Citation Nr: 1335425 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 11-32 366 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to an initial increased rating for posttraumatic stress disorder (PTSD), evaluated as 30 percent disabling for the period prior to December 20, 2012. 2. Entitlement to an initial rating in excess of 30 percent for PTSD for the period from December 20, 2012. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) for the period prior to December 20, 2012. 4. Entitlement to a TDIU for the period from December 20, 2012. REPRESENTATION Appellant represented by: Penelope E. Gronbeck, Esq. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION The Veteran had active service from June 1970 to February 1972. This matter comes to the Board of Veterans' Appeals (Board) from the March 2010 rating decision of the Department of Veterans Affairs (VA) Appeals Management Center (AMC) in Washington, DC. This decision granted the Veteran's claim for service connection for PTSD, and evaluated it as 30 percent disabling effective February 11, 2004. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). A personal hearing was held in September 2011 at the RO in Manchester, New Hampshire before the Decision Review Officer (DRO). The Veteran testified at this hearing, and a transcript of the testimony is in the claims file. During the current appeal, and specifically in July 2013, the Veteran also testified at a videoconference hearing at the RO conducted before the undersigned Veterans Law Judge (VLJ), who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107 (c) (West 2002 & Supp. 2012). A transcript of the testimony has been associated with the Veteran's claims file. The issues of entitlement to an initial increased rating for PTSD, for the period from December 20, 2012, and entitlement to a TDIU for the period from December 20, 2012, are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the period prior to December 20, 2012, the Veteran's PTSD has been productive of sleep impairment, intrusive thoughts, nightmares, hypervigilance, depression, anger problems, avoidant behavior, a flattened affect, difficulty with social interactions, and difficulty in establishing relationships, which have resulted in social impairment with reduced reliability and productivity. However, such symptoms as obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; spatial disorientation; and, neglect of personal appearance and hygiene; and inability to establish and maintain effective relationships have not been shown. 2. For the period prior to December 20, 2012, the Veteran's service-connected disabilities include: PTSD, rated 50 percent disabling; acne, rated 10 percent disabling; tinnitus, rated 10 percent disabling; and bilateral hearing loss rated noncompensably disabling. 3. For the period prior to December 20, 2012, the Veteran's service-connected disabilities are not reasonably shown to be of such nature and severity as to preclude his participation in any regular substantially gainful employment consistent with his educational and occupational background. CONCLUSIONS OF LAW 1. For the period prior to December 20, 2012, the schedular criteria for a rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2013). 2. For the period prior to December 20, 2012, the schedular criteria for TDIU are not met; a TDIU rating is not warranted; referral for extraschedular consideration is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19, 4.25 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107 and 5126; see also 38 C.F.R. §§ 3.102, 3.156(a), and 3.326(a), VA has a duty to notify the claimant of any information and evidence needed to substantiate and complete a claim, and of what part of that evidence is to be provided by the claimant and what part VA will attempt to obtain for the claimant. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The veteran's increased rating claim for PTSD arises from his disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). In addition, the Veteran was sent a letter in January 2011 that provided information as to what evidence was required to substantiate the TDIU claim and of the division of responsibilities between VA and a claimant in developing an appeal. The Board finds that with regard to any late notification that may be applicable to the TDIU claim, there was no prejudice to the Veteran because the Veteran has been given additional time to submit evidence and argument and the matter was most recently readjudicated in the February 2012 Supplemental Statement of the Case (SSOC). See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The duty to notify has been satisfied. VA has complied with all assistance provisions of VCAA. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). The evidence of record contains service treatment records, VA outpatient treatment records, Social Security Administration (SSA) disability records, and lay statements and hearing testimony from the Veteran. There is no indication of relevant, outstanding records which would support the Veteran's claims. 38 U.S.C.A. § 5103A(c); 38 C.F.R. § 3.159(c)(1)-(3). The Veteran was afforded a VA examination in connection with his PTSD claim in January 2010, the details of which will be discussed below. To that end, 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). As noted below, the Board finds that the VA examination obtained in this case is more than adequate, as it was predicated on a full reading of the treatment records in the Veteran's claims file, a review of his medical history and involved an interview with the Veteran. In addition, the VA examiner reviewed the relevant evidence of record and discussed the pertinent disability and its impact on the Veteran's employability. Therefore, the Board concludes that the January 2010 examination report and opinion are sufficient upon which to base a decision. The RO did not arrange for a VA examination/opinion as to the TDIU claim decided herein. The Board has considered whether an examination is necessary. However, the evidence did not suggest that the service-connected disabilities were so severe as to preclude employment and the Veteran did not meet the schedular criteria for assignment of TDIU under 38 C.F.R. § 4.16(a). Under the circumstances, an examination was not necessary. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome here, the Board finds that any such failure is harmless. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Analysis Initial Increased Rating for PTSD Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Turning to the rating criteria for PTSD, the Board first observes that the symptoms listed in VA's general rating formula for 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 (2002). An evaluation of 30 percent is warranted for PTSD with occupational and social impairment with occasional decreased in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often, chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. An evaluation of 50 percent is warranted for PTSD with occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. See Id. A 70 percent evaluation is warranted for PTSD with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. See Id. A 100 percent evaluation is warranted for PTSD with total occupational and social impairment, due to symptoms such as the following: 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. See Id. For purposes of considering the evidence in connection with the PTSD issue, the Board notes that the Global Assessment of Functioning (GAF) scale is a scale from 0 to 100, reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) ("DSM-IV") (100 representing superior functioning in a wide range of activities and no psychiatric symptoms). See also 38 C.F.R. §§ 4.125, 4.126, 4.130. A GAF score of 31-40 indicates some impairment in reality testing or communications or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A GAF of 41-50 denotes serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning. A GAF of 51-60 denotes moderate symptoms (e.g. flat affect, circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). A GAF of 61-70 denotes 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 record includes the May 2005 private evaluation report, the January 2010 VA examination report, VA outpatient treatment records, and lay statements and testimony from the Veteran. All of these records have been reviewed by the Board, although they will not all be discussed in assessing the rating assigned to the Veteran's PTSD. The Board finds that in this case, the clinical evidence more closely assesses the Veteran's occupational and social impairment around the 50 percent rating. In this regard, the Veteran underwent a private evaluation with a clinical psychologist, T.A., Ph.D., in May 2005. He has also received ongoing psychiatric treatment at the VA Medical Center (VAMC) in Manchester, New Hampshire and was afforded a VA psychiatric examination in January 2010. Throughout the course of the appeal, the Veteran's PTSD symptoms have included impaired memory, sleep disturbances, flashbacks, social isolation, anger, irritability, and emotional restriction. Initially, the Board observes that the record on appeal demonstrates that, in addition to the Veteran's service-connected PTSD, he has also been diagnosed with recurrent major depression; panic disorder with agoraphobia; primary insomnia; and anxiety disorder not otherwise specified (NOS), with obsessive feature. See May 2005 private evaluation report. However, service-connection has not been established for these disorders and it is unclear from the May 2005 report and subsequent VA medical records whether or not symptoms of these disorders are intertwined with his PTSD. The Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102 (2008); Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so). Accordingly, the Board will consider the psychiatric symptoms as depicted by the evidence as a whole in rating the service-connected PTSD unless clearly attributed to the other nonservice connected disorders. During the May 2005 evaluation, the Veteran described his pre-military and military history as well as post-military background and commented that for the first ten to twelve years after returning to the United States, the war "consumed [his] mind all the time." When describing his current symptoms, the Veteran stated that he "obsess[es] over things, over and over and over again" and feels as though he is "stuck in this negative thinking." The Veteran also reported to feel angry a great deal of the time, and stated that he yells at things, to include inanimate objects, because he feels "pissed off all the time." In addition, the Veteran also reported to experience "severe sleep disruption with poor sleep" and stated that he has 'no good dreams' but rather 'stupid nightmares.' According to the Veteran, he experiences significant difficulties with memory and concentration, as he has a difficult time remembering things that have occurred and "always feel[s] like [he's] forgetting something." Dr. A. noted that the Veteran had a difficult time staying focused on the task at hand, and would often drift off into commenting on other issues and symptoms. The Veteran himself described his concentration as "erratic" and noted that he often drifts off in the middle of reading, doing paperwork or writing something. Dr. A. noted that the Veteran struggled when performing the Serial Sevens test and specifically commented that the Veteran experienced "much uncertainty" when finishing the last half of the series. Dr. A. also noted that the Veteran presented with a significant mood disorder. According to the Veteran, although he tries not to feel depressed, he could not recall the last time he felt happy. With regard to his social support system, the Veteran indicated that most of his close friends had passed away and the ones who were still alive did not live near him. He further stated that he bought his home three years prior but had only invited one person over so far. According to the Veteran, he preferred to stay at home, and in fact, has a difficult time leaving his home. The Veteran explained that, at times "it takes everything [he has] to get out of the house" and "the only thing that keeps [him] going to work is [the] fear of being homeless." According to Dr. A., the Veteran described the classic symptoms of PTSD, to include emotional numbing, intrusive experiences, hyperalertness, psychophysiological hyperarousal, social alienation and isolation. Dr. A. also noted that the Veteran has become less able to function in the world and has coped with his PTSD by trying to ignore it. Despite these efforts, Dr. A. observed that the Veteran experiences suicidal ideation and is coping with a serious panic disorder by forcing himself to continue going to work every day. Based on her evaluation of the Veteran, Dr. A. diagnosed the Veteran with PTSD and assigned him a Global Assessment of Functioning (GAF) score of 40. A January 2007 VA outpatient treatment report reflects a negative PTSD screen. Over the past month, the Veteran denied nightmares, feeling on guard or easily startled, detachment, or depression. In a letter dated in November 2009, the Veteran's Readjustment Counseling Therapist, A.P., M.Ed., noted that the Veteran was referred to the Vet Center, by his then representative, for PTSD assessment and counseling in April 2004. According to A.P., he and the Veteran met a total of six times from April 2004 to June 2005. [The Board notes that this letter actually reflects that he and the Veteran met between April 2009 and June 2005. However, the Board concludes that the listed date of 2009 is a typographical error since A.P. indicated that he first met with the Veteran in April 2004 and last met with him in June 2005.] According to A.P., during these sessions, the Veteran reported to experience angry outbursts, road rage incidents, agitation, isolation and trouble staying focused, in addition to feeling emotionally shut down. The Veteran was afforded a VA psychiatric examination in January 2010, at which time he described his current symptoms and reported to experience impaired sleep, frustration, and bad dreams. With respect to his life after service, the Veteran reported that he had been married and divorced once. According to the Veteran, his marriage ended twenty-five years prior partially because he "was screwed up" and partially due to his ex-wife's behavior. The Veteran reported to have one daughter from that relationship with whom he maintains a good relationship. The Veteran also stated that he currently lives alone but does have a female friend who he described as "sort of a girlfriend." With respect to his current occupation, the Veteran stated that he had been working as a truck driver for the last ten years, and prior to getting laid off two years prior, he had been working as a truck driver for a company responsible for 'hauling mail.' According to the Veteran, he was currently not receiving psychiatric treatment or counseling because these treatment visits made him feel worse. Upon conducting a mental evaluation of the Veteran, the examiner described the Veteran's mood as depressed and anxious, his speech as "slow, hesitant and monotonous" and his affect as flat. The examiner also noted that while the Veteran's thought process was slow and circumstantial, he did not exhibit any obsessional or delusional thoughts, and he denied any suicidal or homicidal ideation in the past year. The Veteran reported to get five hours of sleep every night, and stated that he wakes up at least three times a night due to nightmares. According to the Veteran, he thinks about the trauma he experienced in Vietnam "everyday" and these memories intrude upon his thought process and scare him more now than they ever did then. The Veteran went on to describe himself as numb inside, and stated that he has been described as an emotionally distant person. According to the Veteran, he experiences nightmares five to seven nights a week. The examiner noted that the Veteran exhibited all the symptoms of hypervigilance in that he startled easily, was bothered by loud noises, and still kept guns in his house. Based on his discussion with, and evaluation of the Veteran, the examiner diagnosed the Veteran with PTSD and assigned him a GAF score of 55. According to the examiner, the Veteran's GAF score was commensurate with the moderate symptomatology range due to the fact that he isolates himself, does not have any friends and picked a career where he would work alone. According to the examiner, the Veteran's PTSD symptoms mildly to moderately interfere with his employment functioning and moderately-to-seriously interfere with his social functioning. During a July 2010 VA treatment visit, the Veteran asserted that his area of greatest concern, when it came to his PTSD symptoms, was his ability to manage his anger reactivity. The Veteran also reported to experience impaired sleep with multiple awakenings and described a worsening of his PTSD-related symptoms during the past two to three years. With the exception of occasional contact with his ex-wife and daughter, and seeing his current girlfriend on a weekly basis, the Veteran described himself as a socially withdrawn and distrustful person. He also stated that he had been unemployed since January of the past year. At an October 2010 VA treatment visit, the Veteran reported that he had not been doing well for the past few days. He complained of difficulty sleeping, and reported to feel easily angered and irritable. The treatment provider increased the dosage for the Veteran's psychiatric medication to help improve his mood and suggested that he return to the clinic in 2 months for a follow-up visit. In a September 2011 statement, the Veteran's ex-wife, M.P., described the Veteran's unpredictable behavior during their short marriage, and listed various incidents wherein the Veteran acted erratically as a result of flashbacks he was experiencing. In a statement dated in September 2011, the Veteran's daughter, M.N., described her father as someone who had always kept to himself and lived alone since he and her mother separated. Based on her recollection, her parents separated due to what her mother described as her inability to handle her father's "crazy and dangerous delusions," and her father had lived alone since their separation. According to M.N., for as long as she could remember, her father did not have any close friends, had not been involved in any significant relationships, and rarely left his home. She stated that in the last several years, there had been an even greater decline in the amount of time he spent outside of the house. According to M.N., her father was not someone who trusted very easily, but he was someone who was easily provoked, and whenever he did venture outside the house, she believed there would be some type of incident or altercation. M.N. further noted that one of the reasons her father chose to stay at home a majority of the time was to protect his home. She then went on to describe the multitude of home-made "security systems" the Veteran utilized to keep his area safe. According to the M.N., she has been the only person to have a significant relationship with her father for the past thirty years. During the September 2011 hearing before the Decision Review Officer (DRO), the Veteran testified that he tried seeking mental help several years ago, but this only made him feel worse than before. See September 2011 Hearing Transcript (T.), p. 4. The Veteran stated that he currently tries to maintain his treatment visits at the Manchester VAMC but has problems with the long drives back and forth from the treatment facility due to his continuous road rage. See T., pp. 5-6. The Veteran also attributed any problems within this previous marriage to his PTSD symptoms and stated that he had not worked in nearly two years and was laid off from his last job due to the fact that he was always getting into disagreements with his supervisors. See T. pp. 6-9. The Board notes that the Veteran's Social Security Administration (SSA) records have since been obtained and associated with his claims file. In the July 2012 Function Report for Third Party Adults, the Veteran's daughter described how the Veteran's PTSD has deteriorated throughout the years. According to M.N., the Veteran experiences a disrupted sleep pattern, suffers from ongoing nightmares and rarely goes beyond the parameter of his yard if he ventures outside his house. The Board finds that in this case, the clinical evidence more closely approximates the level of occupational and social impairment contemplated by a 50 percent rating. 38 C.F.R. § 4.7. Throughout the course of the appeal, the Veteran's PTSD has been manifested by impaired sleep, nightmares, irritability, intrusive thoughts, flat affect, an isolative nature and avoidant behavior which has resulted in no friendships and very few relationships outside of those he shares with a few family members. Indeed, the evidence shows that the Veteran has experienced difficulty establishing and maintaining effective relationships. The record reflects that his first and only marriage was a tumultuous one which ended after one or two years. The Veteran has not re-married since, and although he has a girlfriend, who he reportedly sees on weekly basis, he has not been able to create or maintain any additional interpersonal relationships with people outside of his immediate family. At the January 2010 VA examination, the Veteran stated that he prefers to be alone because people tend to irritate him, and other than occasional contact with his ex-wife and daughter, he isolates himself and has no friends. Furthermore, the January 2010 VA examiner described the Veteran's symptoms, to include his ongoing nightmares, emotional restriction, and hypervigilance, as moderate in nature and concluded that these symptoms moderately-to-seriously interfere with his social functioning. In the March 2010 VA addendum report, it was noted that the Veteran had lived in New Hampshire for eight years and had not made any friends during that time. In the September 2011 statement, the Veteran's daughter asserted that she was the only person to maintain a significant relationship with her father for the last thirty years. While some of his more recent VA treatment records dated in July 2010 and October 2010, show some level of improvement in the Veteran's overall condition, the May 2005 private evaluation report, the January 2010 VA examiners' findings concerning the Veteran's symptoms, the GAF scores assigned ranging from 40-55, and the most recent statements from the Veteran as well as his ex-wife and daughter, correspond more nearly to the rating criteria for occupational and social impairment indicative of the 50 percent disability rating. In particular, the Board takes note of the May 2005 treatment report, wherein Dr. A. described the general picture exhibited by the Veteran as "one of significant deterioration in functioning" and noted that the Veteran was becoming less able to function in the world. Dr. A. also took note of assertions made by the Veteran expressing how difficult it was for him to leave his home, and noted that while the Veteran did not know what a panic attack was, he did describe thirty years of "[s]harp pains in his chest and head" - a sensation he likened to having a heart attack. According to Dr. A., the Veteran also reported that his PTSD symptoms, to include his ability to concentrate, remember and contain the irritability, were worsening. Additionally, in the July 2012 Function Report by a Third Party Adult, the Veteran's daughter noted that the Veteran stopped partaking in activities he once enjoyed, such as fishing and hunting, and was no longer visiting her as often as before, as a result of his worsening psychiatric symptoms. According to M.N., the Veteran has problems getting along with family members, friends and neighbors due to his short-tempered and suspicious nature. The Veteran was assigned a GAF score of 62 during his July 2010 VA psychiatric assessment, which is indicative of some impairment in social, occupational or school functioning. The October 2010 VA treatment report which reveals a GAF score of 64 which reflects that the Veteran suffers from mild symptoms. However, the Veteran was assigned a GAF score of 55 at the January 2010 VA examination. While the GAF scores assigned during the VA treatment visits were based on preliminary assessments of the Veteran, the GAF score assigned on VA examination was based on a more thorough psychiatric evaluation which not only included an interview of the Veteran but was also predicated on a review of his claims file as well as a fully comprehensive mental evaluation. Thus, the more persuasive GAF score for this period range denotes moderate symptoms or impairment in social, occupational or school functioning. The Board finds that the GAF score indicating more moderate symptoms are more consistent with the medical evidence of record. Again, resolving all reasonable doubt in the Veteran's favor, the Board finds that the assignment of a 50 percent evaluation is warranted. However, even though a higher initial rating is warranted, the evidence of record does not reflect symptomatology of PTSD that would meet the criteria for a rating in excess of 50 percent for any period of time during the pendency of this claim. The evidence does not reflect that the Veteran has occupational and social impairment with deficiencies in most areas. The record establishes that the Veteran maintained a steady relationship with some of his family members as well as with his current girlfriend. In addition, the Veteran continued to perform his activities of daily living independently and consistently maintained his personal appearance and hygiene to a socially acceptable level, without any indication of grossly inappropriate behavior. On interview, the Veteran demonstrated no obsessional or delusional thought and was oriented as to person, place and time. Additionally, the January 2010 VA examiner noted that the Veteran's ability for abstract and insightful thinking was within the normal range, and further described the Veteran's common sense, reasoning and judgment, as well as his moral and ethical thinking, to be within normal limits. While the Veteran reported to experience suicidal ideation at the May 2005 evaluation, these episodes appear to be isolated to this particular time. Indeed, the Veteran denied experiencing any suicidal or homicidal ideation during the more recent VA treatment visits, and the more recent VA examination. The Veteran was assigned a GAF score of 40 at the May 2005 evaluation. However, regardless of the GAF score assigned, that score must be considered in light of the actual symptoms of the Veteran's disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a)(2013). Notably, the evidence does not reflect such symptoms as obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; or an inability to establish and maintain effective relationships, as evidenced by the fact that the Veteran became more alert and his thought process more organized throughout the evaluation; and in light of the fact that he was able to complete the Serial Sevens correctly despite his initial struggles. This was also evidenced by the fact that the Veteran continues to do his own cooking, cleaning and grocery shopping, and has maintained a strong and consistent relationship with his daughter. The Board therefore finds that the actual symptoms reflected in the treatment records and VA examination report are more probative than the GAF score of 40 in terms of evidentiary value. Accordingly, the Board finds in the instant case that the Veteran's more moderate underlying symptomatology as described by the medical and lay evidence of record is more compatible with the assignment of GAF scores in the 51 to 60 range. As such, a higher rating of 70 percent is not warranted. Further, the evidence does not reflect even more serious symptoms, such as persistent delusions or hallucinations or persistent danger of hurting self or others, to warrant a rating of 100 percent. In light of the aforementioned evidence and with the application of the benefit of the doubt in the Veteran's favor, the Board finds that for the period prior to December 20, 2012, the Veteran's service-connected psychiatric disability picture more nearly approximates the criteria for a 50 percent evaluation under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411 due to occupational and social impairment with deficiencies in most areas. 38 C.F.R. § 4.7 (2013). The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where schedular evaluations are found to be inadequate. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which would render application of the schedule impractical. Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulations, an extraschedular disability rating is warranted upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular scheduler standards. 38 C.F.R. § 3.321(b)(1) (2013); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-116 (2008), the Court set forth a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the Veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the Veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is, whether the Veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA 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 evidence of record does not reflect that the Veteran's PTSD, is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the disability outside the usual rating criteria. The rating criteria for this disability contemplate his symptoms, and there are no symptoms left uncompensated or unaccounted for by the assignment of a schedular rating. As such, the threshold issue under Thun is not met, and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. In short, this service-connected disability does not present such an exceptional or unusual disability picture as to render impractical the application of the regular scheduler standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2013). Referral of this issue to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. TDIU Awards of TDIU are governed, in part, by 38 C.F.R. § 4.16(a) (2013). Under that regulation, total disability ratings for compensation can be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities: provided that, if there is only one such disability, the disability must be ratable at 60% or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40% or more, and sufficient additional disability to bring the combined rating to 70% or more. See also 38 C.F.R. §§ 3.340, 3.341 (2013). Furthermore, it is the policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service connected disability shall be rated totally disabled. 38 C.F.R. § 4.16(b). Thus, if a veteran fails to meet the applicable percentage standards enunciated in 38 C.F.R. § 4.16(a), an extra-schedular rating is for consideration where the veteran is unemployable due to service connected disability. 38 C.F.R. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Thus, the Board may not consider the effects of the Veteran's nonservice-connected disabilities on his ability to function. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran is service-connected for PTSD, which as determined above, has been evaluated as 50 percent disabling. Service connection is also in effect for acne, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling; and bilateral hearing loss, rated as noncompensably disabling. The current combined evaluation for the Veteran's service-connected disabilities is 60 percent. See 38 C.F.R. § 4.25 (2013). Thus, the Veteran does not meet the schedular requirements for a total disability rating based on individual unemployability due to service-connected disabilities under 38 C.F.R. § 4.16(a). With regard to whether the Veteran is entitled to TDIU pursuant to 38 C.F.R. § 4.16(b), the Board has no authority to award TDIU under § 4.16(b) in the first instance. Rather, the rating board must submit to the Director, Compensation and Pension Service for extraschedular consideration all cases of Veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in § 4.16(a). Bowling v. Principi, 15 Vet. App. 1, 10 (2001). The Veteran contends that his service-connected disabilities prevent him from seeking, gaining, and maintaining meaningful, gainful employment. However, the Board finds that the preponderance of the evidence is against a finding that his service-connected disabilities, alone, preclude his participating in all forms of regular substantially gainful employment; therefore referral for extraschedular consideration is not warranted. As previously discussed above, during the May 2005 evaluation, the Veteran described the difficulties he experienced leaving his home and stated that the only thing that made him continue going to work was the fear of being homeless. At the January 2010 VA psychiatric examination, the Veteran stated that he had been working as a truck driver for the past ten years, and for the past two years, he had worked as a truck driver for a company responsible for "hauling mail." According to the Veteran, he was laid off from this job two weeks prior and was hoping to receive unemployment benefits as a result. Based on his evaluation of the Veteran, the examiner determined that the Veteran's PTSD symptoms "mildly to moderately" interfered with his employment functioning and resulted in "occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to signs and symptoms of generally satisfactorily functioning, routine behavior, self care and normal conversation." In his May 2011 Application for Increased Compensation Based on Unemployability, the Veteran listed his prior employers for the past five or six years, and noted that he had always worked as a truck driver for various companies throughout the years. According to the Veteran, he has not attempted to obtain employment since becoming too disabled to work in January 2010. The Veteran attributes this decision to his road rage, his desire not to leave his house, and his anger towards people in general. In a July 2011 statement, the Veteran asserted that he had not worked in over a year and half as he had a problem getting along with the people he had to work for. According to the Veteran, dealing with these types of people made him very angry and caused him to experiences constant headaches. The Veteran also attributed his inability to work to the fact that he preferred not to leave his home, as he had proper security measures and means of protection at home - something he does not have when outdoors. During his September 2011 hearing, the Veteran testified that he was laid off from his last employer due to the fact that he did not get along with the supervisor and was always getting into disagreements with the owner of the company. See T., p. 8. According to the Veteran, he did not agree with the way either of these individuals handled matters and would let them know when he disagreed with their approach. Based on the Veteran's testimony, this "pissed them off" and they did not get along very well as a result. See T., p. 9. A review of SSA records is clear for any objective medical evidence indicating that the Veteran is unable to obtain or maintain employment as a result of his service-connected PTSD. In the Function Report submitted by a Third Party Adult, the Veteran's daughter attested to the fact that her father experiences extreme difficulty holding onto a job. According to M.N., her father has trouble with organization and interpersonal skills and is a highly suspicious individual which makes it difficult for him to leave his home. When asked whether the Veteran had ever been fired or laid off from a job, M.N. indicated that he had and explained that the Veteran had been fired for insubordination, losing his temper, and arguing with his superiors. Despite these assertions, the July 2012 SSA Disability Determination and Transmittal sheet reflects that the Veteran had a primary diagnosis of disorders of muscle, ligament and fascia and a secondary diagnosis of hyperlipedemia. As such, the Veteran is not receiving SSA disability benefits due to his service-connected PTSD. The Board finds that for the period prior to December 20, 2012, there are other nonservice-connected disabilities which appear to impact the Veteran's employability. While the Veteran's service-connected PTSD may impact negatively upon his employability, his service-connected disabilities [PTSD, tinnitus, acne and bilateral hearing loss] do not preclude his participation in substantially gainful occupation. Significantly, although the January 2010 VA examiner opined that the Veteran's service-connected PTSD "mildly to moderately interfere[d] with [the Veteran's] employment functioning. . ." he did not assert that said disorder precluded the Veteran from continuing and maintaining full time employment. Although Dr. A. noted that the Veteran's PTSD can cause major impairment with respect to several areas, to include his work, she did not find that the Veteran was unable to obtain or maintain substantially gainful employment as a result of said disorder. Indeed, it appears as though Dr. A. attributed any resulting impairment in the Veteran's work, family relations, or mood to the Veteran's PTSD in conjunction with his multiple nonservice-connected disorders. A review of the objective medical evidence of record is clear for any evidence indicating that the Veteran's service-connected disabilities preclude his ability to obtain or maintain employment. The fact that the Veteran's PTSD symptoms cause him to experience certain difficulties, to include frustration and anger, while carrying out his occupational duties, does not mean that he is entirely incapable of employment. While it appears that he is currently unemployed, he indicated in the May 2011 application that he has not tried to obtain employment since becoming too disabled to work. Therefore, there is nothing in the record which shows that the Veteran attempted to secure a different type of employment that did not involve driving or interacting with many others, nor is there any evidence that he is unable to obtain or maintain employment due to his service-connected conditions. Absent the minimum percentage requirements for basic eligibility for TDIU pursuant to 38 C.F.R. § 4.16(a) being met, and given the evidence (summarized above) which does not show impairment due to service-connected disability which would preclude a less stressful type of employment, the Board concludes that referral of this matter for extraschedular consideration is not necessary, particularly in light of the January 2010 VA examination report, which clearly does not establish that the Veteran's service-connected disabilities cause him to be unemployable. The preponderance of the evidence is against this claim for entitlement to TDIU for the period before December 20, 2012. Therefore, there is no reasonable doubt to be resolved. The appeal for this matter must be denied. 38 U.S.C.A. § 5107(b), 38 C.F.R. § 4.3. ORDER For the period prior to December 20, 2012, an initial increased rating of 50 percent, but no higher, for the service-connected PTSD is granted, subject to laws and regulations governing the award of monetary benefits. For the period prior to December 20, 2012, entitlement to a total disability rating based upon individual unemployability due to a service-connected disability is denied. REMAND Initial Increased Rating for PTSD During a December 2012 treatment visit with his private psychiatrist, J.N., M.D., the Veteran described a worsening in his PTSD symptoms and reported to experience ongoing flashbacks and nightmares which keep him up for most of the night. The Veteran also reported that recently his anger accelerates to such a degree that it causes him to throw things and punch holes in the wall. He went on to describe his behavior as bizarre and recalled one particular incident wherein he arrived at a business and became so upset because of a locked door that he ended up breaking the door in. According to the Veteran, his girlfriend has become so frightened of his behavior that she does not come over anymore. When asked about his activities of daily living, the Veteran stated that he tends to awaken late in the morning because his nightmares keep him up at night, and he does not get much done during the day due to poor concentration and focus. The Veteran also noted that he often neglects to bathe or shave, and spends much of his day in a bathrobe. According to Dr. N., although the Veteran does not appear to be delusional, he does have frequent hallucinations in the way of flashbacks of Vietnam. Based on his discussion with, and evaluation of, the Veteran, Dr. N. diagnosed the Veteran with PTSD and assigned him a GAF score of 40. According to Dr. N., "[g]iven the Veteran's impaired concentration, persistent hallucinations, grossly inappropriate behavior, plus disturbed activities of daily living including poor maintenance of personal hygiene, plus memory loss, his appropriate rating would be 100 percent." In light of Dr.N's assessment, and the Veteran's reported symptomatology during this time period, the Board has determined that for the period on and after December 20, 2012, the Veteran should be afforded a more current VA examination to assess the severity of his PTSD. In addition, as this matter is being returned for further development, an effort should be made to obtain any medical records pertaining to ongoing treatment the Veteran has received for his psychiatric condition that are not already on file. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency and must be obtained if pertinent). TDIU During the December 2012 evaluation, the Veteran provided his military and post-military history and reported that he worked as a commercial truck driver for many years after service. According to the Veteran, he had been out of the work force for the past two and half years due to the fact that he no longer felt he could drive on account of his road rage, anxiety and his difficulty concentrating. After interviewing and conducting a mental evaluation of the Veteran, Dr. N. determined that in light of the Veteran's PTSD signs and symptoms, he is unable to function in the workplace environment in a manner that can be described as "independent, appropriate, sustainable and effective; and, therefore, his mental condition keeps him from working." Although Dr. N. has provided a medical opinion addressing the Veteran's employability, prior to adjudication of the TDIU issue, the Board finds that further evidentiary development is necessary-to include obtaining a pertinent medical opinion as to the current extent and severity of the Veteran's service-connected PTSD, and the effect of the Veteran's service-connected PTSD on his employability. [In this regard, the Board notes that neither the Veteran, nor Dr. N., have asserted that his other service-connected disabilities-acne (10 percent), tinnitus (10 percent), and bilateral hearing loss (zero percent)--have affected his employability.] Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. Request records of relevant psychiatric treatment that the Veteran may have received since September 2011 at the VAMC in Manchester, New Hampshire. Copies of such records which are available should be associated with the claims folder. 2. AFTER completion of the above, and after all outstanding treatment records have been associated with the claims file, the Veteran should be afforded a VA psychiatric examination to determine the current nature and extent of his service-connected PTSD and to determine the effect, if any, of this disability on his employability. The claims file, including a copy of this REMAND, as well as all records on Virtual VA, must be made available to the examiner for review, and the examination report should reflect that such review was completed. The examiner should identify the nature, frequency, and severity of all current manifestations of PTSD, and specify the degree of occupational or social impairment due to his service-connected PTSD. Examination findings should be reported to allow for evaluation of PTSD under 38 C.F.R. § 4.130, Diagnostic Code 9411. The examiner should also assign a GAF score and provide an explanation of the assigned score. Also, the examiner should specifically opine on the impact of the Veteran's PTSD on his social and industrial activities, including his ability to obtain and to maintain any full-time employment, for the period from December 20, 2012. In offering these opinions, the examiner should take into consideration all the evidence of record, to include medical records as well as the Veteran's competent and credible lay statements. If need be, further testing should be accomplished. A rationale for all opinions expressed must be provided. 3. After completing the above, readjudicate the issue of entitlement to an initial disability rating greater than 50 percent for the service-connected PTSD for the period on and after December 20, 2012 and the issue of entitlement to a TDIU for the period on and after December 20, 2012. If any of the benefits sought on appeal are not granted, the Veteran and his attorney should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. No action is required of the Veteran until he is notified by the RO; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claims. 38 C.F.R. § 3.655 (2013). The Veteran has the right to submit additional evidence and argument on the 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 or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs