Citation Nr: 1334385 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 10-23 297 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUE Entitlement to an initial rating for posttraumatic stress disorder (PTSD), in excess of 10 percent prior to March 30, 2009, in excess of 30 percent disabling from March 30, 2009 through April 15, 2010, in excess of 50 percent disabling from April 16, 2010 through July 8, 2012, and in excess of 70 percent from July 9, 2012. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1964 to May 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. In May 2012, the Board remanded the Veteran's claim for additional development. In a November 2012 rating decision, the RO granted increased disability ratings of 30 percent from March 30, 2009, 50 percent from April 16, 2010, and 70 percent from July 9, 2012. As these ratings are not the maximum ratings available for this disability, the claim remains in appellate status, and the Board has re-characterized the issue to include staged ratings as shown on the title page. See AB v. Brown, 6 Vet. App. 35 (1993); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). FINDINGS OF FACT 1. Prior to July 9, 2012, the Veteran's PTSD was manifested by depression, intrusive thoughts, nightmares, sleep impairment, a restricted range of affect, irritability, exaggerated startle response, suicidal and homicidal ideations, impaired concentration, some impaired judgment, and impaired impulse control, productive of functional impairment comparable to no worse than occupational and social impairment with reduced reliability and productivity. 2. On and after July 9, 2012, the Veteran's PTSD was manifested by severe depression, chronic sleep impairment, nightmares, intrusive thoughts, impaired concentration, flattened affect, irritability, feelings of detachment, exaggerated startle response, impaired impulse control, suicidal and homicidal ideations, danger of hurting self, isolation, impaired memory, and intermittent ability to maintain minimum personal hygiene, productive of functional impairment comparable to total occupational and social impairment. CONCLUSIONS OF LAW 1. Prior to July 9, 2012, the criteria for an initial disability rating of 50 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). 2. On and after July 9, 2012, the criteria for a disability rating of 100 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Duty to Notify Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his 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 VCAA notice 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. VCAA notice should be provided to a claimant before the initial unfavorable decision of the Agency of Original Jurisdiction on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In March 2006, the U.S. Court of Appeals for Veterans Claims (Court) issued its decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court in Dingess/Hartman held that the VCAA notice requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a "service connection" claim. As previously defined by the courts, those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Upon receipt of an application for "service connection," therefore, VA is required 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 the elements of the claim as reasonably contemplated by the application. This includes notice that a disability rating and/or an effective date will be assigned if service connection is awarded. Once service connection has been granted, the context in which the claim initially arose, the claim has been substantiated; therefore, additional VCAA notice under § 5103(a) is not required because the initial intended purpose of the notice has been fulfilled, and any defect in the notice is not prejudicial. Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Rather, thereafter, once a notice of disagreement has been filed, for example contesting a downstream issue such as the initial rating assigned for the disability, only the notice requirements for a rating decision and statement of the case (SOC) described in 38 U.S.C. §§ 5104 and 7105 control as to the further communications with the Veteran, including as to what evidence is necessary to establish a more favorable decision with respect to downstream elements of the claim. 38 C.F.R. § 3.159(b)(3). The RO has provided the Veteran the required SOC discussing the reasons and bases for not assigning a higher initial rating and citing the applicable statutes and regulations. Therefore, the Board finds the Veteran has been informed of what is necessary to achieve higher ratings for the service-connected disability at issue. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton, 9 Vet. App. 553 (1996). Duty to Assist With regard to the duty to assist, the Veteran's claims file contains service treatment records, VA examination reports, VA treatment records, identified private treatment records, and records from the Social Security Administration (SSA). In May 2012, the Board remanded the Veteran's claim for additional development. Specifically, the Board instructed that the RO contact SSA and request a copy of the decision granting disability benefits as well as the medical records upon which the decision was based. The record includes the Veteran's SSA award and the associated documentation. In addition, the Board directed that the RO obtain copies of all VA treatment records for PTSD dated from January 2009 to the present. The record includes VA treatment records dated through January 2013. Finally, the Board directed that the RO schedule the Veteran for a VA psychiatric examination to determine the current severity of his service-connected PTSD. The record indicates the Veteran underwent VA examination in September 2012, and a VA physician provided an addendum opinion in January 2013. 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). In this case, the Board finds the VA examination and addendum opinion adequate as they were predicated on a review of the Veteran's claims file and the results of an adequate and complete physical examination. Additionally, clinical findings pertinent to the applicable criteria for rating the Veteran's service-connected PTSD were provided. Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Accordingly, the Board finds the RO substantially complied with the remand directives. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). As all relevant facts have been properly and sufficiently developed in this appeal, 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 that could substantiate the claim has been obtained. Legal Criteria Disability evaluations are determined by comparing a veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2013). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2013). The primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability following an initial award of service connection for that disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The evaluation must be based on all the evidence that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2013). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV), a global assessment of functioning (GAF) score reflects the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM-IV, American Psychiatric Association (1994), pp. 46-47; 38 C.F.R. §§ 4.125(a), 4.130 (2013). A GAF score of 11-20 indicates some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or some gross impairment in communication (e.g., largely incoherent or mute). A GAF score of 21-30 indicates behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation). A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41-50 indicates serious symptoms (e.g., suicidal ideations, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51-60 represents 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 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. The Veteran's service-connected PTSD has been rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides: A 10 percent disability rating is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent disability rating is warranted 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 disability rating is warranted when the Veteran experiences 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is warranted when the Veteran experiences occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal 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 work-like setting); and inability to establish and maintain effective relationships. A 100 percent disability rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130. VA treatment records in June 2005, July 2006, and January 2008 reflect negative screenings for PTSD. The Veteran submitted a July 2008 private psychological evaluation report from Dr. Anderson in support of his claim. Dr. Anderson found the Veteran described symptoms consistent with the presence of PTSD and depression, as well as a history of significant substance abuse. The Veteran reported that he did not possess a great deal of contact with his wife due to her work schedule, but that they did engage in discussions of their difficulties. The Veteran also reported limited contact, but good relationships, with his two stepchildren. He described symptoms of occasional intrusive thoughts, occasional nightmares, occasional night sweats, and flashbacks. He described a history of intensive effort to avoid conversations and people associated with his traumatic experiences, and he reported feelings of detachment and estrangement. The Veteran also reported a restricted range of affect and anhedonia in the form of social isolation. He demonstrated marked problems with insomnia and reported severe troubles with irritability and angry outbursts. The Veteran described hypervigilance and exaggerated startle responses, significant fatigue and loss of energy, and having a pretty good mood. The Veteran also described feelings of worthlessness and guilt and cognitive difficulties, including the diminished ability to think and indecisiveness. He reported recurrent thoughts of death, to include suicidal ideation, although plans and intent were denied. He also described intermittent homicidal ideation. Dr. Anderson reported that concentration problems were apparent as well as psychomotor retardation. Dr. Anderson also found the Veteran's impulse control appeared to fall below normal limits. His speech was normal, and his form of thought was remarkable for circumstantiality. His thought content was consistent with the presence of suicidal and intermittent homicidal ideations, and specific means for suicide were described. His affect was labile and generally intense but appropriate. He was oriented, and his attention capacities, concentration abilities, and immediate memory abilities appeared to fall below normal limits. The Veteran's insight was within normal limits but his judgment appeared to fall below normal limits. Dr. Anderson diagnosed PTSD and depressive disorder, not otherwise specified, and assigned a GAF score of 39 based on difficulties in multiple areas, to include social functioning, employment functioning, family relationships, judgment-related issues, thinking difficulties, and mood. The record includes a September 2008 questionnaire submitted by the Veteran in connection with his claim for SSA disability benefits. The Veteran reported that he did his own laundry, washed dishes, vacuumed, and went grocery shopping. He also worked one day per week. He stated that his hobbies included watching television and that he visited with his brother and spent time with his wife. He reported that he did not handle stress or changes in routine very well and did not trust other people. The examiner recorded that the Veteran did not have difficulty with understanding, coherency, concentration, or talking during the interview. The record indicates the Veteran was awarded SSA disability benefits based upon disabilities of emphysema and malignant neoplasm of prostate. In January 2009, the Veteran underwent VA examination in connection with his claim. The Veteran reported that his most difficult problems were irritability and having a relatively short fuse as well as increasing difficulty being around too many people, which is why he had enjoyed his former job as a truck driver. He complained of occasional startle reactions and restless sleep. He did not report any other symptoms associated with PTSD. As such, the VA examiner found the Veteran's minimal reports were inconsistent with Dr. Anderson's report; however, they were consistent with his responses on an April 2005 Agent Orange registry examination. The Veteran denied suicidal ideations and reported that he belonged to the Veterans of Foreign Wars of the United States, went to church each week, visited the Vietnam War Memorial every year, and kept up friendships with some of the men he met there. The Veteran was alert and showed no signs of psychosis. He generally spoke in normal tones, and his conversation was generally relevant and coherent. His mood appeared euthymic, and he did not appear to be significantly depressed or manifestly anxious. He presented himself as somewhat easily irritated and as a person who had some deficits in the area of social skills and social interaction. His affect was sluggish and under-responsive but not flattened or blunted. His memory and intellect appeared to be generally intact and of low average. He was not showing any on-going impairment in insight or judgment. The VA examiner diagnosed alcohol dependence, very severe by history, currently in long-term, full remission, and mild intensity PTSD and assigned a GAF score of 70. The VA examiner found the Veteran's PTSD did not appear to have significantly interfered with his ability to maintain occupational involvement and that his subjective distress appeared to be minimal to mild at worst. A March 2009 VA treatment record shows the Veteran reported increased difficulty with irritability, and he described himself as a loner. He reported several days of feeling depressed, trouble falling asleep nearly every day, and feeling tired several days. He stated that he had trouble concentrating and that his problems had made it somewhat difficult to do his work, take care of things at home, and get along with other people. He reported nightmares, avoidance, being on guard, and being easily startled. The Veteran reported having repeated, disturbing thoughts quite a bit, repeated, disturbing dreams of the trauma a moderate amount of time, feeling very upset extremely often about things reminding him of the trauma, and having physical reactions to reminders of the trauma a little bit. He reported a little loss of interest in activities, and he denied feeling distant from people and emotional numbness. He reported irritability, difficulty concentrating, being extremely watchful, and being extremely jumpy and easily startled. He denied suicidal thoughts, and testing revealed mild depression and PTSD. There was no evidence of mania or psychosis, and he appeared cognitively intact. An additional March 2009 VA treatment record shows a diagnosis of alcohol dependence with physiological dependence in sustained full remission and rule out PTSD. The Veteran presented mildly disheveled and was alert, oriented, pleasant, and cooperative. His eye contact was good, and his speech was normal. There was no evidence of agitation, and his mood was okay, with a full range and reactive affect. The Veteran's thoughts were organized and goal-directed. His thought content was negative for paranoia, delusions, obsessions, and compulsions. He denied suicidal thoughts and hallucinations, and his insight and judgment were intact. In the Veteran's April 2009 Notice of Disagreement, he asserted that the January 2009 VA examiner had degraded him, the examination lasted only 20 minutes, and it was not in compliance with the DSM-IV. An April 2010 VA suicide prevention note indicates the Veteran had fleeting thoughts of suicide every four to five months but had no intentions or plans. He agreed to attend PTSD Basic Training classes. In support of his claim, the Veteran submitted a July 2012 psychological evaluation report from Dr. Anderson. The Veteran reported that he had an overall good relationship with his wife and that his social contacts outside of his family included monthly contact with one other individual. The Veteran was easily engaged, extremely pleasant, and cooperative. His impulse control appeared to fall below normal limits, and his speech was normal. His form of thought was remarkable for circumstantiality, and his thought content was consistent with the presence of occasional suicidal ideation. He reported intermittent, impulsive homicidal ideation. The Veteran reported that his mood was probably a little bit depressed, and his affect was stable but somewhat intense. According to Dr. Anderson, perceptual abnormalities consistent with psychosis were not apparent. He was oriented, and his attention capacities fell below normal limits, while his concentration abilities and immediate memory abilities fell within normal limits. His memory was somewhat impaired, his insight fell within normal limits, and his judgment appeared to fall below normal limits. Dr. Anderson assigned the Veteran a GAF score of 39 based on his difficulties in multiple areas, including social functioning, employment functioning, family relationships, judgment-related issues, thinking difficulties, and mood. He described a marked pattern of social isolation and problems with employment functioning involving problems with authority figures. He had comparative isolation from his wife and a history of irritability and angry outbursts in addition to suicidal and homicidal ideations. Dr. Anderson opined that the Veteran's symptoms were severe. An August 2012 suicide prevention note indicates the Veteran had had chronic, intermittent suicidal thoughts since active duty. The VA physician found the Veteran's symptoms of depression were moderate. The Veteran described irritability and a preference to be alone. An additional August 2012 VA treatment record indicates the Veteran was pleasant and he presented no significant changes from previous assessments. He continued to complain of irritability and described himself as having a short fuse. He tended to isolate himself and continued to enjoy riding his motorcycle. He reported chronic insomnia and a history of suicidal thoughts. The Veteran was somewhat disheveled, alert, and oriented. His eye contact was good, and his speech was normal. His mood was described as becoming irritable a lot with a full range and reactive affect. His thoughts were organized and goal-directed, and his insight and judgment were intact. A September 2012 VA treatment record shows the Veteran reported feelings of sadness, discontent, and displeasure. He showed a positive risk for self-harm and reported sleep problems. An additional September 2012 VA treatment record indicates the Veteran's sleep was poor and he had frequent nightmares. He reported that he tended to isolate himself with the exception of attending church once in a while, and he had difficulty being around other people. He reported continued, chronic suicidal ideation. In September 2012, the Veteran underwent additional VA examination in connection with his claim. The Veteran was unkempt, disheveled, and wore tattered clothing. He was alert and oriented, with good contact with reality, and he showed no signs of psychosis. His conversation was generally relevant and coherent but rather short, terse, and mildly defensive. His mood was one of severe depression, and he reported that there were times when he simply felt like giving up. His affect was sluggish and under-responsive to the point of being almost completely flattened. His memory and intellect appeared to be intact, and his insight and judgment were unhampered. The VA examiner assigned a GAF score of 50 and opined that the Veteran's PTSD and associated depression, along with his concerns for his cancer and its concomitants, presented him with occupational and social impairment with deficiencies in almost every area and certainly with regard to work, family relations, thinking, and mood. A January 2013 VA treatment record shows the Veteran reported chronic, fleeting thoughts of suicide but denied any suicidal ideations. He continued to report intrusive thoughts, nightmares approximately twice a week, difficulty being around crowds, avoidance of things reminding him of Vietnam, feelings of detachment and restricted affect, easy irritability and anger, trouble concentrating, and exaggerated startle response. The Veteran was casually dressed with good hygiene, his speech was normal, and his eye contact was good. His mood was okay, and his affect was slightly constricted at times but otherwise of normal intensity and range. His thought process was logical and goal-directed with no flight of ideas or looseness of associations. There was no evidence of suicidal or homicidal ideations, hallucinations, delusions, or other psychotic symptoms. He was alert and oriented, his memory was grossly intact, and his insight and judgment were good. A VA physician provided an addendum opinion in January 2013. The VA physician stated that the Veteran's PTSD was much worse than described in early 2009. The VA physician noted that the Veteran had recurrent and distressing recollections of the trauma and dreams that caused him intense distress. He avoided things that reminded him of the trauma and had trouble being around people. He was also detached and estranged from others, with a very restricted affect. He had difficulties sleeping, was irritable and angry most of the time, had trouble concentrating, and was very easily startled by loud noises. The VA physician opined that the Veteran's symptoms were certainly causing him clinically significant distress in social, emotional/psychological, and occupational functioning. He worked most of his life alone because he could not tolerate being around other people and still was unable to do so. The VA physician found the Veteran's symptoms were interfering with his ability to reach out for treatment. The Veteran was overwhelmed with his symptoms and rarely went out. He spent most of his time at home with his wife, and the VA physician found the Veteran's symptoms were considered to be severe. The VA physician opined that it was at least as likely as not that the Veteran was individually unemployable and unable to obtain and maintain gainful employment due to his service-connected disabilities of PTSD and prostate cancer. The VA physician stated that the Veteran's PTSD remained his biggest service-connected disability and effectively prevented him at present from obtaining and maintaining gainful employment. Prior to July 9, 2012 Given the above record, the Board concludes that prior to July 9, 2012, the evidence demonstrates that the manifestations of the Veteran's PTSD were productive of functional impairment comparable to no worse than occupational and social impairment with reduced reliability and productivity. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.130, Diagnostic Code 9411. Initially, the Board notes that the Veteran experienced symptoms that are not listed in the rating criteria, and as a result, the Board has considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of occupational and social impairment with deficiencies reduced reliability and productivity. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The evidence demonstrates that during this period, the Veteran's PTSD was manifested specifically by depression, intrusive thoughts, nightmares, sleep impairment, a restricted range of affect, irritability, hypervigilance, exaggerated startle response, suicidal and homicidal ideations, impaired concentration, some impaired judgment, and impaired impulse control. The evidence indicates the Veteran had difficulty in establishing and maintaining effective work and social relationships. In July 2008, Dr. Anderson found that due to the Veteran's PTSD symptoms, he had difficulties in multiple areas, to include social functioning, employment functioning, family relationships, judgment-related issues, thinking difficulties, and mood. In January 2009, the VA examiner found the Veteran had some deficits in the areas of social skills and social interaction. Prior to July 9, 2012, Dr. Anderson assigned a GAF score of 39, while the VA physician assigned a GAF score of 70. These scores indicate a range of symptoms causing major impairment in several areas, to some difficulty in social and occupational functioning, but generally functioning pretty well and having some meaningful interpersonal relationships. Here, the Board finds the Veteran's symptoms more closely align with a higher GAF score of 39, although not necessarily that of a score of 70. Specifically, during this period the Veteran reported working one day a week, albeit in a solitary occupation, having good relationships with his two stepchildren, spending time with his brother and his wife, and having friendships with men he met when visiting the Vietnam War Memorial. Furthermore, the VA examiner found the Veteran's PTSD did not appear to have significantly interfered with his ability to maintain occupational involvement. In this respect, the Board is cognizant of the focus of the Rating Schedule on the occupational impairment due to the Veteran's symptoms. Resolving the benefit of the doubt in favor of the Veteran, the Board concludes that the evidence as a whole more nearly approximates the criteria for an initial disability rating of 50 percent prior to July 9, 2012. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411; see Hart v. Mansfield, 21 Vet. App. 505 (2007). However, the Board finds that a rating in excess of 50 percent is not warranted for the Veteran's service-connected PTSD prior to July 9, 2012. The evidence does not show 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; or spatial disorientation. The Board acknowledges Dr. Anderson's finding that the Veteran's PTSD caused difficulties in multiple areas but finds it significant that Dr. Anderson did not describe the severity of those difficulties. In addition, as determined by the VA examiner, the symptoms the Veteran reported to Dr. Anderson are somewhat inconsistent with those shown on the other treatment records during the period at issue. Although the Veteran reported in January 2009 symptoms of irritability, occasional startle reactions, sleep impairment, and difficulty being around too many people, he denied all other symptoms associated with PTSD. In addition, in March 2009 the Veteran reported that his symptoms made it "somewhat difficult" to do his work, take care of things at home, and get along with other people. For these reasons, the Board finds the criteria for a disability rating of 50 percent, but no more, for PTSD have been met prior to July 9, 2012. 38 C.F.R. § 4.130. However, because functional impairment comparable to occupational and social impairment with deficiencies in most areas is not established, the preponderance of the evidence is against the assignment of a 70 percent disability rating. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). On and after July 9, 2012 On and after July 9, 2012, the Veteran's service-connected PTSD is currently rated as 70 percent disabling. To warrant a higher disability rating, the evidence must show functional impairment comparable to total occupational and social impairment. 38 C.F.R. § 4.130. Upon review, the Board concludes that the evidence demonstrates that since July 9, 2012, the manifestations of the Veteran's PTSD were productive of total occupational and social impairment. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.130, Diagnostic Code 9411. Again, the Board has considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of total occupational and social impairment. See Mauerhan, 16 Vet. App. 436 (2002). In this case, the record demonstrates that since July 9, 2012, the Veteran's PTSD was manifested by severe depression, chronic sleep impairment, nightmares, intrusive thoughts, impaired concentration, flattened affect, irritability, feelings of detachment, exaggerated startle response, impaired impulse control, suicidal and homicidal ideations, danger of hurting self, isolation, impaired memory, and intermittent ability to maintain minimum personal hygiene. In July 2012, Dr. Anderson repeated his findings that the Veteran had difficulties in multiple areas and determined that the Veteran's symptoms were severe. In addition, the September 2012 VA examiner opined that the Veteran's PTSD and associated depression, along with his other health concerns, presented him with occupational and social impairment with deficiencies in almost every area. Furthermore, the January 2013 VA physician found the Veteran's symptoms were causing him clinically significant distress in social, emotional, psychological, and occupational functioning. In fact, the January 2013 VA physician opined that it was at least as likely as not that the Veteran was individually unemployable and that his PTSD effectively prevented him at present from obtaining and maintaining gainful employment. In addition, in a March 2013 rating decision, the RO granted entitlement to a TDIU effective July 9, 2012. For these reasons, the Board finds the criteria for a disability rating of 100 percent for PTSD have been met on and after July 9, 2012. 38 C.F.R. § 4.130, Diagnostic Code 9411. Extraschedular Consideration As the Veteran is now receiving the maximum disability rating for PTSD on and after July 9, 2012, there is no need to consider the assignment of an extraschedular rating for that period. As such, the discussion below pertains to the staged rating assigned for PTSD prior to July 9, 2012. Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Here, the Board finds the Veteran's disability picture is not so unusual or exceptional in nature as to render the ratings assigned for this period inadequate. The Veteran's service-connected PTSD is evaluated as a psychiatric disability, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. Thun, 22 Vet. App. at 115; see also 38 C.F.R. § 4.130, Diagnostic Code 9411. Prior to July 9, 2012, the Veteran's PTSD was manifested by depression, intrusive thoughts, nightmares, sleep impairment, a restricted range of affect, irritability, hypervigilance, exaggerated startle response, suicidal and homicidal ideations, impaired concentration, some impaired judgment, and impaired impulse control. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are contemplated by the evaluation assigned for this period. An evaluation in excess of that assigned is provided for certain manifestations of a psychiatric disability, but the medical evidence does not demonstrate that those manifestations are present in this case. Here, the Board finds that the criteria for the evaluation assigned more than reasonably describes the Veteran's disability level and symptomatology during this period, and therefore, the schedular evaluation is adequate, and no referral is required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). Total Disability Rating Based on Individual Unemployability (TDIU) Finally, the Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a TDIU due to service-connected disability, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, a March 2013 rating decision granted entitlement to a TDIU effective from July 9, 2012. As such, the Board must consider whether the issue of entitlement to a TDIU has been raised with regard to the rating period on appeal prior to July 9, 2012 (from July 25, 2008 through July 8, 2012). In this regard, the Board notes that the Veteran was in receipt of a 100 percent disability rating for service-connected prostate cancer from July 25, 2008 to May 31, 2010, and pursuant to this decision, the Veteran is in receipt of a 100 percent schedualar disability rating for PTSD from July 9, 2012. However, VA has a "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008). This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C.A § 1114. See Bradley, 22 Vet. App. 280, 294 (2008) (finding that SMC "benefits are to be accorded when a Veteran becomes eligible without need for a separate claim"). Indeed, as noted in Bradley, VA must consider a TDIU claim despite the existence of a schedular total rating, and award SMC under 38 U.S.C.A. § 1114(s) if VA finds the separate disability supports a TDIU independent of the other 100 percent disability rating. See Bradley, 22 Vet. App. 280, 294 (2008); see also DVA Sum. Op. Gen. Counsel Prec., 75 Fed. Reg. 11229 -04 (March 10, 2010) (withdrawing VAOPGCPREC 6-99, 64 Fed. Reg. 52375 (1999) (the logic of Bradley suggests that, if a Veteran has a schedular total rating for a particular service-connected disability and subsequently claims TDIU for a separate disability, VA must consider the TDIU claim despite the existence of the schedular total rating and award SMC under section 1114(s) if VA finds the separate disability(ies) support a TDIU independent of the other 100 percent disability rating). In a May 2013 informal hearing presentation, the Veteran's representative acknowledged that the RO did not grant entitlement to a TDIU from the initial date of the claim. However, the representative did not assert that the Veteran disagreed with the effective date assigned; rather, the representative focused on the disagreement with the disability ratings assigned for PTSD from the initial date of the claim. In addition, as described above, the evidence does not show that the Veteran has argued that his PTSD rendered him totally unemployable from July 25, 2008 to July 8, 2012. Further, the record does not otherwise reflect that his service-connected PTSD rendered him totally unemployable during this period. Finally, SSA granted disability benefits based on the Veteran's diagnosed emphysema and malignant neoplasm of prostate, and the medical evidence in support of the decision does not show that the Veteran included his PTSD symptoms as part of his claim for disability benefits. Accordingly, the Board concludes that a claim for a TDIU has not been raised with respect to the period prior to July 9, 2012. ORDER Entitlement to a disability rating of 50 percent, but no more, for PTSD is granted prior to July 9, 2012. Entitlement to a disability rating of 100 percent on and after July 9, 2012 is granted. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs