Citation Nr: 1334153 Decision Date: 10/28/13 Archive Date: 11/06/13 DOCKET NO. 06-00 204A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUES 1. Entitlement to an evaluation in excess of 30 percent for the service-connected posttraumatic stress disorder (PTSD) prior to February 15, 2006. 2. Entitlement to an evaluation in excess of 50 percent for the service-connected PTSD for the period beginning on February 15, 2006 to February 14, 2011. 3. Entitlement to a total disability evaluation based on individual unemployability by reason of service-connected disability (TDIU) prior to February 14, 2011. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Smith, Counsel INTRODUCTION The Veteran served on active duty from October 1964 to September 1966. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from October 1999 and April 2005 rating decisions of the RO. The Veteran was scheduled to testify at a hearing before a Veterans Law Judge in this matter in September 2008, but failed to appear for the hearing and did not request postponement or rescheduling. As determined previously by the Board, his hearing request is deemed withdrawn. 38 C.F.R. § 20.704(d) (2013). As the procedural history of these claims is complex, the Board finds that a brief summary of that history may be helpful prior to further discussion. In October 1999, the RO denied entitlement to a TDIU rating. The Veteran initiated an appeal of this decision. The timeliness of the appeal was developed as an issue on appeal before the Board. It was ultimately adjudicated in October 2008, as will be discussed. In December 2001, the RO awarded service connection for PTSD and assigned a 30 percent rating, effective on March 25, 1999. The Veteran did not appeal this decision. In April 2005, the RO issued a rating decision continuing the 30 percent evaluation for the service-connected PTSD. The Veteran appealed this decision. In May 2007, the RO increased the evaluation for the service-connected PTSD to 50 percent, effective on January 27, 2007. In an October 2008 decision, the Board assigned an increased rating of 50 percent for the service-connected PTSD, effective on February 15, 2006, but denied a further increase. The Board's decision was implemented by the RO in a December 2008 rating decision. Also in the October 2008 decision, the Board found that the Veteran had filed a timely appeal from the October 1999 decision that denied his claim for a TDIU rating, but denied entitlement to a TDIU rating. In March 2010, the United States Court of Appeals for Veterans Claims (Court) granted a Joint Motion for Remand (Joint Motion), vacating the October 2008 decision, except for the portion of the decision involving timeliness. The Court remanded the matter back to the Board for development consistent with the Joint Motion. In August 2010 and March 2012, the Board remanded the case to the RO via the AMC for additional development of the record. In July 2012, the RO granted a 100 percent rating for the service-connected PTSD, effective on February 15, 2011, and granted service connection and assigned a 100 percent rating for ischemic heart disease, effective on February 15, 2011. As a result, the matters of entitlement to a TDIU rating and an increased rating for the service-connected PTSD became moot as of February 15, 2011, as reflected on the first page of this document. In September 2012, the Board remanded the case to the RO via the AMC for additional development of the record. The Board notes that, in an August 2013 Brief, the Veteran's representative raised an issue of an earlier effective date for the grant of service connection for PTSD. With regard to claims for earlier effective date entered over one year after a rating decision assigning effective date becomes final, the Court has barred appellants from seeking to disturb the finality of a prior rating decision by attempting to file such a "freestanding" earlier effective date claim. Rudd v. Nicholson, 20 Vet. App. 296 (2006) (VA claimants may not properly file, and VA has no authority to adjudicate, a freestanding earlier-effective-date claim in an attempt to overcome the finality of an unappealed rating decision). As a result, the Board is not referring the request to the RO for further action, as it is not a valid claim. The Board has considered documentation included in Virtual VA. In the August 2013 brief, the Veteran's representative raised the matter of whether the December 2001 rating decision involved clear and unmistakable error. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction and refers the matter to the AOJ for appropriate action. The issue of a TDIU rating prior to February 14, 2011 is being remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT For the period of the appeal prior to February 14, 2011, the service-connected PTSD is shown to have been productive of a disability picture that more nearly approximated that of occupational and social impairment with deficiencies in most areas, such as school, work, family relations, judgment, and mood, as reflected by Global Assessment of Functioning (GAF) scores in the 30's and 40's, and symptoms such as near continuous panic or depression affecting the ability to function independently, appropriately and effectively, difficulty in adapting to stressful circumstances, and some difficulty in establishing and maintaining effective relationships; total occupational and social impairment was not demonstrated. CONCLUSIONS OF LAW 1. The criteria for the assignment of a 70 percent disability rating, but no higher, for the service-connected PTSD were met prior to February 15, 2006. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. § 4.130 including Diagnostic Code (DC) 9411 (2013). 2. The criteria for the assignment of a 70 percent disability rating, but no higher, for the service-connected PTSD were met beginning on February 15, 2006, to February 14, 2011. 38 U.S.C.A. § 1155 (West 2002 & Supp. 2012); 38 C.F.R. § 4.130 including Diagnostic Code (DC) 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSIONS Notice and Assistance Under applicable law, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical 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. 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); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board finds that the content requirements of a duty to assist notice have been fully satisfied. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). A letter from the RO dated in December 2004 provided the Veteran with an explanation of the type of evidence necessary to substantiate his claim, as well as an explanation of what evidence was to be provided by him and what evidence the VA would attempt to obtain on his behalf. A March 2006 letter additionally provided him with information concerning the evaluation and effective date that could be assigned should his claim be granted, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA has no outstanding duty to inform the Veteran that any additional information or evidence is needed. VA also has a duty to assist the Veteran in the development of the claim. 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. Here, the Board finds that all relevant facts have been properly developed, and that all evidence necessary for final resolution of the issues on appeal has been obtained. The Veteran's service treatment records and post service treatment records have been obtained. He has been afforded the opportunity for a personal hearing. He also has been afforded VA examinations. His records from the Social Security Administration (SSA) have been obtained. The Board is further satisfied that the RO has substantially complied with its September 2012 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). See also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board engagement letter requesting a medical opinion is required). As directed by the Board, the RO afforded the Veteran an additional opportunity to submit more evidence, and secured VA medical opinions. See 38 U.S.C.A. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). For the foregoing reasons, the Board concludes that all reasonable efforts were made by the VA to obtain evidence necessary to substantiate the Veteran's claim. Therefore, no further assistance to the Veteran with the development of evidence is required. Analysis Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity in civil occupations. See 38 U.S.C.A. § 1155. Separate diagnostic codes identify the various disabilities. The assignment of a particular diagnostic code is dependent on the facts of a particular case. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. In reviewing the claim for a higher rating, the Board must consider which diagnostic code or codes are most appropriate for application in the Veteran's case and provide an explanation for the conclusion. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). At the outset, the Board observes that the unappealed rating decision of December 2001 granted service connection for PTSD and assigned a 30 percent rating, effective beginning on March 25, 1999. While the Veteran's entire history is reviewed when making a disability determination, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). In an April 2005 rating decision, the subject of this appeal, the RO continued the 30 percent rating. In May 2007, the RO increased the Veteran's rating to 50 percent, effective on January 27, 2007. The RO also recharacterized the disability as PTSD with schizo-affective type schizophrenia. In an October 2008 decision, the Board assigned an increased rating of 50 percent for the service-connected PTSD, effective beginning on February 15, 2006, but denied any further increase. The Board's decision was implemented by the RO in a December 2008 rating decision. In March 2010, the United States Court of Appeals for Veterans Claims (Court) granted a Joint Motion for Remand (Joint Motion), vacating the Board's October 2008 decision involving the increased ratings for the service-connected PTSD. The portion of the Board's decision addressing entitlement to a rating in excess of 30 percent prior to February 15, 2006 was vacated because the Board failed to adequately account for evidence of record dated prior to October 2004. Specifically, the Joint Motion cited medical records of September 24, 1999, July 26, 2000 to August 3, 2000, October 19, 2000,and January 19, 2001, as well as records during 2001 to 2003 generally, as evidence the Board should have addressed. The analysis for this portion of the appeal period was also found to be deficient due to the Board's failure to adequately analyze the statement of a January 2005 VA examiner that, "'[d]espite medications [the appellant] would have sadness including crying spells, anhedonia, lack of interest, and self critical thinking; such attacks would happen a couple of times per week for a few hours.'" The portion of the Board's decision addressing entitlement to a rating in excess of 50 percent beginning on February 15, 2006 was vacated because of a failure to evaluate potentially favorable medical evidence pertaining to the Veteran's condition. Specifically, the Board was noted not to have discussed reports from C.T., that continued to assign a GAF score of 35 throughout 2007, and a statement in a December 2007 report from the Veteran's social worker that, "'[h]is traumas [were] so acute that any processing sen[t] him into a regression . . . It [was] felt that due to the severity and chronic nature of his condition, prognosis for significant future change [was] guarded.'" In August 2010 and March 2012, the Board remanded the case to the RO via the AMC for further development. In July 2012, the RO granted a 100 percent rating for the service-connected PTSD, effective on February 15, 2011. As a result, the matter of entitlement to an increased rating became moot as of February 15, 2011. In September 2012, the Board remanded the case to the RO via the AMC for further development. The disability rating for the service-connected PTSD has been assigned pursuant to Diagnostic Code (DC) 9411. However, the actual criteria for rating psychiatric disabilities other than eating disorders are set forth in a General Rating Formula. See 38 C.F.R. § 4.130. Pursuant to the current General Rating Formula, a 30 percent 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of long and short-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing or maintaining effective work and social relationships. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as school, work, family relations, judgment, thinking, mood, due to such symptoms as: suicidal ideation; obsessive 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 to personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to symptoms such 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. 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). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. 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 (DSM- IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." A GAF score ranging from 31 to 40 reflects 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). A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF of 51 to 60 is defined as 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). A GAF score of 61-70 contemplates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. The Board has reviewed all of the evidence in the Veteran's claims file and Virtual VA electronic file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Additionally, the Board notes that while, in this case, the Veteran has been diagnosed with both PTSD and schizophrenia, for purposes of rating the Veteran's disability, all psychiatric symptoms have been attributed to the service-connected disability. A number of examiners have indicated that it is not possible to distinguish between the symptoms attributable to each disorder. See, e.g., VA examination reports of November 2012, April 2012, September 2010 and January 2007. When it is impossible to separate the effects of a service-connected disability and a nonservice-connected disability, reasonable doubt must be resolved in the Veteran's favor and the symptoms in question attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Moreover, the service-connected psychiatric disability was recharacterized in May 2007 to include both diagnostic entities. Considering the Veteran's psychiatric symptomatology, and after resolving reasonable doubt in his favor, the Board finds that, for the period of the appeal period, the service-connected disability picture more nearly approximates the criteria for a rating of 70 percent. In January 1990, the Veteran's GAF score was 47. He had no suicidal or homicidal ideation. Memory, thought, and speech were normal. He was oriented. He had a dysphoric mood and flat affect, and cried when talking about stressful things. In July 1995, the Veteran's GAF score was 50. He was depressed. He was oriented. He denied suicidal or homicidal ideation, as well as hallucinations. In June 1996, the Veteran was hospitalized. His GAF score on admission was 35 to 40, and was 55 on discharge. He was withdrawn and made no eye contact. He was worried and preoccupied and did not talk. He was not considered suicidal or homicidal. In October 1996, the Veteran's GAF score was 55. He was hospitalized for feelings of nervousness. His speech was normal. He had no memory impairment or thought disorder. There were no suicidal or homicidal thoughts. He had no delusions or hallucinations. In August 1997, the Veteran's GAF score was around 50. His affect was flat and cognitive functioning was intact. He denied having homicidal and suicidal ideation. He felt in touch with reality. In June 1998, the Veteran's GAF score was 60-65. His mood was good, and he was alert and oriented. Cognition was grossly intact; judgment was intact; there was no suicidal or homicidal ideation, hallucinations or delusions. In September 1999, the Veteran had a GAF score of 30. It was noted that the Veteran "said he had a spell, going back to VN, this [made] him feel hopeless, like killing himself." In October 1999, the Veteran's GAF score was 55-60. He had no hallucinations, delusions, or suicidal or homicidal ideation. His cognition was normal and he was oriented. He was neatly groomed and appropriate. He had nightmares and flashbacks. In January 2000, the Veteran's GAF score was 60. His condition had improved. He was stable and doing well. He had an active social life and stayed busy. He still had flashbacks. He had no hallucinations, delusions, or suicidal or homicidal ideation. His cognition was normal and he was oriented. He was neatly groomed and appropriate. In July 2000 and August 2000, the Veteran was hospitalized. He was "admitted to the locked side for suicide observation Level III." In September 2000, the Veteran's psychiatrist noted his July to August 2000 hospitalization. His symptoms included those of severe nervousness, frequent flashbacks, nightmares, hyperalertness, and a hyperstartle response. He had trouble in social situations His condition made it impossible to carry on any task. Multiple attempts at employment had failed. The condition had worsened, despite multiple treatment changes. In October 2000, the Veteran's GAF score was noted to be 40. He was taking various medications, and it was noted that his last hospitalization was for flashbacks. It was noted that his problems were "related to the social environment." He had no suicidal or homicidal thoughts. He was competent. He had no delusional ideas or hallucinations. He was oriented; memory was normal; speech was normal. He had no disorganized or catatonic behavior. He was dressed appropriately. Cognition was normal. In May 2000, the Veteran's GAF score was 60. His condition had improved. He was stable and doing well. He had an active social life and stayed busy. He still had flashbacks. He had bad days when he felt paranoid and stressed. He had no hallucinations, delusions, or suicidal or homicidal ideation. His cognition was normal, and he was noted to be oriented. He was neatly groomed and appropriate. In January 2001, the Veteran's GAF score was noted to be 40. It was noted that his problems were "related to the social environment." He had no suicidal or homicidal thoughts. He was competent and had no delusional ideas or hallucinations. He was oriented; memory was normal; speech was normal. He had no disorganized or catatonic behavior. He was dressed appropriately. Cognition was normal. In May 2001, the Veteran was hospitalized for PTSD symptoms triggered by watching a Vietnam War movie. On VA examination in January 2005, a GAF score was not assigned. The Veteran reported that his current medications were doing a "real good job" in controlling his mood and his feelings of paranoia. The Veteran's last inpatient psychiatric treatment was noted to have been in May 2001, for PTSD symptoms triggered by watching a Vietnam War movie. Although the medications were helpful, the Veteran reported continuing feelings of hypervigilance, nightmares, intrusive memories and flashbacks. The Veteran reported getting along well with his wife, his children from his first marriage, and his mother. He got along adequately with his wife's family. The Veteran reported having close friends whom he saw regularly. He was not employed, but enjoyed volunteer activities and buying things in flea markets and fixing them up. He regularly attended church. During the interview, the Veteran's mood was noted to be euthymic, and his affect was within normal limits. There was no impairment of thought processes or communication. He denied having hallucinations and current delusional ideas, although the records did suggest a history of delusions. His eye contact and behavior were appropriate, and the Veteran denied having any recent problems with homicidal or suicidal ideation. The Veteran was well groomed and dealt adequately with personal hygiene and basic activities of living. He was oriented and denied any significant memory impairment or obsessive-compulsive behavior. His speech was within normal limits, and he denied having panic attacks. The Veteran reported that, despite medications, he would have sadness including crying spells, anhedonia, lack of interest, and self-critical thinking with attacks that would happen a couple of times per week for a few hours. He denied having significant problems with anxiety or problematic impulse control. He reported that medication helped him to sleep and that he currently slept 8-10 hours per night and felt well-rested; however, he had a history of sleep problems in the past without medication. Specific to PTSD, the Veteran endorsed having nightmares of Vietnam approximately once per week and awakening drenched in sweat. He reported having frequent, daily intrusive memories of Vietnam as well as very frequent dissociative vivid flashback episodes approximately three or four times per week. Stimuli such as war news from Iraq, loud noises, helicopters, and Asian people could tend to trigger upsetting memories. The Veteran reported that he tended to avoid war-related news and movies. He reported having significant problems with hypervigilance, needing to protect his back and to look over his shoulder, and feeling paranoid. He complained of exaggerated startle response, feelings of irritability, and occasionally very poor concentration. The psychologist diagnosed PTSD and schizoaffective disorder. In April and August 2005, the Veteran's GAF score was noted to be 55. He had no suicidal or homicidal thoughts. He was competent. He had some paranoid delusional ideas about people following him, but no hallucinations. He was oriented. Memory and speech were normal. He had no disorganized or catatonic behavior. He was dressed appropriately. In February 2006, June 2006 and November 2006, the Veteran's GAF score was 35. It was noted that his problems were "related to the social environment." He had no suicidal or homicidal thoughts. He was competent. He had some paranoid delusional ideas about people following him, but no hallucinations. He was oriented. Memory and speech were normal. He had no disorganized or catatonic behavior. He was dressed appropriately. In a January 2007 VA treatment note, the Veteran was assigned a GAF score of 35-40. He was stressed. Cognition was intact. He did not have suicidal or homicidal ideation. Speech was normal. On VA examination in January 2007, the Veteran was not assigned a GAF score. The examiner noted based on review of the record that the Veteran's PTSD and schizoaffective disorder both appeared to be currently stable on medication. The Veteran stated that he continued to perform volunteer work for a local automobile parts store, picking up and delivering items one to three times per week, approximately half a day at a time depending on need. The work required the Veteran to interact with a number of people, including strangers, which he could apparently perform adequately. The Veteran reported having a successful relationship with his wife, his children, and his grandchildren; he also reported having a number of friends whom he saw regularly. He continued to have no problem being in public places such as shopping centers. He denied having a history of assaultive behavior or suicide attempts. On examination, the Veteran's affect was within normal limits. His mood was euthymic, and he described his mood as "okay." The Veteran did not appear to be in any significant emotional distress, and there was no significant impairment of thought processing or communication. It was noted that the Veteran's rather chronic suspiciousness of others might reach delusional proportions on some occasions, although not always. The Veteran denied having hallucinations and homicidal or suicidal ideation. Eye contact and behavior were appropriate. He was able to deal adequately with hygiene and activities of daily living. He was oriented and indicated no significant problems with memory impairment or obsessive-compulsive behavior. Speech was rather non-spontaneous, but otherwise normal. The Veteran denied panic attacks. The Veteran reported that medications helped his depressed mood, but still experienced depression for approximately one hour each day, with periodic crying spells. These episodes were sometimes triggered by Vietnam reminders. He also reported occasional anxiety possibly related to a combination of symptoms from both the PTSD and the schizophrenia. The Veteran reported having continued satisfactory sleep of eight hours per night. He denied having current nightmares, but endorsed daily intrusive memories and weekly vivid flashbacks, as well as hypervigilance and hyper-startle response. He also reported occasional problems with concentration and distractibility. The Veteran appeared to do adequately with leisure pursuits and social activities. The examiner diagnosed PTSD and schizoaffective disorder and stated that he had no way to measure how much of the Veteran's anxiety and depression was related to which disorder; the Veteran's psychotic symptoms such as paranoia would be symptomatic of the schizoaffective disorder. Overall, despite having two diagnoses, the Veteran appeared to be functioning adequately in a number of areas such as family and social relationships. In terms of employability, the occasional brief periods of depression with crying spells could affect employment if exposed to such stimuli as people discussing war news, although the Veteran appeared overall to get along adequately with others. The Veteran's schizoaffective disorder, if exacerbated into paranoia, would make it difficult to be around people, and dissociative flashbacks associated with PTSD could influence the employment situation. However, the symptoms were currently managed fairly well through medication. The Veteran received VA inpatient psychiatric treatment from January 27, 2007 to February 9, 2007 for increased flashbacks as aggravated by watching TV news about the current war. On admission, the Veteran's GAF scare was noted as 35, with judgment and insight severely impaired by the flashbacks and paranoid ideation. He reported having recent flashbacks of Vietnam, crying spells, nightmares, and paranoia and was also worried about one son recently returned from Iraq and another son who would go there eventually. During hospitalization, the Veteran's medication was adjusted and his symptoms improved; he was discharged home when he was deemed to have become stable. In a March 2007 VA treatment record, the Veteran's GAF score was noted to be 35. It was noted that his problems were "related to the social environment." He had no suicidal or homicidal thoughts. He was competent. He had some paranoid delusional ideas about people following him, but no hallucinations. He was oriented; memory was normal; speech was normal. He had no disorganized or catatonic behavior. He was dressed appropriately. In March 2007, the Veteran's GAF score was again noted to be 35. It was noted that the Veteran had recently been hospitalized for worsening PTSD symptoms triggered by watching war news on television. His medications were subsequently adjusted with good results, and he also reported avoiding war news. The psychiatrist's impression on interview was the same as previously (Veteran presented alert and appropriately dressed; behavior neither grossly disorganized nor catatonic; neither psychomotor agitation nor retardation; answered questions briefly but not spontaneously; speech appropriate and with logical associations; no evidence of alogia, pressure, or flight of ideas; mood fair and affect appropriate to mood without apparently flattening; no current homicidal or suicidal ideation; some chronic paranoid delusions about being followed but no acute auditory of visual hallucinations; no sign of bizarre grandiose ideation; oriented times three; concentration intact; and, memory functions normal for age). In May 2007, June 2007, July 2007, August 2007 and September 2007, the Veteran's GAF score was noted to be 35. He had no suicidal or homicidal ideation. He had a chronic psychotic disorder. He had no hallucinations. He had a stable paranoia of strangers. In a December 2007 social worker's report, the Veteran was noted to constantly re-experience his wartime traumas and was considered emotionally fragile. He enjoyed the camaraderie of group therapy. He was tearful at times. The love and support of his family was his biggest asset. It was noted that, "[h]is traumas [were] so acute that any processing sen[t] him into a regression . . . It [was] felt that due to the severity and chronic nature of his condition, prognosis for significant future change [was] guarded." On VA examination in March 2008, the Veteran's GAF score was noted to be 55. The psychologist noted the recent inpatient treatment and added that, since then, the Veteran appeared to have been relatively stable, with no severe exacerbations or symptomatology. The improvement was apparently due to medication and to avoidance of war-related stimuli. The Veteran reported that he continued to help his friend at the auto parts store by doing pickups and deliveries two days per week, 8-10 hours per week; he found the driving associated with the job to be soothing and dealt adequately with the people at either end of the pickup and delivery. He continued to get along well with his immediate family and his in-laws, although he spent less time with friends for unclear reasons. The Veteran continued to have no problems with crowded areas such as shopping areas or restaurants. On examination, the Veteran's affect and mood were within normal limits. He appeared to be calm and in a euthymic mood. There was no impairment of thought processing or communication. The Veteran did not appear to be delusional that day, and the record suggested that he occasionally had paranoid beliefs associated with schizophrenia that appeared to be relatively well controlled by medication. There were no hallucinations. Eye contact and behavior were appropriate. The Veteran denied suicidal or homicidal ideation and did adequately with personal hygiene and basic activities of living. He was oriented and indicated no significant memory impairment or obsessive-compulsive behavior. There were no panic attacks, and speech was within normal limits. The Veteran denied significant problems with depressed mood and was able to enjoy life and was usually content, but when exposed to stimuli of Vietnam he became appropriately sad and anxious. The anxiety appeared to be due to a combination of the schizoaffective disorder and the PTSD, but at any rate the anxiety itself was sporadic and periodic and the Veteran appeared to be relatively calm on examination. Impulse control and sleep appeared to be adequate. In regard to PTSD symptoms, the Veteran reported having no current problems with nightmares, but continued to be very sensitive to intrusive memories and war-related stimuli, with could upset him significantly. He reported intrusive memories of Vietnam multiple times per week although not daily. He had occasional dissociative flashbacks of Vietnam approximately once per week, which was an improvement since his hospitalization. He reported continuing hypervigilance that was noted to be due to both PTSD and schizoaffective disorder. He reported having adequate concentration and no significant problems with irritability or anger. The examiner diagnosed PTSD and schizoaffective disorder. The examiner noted that the Veteran's PTSD and schizoaffective disorder appeared to have been relatively stable since his hospitalization, and the Veteran appeared to be functioning adequately despite having two significant psychiatric disorders. In June 2008, July 2008, August 2008, September 2008, October 2008 and November 2008, the Veteran's GAF score was noted to be 35. It was noted that his problems were "related to the social environment." He had no suicidal or homicidal thoughts. He was competent. He had some paranoid delusional ideas about people following him, but no hallucinations. He was oriented. Memory was normal. Speech was normal. He had no disorganized or catatonic behavior. He was dressed appropriately. In October 2008 and in December 2008, the Veteran's GAF score was noted to be 35. He was stable on a number of medications. In a December 2008 report of a social worker, the Veteran was noted to be very fragile and tried hard to enjoy a decent quality of life. He had sleep disturbances and nightmares and had difficulty expressing himself. His prognosis for significant change was guarded. In January 2010, the Veteran's GAF score was 35. It was noted that his problems were "related to the social environment." He had no suicidal or homicidal thoughts. He was competent. He had some paranoid delusional ideas about people following him, but no hallucinations. He was oriented. Memory was normal. Speech was normal. He had no disorganized or catatonic behavior. He was dressed appropriately. In an August 2010 report of a social worker, the Veteran was noted to be emotionally fragile and susceptible to easy regression. He was not aggressive. It was noted that he had spent decades trying to normalize his existence. Social interaction was very limited to family and immediate family. It was noted that, because of the chronic and severe nature of his condition, therapeutic support would be needed for an indefinite time. On VA examination in September 2010, the Veteran's GAF score was noted to be 56. He reported being married for 6 years and having no significant marital problems. He had 3 children and 6 grandchildren and had a good relationship with them. He had a number of friends who he saw less than he used to. He performed household tasks and watched TV. He got out regularly. He enjoyed flea markets, reading, and attended church regularly. He walked with his wife several times per week and enjoyed fishing with his grandchildren. He enjoyed restaurants and had gone on a recent trip to Missouri. He attended his grandchildren's' sporting events occasionally. The Veteran had no impairment in thought processes or communication. He had no hallucinations. He had some chronic delusions about people following him. He had no suicidal or homicidal thinking. He had good personal hygiene and was oriented. Memory was normal. Speech was normal. There were no panic attacks. He reported upsetting intrusive memories, periodic dissociative flashbacks, and had had periods of emotional deterioration. He denied problems with impulse control. On VA examination in November 2012, a retrospective opinion was obtained. The examiner reviewed the claims file and opined that from 1999 through February 14, 2011, the Veteran's PTSD and schizoaffective disorder more likely than not led to occupational and social impairment with reduced reliability and productivity. The examiner noted that it was not possible to separate the impairment caused by each disability, as their symptoms overlapped considerably. The Board notes that, while VA psychiatric examinations were conducted in April 2012 and March 2013, these findings are not relevant to the current decision. Considering the evidence of record, and resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's overall symptomatology more closely resembled the criteria for a rating of 70 percent for the course of the appeal. The evidence shows GAF scores in the 30's and 40's, and symptoms such as near continuous panic or depression affecting the ability to function independently, appropriately and effectively, difficulty in adapting to stressful circumstances, and difficulty in establishing and maintaining effective relationships. The Board relies heavily on the Veteran's Global Assessment of Functioning (GAF) scores in support of the assignment of a 70 percent evaluation for his PTSD. In the years preceding his claim, the Veteran manifested low GAF scores numerous times. His score was 47 in 1990, 35-40 in 1996, 30 in 1999, and 40 in 2000 and 2001. On numerous occasions in 2006, 2007, 2008, and 2010, the Veteran was assigned a GAF score of 35. These occasions included February 2006, June 2006, November 2006, January 2007, February 2007, March 2007, May 2007, June 2007, July 2007, August 2007, September 2007, June 2008, July 2008, August 2008, September 2008, October 2008, November 2008, December 2008, and January 2010. As noted, a GAF score ranging from 31 to 40 reflects 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). A GAF score of 41-50 contemplates 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). Indeed, in the March 2010 Joint Motion, the Court emphasized the GAF score of 35 that had appeared consistently throughout the record, and highlighted various pieces of evidence that illustrate the severity of the Veteran's illness. This combination of low GAF scores and various periods of severe declines in functioning support an overall disability picture contemplated by a 70 percent evaluation. While the Veteran does not demonstrate every single symptom associated with the 70 percent rating criteria, the symptoms noted in the rating schedule 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 disability rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition to the GAF scores, near continuous panic or depression affecting the ability to function independently appropriately and effectively, and his difficulty in adapting to stressful circumstances is evidenced by the Veteran's periods of psychiatric hospitalization over the years. The Veteran's difficulty in establishing and maintaining effective relationships is demonstrated by the various findings that he spends less time with his friends than he used to, and his social relationships are largely limited to immediate family members. In resolving all reasonable doubt in the appellant's favor, the Board finds that an increased rating of 70 percent for the service-connected psychiatric disability manifested by PTSD with schizo-affective schizophrenia for the period of the appeal is warranted. However, prior to February 15, 2011, the service-connected PTSD is not shown to have met the criteria for a 100 percent rating. A 100 percent rating requires evidence of total social impairment. This is simply not supported by the record. Indeed, the record consistently shows the contrary. Throughout the appeal, the Veteran has reported having a successful marriage with no marital problems. He has consistently stated that he got along well with his former wife, his children from his first marriage, his grandchildren and his mother, and got along adequately with his wife's family. He has reported having close friends whom he saw regularly. He enjoyed volunteer activities, attended flea markets, went to restaurants and sporting events, and traveled with his wife. He regularly attended church. While the Veteran might see his friends less, and have limited interactions with his immediate family, his social functioning could not be said to be totally impaired, as is required for a 100 percent rating. Moreover, essentially none of the symptomatology contemplated by a 100 percent rating is documented in the evidence. There is no evidence of such symptoms as a gross impairment in thought processes or communication, persistent hallucinations, grossly inappropriate behavior, a persistent danger of the Veteran hurting himself or others, disorientation to time or place or memory loss for names of close relatives, own occupation, or his own name. The Board acknowledges that the Veteran has recurrently experienced delusions involving paranoid thoughts of people following him, and that his hospitalizations reflected an intermittent inability to perform activities of daily living. These symptoms alone, however, particularly in the absence of total social impairment, cannot justify the assignment of a 100 percent disability rating for any period of the appeal. Finally, on review of the entire record in this case, the November 2012 VA examiner determined that, from 1999 to 2011, the Veteran's PTSD and schizoaffective disorder more likely than not led to "occupational and social impairment with reduced reliability and productivity." Significantly, the examiner did not find for "total occupational and social impairment," as is contemplated for a 100 percent evaluation. For all of these reasons, the assignment of a 100 percent disability rating is not met. In reaching this decision, he Board has specifically considered the Veteran's statements , and those of his family and friends. The Veteran and his family and friends are competent to report the manifestations of his disability. However, competence and credibility are different matters. Here, the record contains volumes of evidence, and to the extent they assert total social and occupational impairment, the lay assertions are generally inconsistent with the more probative findings of the examiners. \ In sum, the assertions are inconsistent with and less probative than the evidence that is provided by the medical professionals. The findings of medical professionals, given their experience, education, and experience, are given more weight than the lay statements. The criteria needed to support higher ratings require medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the Veteran's assertions, and those of his family and friends, are not considered more persuasive than the objective medical findings which, as indicated above, do not support a higher rating than that already assigned. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2013); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). There are no exceptional or unusual factors with regard to the Veteran's PTSD. The threshold factor for extraschedular consideration is a finding that the evidence presents an exceptional or unusual disability picture so that the established criteria for rating the service-connected disability are rendered inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating schedule will apply unless there are "exceptional or unusual" factors which render application of the schedule impractical.") Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, as they address various symptoms and their effect on functioning, and provide for consideration of greater disability and symptoms than currently shown by the evidence. Thus, his disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, referral for extraschedular consideration is not warranted. Finally, the Board must consider whether an inferred claim for a total compensation rating based on individual unemployability has been raised pursuant to Rice v. Shinseki, 22 Vet. App. 447 (2009). In this case, entitlement to a TDIU rating has been developed as an issue on appeal. Indeed, the issue of entitlement to a TDIU rating prior to February 14, 2011 is being remanded, as described hereinbelow. As such, Rice is not applicable. For the foregoing reasons, the Board concludes that the record supports assignment of a 70 percent but no higher rating for the service-connected psychiatric disability. The Board has applied the benefit-of-the doubt doctrine in determining that the criteria for an initial 70 percent rating are met, but finds that the preponderance of the evidence is against assignment of any higher rating. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An increased rating of 70 percent, but no higher, for the service-connected PTSD for the period of the appeal prior to February 14, 2011 is granted, subject to the regulations governing the payment of monetary benefits. REMAND After carefully considering the record, the Board finds that the claim for a TDIU rating prior to February 14, 2011 must be remanded for further development. A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In September 2012, the Board requested an opinion as to the Veteran's employability from his 1999 date of claim, to February 14, 2011. Specifically, in Remand Directive #3(b), the examiner was asked to opine on whether for any period from 1999 to February 14, 2011, the Veteran was precluded from securing or following substantially gainful employment, consistent with his education and occupational experience, by reason of his service-connected disabilities. The examiner was to be informed as to the disabilities for which service connection has been in effect during the period from 1999 to February 14, 2011. The Board stated that at the time of the remand, this included (a) psychiatric disability to include PTSD for the full period; (b) type II diabetes mellitus effective on August 1, 2001 (rated as 20 percent disabling); (c) erectile dysfunction effective on December 12, 2008 (rated as noncompensably disabling; and (d) diabetic retinopathy effective on December 12, 2008 (rated as noncompensably disabling). The examiner was also to be informed that, in 1990, the Veteran had been granted disability benefits by SSA, based primarily on psychiatric disability, and that the SSA disability records, including records of psychiatric treatment and examination, were located toward the bottom of volume 3 of the paper claims file. On VA examination in November 2012, a psychiatrist opined that the Veteran's service-connected PTSD precluded his ability to maintain substantially gainful employment during the relevant time period. The VA examinations for the heart, diabetes mellitus, and PTSD were then conducted in March 2013. In June 2013, another medical opinion was secured. The examiner opined that, from 1999 to 2011, it was less likely than not that the service connected disabilities precluded employment. The examiner determined that the Veteran was capable of sedentary work with little need for supervision during this time. In rendering this opinion, the June 2013 examiner failed to address or discuss two of the Veteran's service-connected disabilities, namely, his retinopathy and erectile dysfunction. The examiner also made no mention of the SSA finding. Additionally, the validity of the report is questionable, as its findings, to include psychiatric findings and findings referable to the service-connected diabetes mellitus, were authored by an appropriate medical specialist. 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). Therefore, the Board finds that an additional medical opinion is necessary to comply with the directives of the September 2012 remand. The Board has considered the positive findings of the November 2012 examiner. However, this opinion is in conflict with other evidence of record. For example, on VA examination in September 2010, the examiner determined that the Veteran's psychiatric condition did not render him unemployable. His treatment regimen created increased stability. He was doing well in his part-time volunteer position. The examiner found the Veteran did not "have a lot of symptoms that commonly interfere[d] with employment, such as he ha[d] no significant problem with anger management. He [got] along with people well. He denied significant problems with excessive anxiety around people or out in public. In fact, he [got] out fine to various errands and trips as noted above, and other activities." On VA examination in March 2008, the examiner determined the Veteran was not unemployable. He was doing well in various areas of his life, including his part-time volunteer job. He got out of the house regularly, and reported enjoying driving to various places and getting along well with the people he dealt with on the particular job. In light of the favorable action taken hereinabove, the Veteran now meets the schedular criteria for a TDIU rating for much of the period between 1999 and 2011. As such, the Board finds that an additional medical opinion must be secured prior to appellate adjudication. Accordingly, this remaining matter is REMANDED to the RO for the following action: 1. The RO should take all indicated action to forward the Veteran's claims file to an appropriate VA medical facility for the purpose of obtaining a retrospective medical opinion as to the following matter: Whether for any period from 1999 to February 14, 2011, the Veteran was precluded from securing or following substantially gainful employment, consistent with his education and occupational experience, by reason of his now service-connected disabilities. The medical reviewer must indicate that the claims file was reviewed. The examiner must be informed as to the disabilities for which service connection had been in effect for the period from 1999 to February 14, 2011. At the time of this remand this includes (a) psychiatric disability, to include PTSD, for the full period; (b) type II diabetes mellitus effective on August 1, 2001 (currently rated as 20 percent disabling); (c) erectile dysfunction effective on December 12, 2008 (currently rated as noncompensably disabling; and (d) diabetic retinopathy effective on December 12, 2008 (currently rated as noncompensably disabling). The examiner's opinion must reflect consideration of all of these disabilities. The examiner must address the fact that, in 1990, the Veteran was granted disability benefits by SSA, based primarily on psychiatric disability. The examiner is advised that the SSA disability records are located toward the bottom of volume 3. In rendering the requested opinion, the examiner must attempt to reconcile the conflicting evidence of record on this issue, to include the VA medical opinions of June 2013, November 2012, September 2010, and March 2008. The examiner must be informed that, as the Veteran has been rated as 100 percent disabled due to the service-connected psychiatric disability for the period beginning on February 15, 2011, he or she need not provide a medical opinion for the period from February 15, 2011, forward. The examiner must to provide a FULLY REASONED EXPLANATION for his or her opinions, as a matter of based on his or her clinical experience, medical expertise, and established medical principles. 2. After completing all indicated development, the RO should readjudicate the claim for a TDIU rating prior to February 14, 2011 in light of all the evidence of record. If any benefit sought on appeal remains denied, a fully responsive Supplemental Statement of the Case should be furnished to the Veteran and his representative, and they should be afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs