred to sit with his back to the door or the back of the booth when he goes to a restaurant. The examiner noted that there has been no change since his last VA examination in October 2007 but that the Veteran now had brief auditory hallucination, occasional paranoid ideation, and panic attacks. He was diagnosed with PTSD and a GAF score of 55 was given. Based on the foregoing evidence, and resolving any doubt in the Veteran's favor, the Board finds that the criteria for a 50 percent rating have been met for this period. In this regard, the private treatment records and examination reports reflect symptoms associated with a 50 percent rating, including flattened affect, disturbances of motivation and mood (i.e. irritability, anxiousness, and feeling "panicky"), feelings of detachment from others, and difficulty maintaining effective work relationships (i.e. losing his temper at work). Significantly, the Veteran's GAF score was 55 to 60 reflecting that the Veteran's symptoms were considered to be of moderate severity, which supports assignment of a 50 percent rating. The apparently minimal impact of the Veteran's PTSD symptoms on his occupational functioning generally weighs against assignment of a 50 percent rating under DC 9411, which reflects reduced reliability and productivity. See 38 C.F.R. § 4.130. While "reduced reliability and productivity" is not defined in the General Rating Formula, it is necessarily more severe than an "occasional decrease in work efficiency" with "intermittent periods of inability to perform occupational tasks," as suggested for a 30 percent rating. In this case, the evidence of record is equivocal, at best, with regard to whether there has been an occasional decrease in work efficiency associated with a 30 percent rating, let alone a more severe decline in work performance associated with a 50 percent rating. The Veteran's work problems have been primarily due to physical limitations stemming from his back condition, and the Veteran discontinued working in April 2006 due to his physical limitations. He has never stated that he stopped working due to his PTSD symptoms. Thus, the record does not show that the Veteran's ability to work has ever been significantly impacted by his PTSD symptoms. Furthermore, the evidence shows that the Veteran has maintained a long-standing and generally supportive relationship with his spouse, and is in contact with his adult children. Although he has reported less frequent contact with friends he is still able to attend church regularly. The social impairment alone cannot be the basis for a higher rating under the General Rating Formula. See 38 C.F.R. § 4.126 (providing that while VA considers the level of social impairment, it shall not assign an evaluation based solely on social impairment). In short, the Veteran's occupational impairment due to PTSD symptoms has only been shown to be minimal during this period, and his social impairment is moderate The ratings assigned under the General Rating Formula turn on the level of occupational and social impairment caused by the types of symptoms (or symptoms equivalent in severity) associated with each rating. See 38 C.F.R. § 4.130. In this case, the evidence of record is doubtful, at best, with regard to whether the Veteran's PTSD symptoms have resulted in the degree of occupational and social impairment (i.e. reduced reliability and productivity) associated with a 50 percent rating. Nevertheless, given the private counselor's and the VA examiner's findings of moderate symptoms associated with a 50 percent rating, the GAF scores of 60 to 55, and T.M.K's recommendation that the Veteran's symptomatology meet a higher disability rating, the Board resolves any doubt in the Veteran's favor in finding that his PTSD more closely approximates the criteria for a 50 percent rating. The Board has considered whether a rating in excess of 50 percent is warranted. There is no evidence the Veteran's PTSD more closely approximates the criteria for a 70 percent or higher evaluation. As explained above, the Veteran's PTSD symptoms have caused minimal occupational impairment. The occupational and social impairment contemplated by a 70 percent rating, which requires "deficiencies in most areas," is necessarily more severe than the "reduced reliability and productivity" associated with a 50 percent rating. See 38 C.F.R. § 4.130. Because the Board has found only minimal occupational impairment which did not actually result in reduced reliability and productivity, and rather based the assignment of a 50 percent rating principally on the nature of the Veteran's symptoms, it follows that a 70 or 100 percent rating cannot be granted for more severe functional impairment. Accordingly, the Board has considered whether the criteria for a rating in excess of 50 percent have been met. Moreover, there is no evidence showing that the Veteran has any symptoms equivalent in severity to those associated with a 70 percent rating, especially in light of the fact that they only minimally impacted his ability to work. Rather, the evidence shows that although the Veteran has been prone to anger at times, he has generally been able to maintain effective occupational and social relationships notwithstanding his PTSD symptoms. In this regard, he maintained full time employment for many years until he discontinued working due to his physical condition, and also has maintained a long-standing relationship with his wife. Thus, the evidence does not show that he has had difficulty adapting to stressful circumstances. There is no evidence of suicidal or homicidal ideation, neglect of personal appearance, or near-continuous panic or depression affecting the ability to function independently, there is no evidence suggesting that this symptom impacted his occupational or social functioning. Furthermore, while the Veteran reported obsessional rituals, they do not interfere with his routine activities. The Veteran's speech was not intermittently illogical, obscure, or irrelevant. Accordingly, the Board finds that the Veteran's PTSD most closely approximates the criteria for a 50 percent rating, no higher. As discussed above, there is no evidence showing that the Veteran is entitled to a rating in excess of 50 percent at any point since his claim for service connection. While the evidence shows some fluctuation in the severity of his PTSD, at its worst it has not met the criteria for a rating in excess of 50 percent. Thus, staged ratings are not appropriate during the pendency of this claim. See Fenderson, 12 Vet. App. at 126. Accordingly, the Board finds that the evidence is at least in equipoise as to whether the Veteran's PTSD most closely approximates the criteria for a 50 percent rating. As such, the benefit-of-the-doubt rule applies, and entitlement to a 50 percent rating, but no higher, for PTSD is granted. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102; 4.3; Gilbert, 1 Vet. App. at 55. Extraschedular consideration The Board has also considered whether the Veteran's claim should be referred for an extraschedular rating. See 38 C.F.R. § 3.321(b) (2012); Thun v. Peake, 22 Vet. App. 111, 114 (2008). Because the ratings provided under the VA Schedule for Rating Disabilities are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstances, but nevertheless would still be adequate to address the average impairment in earning capacity caused by the disability. Thun, 22 Vet. App. at 114. However, in exceptional situations where the rating is inadequate, it may be appropriate to refer the case for extraschedular consideration. Id. The governing norm in these exceptional cases is a finding that the disability at issue 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). The Board finds that referral for extraschedular consideration is not warranted. The Veteran's service-connected PTSD is contemplated and reasonably described by the rating criteria. See id. As shown in the above discussion, the Veteran does not have symptoms associated with this disability that have been left uncompensated or unaccounted for by the assignment of a schedular rating. See Thun, 22 Vet. App. at 115. Rather, his intrusive thoughts, nightmares, flat affect, irritability, feelings of detachment, hypervigilance, and other such symptoms are set forth in the General Rating Formula. See 38 C.F.R. § 4.130, DC 9411. Moreover, symptoms not mentioned in the General Rating Formula but which are equivalent in severity to such symptoms are likewise considered in assigning a schedular rating. See Mauerhan, 16 Vet. App. at 443. Ultimately, the rating criteria explicitly take into account the impact of such symptoms on occupational and social functioning. Accordingly, the Board finds that a comparison of the Veteran's PTSD symptoms and resulting functional impairment and the rating criteria does not present "such an exceptional or unusual disability picture . . . as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b). Consequently, the Board finds that the available schedular evaluations are adequate to rate this disability. As such, in the absence of this threshold finding, there is no need to consider whether there are "related factors" such as marked interference with employment or frequent periods of hospitalization. See Thun, 22 Vet. App. at 118-19 (holding that the Board's finding that the rating criteria were adequate to evaluate the claimant's disability was a sufficient basis for denying extraschedular consideration without regard to whether there was marked interference with employment). However, as discussed above, the Board finds that such related factors are not present in this case. Therefore, referral for extraschedular consideration is not warranted. See id. The Board has considered whether to the address the issue of a total disability rating based on individual unemployability (TDIU). See Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009) (holding that the issue of entitlement to TDIU is "part and parcel" of the evaluation of a disability when unemployability as a result of such disability has been raised by the claimant or by the record); see also 38 C.F.R. §§ 3.340, 4.16 (2012). Here, the Veteran has not stated and the evidence of record does not otherwise suggest that his PTSD is sufficiently incapacitating as to prevent him from obtaining and maintaining substantially gainful employment. Rather, the evidence shows that the Veteran was able to work full time despite his PTSD symptoms, and discontinued working secondary to a back injury. Thus, the Board finds that the issue of entitlement to TDIU has not been raised in the present appeal. See id. ORDER Entitlement to an initial disability evaluation in excess of 10 percent for PTSD, effective May 21, 2007 to October 15, 2008, is denied. A rating of 50 percent, but no higher, for PTSD, effective October 16, 2008, is granted, subject to controlling regulations applicable to the payment of monetary benefits,. REMAND Unfortunately, a remand is required in this case. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. §§ 5107(a) 5103A (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(c) (2012). The Veteran testified at the September 2011 Board hearing that he injured his shoulder and back from a helicopter accident while stationed in Vietnam. He stated that the helicopter was not very high off the ground when one of the engines lost power. The Veteran stated that when the pilot stated he could not control the helicopter, as the crew chief, he stood from his seat and headed to the side door. By the time he arrived at the side door, the helicopter hit the ground. Upon impact, he was thrown into the crew chief seat and then into the control closet. He stated he injured his back and shoulder in this incident. Subsequently, he treated his injuries with ice packs for a few days but "had some trouble with [his] back and [his] shoulder since then." He stated later in life, approximately 15 to 20 years since the incident, the injuries started to bother him a lot more. The Veteran further stated that he injured his back while employed at Ormet Corporation and subsequently underwent back surgery. However, the Veteran stated he was told by his surgeon, Dr. J. Maroon, that prior to the back injury while employed at Ormet, he had "a lot of arthritic conditions" in his back which the Veteran attributes to his helicopter crash during service. The Board finds the Veteran's statements and lay evidence credible that he was involved in a helicopter accident during service. According to the Veteran's DD 214, his military occupational specialty was a helicopter mechanic and as stated above, he was awarded the Combat Air Crew Insignia with three stars and the Air Medal. The Veteran is competent to report as to his own symptoms, and the Board finds the Veteran's history credible and consistent with the nature and circumstances of his service. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2008); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (a layperson may be competent to identify the condition where the condition is simple). Post-service treatment records indicate the Veteran has sought treatment for his back and shoulder pain. It is unclear, however, if there is a diagnosis. Here, the Veteran has not yet been afforded a VA examination for his claimed conditions. Furthermore, given a lack of a clear diagnosis and the Veteran's lay statements, the Board finds this claim should be remanded for a VA examination to clarify the Veteran's diagnoses and obtain an adequate etiological opinion. As such, further development is necessary before a final determination is made. The Veteran should be afforded a VA examination(s) to clarify the diagnosis and the etiology of the disabilities. 38 C.F.R. § 3.159(c)(4) (2012); Green v. Derwinski, 1 Vet. App. 121 (1991) (duty to assist may include conduct of a thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one). Accordingly, the case is REMANDED for the following action: 1. Copies of pertinent updated treatment records should be obtained and added to the claims folder. 2. Following completion of the above, schedule the Veteran for a VA examination with an appropriate specialist to ascertain the current nature and etiology of any low back and bilateral shoulder disorder. After a review of the record on appeal and an examination of the Veteran, the examiner must provide an opinion regarding whether it is at least as likely as not (i.e., 50 percent or greater probability) that any current low back and/or bilateral shoulder disability is directly related to service, that is, whether the current low back and/or shoulder condition had its onset in, or is otherwise due to, service. The claims file must be made available to and reviewed by the examiner in conjunction with the examination, and the examination report should reflect that such a review was made. All pertinent symptomatology and findings should be reported in detail. Any indicated diagnostic tests and studies should be accomplished. The Veteran's complaints and lay history should be recorded in full and addressed. A rationale for any opinion expressed must be provided. If the examiner opines that any of the above questions cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 3. Upon completion of the foregoing, review the examiner's report to ensure substantial compliance with the Board's directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Take any needed corrective action. 38 C.F.R. § 4.2. 4. Following the completion of the foregoing, and after undertaking any other development it deems necessary, the AMC should readjudicate the Veteran's claims, considering all applicable laws and regulations. The AMC should provide the Veteran and his representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. 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 (CONTINUED ON NEXT PAGE) action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs