Citation Nr: 1336005 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 09-38 468 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a disability rating in excess of 10 percent for anxiety disorder with posttraumatic stress disorder (PTSD) from November 16, 1994 to December 20, 1994 and from March 1, 1995 to July 13, 1998; a disability rating in excess of 30 percent from July 14, 1998 to June 27, 2004 and from August 1, 2004 to August 26, 2007; and a disability rating in excess of 50 percent on and after August 27, 2007. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) from November 16, 1994 to December 20, 1994; from March 1, 1995 to July 13, 1998; from July 14, 1998 to June 27, 2004; from August 1, 2004 to August 26, 2007; and on and after August 27, 2007. REPRESENTATION Veteran represented by: Joseph R. Moore, Attorney ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1968 to June 1990. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated in March 2007 and January 2010 by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The RO has granted temporary 100 percent disability ratings for the Veteran's anxiety disorder with PTSD from December 21, 1994 to February 28, 1995 and from June 28, 2004 to July 31, 2004. As the Veteran is receiving the maximum disability rating during those periods, the Board will not address the issues of entitlement to a higher disability rating for those times. The issues of entitlement to a TDIU from November 16, 1994 to December 20, 1994; from March 1, 1995 to July 13, 1998; from July 14, 1998 to June 27, 2004; and from August 1, 2004 to August 26, 2007 are addressed in the REMAND portion of the decision below and are REMANDED to the Department of Veterans Affairs Regional Office. FINDINGS OF FACT 1. From November 16, 1994 to December 20, 1994, from March 1, 1995 to July 13, 1998, from July 14, 1998 to June 27, 2004, and from August 1, 2004 to August 26, 2007, the Veteran's anxiety disorder with PTSD was manifested by occupational and social impairment with reduced reliability and productivity, due to such symptoms as depression, anger, anxiety, sleep impairment, paranoia, problems concentrating, hypervigilance, intrusive thoughts, nightmares, isolation, avoidance, an exaggerated startle response, and an inability to make meaningful contact within an interpersonal environment, but not occupational and social impairment with deficiencies in most areas, due to such symptoms as delusions, hallucinations, obsessional rituals, speech intermittently illogical, obscure or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, and neglect of personal appearance and hygiene. 2. On and after August 27, 2007, the Veteran's anxiety disorder with PTSD was manifested by occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, and mood, due to such symptoms as depression, anxiety, anger, nightmares, panic attacks, flashbacks, intrusive thoughts, avoidance, isolation, extreme feelings of detachment, hypervigilance, an exaggerated startle response, impaired sleep, suicidal ideations, homicidal ideations, diminished interest, impaired impulse control, impaired memory, difficulty concentrating, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships. 3. The Veteran's service-connected disabilities rendered him unable to secure or follow a substantially gainful occupation on and after August 27, 2007. CONCLUSIONS OF LAW 1. From November 16, 1994 to December 20, 1994, from March 1, 1995 to July 13, 1998, from July 14, 1998 to June 27, 2004, and from August 1, 2004 to August 26, 2007, the criteria for a disability rating of 50 percent for anxiety disorder with PTSD have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). 2. On and after August 27, 2007, the criteria for a disability rating of 70 percent for anxiety disorder with PTSD have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for a TDIU have been met on and after August 27, 2007. 38 U.S.C.A. §§ 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS After review of the claims file, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions with respect to the issues decided herein. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). The information contained in letters dated in March 2005 and September 2007 satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Moreover, the Veteran was notified of regulations pertinent to the establishment of an effective date and disability rating in the September 2007 letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Following the issuance of the September 2007 letter, the Veteran's claim was re-adjudicated in an August 2009 Statement of the Case. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (finding that a notice defect may be cured by issuance of a fully compliant notification followed by a re-adjudication of the claim). For these reasons, the Board finds that the content requirements of the notice VA is to provide have been met, and, thus, no further development is required regarding the duty to notify. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The Veteran's service treatment records, VA treatment records, Social Security Administration (SSA) records, and identified private treatment records have been obtained and associated with the claims file. The Veteran was also provided multiple VA examinations during the pendency of the appeal. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The record demonstrates that the VA examiners reviewed the pertinent evidence of record and the Veteran's lay statements. Additionally, the examinations provided sufficient information to rate the service-connected disability on appeal. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). As such, the Board finds the examinations to be sufficient and adequate for rating purposes. There is no indication in the record that any additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). The Board has thoroughly reviewed all of the evidence in the Veteran's claims file. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matters on appeal. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2013). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule but findings sufficient to identify the disease and the resulting disability, and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2013); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability following an initial award of service connection for that disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2013). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV), a global assessment of functioning (GAF) score reflects the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM-IV, American Psychiatric Association (1994), pp. 46-47; 38 C.F.R. §§ 4.125(a), 4.130 (2013). A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41-50 indicates serious symptoms (e.g., suicidal 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). A GAF score of 51-60 represents moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. The Veteran's service-connected disability has been rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides: A 10 percent disability rating is warranted when the Veteran experiences occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by continuous medication. A 30 percent disability rating is warranted when the Veteran experiences occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is warranted when the Veteran experiences occupational and social impairment with reduced reliability and productivity, due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is warranted when the Veteran experiences occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work-like setting); and inability to establish and maintain effective relationships. A 100 percent disability rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130. In November 1994, the Veteran reported that he had been treated by VA for his mental health issues since July 1994. He stated that he had sleeping problems, social relationship problems, nightmares, and some low-powered drug use. The Veteran also claimed that he distrusted people in authority positions and tended to isolated himself from other people. In a subsequent written statement, the Veteran asserted that his in-service stressors had led to a high degree of hostility, anger, anxiety, and a distrust of all people. He stated that he could not work for anyone on a full-time basis. Upon his admission to the VA hospital in December 1994, a GAF score of 40 was assigned, and it was noted that the Veteran's past GAF scores ranged from 50 to 60. The record shows he was admitted to the hospital for exacerbation of his symptoms, increasing anxiety, sleep disturbances, depression, and nightmares, secondary to stress. The Veteran reported that he had not worked for the past six months. He denied a history of suicide attempts and major medical problems. During the Veteran's hospitalization, a VA social worker reported that the Veteran had potential employability. A December 21, 1994 VA medical record shows the Veteran had problems with concentration, isolation, depression, and PTSD. In March 1995, the Veteran underwent VA examination in connection with his claim. The Veteran reported that he had not had a "real" job since the military but had been all over the country trying to get a job. The Veteran reported not trusting people and that whenever he went to public places, he stayed by himself. He reported that he avoided going out in rainy weather and had difficulty flying. The Veteran stated that he started receiving treatment at the VA outpatient clinic in September 1994. The Veteran was neatly dressed, cooperative, and appropriate. He was alert and oriented, his intellect was about average, and his cognitive functioning was good. He reported intrusive recollections and intrusive thoughts, and he became tearful and cried periodically. The Veteran stated that because of service, he had started to alienate people. He also reported an exaggerated startle response and avoiding situations that might evoke further recollections. He reportedly had difficulty with interpersonal relationships, decreased tolerance, difficulty trusting people, and difficulty with authority figures. There was no evidence of psychotic symptoms, thought disorder, hallucinations, or delusions. He denied suicidal ideations, and his mood was euthymic with no evidence of consistent dysphoria or anxiety. The VA examiner diagnosed PTSD. In July 1995, SSA awarded the Veteran disability benefits, with an effective date of May 15, 1993. SSA found the Veteran had a severe adjustment disorder with mixed features, a personality disorder with passive/aggressive traits, and an alcohol abuse problem. SSA determined that the Veteran's disability had restricted him to less than even sedentary work. Even with varying diagnoses, SSA concluded that the Veteran would not be able to maintain predictable or competitive work activity. SSA stated that the functional demands of his relevant past work exceeded the Veteran's residual functional capacity. An August 1995 VA treatment record shows the Veteran was oriented, with a neat appearance and a restless mood. The Veteran had full range of affect, with goal-directed speech. He denied hallucinations and delusions, and his insight was fair to poor. A September 1995 progress note shows the Veteran reported avoidance, hypervigilance, intrusive thoughts, and sleep disturbance. A November 1995 social work assessment indicates the Veteran had potential employability. The record shows the Veteran had a BA in Japanese History and had done some graduate work in Public Administration. He was currently working to obtain teaching credentials. The Veteran was divorced with two sons, to whom he was reportedly not close. The Veteran acknowledged using both alcohol and marijuana. The Veteran had been triaged to the trauma clinic for assessment of PTSD. The Veteran complained of nightmares, a fear of flying, insomnia, restricted affect, and being easily frustrated with people. According to the social worker, the clinical scales suggested the presence of depression, social inadequacy, and interpersonal discomfort. An October 1996 private treatment record indicates the Veteran was well-groomed and maintained eye contact, his speech was normal, his mood was mildly depressed, and he had a full range of affect. There was no evidence of delusions or hallucinations, and he denied suicidal ideations and past suicide attempts. His thought processes were normal, he was oriented, and his memory was intact. His insight and judgment were good. He reported that in the morning, he watched the news, talked with his wife, and went for walks. He would talk with his son when he came home, and he listened to the radio. The Veteran attended to his own personal needs and went shopping with his wife. He denied having any friends. The private physician assigned a GAF score of 75. The private physician found the Veteran could maintain the attention required to perform simple, repetitive tasks and would have some difficulty withstanding the stresses and pressures associated with day-to-day work activities. The private physician considered the Veteran's impairment as moderate. The Veteran underwent additional VA examination in May 1997. The VA examiner noted the Veteran was followed at the VA Medical Center in Albuquerque. He reported that he married for the second time in October 1995 and stated that he currently had a good relationship with his wife. The Veteran described his sleep pattern as fair and his appetite as good. There were occasional crying episodes, his energy level was good, and his motivation was fair. He reported that he had a tendency to stay to himself as he found it difficult to trust people. He avoided media information that reminded him of his in-service experiences. His last regular employment was September 1990 through March 1991 as a juvenile probation officer when he was let go after grabbing one of the juveniles. The Veteran stated he had found it hard to return to regular employment due to a combination of bad dreams and difficulty taking orders. The Veteran was appropriately dressed, his eye contact was good, and he was felt to be of above average intelligence. There was no obvious evidence of anxiety. The Veteran was oriented and alert, his mood was depressed, and his affect was appropriate. There was no evidence of hallucinations, delusions, paranoid ideations, feelings of depersonalization, or feelings of derealization. He denied suicidal attempts and ideations, and he denied any history of violence unless it was in self-defense. The VA examiner assigned a GAF score of 55 for moderate impairment. In December 1997, the Veteran reported symptoms of hypervigilance, paranoia, nightmares, and intrusive thoughts. He stated that he became withdrawn from everything three times per week. A December 1997 treatment plan shows the Veteran's goals included decreased anxiety/panic attacks, less irritability, and development and acceptance of trusting, supportive relationships. The record reflects a GAF score of 60. A January 1998 VA treatment record indicates the Veteran was working to find a job but was careful about "getting triggered" by people. He reported having no angry or aggressive outbursts lately. He was hypervigilant and avoided talking about war stories. A June 1998 VA treatment record shows the Veteran had been having problems with his temper and had been becoming violent. He also reported having nightmares three to four times per week and that loud noises bothered him. He stated that he did not want to be around people and had been feeling nervous most of the time. He stated he had a good relationship with his wife. The Veteran was oriented, alert, and coherent. His mood was anxious and depressed, and he denied any suicidal ideations. There were no psychotic features and his insight and judgment were fair. The record demonstrates a GAF score of 51-60. In October 1998, the Veteran underwent additional VA examination. The Veteran reported that three years prior he had started going to school; however, he had to quit due to problems concentrating and problems being in a crowd. The Veteran also stated that he had attempted to get a job in September 1997 but that no one would hire him. He stated that he planned to teach martial arts. The Veteran reported an inability to sleep, bad dreams, sudden intrusive recollections, and difficulty flying. He usually stayed away from people because he became irritated easily. He reported that he had dreams approximately three to four times per week and wanted to get away from violence. On examination, the Veteran was neatly dressed, alert, cooperative, and he seemed to somewhat minimize some of his problems. He also described hypervigilance and frequent intrusive thoughts that left him in a dysphoric mood. There were no consistent periods of depression or suicidal thoughts. There was no impairment of thought processes or communication. There was no evidence of delusions, and the VA examiner felt that the Veteran's reports of shadows were more a result of extreme hypervigilance rather than hallucinations. There was no evidence of inappropriate behavior or suicidal thoughts. His ability to maintain personal hygiene and other basic activities of daily living was good, and there was no evidence of memory loss. His speech was normal and logical. He described partial symptoms of panic attacks that seemed to be a lot of anticipatory anxiety. He had good impulse control. The VA examiner diagnosed PTSD, chronic, and history of anxiety episodes and assigned a GAF score range of 51 to 60. In December 1998, a private neuropsychologist administered a mental status examination. The Veteran was appropriately dressed and groomed, his affect was slightly depressed and remained stable, and he denied suicidal ideations. The Veteran's affect was appropriate, his thought pattern was without major delusions, and he was oriented. He denied auditory, visual, tactile, olfactory, and gustatory hallucinations, his speech pattern was without significant push, and there were no observable signs of literal or verbal paraphasias. There were some subtle signs of anxiety, and the Veteran appeared to be slightly restless and hypervigilant. The examiner found the Veteran's emotional status was basically unremarkable except for some slight anxiety. He did report a number of neurovegetative signs and symptoms of depression and anxiety, all of which appeared to be part of his PTSD. The examiner opined that the Veteran continued to have the ability to do complex, detailed, and simple repetitive types of tasks, although he appeared to have some difficulty with consistency. He would seem to have some difficulty handling work-like stresses. The Veteran continued to have the ability to be fairly independent and had a moderate degree of difficulty consistently relating to co-workers and interacting with supervisors. The examiner assigned a GAF score range of 55 to 60. In February 1999, a Social Security examiner found anxiety was the Veteran's predominant disturbance, which was manifested by recurrent and intrusive recollections of a traumatic experience. The examiner reported that the Veteran's symptoms caused a slight restriction of activities of daily living, slight difficulties in maintaining social functioning, often deficiencies of concentration, persistence, or pace resulting in failure to complete tasks in a timely manner, and no episodes of deterioration or decomposition in work or work-like settings. The Veteran was moderately limited in his ability to understand and remember detailed instructions, moderately limited in his ability to carry out detailed instructions, moderately limited in his ability to maintain attention and concentration for extended periods, moderately limited in his ability to complete a normal workday, moderately limited in his ability to interact appropriately with the general public, and moderately limited in the ability to respond appropriately to changes in the work setting. In a July 1999 written statement, the Veteran reported nightmares, sleep impairment, an intense fear of flight, and difficulty trusting people. He stated that as a result of his symptoms, he had not had a permanent job since his retirement from the military. In May 2000, the Veteran reported that he was not working and that he was doubtful anyone would hire him at his age. He reported spontaneous panic attacks that lasted up to 30 minutes. The Veteran stated that he had bad dreams. He had good hygiene, his speech was somewhat pushy, his mood was cheerful, and his affect was appropriate. There were no suicidal ideations or psychoses. The VA physician assigned a GAF score of 75. A September 2000 VA treatment record indicates the frequency of the Veteran's panic attacks had decreased. VA treatment records in July 2000, September 2000, November 2000, February 2001, and May 2001 reflect GAF scores of 80. In May 2001, the Veteran underwent additional VA examination. The Veteran reported that he retired in 1990 and that he had not been able to find a job because he was too old and no one would hire him. He reportedly got a job with the Census Bureau which only lasted two days because he could not stand working in a high building. The Veteran stated that he was self-employed and did not report how much money he had made in the past year. The Veteran had been married once before and had been married to his current wife for six years. He stated that his main complaint was his fear of heights, which the VA examiner found realistic. The VA examiner also found the Veteran presented the rest of his symptoms in a very hysterical manner. He complained about dreams and cold night sweats but did not appear realistic in his complaints. The Veteran was well-groomed, very talkative, with some pressured speech and some degree of grandiosity. He did not appear delusional but there were somewhat euphoric and grandiose elements in the way he presented his information. He remained coherent and relevant and was well-oriented. His memory and recall were adequate and his mood was mildly elated. The VA examiner diagnosed anxiety disorder and suspected bipolar disorder and assigned a GAF score range of 55 to 60. An August 2001 VA treatment record shows the Veteran saw a car blow up on television, which triggered old memories and caused him to not sleep well. He had good hygiene, no agitation or retardation, his speech was okay, his mood was cheerful, and his affect was appropriate. There was no psychosis. The VA physician assigned a GAF score of 80. A February 2002 VA treatment record shows the Veteran reported nightmares and memories of his in-service stressors. The VA physician assigned a GAF score of 70. VA treatment records dated in August 2002 and November 2002 reflect GAF scores of 67 and 70, respectively. The August 2002 record shows the Veteran could not find a job because of his problems. The Veteran had not been taking one of his prescribed medications and had been getting more nervous, angry, and irritable and having more panic attacks. His speech was spontaneous, his mood was mildly anxious, and his affect was appropriate. There was no evidence of psychosis or suicidal ideas. A May 2003 VA treatment record indicates the Veteran was sleeping better and interacting with people a little more without getting angry. He admitted to being hypervigilant, and he stated his mood was "pretty cool," normal, and irritable at times. The VA physician assigned a GAF score of 65. An additional May 2003 record reflects a GAF score of 63. An August 2003 VA record reflects a GAF score of 65. The Veteran reported feeling less aggressive and more interested in doing things. He was still reminded of his military experiences by news of war and stated that he had been unable to keep a job since his separation from service. He was tearful when speaking about his military experiences. The Veteran was more interactive and cooperative but still very suspicious and overinclusive. His mood was better and his affect was suspicious and reactive. His thought processes were goal-oriented and circumstantial. His thought content included paranoia, and there were no auditory or visual hallucinations and no suicidal or homicidal ideations. In May 2004, the Veteran complained of PTSD symptoms, including bad dreams, nightmares, and hypervigilance. The VA social worker found the Veteran appeared to have a clear and distinct paranoia and suspiciousness when around people. The Veteran was oriented, his insight and judgment were good, his mood was euthymic, and his affect was appropriate. His speech was somewhat pressured, and he denied suicidal and homicidal ideations. In August 2004, following his hospitalization, the Veteran was alert and oriented, with good eye contact, his affect was appropriate, and no delusions or hallucinations were noted. He denied any suicidal and homicidal ideations. A subsequent August 2004 VA treatment record shows the Veteran reported that he had isolated himself from people for years. He reported that he would often sink into a depression for days or weeks at a time and become detached from everything. As his anxiety level increased, his tolerance for people decreased. He had been unable to regain his concentration to do things and although he had been married for almost 10 years, he often felt detached, alone, and emotionally numb. The Veteran stated that his anxiety had caused him to become increasingly overprotective and hypervigilant. He also reported nightmares and waking up with cold sweats. In September 2004, the Veteran appeared more upbeat, relaxed, and hopeful. He continued to report nightmares and hypervigilance but reported a reduction in their frequency and severity. His affect was limited in range but reactive, and he denied suicidal and homicidal ideations. An additional September 2004 VA treatment record indicates the Veteran was depressed, anxious, and suspicious. Unresolved anger was apparent. Upon presentation, the Veteran was cooperative, his hygiene and grooming were appropriate, and he was casually dressed. He displayed moderate eye contact, and his affect was mobile and reactive with underlying anxiety, anger, and depression. His speech was pressured at times but overall coherent and productive. He denied experiencing any suicidal or homicidal ideations. Paranoid undertones were present, and he referred to himself as being hypervigilant. No looseness of associations or flights of ideas were observed, and he denied any perceptual disturbances. His memory was grossly intact. A December 2004 VA treatment record reflects a GAF score of 65. The Veteran's hygiene was appropriate, he displayed moderate eye contact, and his affect was mobile. Underlying anxiety, frustration, and anger were observed. The Veteran's speech was goal-directed, he denied any intent to harm himself or others, and he denied hallucinations. There was no looseness of associations or flights of ideas. His memory was grossly intact and he was reality-oriented. In March 2005, the Veteran reported making more of an effort not to self-isolate. He reported that he went out walking during the day and out shopping with his wife in the evening. His insight and judgment were good, his mood continued to improve, and his affect remained limited in range but reactive. He continued to manifest paranoia; however, the social worker felt the level continued to be reduced. An additional March 2005 VA treatment record shows a GAF score of 75. The Veteran was well-groomed and not depressed. He was paranoid but had no suicidal ideations, homicidal ideations, delusions, or hallucinations. He had good insight and good impulse control. The Veteran underwent additional VA examination in April 2005. The Veteran reported that his current marriage was good. The Veteran was intense, cooperative, and dressed in sports attire. He appeared intelligent and had good social skills. He did not appear anxious or depressed. His thoughts appeared to be logical and coherent. He reported problems with sleep and chronic problems with irritability. He was not suicidal and he denied any psychotic symptoms. He reported that he did not like to go outside because he did not want to be around people, which was in distinct contrast to the excellent social skills he demonstrated. He also said that he had a tendency to isolate himself and to dwell on the past. The Veteran reported that he spent most of his time at home reading the newspaper and surfing the web. He spoke to his family every day and helped out around the house. He also reported speaking to one of his good friends on the phone at times. He stated that his last job was in the service in 1990 and that he was supported through his military retirement benefits, pension benefits, and his wife. The Veteran stated that he had tried to find work but had been unsuccessful. He stated that he would be willing to take on any job, except for working in a fast food restaurant. The Veteran also asserted that he felt he was still able to work but preferred to stay away from the "rat race." The VA examiner assigned a GAF score of 75. A September 2005 VA treatment record reflects a GAF score of 60. In November 2005, the Veteran stated that he continued to force himself to go out later in the day, several days per week. His mood was improved and his affect remained anxious. In December 2005, a VA social worker noted that the Veteran's mood was anxious, his affect was congruent, and he denied suicidal and homicidal ideations. The Veteran's insight and judgment were deemed fair. A March 2006 VA treatment record reflects a GAF score of 55. The Veteran reported impaired sleep with nightmares, particularly exacerbated by war news. He was increasingly isolating himself. He had goal-directed speech, an anxious mood, and was somewhat paranoid. He denied suicidal and homicidal ideations, delusions, and hallucinations. He was well-oriented and had fairly good insight and judgment. VA treatment records show the Veteran was hospitalized for treatment of PTSD from May 16, 2006 to May 26, 2006. The Veteran complained of sleeping problems, night sweats, nightmares, flashbacks, and social isolation. The assigned GAF score was 32. During the hospitalization, the Veteran had high arousal manifested by persistent hypervigilance, which resulted in distance from his family and an inability to make meaningful contact within an interpersonal environment. He had avoidance manifested by social and emotional isolation and a depressed mood. He also had re-experiencing trauma manifested by intrusive thoughts and distorted perceptions. At discharge, the Veteran was alert, oriented, and cooperative, with good eye contact. He had no thought disorder, delusions, or hallucinations. His mood was neutral, and his insight was fair. VA treatment records dated in August and September 2008 show the Veteran continued to experience nightmares, flashbacks, and intrusive thoughts. He continued to avoid crowds and preferred to be alone most of the time. He was well-groomed, with good eye contact, and his speech was normal. His mood and affect were anxious and reactive, his thought content and processes were logical, and his insight and judgment were good. He denied any suicidal or homicidal ideations. In February 2009, the Veteran reported that he could no longer contact old friends because it caused him great concern and increased his depression and anxiety. He stated that he had very little desire to do many of the things that he had once enjoyed. A March 2009 VA treatment record shows the Veteran continued to have unwanted intrusive memories and that he slept very little. He also reported that his hypervigilance was up and that he most recently had an incident that caused him to lose control. He stated that he was often angry and that the slightest thing could set him off. He had no desire to encounter people and experienced extreme difficulty when dealing with groups of people. He denied any thoughts of suicide or homicide but preferred to be left alone. The VA social worker reported that the Veteran was maintaining, although he was not progressing. He continued to harbor a lot of anger, hypervigilance, and emotional numbness. In July 2009, the Veteran reported that his wife would not sleep with him as a result of his nightmares. He denied any current thoughts of suicide or homicide, but stated that at times he felt as though he was already dead because he had no real emotions. In January 2010, the Veteran reported intrusive thoughts, memories, and severe nightmares. He stated that he was easily agitated, easily startled, did not like people, did not trust people, and would not go outside after 10:00 am. The Veteran reported that his current marriage had not been easy. He was alert and oriented, with normal speech and an anxious mood. He had full range of affect, his thought processes were logical and goal-directed, and he admitted to difficulty concentrating. The Veteran denied delusions and hallucinations, and his insight was good. He also reported that he had severe thoughts of suicide in the past and still had those thoughts creep up on occasion. He denied any plans, thoughts, or intents to commit homicide. The VA social worker assigned a GAF score of 55. A February 2010 intake assessment from the Toledo Vet Center shows the Veteran had a great deal of hypervigilance, almost nightly nightmares, intrusive memories, and guilt over what he had put his previous family through. The main areas of focus were PTSD, generalized anxiety, and depression, not otherwise specified. The Veteran was neat and friendly, with above average intelligence and appropriate speech. He was oriented and his affect was appropriate. His judgment was good, and there was no evidence of delusions, disorganized thinking, or hallucinations. The Veteran reported an average appetite, sleep disturbance, less sex drive, and low energy. The Veteran also reported a history of suicidal and homicidal thoughts. He reported that he had no friends and stated that he preferred to not go outside his home after 11:00 a.m. He reported emotional numbing and stated that he had very little desire to do anything as nothing gave him pleasure anymore. The VA physician found it was evident and visible that the Veteran was emotionally disturbed when talking about his experiences and what his had family endured. He was unemployed, and he reported very little desire to seek employment because he did not want to interact within a social or work setting. The VA physician assigned a GAF score of 54. An August 2010 client treatment plan from the Toledo Vet Center indicates the Veteran had symptoms of anger, agitation, hypervigilance, guilt, isolation, and nightmares. The Veteran submitted a September 2010 letter from a VA clinical social worker, T. Heath, in support of his claim. T. Heath reported that he had been treating the Veteran for approximately 15 months. He stated that the Veteran experienced extreme symptoms associated with PTSD, which included recurrent distressing dreams, intense psychological distress, diminished interest and participation in many activities once enjoyed, extreme feelings of detachment from others, hypervigilance, difficulty concentrating at times, and extreme irritability and anger outbursts. T. Heath opined that the Veteran's disturbances and symptoms were sure to cause clinically significant distress and social and occupational impairments, which would make it difficult to maintain employment. T. Heath reported that the Veteran had an inability to trust and could not and preferred not to have any interaction with people in the community. He experienced a great deal of guilt with regard to how the military had treated him and his family. T. Heath stated that the Veteran did not leave his home after 10:30 in the morning for fear that he may have an altercation with someone in society. According to T. Heath, the Veteran walked in the woods as a process of getting exercise and desensitizing, where his interaction with others was virtually nonexistent. In November 2010, the Veteran reported symptoms of anger, guilt, isolation, inability to trust, nightmares, and intrusive memories. A June 2011 client treatment plan from the Toledo Vet Center indicates the Veteran had symptoms of anxiety, shame, guilt, hypervigilance, anger, and isolation. The Veteran underwent VA examination in November 2011 in connection with his claim. The VA examiner assigned a GAF score of 55 based on symptoms of severe insomnia, high re-experiencing symptoms, having conflicts with his wife, and having a few friends. The VA examiner opined that the Veteran's symptoms resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The Veteran reported that he had been married to his second wife for 16 years and that he spoke to one of his sons every two weeks. He took early morning walks with a group of other veterans and stayed at home during the day to avoid physical altercations. The Veteran reported looking for work but not getting any interviews. The Veteran was concerned that he could be violent or inappropriate if a customer was being critical. The VA examiner found the Veteran met the diagnostic criteria for PTSD due to symptoms of recurrent and distressing recollections and dreams, intense psychological distress at exposure to cues, efforts to avoid thoughts and activities, feelings of detachment, restricted range of affect, difficulty falling asleep, irritability, difficulty concentrating, and an exaggerated startle response. The VA examiner opined that the Veteran's PTSD caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. For VA purposes, the VA examiner found the Veteran displayed symptoms of chronic sleep impairment, impairment of short-and long-term memory, and difficulty in adapting to stressful circumstances. Testing revealed mild depression and mild to moderate anxiety. The VA examiner opined that it was likely the Veteran would be able to function in an isolated work setting, although his high level of re-experiencing and extremely poor sleep would make it difficult to focus in a work-like setting. The Veteran submitted a June 2013 letter from Dr. M. Cesta in support of his claim. Dr. Cesta reported that he had reviewed the Veteran's medical records and service records and conducted a two-hour diagnostic interview of the Veteran. Dr. Cesta opined that it was very clear the Veteran had been completely, psychiatrically disabled since 1994, and in reality, far earlier. Dr. Cesta reported that the Veteran was completely unemployable and struggling with every social interaction, especially with his family. Dr. Cesta found the medical record was very clear in documenting extremely severe symptoms of PTSD, to include irritability, outbursts of violence, difficulty concentrating, cognitive deficits, avoidance, fear of violence directed at himself and others, severe and ongoing flashbacks, hypervigilance, nightmares, and overt anxiety. Dr. Cesta noted the Veteran's hospitalizations and found the Veteran was incapable of socializing with anyone but his wife and immediate family. Dr. Cesta found it significant that in 2010 the Veteran was described as becoming a prisoner within his own home and has had severe thoughts of suicide in the past. Dr. Cesta reported that during the interview, the Veteran had ongoing suicidal ideations, severe neurovegetative symptoms, anxiety, fear, horror, and flashbacks. He was extremely detached and qualified for a diagnosis of PTSD. The Veteran reported that his present life was of extremely poor quality and that although he had been married for 16 years, he did not trust his wife, had a contentious relationship with her, and had difficulties with basic communication. According to Dr. Cesta, the Veteran was estranged from his children, had no interactions with others, no friends, no interests, no hobbies, and no hope. The Veteran's entire life was managing his psychiatric illness and behaving in a fashion so that he did not jeopardize himself or other people. Dr. Cesta stated that the Veteran had periods of depersonalization and disassociation that led him to an even more extensive level of isolation. Dr. Cesta argued that the Veteran went on walks to remove himself from his environment, not to interact with others. Dr. Cesta opined that in reality there were no isolated work settings of the nature that would keep the Veteran safe and others safe and that the Veteran's GAF score according to the last VA examination findings was a 40. On mental status examination, the Veteran was reasonably cooperative and appropriate with speech that was labile. There were periods of agitation, and his mood was angry. His thought content was positive for intermittent suicidal ideations, and he reported frequent thoughts of homicidal ideation. He had paranoid illusions and bizarre causal relationships. His thought processing was neither linear nor logical and but would be considered ruminative and preservative. He did not have any auditory, visual, or tactile hallucinations. He appeared cognitively intact. Dr. Cesta found the Veteran had never been able to reintegrate into society after his discharge, had failed to maintain any type of reasonable employment, was socially isolated, and had minimal interactions with anyone but one or two members of his family. Dr. Cesta opined that the Veteran has had PTSD which has been totally disabling since 1992. After his discharge, the Veteran was profoundly impaired and incapable of any type of meaningful and appropriate functioning in society, whether it was occupational or social. Dr. Cesta opined that the Veteran was 100 percent disabled from PTSD and had been for decades. Dr. Cesta assigned the Veteran a current GAF score of 35 to 40 and also assigned a GAF score of 35 to 40 for the past year. From November 16, 1994 to December 20, 1994 and from March 1, 1995 to July 13, 1998 The Veteran's service-connected disability is currently rated as 10 percent disabling from November 16, 1994 to December 20, 1994 and from March 1, 1995 to July 13, 1998. Therefore, to warrant a higher disability rating, the evidence must show occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Given the above record, the Board concludes that the evidence demonstrates that from November 16, 1994 to December 20, 1994 and from March 1, 1995 to July 13, 1998, the Veteran's anxiety disorder with PTSD was manifested by occupational and social impairment with reduced reliability and productivity. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.130, Diagnostic Code 9411. Initially, the Board notes the Veteran experienced symptoms that are not listed in the rating criteria, and as a result, the Board has considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of occupational and social impairment with reduced reliability and productivity. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The evidence demonstrates that the Veteran's anxiety disorder with PTSD was manifested by anger, anxiety, depression, impaired sleep, nightmares, intrusive recollections, isolation, problems with concentration, an exaggerated startle response, hypervigilance, impaired insight, and difficulty with interpersonal relationships and interactions with co-workers. In October 1995, a private physician considered the Veteran's impairment as moderate. Likewise, the May 1997 VA examiner assigned a GAF score of 55 for moderate impairment. During these periods, physicians and clinical social workers assigned GAF scores ranging from 51 to 75, which indicated moderate symptoms, such as a few friends and conflicts with co-workers, to mild symptoms, such as depressed mood and mild insomnia. Here, the Board finds the Veteran's specific symptoms are more accurately reflected by the lower range of GAF scores assigned, which represent moderate difficulty in social and occupational functioning. Specifically, the evidence reflects symptoms of depression, impaired sleep, problems with concentration, and difficulty with interpersonal relationships and interactions with co-workers. While there were times wherein the Veteran's GAF score improved or worsened, the manifested symptoms remained largely constant. As such, the Board concludes that the evidence as a whole more nearly approximates the criteria for a 50 percent disability rating from November 16, 1994 to December 20, 1994 and from March 1, 1995 to July 13, 1998. 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411; see Hart v. Mansfield, 21 Vet. App. 505 (2007). However, the Board finds that a rating in excess of 50 percent is not warranted for the Veteran's service-connected anxiety disorder with PTSD during these periods. The evidence of record does not reflect occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Specifically, the evidence does not demonstrate suicidal ideations, hallucinations, delusions, obsessional rituals that interfered with routine activities, or speech intermittently illogical, obscure, or irrelevant. The Veteran has not reported near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, and the evidence does not reflect neglect of personal appearance and hygiene. The Board acknowledges SSA's determination that the Veteran's disability had restricted him to less than even sedentary work and that the functional demands of the Veteran's relevant past work exceeded his residual functional capacity. In addition, the Board notes Dr. Cesta's opinion that the Veteran had been 100 percent disabled since 1994. In this case, however, the Board finds the VA treatment records and private treatment records indicating the Veteran's anxiety disorder with PTSD produced only moderate impairment carry greater probative value than the SSA findings and Dr. Cesta's opinion. Despite his hospitalization, a VA social worker reported that the Veteran had potential employability, and following the Veteran's hospitalization a VA social worker also reported that the Veteran had potential employability. Further, the record shows the Veteran was working to obtain his teaching credentials in November 1995. In addition, the SSA award was premised on the finding that the Veteran would not be able to maintain predictable or competitive work activity, which is a different standard from VA regulations for rating purposes. Resolving the benefit of the doubt in favor of the Veteran, the Board finds that the criteria for a disability rating of 50 percent, but no more, for anxiety disorder with PTSD have been met from November 16, 1994 to December 20, 1994 and from March 1, 1995 to July 13, 1998. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). From July 14, 1998 to June 27, 2004 and from August 1, 2004 to August 26, 2007 The Veteran's service-connected disability is currently rated as 30 percent disabling from July 14, 1998 to June 27, 2004 and from August 1, 2004 to August 26, 2007. Therefore, to warrant a higher disability rating, the evidence must show occupational and social impairment with reduced reliability and productivity. 38 C.F.R. § 4.130. Here, the Board finds the evidence demonstrates that from July 14, 1998 to June 27, 2004 and from August 1, 2004 to August 26, 2007, the Veteran's anxiety disorder with PTSD was manifested by occupational and social impairment with reduced reliability and productivity. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.130, Diagnostic Code 9411. Again, the Board notes the Veteran experienced symptoms that are not listed in the rating criteria and, as a result, has considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of occupational and social impairment with reduced reliability and productivity. See Mauerhan, 16 Vet. App. 436. Specifically, the evidence demonstrates that the Veteran's anxiety disorder with PTSD was manifested during these periods by depression, anger, anxiety, partial symptoms of panic attacks, sleep impairment, paranoia, problems concentrating, hypervigilance, intrusive thoughts, nightmares, isolation, and an inability to make meaningful contact within an interpersonal environment. The December 1998 private neuropsychologist found the Veteran would have some difficulty handling work-like stresses. In February 1999, the Social Security examiner stated that the Veteran's symptoms caused a slight restriction of activities of daily living, slight difficulties in maintaining social functioning, often deficiencies of concentration, persistence, or pace resulting in failure to complete tasks in a timely manner, and no episodes of deterioration or decomposition in work or work-like settings. In addition, the Social Security examiner determined that the Veteran was moderately limited in his ability to understand and remember detailed instructions, moderately limited in his ability to carry out detailed instructions, moderately limited in his ability to maintain attention and concentration for extended periods, moderately limited in his ability to complete a normal workday, moderately limited in his ability to interact appropriately with the general public, and moderately limited in the ability to respond appropriately to changes in the work setting. During these periods, physicians and clinical social workers assigned GAF scores ranging from 32 to 80, which indicate a wide range of symptoms, to include major impairment in several areas to mild impairment. Here, the Board finds the Veteran's symptoms during these periods are more closely represented by the GAF scores ranging from 51 to 65 and indicate moderate impairment. First, this range represents the majority of GAF scores assigned. In addition, the bases of these scores are consistent with the Veteran's reported symptoms during these periods. Specifically, the Veteran's symptoms included depression, panic attacks, and moderate difficulty in occupational and social functioning. Here, the Veteran reported that although his current marriage was good and that he occasionally spoke with one of his friends, he still felt detached and isolated from people. However, the Board finds that a rating in excess of 50 percent is not warranted for the Veteran's service-connected anxiety disorder with PTSD during these periods. Here, the evidence does not reflect occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The evidence does not demonstrate consistent periods of suicidal ideations, delusions, hallucinations, obsessional rituals, illogical speech, near-continuous panic or depression affecting the ability to function independently, spatial disorientation, or neglect of personal appearance and hygiene. In October 1998, the VA examiner found the Veteran's ability to maintain personal hygiene and other basic activities of daily living was good. In addition, the Veteran stated that although he had been unsuccessful in his attempts to obtain a job, he planned to teach martial arts. In December 1998, the Veteran continued to have the ability to be fairly independent, and he had only a moderate degree of difficulty consistently relating to co-workers and interacting with supervisors. In May 2001, the Veteran reported that he was self-employed. In April 2005, the Veteran also asserted that he felt he was still able to work but preferred to stay away from the "rat race." In this respect, the Board has considered the particular focus of VA regulations on the Veteran's occupational impairment for rating purposes. The Board acknowledges that VA treatment records show the Veteran was hospitalized for treatment of PTSD from May 16, 2006 to May 26, 2006 and that a physician assigned a GAF score of 32. However, the record shows this time was extremely brief. In addition, the Board finds it significant that the Veteran's described symptoms during his hospitalization are consistent with his symptoms as reported during the rest of the periods at issue. In addition, the Board again notes Dr. Cesta's opinion that the Veteran had been 100 percent disabled since 1994. However, this opinion is inconsistent with the extensive treatment records and examination reports prepared by physicians treating the Veteran at the time of his reported symptoms. Therefore, the Board affords Dr. Cesta's findings less probative value than the contemporaneous evidence during these periods. VA treatment records also show a GAF of 40 in December 1994, but this also represents a very brief period of time and the GAF is based on the same level of symptoms that later led to GAF scores of 51-65. In light of that, the Board finds that there is no basis for a rating in excess of 50 percent prior to August 27, 2007. Resolving the benefit of the doubt in favor of the Veteran, the Board finds that the criteria for a disability rating of 50 percent, but no more, for anxiety disorder with PTSD have been met from July 14, 1998 to June 27, 2004 and from August 1, 2004 to August 26, 2007. See 38 C.F.R. § 5107(b); Gilbert, 1 Vet. App. 49 (1990). On and after August 27, 2007 On and after August 27, 2007, the Veteran's service-connected PTSD is currently rated as 50 percent disabling. To warrant a higher evaluation, the evidence must show occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 38 C.F.R. § 4.130. Given the above record, the Board concludes that the evidence demonstrates the Veteran's anxiety disorder with PTSD on and after August 27, 2007 was manifested by occupational and social impairment with deficiencies in most areas. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.130, Diagnostic Code 9411. The evidence demonstrates that the Veteran's anxiety disorder with PTSD was manifested by symptoms of depression, anxiety, anger, nightmares, flashbacks, intrusive thoughts, avoidance, isolation, extreme feelings of detachment, hypervigilance, impaired sleep, suicidal ideations, homicidal ideations, diminished interest, impaired impulse control, impaired memory, difficulty concentrating, difficulty in adapting to stressful circumstances, and inability to establish and maintain effective relationships. In February 2009, the Veteran reported that he could no longer contact old friends because it caused him great concern and increased his depression and anxiety. He stated that he had very little desire to do many of the things that he had once enjoyed. In September 2010, T. Heath opined that the Veteran's disturbances and symptoms caused clinically significant distress and social and occupational impairments. The June 2013 letter from Dr. Cesta shows the Veteran reported that his present life was of extremely poor quality, that he had a contentious relationship with wife, and that he had difficulties with basic communication. The Veteran was estranged from his children; he had no interactions with others, no friends, no interests, and no hope. On and after August 27, 2007, VA physicians and private physicians assigned GAF scores ranging from 35 to 55, which indicate some impairment in reality testing or communication, or major impairment in several areas, to moderate difficulty in social or occupational functioning. Here, the Board finds the Veteran's symptoms demonstrate major impairment in several areas, to include family relations, thinking, and mood, based on his reports of avoiding his friends, neglecting his family, and being unable to work. Dr. Cesta opined that the Veteran was completely unemployable and struggling with every social interaction, especially with his family. Dr. Cesta reported that the Veteran's thought content was positive for intermittent suicidal ideations and that he reported frequent thoughts of homicidal ideation. He had paranoid illusions and bizarre causal relationships, and his thought processing was neither linear nor logical. However, the Board finds that a rating in excess of 70 percent is not warranted for the Veteran's service-connected anxiety disorder with PTSD. The evidence of record does not show total occupational and social impairment. There was no gross impairment in thought processes, persistent delusions or hallucinations, grossly inappropriate behavior, intermittent ability to perform activities of daily living, disorientation to time or place, or memory loss for names of closest relatives, own occupation, or own name. The records demonstrate that the Veteran denied delusions and hallucinations, he was oriented, and his affect was appropriate. The evidence also does not demonstrate the presence of delusions, disorganized thinking, or hallucinations. In addition, Dr. Cesta reported that the Veteran did not have any auditory, visual, or tactile hallucinations, and he appeared cognitively intact. The November 2011 VA examiner opined that it was likely the Veteran would be able to function in an isolated work setting, although his high level of re-experiencing and extremely poor sleep would make it difficult to focus in a work-like setting. While this evidence suggests severe social and occupational impairment, it is not total impairment, nor does it most closely approximate total impairment. For these reasons, the Board finds that the criteria for a disability rating of 70 percent, but no more, for anxiety disorder with PTSD have been met on and after August 27, 2007. 38 C.F.R. § 4.130. TDIU on and after August 27, 2007 Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated as totally disabled. 38 C.F.R. § 4.16(b). Factors such as employment history, as well as educational and vocational attainments, should be considered. Id. For VA purposes, the term unemployability is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The word substantially suggests intent to impart flexibility into a determination of a veteran's overall employability, as opposed to requiring the veteran to prove that he is 100 percent unemployable. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities; provided that, if there is only one such disability, this disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a); see also 38 C.F.R. §§ 3.340, 3.341. For purposes of one 60 percent disability or one 40 percent disability in combination, disabilities of a common etiology or from a single accident are considered to be one disability. 38 C.F.R. § 4.16(a). Prior to the Board's decision, the Veteran's combined schedular rating for his service-connected disabilities was 10 percent from November 16, 1994 to December 20, 1994, 10 percent from March 1, 1995 to July 13, 1998, 30 percent from July 14, 1998 to June 27, 2004, and 30 percent from August 1, 2004 to August 26, 2007, with no single disability rated as 60 percent disabling. In addition, even with the Board's grant of increased ratings for those periods, the minimum schedular criteria for a TDIU were not met on those dates. On and after August 27, 2007, the Veteran's service-connected anxiety disorder with PTSD is now rated as 70 percent disabling. Thus, the minimum schedular criteria for a TDIU were met on August 27, 2007, and the question is whether the Veteran's service-connected disabilities alone were of sufficient severity to produce unemployability on and after August 27, 2007. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In September 2010, T. Heath opined that the Veteran's disturbances and symptoms were sure to cause social and occupational impairments, which would make it difficult to maintain employment. In addition, although the November 2011 VA examiner opined that it was likely the Veteran would be able to function in an isolated work setting, the examiner found the Veteran's high level of re-experiencing and extremely poor sleep would make it difficult to focus in a work-like setting. In this respect, Dr. Cesta opined that in reality there were no isolated work settings of the nature that would keep the Veteran safe and others safe. Dr. Cesta found that the Veteran was completely unemployable. In addition, the record shows that a December 2011 VA examiner opined that the Veteran's shin splints prevented him from working. Resolving the benefit of the doubt in the Veteran's favor, the Board finds that the Veteran's service-connected disabilities rendered him unable to secure or follow a substantially gainful occupation beginning August 27, 2007. Accordingly, entitlement to a TDIU is warranted on and after August 27, 2007. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER Entitlement to a disability rating of 50 percent, but no more, for anxiety disorder with PTSD is granted from November 16, 1994 to December 20, 1994; from March 1, 1995 to July 13, 1998; from July 14, 1998 to June 27, 2004; and from August 1, 2004 to August 26, 2007. Entitlement to a disability rating of 70 percent, but no more, for anxiety disorder with PTSD is granted on and after August 27, 2007. Entitlement to a TDIU is granted on and after August 27, 2007. REMAND As stated above, the minimum schedular criteria for a TDIU were not met from November 16, 1994 to December 20, 1994; from March 1, 1995 to July 13, 1998; from July 14, 1998 to June 27, 2004; and from August 1, 2004 to August 26, 2007. However, it is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). Rating boards are required to submit to the Chief Benefits Director or Director, Compensation and Pension Service, for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). Id. Where a veteran does not meet the schedular requirements of 38 C.F.R. § 4.16(a), the Board has no authority to assign a TDIU rating under 4.16(b) and may only refer the claim to the Chief Benefits Director or Director, Compensation and Pension Service, for extraschedular consideration. Bowling v. Principi, 15 Vet. App. 1 (2001). Based upon the VA treatment records, private treatment records, and Dr. Cesta's report, the Board concludes that the facts of this case meet the criteria for submission of the Veteran's claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of entitlement to a TDIU on an extraschedular basis from November 16, 1994 to December 20, 1994; from March 1, 1995 to July 13, 1998; from July 14, 1998 to June 27, 2004; and from August 1, 2004 to August 26, 2007. Therefore, remand is warranted. Accordingly, the case is REMANDED for the following actions: 1. Refer the claim to the Chief Benefits Director or the Director, Compensation and Pension Service, for consideration of whether a TDIU on an extraschedular basis is warranted from November 16, 1994 to December 20, 1994; from March 1, 1995 to July 13, 1998; from July 14, 1998 to June 27, 2004; and from August 1, 2004 to August 26, 2007. Include a full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issues. See 38 C.F.R. § 4.16(b). 2. After completing this and any other development deemed necessary, re-adjudicate the issues of entitlement to a TDIU from November 16, 1994 to December 20, 1994; from March 1, 1995 to July 13, 1998; from July 14, 1998 to June 27, 2004; and from August 1, 2004 to August 26, 2007. If any benefit sought remains denied, provide an additional Supplemental Statement of the Case to the Veteran and his representative, and return the appeal to the Board for appellate review after the Veteran has had an adequate opportunity to respond. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs