Citation Nr: 1335857 Decision Date: 11/05/13 Archive Date: 11/13/13 DOCKET NO. 09-44 705 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD H. Yoo, Counsel INTRODUCTION The Veteran served on active duty from June 1967 to June 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal from a May 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. In July 2011, the Board remanded the Veteran's appeal, for further development. The Board is satisfied that there has been substantial compliance with the remand directives and the Board may proceed with review. See Stegall v. West, 11 Vet. App. 268 (1998). As a result of the evidence relating to the effect the Veteran's service-connected disability has had on his ability to engage in substantially gainful employment, the Board finds that his increased rating claim includes a claim for TDIU, and that this claim has therefore been added as an additional claim entitled to current appellate review. Rice v. Shinseki, 22 Vet. App. 447 (2009). A review of the Virtual VA paperless claims processing system does not reveal 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. VA will notify the appellant if additional action is required on his part. FINDING OF FACT Throughout the rating period on appeal, it is reasonably shown that the Veteran's PTSD has been manifested by depression, anger outbursts, irritability, recurrent intrusive recollections, emotional distress triggered by trauma-related stimuli, sleeping disturbance with nightmares, flashbacks, anxiety, panic attacks, hypervigilance, exaggerated startle response, mood swings, impaired concentration, social isolation, feeling distant from people, occasional fleeting suicidal ideation, avoidance behaviors, variable mood, and mildly restricted affect, productive of occupational and social impairment comparable to no worse than reduced reliability and productivity. CONCLUSION OF LAW The criteria for an initial rating of 50 percent, but no higher, for PTSD are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.10, 4.126, 4.130, DC 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2013). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). The Veteran was provided VCAA notice in a November 2005 letter. This letter notified the Veteran of what information and evidence is needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. This letter also advised the Veteran of the evidence needed to establish a disability rating and effective date for the claim on appeal. Furthermore, it was sent to the Veteran prior to the rating decision. However, the appeal arises from the initial award of service connection. In Dingess, the United States Court of Appeals for Veterans Claims (Court) held that in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see also Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (section 5103(a) notice is no longer required after service-connection is awarded); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Thus, VA's duty to notify in this case has been satisfied. VA also has a duty to assist the Veteran in the development of the claims. This duty includes assisting the Veteran in the procurement of service treatment records and pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore, appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained the Veteran's service treatment records and VA treatment records. Additionally, the Veteran was provided with VA PTSD examinations in July 2007 and July 2011. With respect to VA examinations, the Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The most recent VA examination was provided in July 2011. The examination report is based on review of the claims file, taking a relevant history from the Veteran, and clinical evaluation of the Veteran. The examination report is adequate; the information provided by the VA examiner is supported by a thorough history, fully reasoned explanations and clinical findings. A new examination is not required as the examiner's opinions are well-supported and the Veteran has not described a worsening in the severity of his PTSD symptoms. Additionally, the Board finds there has been substantial compliance with its July 2011 remand directives. The Board notes that the Court has held that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand). As stated the Veteran was afforded a new VA examination in July 2011. In addition, pursuant to the July 2011 Board remand, the AMC attempted to obtain Social Security Administration (SSA) records. In a response, the AMC was notified that there were no medical records as the Veteran did not file for disability benefits or did apply but no medical records were obtained. The AMC later issued a supplemental statement of the case in June 2012. Based on the foregoing, the Board finds that the AMC substantially complied with the mandates of its remand. See Stegall, supra, (finding that a remand by the Board confers on the claimant the right to compliance with its remand orders). All relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claim decided herein. Essentially, all available evidence necessary to substantiate the claim and reach an accurate rating determination has been obtained. The Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). Importantly, the Board notes that the Veteran is represented in this appeal. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). The Veteran has submitted argument and evidence in support of the appeal. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. Consequently, the duty to notify and assist has been satisfied as to the claim now being finally decided on appeal. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Merits of the Claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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 for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Fenderson v. West, 12 Vet. App. 119, 126-127 (1999). The Veteran was originally granted service connection for PTSD in a May 2008 rating decision. A 30 percent disability rating was assigned effective September 12, 2005, the original date of the Veteran's service connection claim. The Veteran appealed the initial rating assigned, contending that the severity of his PTSD warrants a higher rating. The Veteran's PTSD is currently evaluated under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411. Under such regulations, ratings are assigned according to the manifestation of particular symptoms. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase 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). 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 condition 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). Under the formula, a 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted where there is 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; 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 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In assigning a PTSD disability rating, the Board also considers Global Assessment of Functioning (GAF) scores. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). A GAF score ranging between 31 and 40 is assigned when there is some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family and is unable to work). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A score of 61 to 70 is defined as indicating some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning but generally functioning pretty well, has some meaningful interpersonal relationships. See Carpenter v. Brown, 8 Vet. App. 240, 242-44 (1995). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the appellant. Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When all 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 preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this instance, the Board finds the Veteran's PTSD disability does warrant a rating in excess of 30 percent. According to the evidence of record, the Veteran was treated at the VA Medical Center (VAMC) in March 2005 where a history of depression was noted but that he was stable on medication. The Veteran reported his mood was good and he was pleased with the current dosage. His stressors included his finances. The Veteran denied suicidal thoughts or hallucination. There was no difficulty sleeping. He remained active working 10 to 12 hour days and when there was no work available, he was busy with household repairs. He reported tiring easily after long work days. His appetite was good, had a regular diet and his weight was stable. In April 2005, the Veteran reported nightmares, increased irritability, flashbacks, but denied suicidal thoughts or hallucinations. He stated he will increase his Sertaline to improve mood and was instructed to notify the clinic of any additional problems. In May 2005, the Veteran was diagnosed with PTSD and generalized anxiety disorder. The Veteran's GAF score was 50. In June 2005, the Veteran reported depression and he was not sleeping well. He stated he dreams and would wake 5 to 6 times a night and was tired on arising. He stated he did not feel like going to work. He stated he was married for 20 years and had an adult son. He stated he drinks three beers after work before supper and none afterwards. On weekends he may drink 6 to 8 beers when fishing or cooking out. He stated beer relaxes him after work when he "has answered a thousand questions." He works 12 hours or more a day, seven days a week. He stated he was living alone in a motel. A mental status examination revealed the Veteran was alert and oriented. He had good memory, good eye contact, and no apparent dissociation. He has nightmares of someone chasing him. He gets irritable and has difficulty focusing and concentrating. Short term memory problems were noted. He stated frustration builds and had to let it go. Mild PTSD with sleep deprivation syndrome was confirmed with a GAF score of 51. In July 2005, the Veteran stated he has stopped using Clonazepam and has been sleeping well with Paxil. He stated he slept 8 1/2 hours the night prior and worked 13 hours. The Veteran was described as kempt and calm with a sense of humor. He expressed his job was frustrating. He gets in and out of depressive moods. He was not depressed at the moment. He was mainly angry because of his long hours at work and working seven days a week while his contemporaries were retired. The Veteran did not experience panic, anxiousness, flashbacks, or nightmares. The Veteran was diagnosed with moderate depressive disorder, not otherwise specified, with improvement on medication. The examiner noted the Veteran did not have pattern of symptoms for PTSD. His GAF score was 55. In November 2005, the Veteran again expressed frustration with his job. The Veteran was alert, oriented to all four spheres, and had good memory. He was emotionally responsive appropriately but was agitated when recounting horrific memories. He reported intrusive thoughts that he expects will disturb his sleep with nightmares and waking in panic. He stated he is a workaholic to suppress these memories but since he had to review old records, it has all returned. He was irritable and angry. The Veteran was diagnosed with PTSD and moderate depressive disorder, not otherwise specified. The Veteran's GAF score was 51. According to a February 2006 treatment report from the VAMC, the Veteran stated he could not take Clonazepam because he could not wake up in the morning at normal time. He stated he has been drinking a few beers nightly. The Veteran was described as kempt. The Veteran stated he was laid off as his job was done. He was angry about his circumstances of hard work, little money and has to be away from home. He reported nightmares of Vietnam occurring 2 to 3 times a week. He stated he was irritable when he cannot get his nightmares out of his mind. His diagnosis of PTSD and moderate depressive disorder, not otherwise specified, was confirmed. A GAF score of 48 was noted. In August 2006, the Veteran reported marital problems because of his anger and depression. He reported nightmares, sleep walking, and scaring his family. He also reported sleep deprivation. The examiner noted the Veteran was agitated and angry that he could not get compensation in spite of exemplary service. He was tired and could not work as before. He was stressed regarding his finances. There was no change in his diagnosis and his GAF score was 48. In October 2006, the Veteran reported suffering from intrusive thoughts related to combat trauma, nightmares, depression, flashbacks, and withdrawal. The Veteran has been attending a PTSD support group at the Vet Center and reported that since attending, he has experienced a decrease in trauma related symptoms. The Veteran was still currently employed. In November 2006, the Veteran reported the rain was depressing and only got one day off on Thanksgiving but had to work. He stated his work was "getting to him" and was stressed out over it. He was not sleeping well. He arrived to the appointment neat and clean. He was tired, worried, and demoralized from the grind from having to work under so much stress and was having to work hard to control himself and his anger. He was fearful and phobic but has to work anyways. He has nightmares and wakes in sweat and panic. There was no change in his diagnosis or his GAF score. In July 2007, the Veteran was afforded a VA PTSD examination where it was noted the Veteran was currently taking prescription medication for his mental disorder symptoms. The examiner noted the Veteran's "symptoms of depression, anxiety and [PTSD] are considered frequent and severe. His alcohol dependence is chronic and moderate in severity." The Veteran was currently married to his second wife and has one adult son. He stated that his relationship with his wife was "touch and go" and that they live separately much of the time because he lives in other parts of the state while supervising a pipeline construction. He stated when they are together, he is "touchy" and they argue frequently. He stated he does not communicate well with her. They still sleep together but he sometimes acts out his nightmares and hits her in his sleep. He stated he has no friends and avoids being around people unless he must socialize as part of his job. The Veteran stated he has no hobbies or leisure time interests. He used to go fishing but has lost interest. The Veteran stated he drinks in order to sleep and does not identify any problems due to drinking. The examiner noted the Veteran's current psychosocial functional status was mildly impaired in regard to employment, severely impaired in regard to social/interpersonal relationships, unimpaired with regard to self-care, moderately impaired with regard to physical health, and severely impaired with regard to leisure time pursuits. A psychiatric examination revealed the Veteran's general appearance was clean, neatly groomed and appropriately dressed. He was restless with unremarkable speech. He was cooperative and attentive. His affect was blunted, mood was anxious and depressed, and his attention was easily distracted. He was oriented to person, place and time. His thought process and content were unremarkable. There was no evidence of delusions. The Veteran was able to understand the outcome of behavior and understood he had a problem. There was no hallucination or inappropriate behavior but did have ritualistic behavior, such as checking on his house at night. He has panic attacks as sudden loud noise makes his heart rate increase but resolves in a few minutes. There was no presence of homicidal or suicidal thoughts. He had fair impulse control with no episodes of violence. The Veteran was able to maintain minimum personal hygiene and had no problems with activities of daily living. The Veteran's remote memory was normal but his recent memory was moderately impaired and his immediate memory was mildly impaired. The Veteran was diagnosed with PTSD, dysthymic disorder, alcohol dependence and alcohol-induced mood disorder. The examiner noted the Veteran reported poor appetite, insomnia, low energy or fatigue, low self-esteem, poor concentration, and difficulty making decisions. The Veteran's GAF score was 61. The examiner determined there were no total occupational and social impairments due to PTSD signs and symptoms. There were deficiencies in thinking, family relations, and mood but not with his judgment and work. There was reduced reliability and productivity due to PSD as the Veteran had no recreational interests, friends, and his relationship with his wife was tenuous. According to a March 2008 VA treatment record, the Veteran's behavior was appropriate, motor activity was normal, euthymic mood with congruent affect. His speech was within normal limits and spontaneous. There was no evidence of hallucinations, illusions, delusions, suicidal ideation, or homicidal ideation. The Veteran's thought content was normal and appropriate. He was alert and had fair judgment and insight. The examiner determined his symptoms were serious and causing him problems socially, work and home. He stated he quit his job in February 2008 as he could not handle it anymore. He was currently on Social Security at age 62. He reported nightmares worsening over the past year with increasing irritability and inability to be around others. He stated he uses alcohol as it helps his medication work better. His diagnoses of PTSD and depressive disorder with panic disorder, alcohol abuse (rule out addiction), and tobacco use disorder were confirmed. His GAF score was 55. In April 2008, the Veteran reported 4 hours of nightmares and night sweats nightly. He has decreased appetite and eats only one meal daily in the evening. He reported difficulty in his memory. He was socially isolated. The examiner noted moderate depression, mild psychosis, and severe anxiety but there was no evidence of suicidal or homicidal ideation or intent. The Veteran was dressed appropriately and reddened face and nose was consistent with chronic alcohol use. The Veteran's behavior was anxious, worried, intense, no unusual mannerisms, and motor activity agitated moderately. He was able to interact and exchange information adequately. His eye contact was adequate. The Veteran's mood was fearful, depressed and intense with congruent affect. His speech was spontaneous and somewhat pressured with frequent repetitive comments of the same sentence. His thoughts related to fearful ideas. The Veteran denied hallucination, suicidal and homicidal ideation but expressed illusions triggered by weather conditions of rain or overcast conditions and delusions from worry about fears associated with Vietnam. The Veteran was obsessive and worried about unknown reasons. He was alert but his judgment and insight were poor. There was no change in his diagnoses or his GAF score. In June 2008, the Veteran's behavior was described as appropriate, cooperative and his motor activity was normal. He was anxious with congruent and tense affect. His speech as spontaneous and soft. He had no hallucination, illusions, elusions, suicidal ideation, or homicidal ideation. The Veteran's thought content was normal, he was alert, and his judgment and insight were good. The examiner noted the Veteran was able to make decisions independently and was able to appropriately care for himself. The Veteran was diagnosed with PTSD, dysthymic disorder, alcohol dependence, and alcohol induced mood disorder. His GAF score was 52. In July 2008, the Veteran's face was much less red as the examiner attributed it to less alcohol use. He was not as irritable and expressing situations that cause him distress and anxiety. Otherwise, there was no change since June 2008. His GAF score was 53. In August 2008, the Veteran reported depression, anxiety, obsessions, compulsions, and psychosis/delusions. He had no suicidal and homicidal ideation. The examiner stated the Veteran is not employable as his symptoms place him at risk and harm of danger to himself as well as others around him. The Veteran's condition has worsened over time and rehabilitation to an improved more functional state was not likely. The Veteran was diagnosed with PTSD, nightmare disorder, dysthymic disorder, alcohol dependence without abuse, and secondary alcohol-induced mood disorder was ruled out. His GAF score was 53. In September 2008, the Veteran reported depression, anxiety, and psychosis but denied sleep, mania, obsessions, compulsions, suicidal or homicidal ideation. He continues to experience poor sleep at night. He stated over the past weeks he would get up from bed because he heard the television on but came to find it was not. He stated he hears voices of foreign people but cannot understand what they are saying or where it is coming from. He stated he was worried people were trying to come into his house but it was never the case. His diagnosis and GAF score remained unchanged. In January 2009, the Veteran reported depression and anxiety. He denied mania, obsessions, compulsions, psychosis, suicidal and homicidal ideation. His diagnoses remained the same and his GAF score was 59. In February 2009, the Veteran stated he is experiencing good and bad nights of sleep. He stated he plays solitaire on the computer as it helps him relax. On certain days, he does not want to be around anyone so he goes out to the woods to be alone. The Veteran stated he did not continue to go to the Vet Center as he felt more depressed leaving than when he entered. He was appropriately dressed. In April 2009, the Veteran indicated his alcohol consumption had decreased. He discussed his experiences in Vietnam. The Veteran was appropriately dressed, was in a good mood, and smiling with a congruent affect. He appeared to be well-rested and unshaven. In June 2009, the Veteran described nightmares and stated it helped to discuss it. He was appropriately dressed but was in a tired mood with congruent affect. He did not appear to be well-rested, was unshaven, with intermittent eye contact and was very talkative. In August 2009, the Veteran denied depression, mania, obsessions (compulsions), concentration, hopelessness/helplessness, suicidal ideation, homicidal ideation. He did report sleep problems, anxiety and psychosis. He was alert, not in acute distress, was casually dressed, and hygiene appeared managed independently, effectively, and appropriately. He was appropriate with cooperative behavior. His motor activity was within normal limits without off mannerisms and with good eye contact. His mood was stable and affect was appropriate. His speech was normal and carried on conversation with difficulty. There were no delusions or homicidal and suicidal ideation. The Veteran's thought content was unremarkable as it was intact, logical and coherent. He was alert and oriented and his judgment and insight were intact. The Veteran had impairment in functioning at work, home and socially. His diagnoses remained unchanged and his GAF score was 59. In September 2009, the Veteran stated his depression was better than before but that it had been bad for a couple of days, which stemmed from interactions with friends, who were not drafted to Vietnam, and questioned the Veteran about his military experiences. He stated his wife is now starting to understand him better about the way he sometimes acts. He stated he when he is depressed, he does something alone. He does not like to be around a lot of people. In October 2009, the Veteran stated he was able to go hunting and build a deer stand for a friend. He stated his wife is beginning to "get on [his] nerves." He stated he is sleeping about four to five hours a night. He was in a good mood with nervous affect. He appeared to be well-rested with good eye contact and no hallucinations. In November 2009, the record described the Veteran was appropriately dressed, in a dysthymic mood with an aggravated affect. He was upset about the traffic on his way to this appointment. He appeared to be rested but stated the time change disrupted his sleep pattern. He had good eye contact and was talkative. There were no auditory or visual hallucinations. He denied homicidal and suicidal ideation. In December 2009 and January 2010, the Veteran reported continuing to experience sleep disturbances. He stated he was in a better mood. He had congruent affect with good eye contact and was talkative. There were no auditory or visual hallucinations. The Veteran denied homicidal and suicidal ideation. Records from February 2010 indicate the Veteran was seen on several occasions. His GAF score ranged from 75 to 62. The Veteran denied depression; lack of energy or motivation; mania; obsessions; problems with contraction, focus, and memory; hopelessness/helplessness; suicidal and homicidal ideations; or impaired judgment and insight. He reported anxiety and psychosis. He appeared alert and appropriately dressed. His hygiene appeared managed independently and effectively. He was cooperative and his motor activity was within normal limits. He had appropriate eye contact. He mood was stable, affect was flattened , constricted mood congruent, speech was normal, did not respond to external stimuli, did not have delusions, with no suicidal or homicidal ideation. The Veteran's thought content was unremarkable; he was alert and oriented, and his judgment and insight were intact. In April 2010, the Veteran stated he could not tolerate the large crowd at the funeral home in connection with his sister-in-law's funeral. He reported one nightmare. In May 2010, the Veteran continued to experience nightmares but slept better. He thinks back on his experiences in Vietnam. In both appointments and in June 2010, he denied suicidal ideation. He stated he was in a good mood. He had good eye contact and was talkative. He denied hallucinations. In July 2010, the Veteran was alert and appropriately dressed. His hygiene appeared managed independently and effectively. He was cooperative and his motor activity was within normal limits. He had appropriate eye contact. His mood was stable, affect was flattened, constricted mood congruent, speech was normal, did not respond to external stimuli, did not have delusions, with no suicidal or homicidal ideation. The Veteran's thought content was unremarkable as he was alert and oriented, and his judgment and insight were poor to limited. His symptoms of paranoia, nightmares, and irritability continued. His diagnosis was chronic PTSD, alcohol dependence with noncompliance with treatment recommendations, nightmare disorder, dysthymic disorder, and a GAF score of 60. In September 2010, the Veteran stated he likes to be away from people and was overwhelmed with company. He stated he has been thinking of Vietnam a lot when he gets stressed. The Veteran also reported continued difficulty sleeping. He described his mood as not too good with an anxious affect. He was alert with good eye contact, talkative, with questionable hygiene. There were no hallucinations and no suicidal/homicidal ideations. In October 2010, the Veteran was described as nervous, and presents consistent with past. He was alert, awake and oriented to person, place, time and situation. He was spontaneous, had good eye contact, casually dressed with good hygiene/grooming. His psychomotor skills were normal, purposeful, and coordinated. He was cooperative, thought process was linear, goal-directed and did not have suicidal or homicidal ideation. His speech was normal and judgment and insight were adequate. There was no change in his diagnosis and his GAF score was 60. In November 2010, the Veteran continued to express his inability to cope with large groups of people. He stated he has started joining a group of veterans that lives near him for breakfast. He described his mood as "pretty good." There was no evidence of hallucinations or suicidal ideation. There was no change in December 2010. In March 2011, the Veteran expressed he is becoming less and less tolerable with people. His sleep situation has improved stating, "[l]ately it has been pretty good. It's the opposite of what it was." There was no difference otherwise since November 2010. On April 5, 2011, the Veteran stated he was feeling more depressed experiencing more flashbacks and nightmares. He stated he needed more time to be by himself, such as going fishing and getting away from everybody. He stated he feels more jumpy. Otherwise, there was no difference in his symptoms since November 2010. On April 11, 2011, the Veteran reported he still lives with his wife but does not like crowds and has sleep problems. There was a decrease in nightmares and flashbacks. He has a few friends. He was alert, oriented, appropriately dressed, good eye contact, related well, appropriate mood, denied thoughts of self harm, and expressed willingness to learn. His diagnosis did not change but his GAF score was 60. In May 2011, the Veteran again reported feeling depressed experiencing more flashbacks and nightmares. He stated he does not like to be bothered by people and likes to be alone. He denied suicidal ideation and no hallucinations. His mood was good with anxious affect and was courteous and cooperative. In June and July 2011, the Veteran continued to express sleep disturbances and difficulty staying asleep. There was no difference otherwise since May 2011. In July 2011, the Veteran was afforded a VA PTSD examination where he stated his therapy was helpful. He stated his marriage was intact but that he spends time alone when things are stressful in his marriage. He does not have a close relationship with his children. He stated he has a couple of friends that he occasionally spends time with and enjoys spending time alone. There was no history of suicide attempts or violence. He was casually dressed, his psychomotor skills and speech were unremarkable, he was cooperative, normal affect, and was anxious and dysphoric. He had a short attention span but his orientation was intact to person, place and time. His thought process was rambling and had preoccupation with one or two topics. He was paranoid but understood the outcome of behavior. He had average intelligence and understood he had a problem. The Veteran had sleep impairment. There was no evidence of hallucinations. The Veteran had inappropriate behavior of yelling at his wife and losing his temper with people who come to visit him. There was no evidence of obsessive or ritualistic behavior. The Veteran did experience mild to severe panic attacks daily. There was no presence of homicidal thoughts but admitted to suicidal thoughts although there was no plan or intent. The Veteran's impulse control was fair and had episodes of violence. He was able to maintain minimum personal hygiene with some problems of daily living. Currently, the Veteran's alcohol consumption was not an issue. While his remote memory was normal, the Veteran's recent and immediate memory was moderate impaired. The Veteran's PTSD symptoms included persistent reexperiencing of the traumatic events, persistent avoidance of stimuli associated with the trauma through avoidance of thoughts and activities, markedly diminished interest or participation, feelings of detachment or estrangement from others, and restricted range of affect. The Veteran also had persistent symptoms of increased arousal with difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilence, and exaggerated startle response. The symptoms occurred most days, its severity was moderate to severe, and lasted several hours. The Veteran retired in 2008 as he was eligible by age or duration of work and medically due to his psychiatric problems. The Veteran was diagnosed with PTSD and dysthymic disorder. His GAF score was 55. The Veteran was not determined to be totally occupationally and socially impaired due to his PTSD but it did result in deficiencies in judgment, thinking, family relations, work, and mood. In August 2011, the Veteran reported he was doing "pretty good" and tries to get out so he could be alone. He goes to his new "hiding places" and still thinks about Vietnam as he "just [cannot] get them out." He stated he did not have any suicidal ideation. There were also no auditory or visual hallucinations. In September 2011, the Veteran stated he was depressed lately. He felt useless but he had "good days and bad days." There were no other changes since the August 2011 treatment. In November 2011, the Veteran stated he still experiences nightmares. There were no other changes since the August 2011 treatment. The record reflects that the Veteran has been assigned psychiatric diagnoses other than PTSD (nightmare disorder, dysthymic disorder, alcohol dependence, alcohol-induced mood disorder, and depressive disorder) which are not service connected. While symptoms/impairment due to disability that is not service connected generally may not be considered in rating a psychiatric disability, governing caselaw provides that where it is not possible to distinguish the effects of a nonservice-connected disability from those of the service-connected disability being rated, the reasonable doubt doctrine dictates that all symptoms be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App, 181 (1998). In the instant case, the examiners have generally not distinguished symptoms due to the Veteran's PTSD from those due to other, co-existing and nonservice-connected, psychiatric disability. Therefore, for the limited purposes of this appeal only, the Board will consider all psychiatric symptoms shown as due to the service-connected PTSD. Notably, in assigning the ratings on appeal the RO also did not exclude any symptoms from consideration as due to nonservice-connected disability. On longitudinal review of the record, the Board finds that the Veteran, his treating mental health professionals, and VA examiners have reported PTSD symptoms productive of occupational and social impairment with reduced reliability and productivity. He has shown symptoms including flattened affect, panic attacks more than once per week, disturbances of motivation and mood, impaired judgment, some occasional short- and long-term memory impairment and difficulty in establishing and maintaining effective work and social relationships. Although he has not displayed circumstantial, circumlocutory or stereotypical speech; difficulty understanding complex commands; or impaired abstract thinking, he need not display every symptom listed to establish entitlement to a higher rating. Furthermore, the Veteran's GAF score ranged from 48 to 61, As stated GAF scores of 51 to 60 are defined as indicating 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). Arguably, a GAF score of 48 can support a 50 percent or 70 percent rating. However, the Board notes that there was only one instance of a GAF score of 48 during the entire appeal period and the GAF score only provides guidance and is not determinative of the proper evaluation to be assigned. Here, the Board finds that the totality of the evidence shows the Veteran's symptoms more nearly approximate the 50 percent rating criteria during the entire period at issue. The Board finds no reason to question the credibility of the Veteran's accounts, particularly as they are entirely consistent with reports from his treating mental health specialists and VA examiners. In summary, it is reasonably shown that symptoms of the Veteran's PTSD have produced occupational and social impairment with reduced reliability and productivity throughout the appeal period. Therefore, the evidence supports the award of a 50 percent rating for PTSD throughout. However, the Board concludes that the criteria for a 70 percent rating have not been met. As noted above, symptoms illustrative of a 70 percent rating with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood include symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; speech that is intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and an inability to establish and maintain effective relationships. In this regard, the Board acknowledges that the evidence of record showed findings of occasional delusions and impaired impulse control; however, the evidence as a whole supports the assignment of no more than a 50 percent evaluation during the appeal period. In this regard, the Veteran was able to perform activities of daily living and there was no evidence of speech that was intermittently illogical, obscure, or irrelevant; the Veteran was not in a near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; spatial disorientation was not present; and there was never evidence of neglect of personal appearance and hygiene, or other symptoms commensurate with a 70 percent evaluation. Similarly, he does not meet or approximate the symptoms for a 100 percent evaluation. In regard to the Veteran's inability to establish and maintain effective relationships, the Board acknowledges that he expressed the inability to deal with others, avoided crowds, and enjoyed spending time alone; however, the evidence demonstrated the Veteran was still able to interact with his wife as his marriage was intact and he was able to social with, albeit small, a group of friends. As such, the Veteran's symptomatology most closely reflects a 50 percent disability rating for PTSD. Here, staged ratings have been considered. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence of record does not show a distinct period of time on appeal during which a rating in excess of 50 percent would be warranted for the Veteran's service-connected PTSD. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 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). An extraschedular disability rating is warranted based 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 schedular standards. 38 C.F.R. § 3.321(b)(1) (2013). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture such that the available schedular criteria are inadequate. The rating criteria reasonably describe the Veteran's disability level and symptomatology due to his service-connected PTSD. Higher ratings are provided for greater levels of symptomatology. His symptoms fall within the descriptions provided for the 50 percent level of impairment. Therefore, a further analysis under Thun is not warranted. In sum, the Board finds that the evidence supports the assignment of a rating of 50 percent for PTSD under Diagnostic Code 9411 during the rating period on appeal. The Veteran is competent to report the symptoms he experiences, and the Board finds him credible in this regard; the reported symptoms are consistent with the schedular evaluation assigned herein. Accordingly, the Board finds that the preponderance of the evidence supports the assignment of a 50 percent, but no higher, rating for PTSD. ORDER A 50 percent rating is granted for PTSD and is subject to regulations governing the payment of monetary benefits. REMAND In Rice v. Shinseki, 22 Vet. App. 447 (2009), it was held that a claim for a TDIU is part and parcel of an increased-rating claim when the issue of unemployability is raised by the record. In this case, the issue of unemployability is raised by the record. As previously stated, in August 2008, the Veteran was felt to be not employable, as his symptoms placed him at risk and harm of danger to himself as well as others around him. According to the July 2011 VA examination, it was noted by the examiner that the Veteran retired in 2008 as he was eligible by age or duration of work and for medical, namely psychiatric, reasons. The examiner stated that the Veteran reported having increased difficulty "being around people... [t]he stress of getting everything done..." Therefore, pursuant to Rice, the Board is assuming jurisdiction over the TDIU claim, since the issue of unemployability is raised by the record. Generally, a veteran will be entitled to a TDIU upon establishing he is in fact unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. Consideration may be given to his level of education, any special training, and previous work experience in making this determination, but not to his age or impairment from disabilities that are not service connected (i.e., unrelated to his military service). See 38 C.F.R. §§ 3.341, 4.15, 4.16, 4.19. To qualify for a total rating for compensation purposes, the evidence must show (1) a single disability rated as 100 percent disabling; or (2) that the veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities - provided there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16(a). When the percentage standards of 38 C.F.R. § 4.16(a) have not been met, VA must consider assigning an extra-schedular rating. 38 C.F.R. § 4.16(b). If the evidence demonstrates that the veteran is unemployable by reason of his service-connected disabilities, but fails to meet these percentage standards (as appears to be the case here), the claim shall be submitted to the Director of Compensation and Pension (C&P) Service for extraschedular consideration. 38 C.F.R. § 4.16(b). The recent examination does not contain an explicit opinion as to whether the Veteran's unemployment is attributable to his service-connected disability or whether the disability would preclude all gainful employment consistent with his education and occupational experience. Accordingly, the case is REMANDED for the following action: 1. Notify the Veteran about (1) the information and evidence not of record that is necessary to substantiate his claim for a TDIU; (2) the information and evidence that VA will seek to obtain on his behalf; and (3) the information or evidence that he is expected to provide. A copy of this notification must be associated with the claims file. 2. Copies of updated treatment records should be obtained and added to the claims file. 3. Following completion of the above, schedule the Veteran for an appropriate examination to determine whether it is at least as likely as not (50 percent or greater probability) that his service-connected PTSD prevents him from obtaining or retaining gainful employment that his education and occupational experience would otherwise permit him to undertake. The examiner should review the claims folders and note such review in the examination report. The examiner should provide a rationale for the opinion. 4. Adjudicate the issue of entitlement to TDIU. If the benefit sought remains denied, the Veteran and his representative must be issued a supplemental statement of the case and provided an appropriate period of time for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs