Citation Nr: 1335665 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 02-02 696 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial disability rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD) prior to March 2, 2005; and in excess of 50 percent thereafter. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Hudson, Associate Counsel INTRODUCTION The Veteran had active military service from September 1969 to April 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in June 2001 by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia, which denied a disability rating greater than 30 percent for service-connected PTSD. In a February 2006 rating decision, the RO granted an increased disability rating to 50 percent effective March 2, 2005, for the Veteran's service-connected PTSD. In June 2007, the Veteran testified before a Decision Review Officer (DRO) at the RO. The hearing transcript is of record. In November 2003, January 2011 and May 2013, the Board remanded the case to the RO for additional evidentiary development. As discussed in more detail below, the Board finds there was substantial compliance with its remand orders and that it may therefore proceed with a determination of the issues on appeal. See Stegall v. West, 11 Vet. App. 268 (1998). The RO continued the denial of the claims as reflected in the August 2013 supplemental statement of the case (SSOC) and returned this matter to the Board for further appellate consideration. A review of the Virtual VA paperless claims processing system reveals additional VA Medical Center (VAMC) and Social Security Administration (SSA) records. The VBMS paperless claims system does not contain any additional documents pertinent to the present appeal. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to March 2, 2005, the Veteran's PTSD most nearly approximated occupational and social impairment with reduced reliability and productivity. 2. From March 2, 2005 to October 21, 2009, the Veteran's PTSD most nearly approximated occupational and social impairment with deficiencies in most areas. 3. Since October 21, 2009, the Veteran's PTSD most nearly approximates occupational and social impairment with reduced reliability and productivity. CONCLUSIONS OF LAW 1. Prior to March 2, 2005, the criteria for an initial disability rating for PTSD of 50 percent, but no higher, have been met. 38 U.S.C.A. § 1155, 5013A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411 (2013). 2. From March 2, 2005 to October 21, 2009, the criteria for an initial disability rating for PTSD of 70 percent, but no higher, have been met. 38 U.S.C.A. § 1155, 5013A, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.130, DC 9411. 3. Since October 21, 2009, the criteria for an initial disability rating for PTSD in excess of 50 percent have not been met. 38 U.S.C.A. § 1155, 5013A, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Compliance with Prior Board Remands The Board observes that this case was previously remanded in November 2003, January 2011 and May 2013. The purpose of the November 2003 remand was to issue the Veteran appropriate notice regarding his PTSD increase rating claim, determine whether the Veteran wanted a hearing before a DRO and to identify and obtain any new medical treatment records. Appropriate notice was provided to the Veteran in August 2005, February 2008, September 2009, and July 2013. A July 2004 statement from the Veteran identified all of his medical treatment occurring at the Huntington VAMC and these records were obtained. The Veteran was afforded a DRO hearing in June 2007. The case was remanded in January 2011 in order to obtain any new psychiatric treatment records from February 2000 to March 2005, a written statement from the individual who represented the Veteran at the June 2007 DRO hearing as to his personal knowledge of the issues on appeal, and a VA medical opinion regarding the nature and severity of the Veteran's PTSD from February 2000 to March 2005. A February 2011 letter to the Veteran requested that the Veteran identify all records of VA and non-VA treatment from February 2000 to March 2005. The Veteran did not respond to the letter. In a February 2011 written statement, the Veteran's prior representative disclosed his personal knowledge of the issues surrounding the Veteran's 2004 withdrawal of his increased rating appeal. The Veteran received a VA PTSD examination in February 2011, wherein the VA examiner discussed the Veteran's various PTSD symptoms from February 2000 to March 2005. The VA examiner opined that based on the lack of treatment records from April 2002 to March 2005, it was not possible to state whether the Veteran's baseline condition had changed significantly over the specified time period. This VA examination was adequate as the examiner considered the entire record, noted the history of the disability, addressed relevant evidence, and provided an explanation for why a definitive opinion could not be rendered. See 38 C.F.R. § 3.159(c)(4); see also Jones v. Shinseki, 23 Vet. App. 382, 389 (2010) (an examiner's conclusion that a diagnosis or etiology opinion is not possible without resort to speculation is a medical conclusion just as much as a firm diagnosis or conclusive opinion, but a bald statement that it would be speculative to render an opinion on etiology or diagnosis is fraught with ambiguity). In May 2013, the Board found it necessary to remand the Veteran's case so the Veteran's treatment records from the Huntington Vet Center could be obtained, the Veteran could authorize release of medical records from the private providers who treated him for PTSD in 1999 and 2000, SSA records could be obtained, TDIU notice could be provided to the Veteran, and the Veteran could state whether or not he desired a hearing at the RO before a DRO. Records from the Huntington Vet Center and the SSA were obtained. A letter was sent to the Veteran in July 2013, requesting identification of the private treatment providers who treated his PTSD in 1999 and 2000 and providing him appropriate notice regarding the TDIU claim. The Veteran did not respond to the July 2013 letter. An August 2013 written statement from the Veteran's representative states that the Veteran does not desire a DRO hearing. It appears there was substantial compliance with the prior remand orders and the Board may continue with its determination. Stegall, 11 Vet. App. at 271; see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). II. VA's Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). To the extent that the benefits sought on appeal are herein granted, the need to ascertain whether full VCAA compliance has been achieved is obviated. This appeal arises from disagreement with the initial evaluation following the grant of service connection. The courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required, and any defect in the notice is not prejudicial. Dunlap v. Nicholson, 21 Vet. App. 112 (2007). However, notice was provided in February 2001, August 2005, February 2008 and September 2009 letters. The Veteran's service treatment records, VA medical treatment records, and private treatment records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Additionally, the Veteran is in receipt of SSA disability benefits and these records have been obtained. 38 C.F.R. § 3.159 (c)(2). The Veteran has not identified, and the record does not otherwise indicate, any additional relevant medical records that have not been obtained and associated with his file. Seven VA examinations have been secured in connection with the current claim. 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). Taken together, the Veteran's June 2000, May 2001, April 2002, March 2008, October 2009, February 2011 and June 2012 VA examinations are sufficient as the VA examiners considered the entire record, noted the history of the disability, addressed relevant evidence, and provided explanations for the opinions stated as well as the medical information necessary to reach a decision. VA's duty to assist with respect to obtaining an examination has been met. 38 C.F.R. § 3.159(c)(4). VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. III. PTSD - Increased Rating Service connection for PTSD was granted by RO action in July 2000, at which time a 30 percent rating was assigned under 38 C.F.R. § 4.130, DC 9411, effective from February 8, 2000. In June 2001, the RO confirmed and continued this rating. By further rating action in February 2006, the RO increased the rating assigned for PTSD from 30 percent to 50 percent effective March 2, 2005. The issue now before the Board is the question of whether an initial rating in excess of 30 percent is assignable for PTSD prior to March 2, 2005 and whether a rating in excess of 50 percent is assignable for PTSD on or after March 2, 2005. The Veteran contends that an increased rating is warranted as he experiences severe symptoms of PTSD. 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. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 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. The veteran's entire history is reviewed when making disability ratings. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where, as here, the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged ratings" is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). As discussed below, the Board concludes that staged ratings are warranted. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA also will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The Veteran's PTSD is currently evaluated as 30 percent disabling from February 8, 2000 to March 2, 2005, and 50 percent disability since March 2, 2005 under DC 9411, in accordance with the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130. Under the general rating formula, a 30 percent rating is warranted for PTSD if it is productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for PTSD if it is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to compete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for PTSD if the veteran exhibits 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 actives; 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. Id. A maximum 100 percent evaluation 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 inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The list of symptoms in the rating formula is not intended to constitute an exhaustive list, but rather show examples of the types and degrees of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) ("DSM-IV"). According to DSM-IV (adopted by VA at 38 C.F.R. §§ 4.125 and 4.126 (2013)), a GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." The Board notes that GAF scores are just one component of the Veteran's disability picture, and that it does not have a "formula" that it follows in assigning evaluations. Rather, the Board considers the Veteran's entire disability picture, including GAF scores. See 38 C.F.R. § 4.126(a). GAF scores ranging from 61 to 70 indicate some mild symptomatology (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, with some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect 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). GAF scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Id. The Board finds that a 50 percent evaluation is warranted prior to March 2, 2005 and a 70 percent evaluation is warranted from March 2, 2005 to October 21, 2009. The Board additionally finds that an evaluation in excess of 50 percent is not warranted for the period beginning October 21, 2009. The Board will explain its reasoning below. Initially, the Board notes that the Veteran has been diagnosed with nonservice-connected alcohol abuse. However, VA is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). None of the Veteran's treating or examining physicians have separated the symptomatology manifested by his alcohol abuse and PTSD. The May 2001 and April 2002 VA examiners specifically stated that the symptomology of the Veteran's PTSD and alcohol abuse overlap. The March 2005 Huntington VAMC doctor found the Veteran's alcohol abuse was a self-medicating strategy for management of his PTSD symptoms of sleep disturbance and anxiety. The March 2008 VA examiner found the Veteran's alcohol abuse was secondary to his PTSD. Therefore, the Board will consider the Veteran's alcohol abuse when determining the appropriate initial rating for service-connected PTSD. Prior to March 2, 2005 The Board finds that the Veteran's PTSD warrants a disability rating of 50 percent prior to March 2, 2005. Turning to the evidence of record, the Veteran's GAF scores ranged from 62 to 52 between June 1999 and April 2002. These scores represent mostly moderate symptoms, reflecting difficulty in social and occupational functioning. In June 2000, the Veteran was afforded a VA psychiatric examination. The examiner noted the Veteran suffers from anxiety, nervousness and sleep disturbances. He is employed full-time as a car salesman and has been selling cars since 1981. The Veteran does not drive on the highway but can drive in city traffic and drove to the VA examination. He lives with his wife of 28 years and has a son. The Veteran began using alcohol at the age of 18 years old and drank quite heavily in the military. He currently drinks five or six beers after work and on his days off. The Veteran stated that alcohol helps him to relax and sleep and when his nerves bother him he drinks more than he should. The Veteran does not participate in church services, does not belong to any veteran organizations, likes to fish but does not get to fish very often. The VA examiner noted the Veteran's December 1999 diagnosis of severe PTSD and treatment by Dr. D. L. P. The Veteran claimed he becomes so anxious he cannot read his own handwriting. He reported some problems with his temper and being snappy with his wife. The Veteran denied suicidal or homicidal ideas. The Veteran was diagnosed with chronic PTSD and alcohol abuse and given a current GAF score of 58 due to the severity and frequency of his PTSD symptoms. The VA examiner stated that over the past year, the Veteran's GAF score was 62. The Veteran sought treatment for his PTSD from the Huntington Vet Center. August 2000 Vet Center treatment records show the Veteran suffering from anxiety, nervousness, memory problems, sleep disturbances, dreams, and problems with his temper. The Veteran averages five to six beers after work. The counselor found the Veteran had an increase in anxiety symptoms, sleep problems, isolating behaviors, loss of interest and dreams. Additionally, the intensity of his symptoms impaired his work performance, including his ability to drive. In September 2000, the Veteran's employer submitted a statement that the Veteran seems to have a severe nervous problem. While the Veteran performs his work to the best of his ability, he sometimes needs help because of his problems. The employer stated that the Veteran's problems are overlooked because he is a Vietnam veteran. The Veteran was provided a second VA PTSD examination in May 2001. The VA examiner found the Veteran had current psychiatric symptoms of anxiety, lightheadedness, sleep disturbance and short temper. The Veteran stated that his nerves affect his writing, driving and talking to people. He has difficulties maintaining sleep. He can be easily aggravated, flying off the handle, cursing and feeling little hitting someone. However, the Veteran refrains from physical violence and tries to hold his anger. He works full-time as a car salesman and lives with his wife of 28 years. The Veteran drinks eight to nine beers at night. His family relations are good. He likes to play golf but last played five years ago. His leisure activities consist of swimming and watching television. The Veteran does not belong to a church but does have friends that come over to his house. The Veteran drove to his VA examination and appeared well-groomed and neatly attired. The Veteran denied suicidal and homicidal ideas. His mood was anxious. The VA examiner diagnosed the Veteran with chronic PTSD and alcohol abuse, which overlap in their symptoms and render the Veteran significantly anxious. The Veteran's GAF score was currently 55, with a score of 58 over the past year. In a September 2001 statement, the Veteran claimed his nervous condition, lack of sleep, inability to deal with his family, and inability to interact in a social setting had increased. He stated he was very disturbed and suffered from mood shifts. A November 2001 statement from the Veteran stated his nerves had gotten worse with age, he gets easily irritated and he had three car wrecks because he is so nervous. In March 2002, the Veteran stated that his condition had gotten worse and his medications were increased. Overall, he felt that his condition was more in line with a 50 percent PTSD disability evaluation. The Veteran underwent a third VA examination in April 2002. He reported nervousness, sleep problems, short temper and anger outbursts. The Veteran was on medication for his PTSD condition. He isolates himself from his family and does not go outside on the weekends when he is not working. He sometimes helps his wife with household activities. The Veteran suffered from bad dreams, but did not recall the content. The Veteran's wife told him that he talks about Vietnam in his sleep. The Veteran experienced increased nervousness and anxiety over the past two years. The Veteran drinks eight to ten beers per night. He has limited his driving at work because of increased anxiety while driving. He has wrecked some cars at work because he has a difficult time controlling his nervousness. The Veteran works full-time as a car salesman and lives with his wife of 29 years. He describes his family relations as okay but isolates more and at times conflicts with his wife. The Veteran used to go fishing, but has not fished for five years and his leisure activities consist mainly of watching television. He has no close friends that come to his home, does not go to church and does not belong to any social organizations. The VA examiner found the Veteran fair in hygiene and grooming, with inadequate eye contact, anxious mood, and good memory. The Veteran's significant anxiety impairs his work performance, including his driving ability. The Veteran was diagnosed with chronic PTSD and alcohol abuse, with these conditions overlapping in their symptoms. The VA examiner assigned a current GAF score of 52, with a score of 55 over the past year. The Veteran continued to seek treatment of his PTSD at the Huntington VAMC. August 2004 records show the Veteran reporting no new problems and feeling well. The diagnosis was PTSD, with the Veteran having some nightmares. He requested a mental health counseling referral. Additionally, the Veteran complained of depression and was prescribed Prozac. There was an assessment of excessive alcohol intake of ten beers a day. In October 2004, an acquaintance of the Veteran submitted a statement wherein he said the Veteran seeks other sales associates to go on test drives with his customers, excuses himself while discussing a sale to go to an employee break area to compose himself, and grimaces when you first speak with him, which seems to be a startle response. See Statement from C. W. B., October 2004. The acquaintance also discussed the Veteran not driving due to his nerves and his wife driving him to and from work. Id. Vet Center treatment records from November 2004 document the Veteran's consumption of alcohol to help him relax and sleep better. The Veteran's chief complaint is nervousness, which he states is beginning to affect his job. He is not able to drive because of his nerves and his wife drives him to and from work. He is not able to test drive with customers and has to take frequent breaks to compose himself when dealing with customers. He also had a bad startle response and sleep problems. The counselor's assessment was PTSD. In February 2005, the Veteran sought mental health treatment at the Huntington VAMC. He complained of worsening PTSD symptoms. Although he was still employed, he gets so nervous when he drives that he has to pull off the road. The Veteran reported that the news about Iraq has created more flashbacks and nightmares. The assessment was PTSD and a PTSD intake was scheduled for March 2005. Additionally, in February 2005, the Veteran went to the Huntington Vet Center for treatment of his PTSD. He stated his symptoms are getting worse. He is nervous when he drives and is not sure how much longer he will be able to drive. He is drinking approximately 12 to 13 beers every night when he gets home from work to help him calm down and sleep. The assessment by the counselor was stable PTSD. From February 8, 2000 to March 2, 2005, the Veteran's GAF scores ranged from 62 to 52, consistent with moderate symptoms and impairment in social and occupational functions. A February 2011 VA examiner reviewed the Veteran's PTSD symptoms from February 2000 to March 2005. He stated that the Veteran's June 2000 GAF score of 58 was the high end of moderate impairment, his May 2001 GAF score of 55 was still in the moderate range and statistically insignificant in its difference from 58 and his April 2002 GAF score of 52 was still in the moderate range and again not statistically significant from the prior 55. Thus, from February 8, 2000 to March 2, 2005, the Veteran's GAF scores have been consistent with a level of occupational and social impairment associated with an increased 50 percent rating. Based on the foregoing, the Veteran's PTSD, from February 8, 2000 to March 2, 2005, resulted in occupational and social impairment with reduce reliability and productivity and difficulty in establishing and maintaining effective work and social relationships. Specifically, the Veteran suffered from persistent anxiety, nervousness, and depression with minimal social interactions. At work he experienced nervousness driving that resulted in three car wrecks and anxiety when speaking with customers. The Veteran was also irritable and can fly off the handle. While the Veteran does not exhibit all of the specific symptoms associated with a 50 percent evaluation in the general rating formula, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442-43. As the evidence shows that the Veteran consistently suffered similar symptoms or effects that cause occupational or social impairment equivalent to a 50 percent rating, a 50 percent evaluation is appropriate from February 8, 2000 to March 2, 2005. Id. at 443; see also Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The Board notes that from February 8, 2000 to March 2, 2005, the overall symptomatology associated with the Veteran's PTSD does not more closely approximate the schedular criteria required for the next higher 70 percent disability rating. The evidence does not show the Veteran experienced suicidal ideation, obsessional rituals which interfere with routine actives, speech intermittently illogical, obscure, or irrelevant, spatial disorientation, or neglect of personal appearance and hygiene. While the record shows that the Veteran had difficulty establishing and maintaining effective social relationships, he was able to maintain the relationship with his wife of 29 years and his adult son. Although the Veteran complained of constant nervousness, it did not affect his ability to function independently, appropriately and effectively, as he was still able to work full-time as a car salesperson. While the Veteran complained of increased irritability and an occasional desire to hit someone, he stated that he exercised impulse control and contained his anger. Although the Veteran experienced nervousness and anxiety at work, he was able to maintain full-time employment. Overall, the Board finds that the Veteran's symptomatology more closely approximates the schedular criteria for the 50 percent disability rating prior to March 2, 2005. From March 2, 2005 to October 21, 2009 From March 2, 2005 to October 21, 2009, the Board finds the Veteran's PTSD warrants a disability rating of 70 percent. During this timeframe, the Veteran's GAF scores ranged from 45 to 47. These scores represent serious symptoms, reflecting serious impairment in social and occupational functioning. The Veteran continued to seek treatment for his PTSD and on March 2, 2005, he underwent a mental health intake interview at the Huntington VAMC. The Veteran was living with his wife of 30 years and his 28 year old son and was employed as a car salesman. The Veteran reported a variety of adjustment problems, including persistent disturbing memories of past traumatic military experiences, dreams that impaired his sleep, and nervousness at work. Any loud noise provoked startle and pronounced shakiness. He was socially isolated and withdrawn and tried to avoid talking about things associated with past traumas. He drank 12 to 14 beers nightly to numb out and enable sleep. Upon mental status examination, the VA examiner found the Veteran appropriately dressed and groomed, cooperative, and with appropriate eye contact. The Veteran was immensely anxious, speech was appropriate but at times his voice was shaky. He was alert without indications of memory impairment, but stated that anxiety was contributing to increased forgetfulness at work. He reported some difficulties with concentration. Judgment was poor at times. Affective tone was dysphoric. The examiner found the Veteran almost globally avoidant of anything that might remind him of past traumatic experiences. He denied suicidal or homicidal ideation. The diagnosis was chronic and severe PTSD and alcohol abuse, representing a self-medicating strategy for management of sleep disturbance and anxiety. The VA examiner assigned the Veteran a GAF score of 45 due to severely debilitating levels of anxiety and depression accompanied by impairment in thinking (concentration, memory and judgment), family role functioning, and serious impairments vocationally and socially. There is no documentation of the Veteran seeking PTSD treatment from March 2, 2005 until March 12, 2008. On March 12, 2008, the Veteran was provided with a VA PTSD examination. The VA examiner reviewed the Veteran's claims file and all available service and VA medical treatment records. The Veteran was found to be a reliable historian. The Veteran reported re-experiencing trauma, avoidance, numbing, arousal, depression and panic symptoms. The Veteran reported drinking 12 to 14 beers nightly in order to reduce his anxiety and induce sleep. The Veteran was employed full time as a car sales representative. However, he had problems fitting in with co-workers and poor efficiency and productivity at work. He reported being married to his wife of 33 years but related problems including emotional distancing, avoidance of social, recreational, and family activities, avoidance of interaction with family members and avoidance of participation in necessary problem-solving. The Veteran engaged in no social or leisure activities. Upon mental status examination, the Veteran was dressed neatly with grooming and hygiene within normal limits. He was attentive, cooperative, and behaviorally appropriate. His attention and concentration was slightly impaired, his immediate, recent and remote recall was intact, but his delayed recall was moderately impaired and his working memory was slightly impaired. The Veteran's judgment and insight was intact. His prevailing mood was nervous, agitated, sad, anxious and depressed with episodes of anger dyscontrol and road rage. There was a history of poor capacity for self-regulation of affect. The Veteran had no suicidal thoughts but vague homicidal ideation when angry, with no specific target, plan, intent or method. The Veteran was found to have paranoid ideation without formal delusions. The Veteran drives, but only locally and will not drive on the interstate. With regard to sleep disturbances, the Veteran takes at least 30 minutes to fall asleep and then wakes up four to five times a night but is able to return to sleep quickly. The Veteran reported symptoms of depression. The VA examiner found the Veteran's PTSD symptoms of difficulties with concentration and memory, nervousness, irritability, and chronic fatigue seriously impacting his performance in the workplace. Socially, the Veteran's impairment is major as he is withdrawn, reclusive, distrusts others, avoids participation in leisure or recreational activities, and has no close friends. Overall, the Veteran was found to have total incapacity in social functioning due to PTSD. The VA examiner diagnosed the Veteran with PTSD, major depressive disorder secondary to PTSD and alcohol abuse secondary to PTSD. The Veteran was assigned a GAF score of 47, indicating serious social and occupational functional impairment. From March 2, 2005 to October 21, 2009, the Veteran's GAF scores ranged from 45 to 47, consistent with serious symptoms and serious impairment in social and occupational functioning. Thus, from March 2, 2005 to October 21, 2009, the Veteran's GAF scores are consistent with a level of occupational and social impairment associated with an increased 70 percent rating. Based on the foregoing, the Veteran's PTSD, from March 2, 2005 to October 21, 2009, resulted in occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, and mood. The Veteran was socially isolated and withdrawn with severely debilitating levels of anxiety and depression. The March 2008 VA examiner found the Veteran totally socially impaired. While the Veteran does not exhibit all of the specific symptoms associated with a 70 percent evaluation in the general rating formula, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442-43. As the evidence shows that the Veteran consistently suffered similar symptoms or effects that cause occupational and social impairment equivalent to a 70 percent rating, a 70 percent evaluation is appropriate from March 2, 2005 to October 21, 2009. Id. at 443; see also Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The Board notes that from March 2, 2005 to October 21, 2009, the overall symptomatology associated with the Veteran's PTSD does not more closely approximate the schedular criteria required for the next higher 100 percent disability rating. The evidence does not show that from March 2, 2005 to October 21, 2009, the Veteran experienced total occupational impairment. While the record shows that the Veteran had an inability to establish and maintain effective social relationships, he continued working full-time as a car sales associate, despite some difficulties at work. Although the Veteran had some memory loss, his immediate, recent and remote recall was intact. He had no gross impairment in thought processes or communication, no persistent hallucinations, no grossly inappropriate behavior, no persistent danger of hurting self or others, no inability to maintain minimal personal hygiene and no disorientation to time or place. While the Veteran had paranoid ideation, he had no formal delusions. Overall, the Board finds that the Veteran's symptomatology more closely approximates the schedular criteria for the 70 percent disability rating from March 2, 2005 to October 21, 2009. Since October 21, 2009 Since October 21, 2009, the Board finds that the Veteran's current PTSD disability rating of 50 percent is appropriate. The evidence of record documents the Veteran's GAF scores ranging from 55 to 65. These scores represent mostly moderate symptoms, reflecting difficulty in social or occupational functioning. On October 21, 2009, the Veteran was afforded a VA psychiatric examination. The examiner reviewed the Veteran's claims file and medical records. The Veteran reported feeling sad, only four hours of sleep per night, frequent military themed dreams, irritability and social isolation although he still goes to a bar with friends a couple of times a week. The Veteran lives with his wife of 35 years, but they often stay in different parts of the house. He sees his 33 year old son and two year old granddaughter once a week and gets along well with his son. He denied having close friends but later acknowledged having one "vet buddy" and going out to a bar for a drink with a couple of guys a couple of times a week. In his spare time, he watches television and reads the newspaper. He drinks daily in the evening, approximately 10 to 12 beers. The VA examiner found the Veteran clean and neatly groomed with unremarkable speech, appropriate, constricted affect, good mood and attention intact. The Veteran has inappropriate behavior as he experiences regular irritability with mild verbal acting out. The Veteran has no panic attacks, no obsessive or ritualistic behaviors and no homicidal or suicidal thoughts. The Veteran's wife had a stroke several months ago and the Veteran does all of the grocery shopping. The Veteran's remote, recent, and immediate memory were normal. The Veteran is currently employed part-time as a car salesman, but has poor social interaction at work. The VA examiner found the Veteran employable from a mental health perspective. Overall, the VA examiner diagnosed the Veteran with chronic PTSD, depressive disorder NOS and alcohol dependence. A GAF score of 55 was assigned to the Veteran's current level of functioning, indicating moderate symptoms and moderate functional impairment. The Veteran underwent his sixth VA mental health examination in February 2011. He reported a depressed mood, fatigue, poor motivation for activity, dislike of small spaces, hyperarousal to unexpected loud noises and diminished degree of attachment. The Veteran also reported generally getting along well with others and discussing military experiences with friends, primarily old buddies from the service. The Veteran continues to live with his wife and they get along alright but they continue to largely stay in different parts of the house. He sees his son and granddaughter weekly and communicates with his son "about every night" and gets along well with him. The Veteran has one good friend, another veteran, and they go out to a bar to drink a couple of times a week. In his leisure time, the Veteran watches television and maintains his property. He reports drinking 12 to 15 beers a night. The VA examiner found the Veteran clean and neatly groomed, cooperative, friendly, with a good mood and a mildly constricted affect. The Veteran suffers from sleep impairment as he wakes up about four times a night and overall only sleeps about four hours. The Veteran was found to have no inappropriate, obsessive or ritualistic behavior, no panic attacks and no homicidal or suicidal thoughts. He has good impulse control and normal remote, recent, and immediate memory. The Veteran is employed part-time as a car salesman and works regularly but less than usual full-time hours due to recent heart problems. The VA examiner diagnosed the Veteran with anxiety disorder NOS and alcohol dependence. A GAF score of 65 was assigned, representing mild symptoms and mild functional impairment associated with his service-connected anxiety. The VA examiner found the Veteran employable from the standpoint of his PTSD. In June 2012, the Veteran was afforded his final VA PTSD examination. The Veteran currently lives with his wife of 37 years but that they argue all the time and do not spend much time together. He visits with his son once a week, visits his sister in Florida three times a year, and has a couple of veteran buddies. The Veteran previously worked as a car salesman but stopped working in November 2011. He reports irritability and drinking approximately ten beers each evening. The VA examiner found the Veteran has a depressed mood, anxiety, suspiciousness and chronic sleep impairment. He has feelings of detachment or estrangement from others and a restricted range of affect. The Veteran experiences intrusive, trauma-related thoughts two to three times per day and experiences some anxiety and depression when the thoughts occur. He has lost interest in shooting pool and golf due to medical concerns. The VA examiner diagnosed the Veteran with chronic PTSD and assigned a GAF score of 61. The Veteran applied for SSA disability benefits. In January 2013, the Veteran was found to be disabled based on a primary diagnosis of peripheral vascular (arterial) disease and a secondary diagnosis of alcohol addiction. See SSA Disability Determination and Transmittal, January 2013. The Veteran was not found to be disabled as a result of his PTSD. From October 21, 2009 to the present, the Veteran's GAF scores ranged from 55 to 65, consistent with moderate symptoms and impairment in social and occupational functions. Since October 21, 2009, the Veteran's GAF scores have been consistent with a level of occupational and social impairment associated with his currently assigned 50 percent PTSD rating. Based on the foregoing, the Veteran's PTSD, since October 21, 2009, has resulted in occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective social relationships. Specifically, the Veteran has a constricted affect, poor social interaction at work, poor motivation for activity and depressed mood. While the Veteran does not exhibit all of the specific symptoms associated with a 50 percent evaluation in the general rating formula, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442-43. As the evidence shows that the Veteran consistently suffered similar symptoms or effects that cause occupational or social impairment equivalent to a 50 percent rating, the currently assigned 50 percent evaluation is appropriate from October 21, 2009 to the present. Id. at 443; see also Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The Board notes that since October 21, 2009, the overall symptomatology associated with the Veteran's PTSD does not more closely approximate the schedular criteria required for the next higher 70 percent disability rating. The evidence does not show that since October 21, 2009, the Veteran experienced suicidal ideation, obsessional rituals which interfere with routine actives, speech intermittently illogical, obscure, or irrelevant, spatial disorientation, or neglect of personal appearance and hygiene. While the record shows that the Veteran has difficulty establishing and maintaining effective social relationships, especially with his wife, he describes a good relationship with his son, weekly visits and almost daily communication with his son, three annual visits to see his sister in Florida, and going to a bar a couple of nights a week with some veteran buddies. Although the Veteran has depression and anxiety with some impaired impulse control, it does not affect his ability to function independently, appropriately and effectively, as he is able to go grocery shopping, maintain his home and spend time with his son and veteran buddies. While the Veteran has not worked since November 2011, the Veteran claims this is due to a heart condition, not his PTSD. Additionally, the February 2011 VA examiner found the Veteran employable from the standpoint of his PTSD. Overall, the Board finds that since October 21, 2009, the Veteran's symptomatology more closely approximates the schedular criteria for the 50 percent disability rating for PTSD. In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court of Appeals for Veterans Claims (Court) has set out a three-part test for determining whether a veteran is entitled to an extra-schedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extra-schedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's disability. 38 C.F.R. §§ 4.130. Prior to March 2, 2005 and since October 21, 2009, the Veteran's PTSD is manifested by symptoms that result in moderate social and occupational impairment. From March 2, 2005 to October 21, 2009, the Veteran's PTSD was manifested by symptoms that resulted in serious social and occupational impairment. These manifestations are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's disability and referral for consideration of extraschedular rating is not warranted. ORDER An initial rating of 50 percent, but no greater, for PTSD is assigned for the period prior to March 2, 2005. An initial rating of 70 percent, but no greater, for PTSD is assigned for the period from March 2, 2005 to October 21, 2009. An initial rating in excess of 50 percent for PTSD since October 21, 2009, is denied. REMAND A remand is necessary for further evidentiary development of the Veteran's TDIU claim. The Veteran contends he is unable to maintain a substantially gainful occupation as a result of his service connected PTSD and heart condition. See, e.g., Veteran's Application for Increased Compensation Based on Unemployability, November 2011. Although the Veteran submitted a claim for entitlement to TDIU in November 2011, no rating decision was ever issued. In the May 2013 Board decision, the issue of TDIU was raised and remanded as part of the Veteran's claim for an increased disability rating for his service-connected PTSD. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Upon remand, no additional evidentiary development of the Veteran's TDIU claim was undertaken. In denying the Veteran's TDIU claim in the August 2013 SSOC, the RO cited to prior VA examinations. However, none of these examinations had considered the combined effect of all of the Veteran's service-connected disabilities on his ability to secure or follow a substantially gainful occupation. Therefore, it is necessary to obtain a pertinent medical opinion as to the effect of all of the Veteran's service connected disabilities on his employability. Additionally, the RO should issue a rating decision on the TDIU claim in response to the Veteran's November 2011 claim for a TDIU. The Veteran is hereby notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of the case, and that the consequences of failing to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2013). Accordingly, the case is REMANDED for the following action: 1. Obtain records of any relevant medical treatment the Veteran has received since August 2013 from the Huntington VAMC and Huntington Vet Center. A response, negative or positive, should be associated with the claims file. 2. After all new medical records have been associated with the claims file, schedule an appropriate VA examination to ascertain whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's service-connected disabilities (PTSD, coronary artery disease status post myocardial infarction and coronary artery bypass grafting surgery, asymmetrical sensorineural hearing loss, tinnitus and chest and leg scars), either singly or taken together, render him unable to secure or follow a substantially gainful occupation. Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to any impairment caused by non-service-connected disabilities. The examiner must provide a comprehensive report including complete rationales for all conclusions reached. Note: if the examiner concludes that the requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why this opinion would be speculative and what, if any, additional evidence would permit such an opinion to be made. 3. After completion of the above, adjudicate the issue of TDIU as raised by the Veteran's November 2011 claim. If additional development is necessary such should be accomplished. A separate rating action should be issued by the AOJ. The appellant should be informed that this new rating action, if unfavorable, will not be before the undersigned unless it is appealed by the appellant to the Board by submitting a notice of disagreement. 4. Additionally, readjudicate the TDIU issue on appeal. If any benefit remains denied, the Veteran and his representative should be provided an SSOC and given an appropriate opportunity to respond. The case should then be returned to the Board for further consideration, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs