Citation Nr: 1336126 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 07-06 483A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with major depressive disorder, for the period of August 1, 2008 to December 20, 2012. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU), for the period of August 1, 2008 to July 28, 2011. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Debbie A. Breitbeil, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from July 1965 to July 1969. This matter is before the Board of Veterans' Appeals (Board) on appeal of a May 2006 rating decision of a Department of Veterans Affairs (VA) Regional Offices (RO) in Cleveland, Ohio, which granted service connection for PTSD, rated 30 percent. A February 2010 rating decision increased the rating for PTSD to 50 percent, effective July 15, 2008, after which a March 2011 rating decision amended the effective date to August 1, 2008, a temporary total (100%) disability rating had already been assigned through July 2008(under 38 C.F.R. § 4.29, based on hospitalization for PTSD in excess of 21 days). In October 2011 a Travel Board hearing was held before the undersigned; a transcript is associated with the record. At the hearing, the Veteran clarified that the only issue he was pursuing on appeal was that of a rating in excess of 50 percent for PTSD with major depressive disorder from August 1, 2008. In a March 2012 decision, the Board granted a 70 percent (but no higher) rating for the Veteran's PTSD with major depressive disorder from August 1, 2008. The Board also remanded the issue of entitlement to a TDIU rating. The Veteran appealed the Board's decision in part, as to the denial of a rating higher than 70 percent from August 1, 2008 for PTSD with major depressive disorder, to the United States Court of Appeals for Veterans Claims (Court). In an Order dated in October 2012, the Court granted a Joint Motion for Partial Remand of the parties (the Secretary of VA and the Veteran), and vacated the Board's decision to the extent that a rating higher than 70 percent from August 1, 2008 was denied, and remanded the case to the Board for readjudication consistent with the Joint Motion. Thereafter, while the Veteran's case was on remand to the RO (from the Board's March 2012 remand), a decision review officer (DRO) decision granted a 100 percent rating for PTSD with major depressive disorder (and dysthymia), effective December 20, 2012 (the date of a VA examination), and granted a TDIU rating, effective July 28, 2011 (the date of receipt of a TDIU application). As neither award was a complete grant of the benefits sought on appeal going back to August 1, 2008, the case has been returned to the Board for its further consideration. FINDINGS OF FACT 1. For the period of August 1, 2008 to December 20, 2012, the Veteran's PTSD with major depressive disorder is shown to be productive of a disability picture that more nearly approximates that of occupational and social impairment with deficiencies in most areas, such as work, family relations, and judgment, and an inability to establish and maintain effective relationships; his disability picture is without evidence of 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, and memory loss for names of close relatives, own occupation, or own name. 2. For the period of August 1, 2008 to July 28, 2011, the evidence shows that the Veteran was unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities. CONCLUSIONS OF LAW 1. A rating for PTSD with major depressive disorder in excess of 70 percent is not warranted for the period from August 1, 2008 to December 20, 2012. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code (Code) 9411 (2013). 2. A TDIU rating, is warranted for the period from August 1, 2008 to July 28, 2011. 38 U.S.C.A. §§ 1155, 5110 (West 2002); 38 C.F.R. §§ 3.400, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of: (1) the information and medical or lay evidence necessary to substantiate the claim, (2) the information and evidence VA will obtain, and (3) the information and evidence the claimant is to provide. VCAA notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009) (interpreting 38 U.S.C.A. § 5103(a) as requiring generic claim-specific notice and rejecting veteran-specific notice as to the effect on daily life and as to the assigned or a cross-referenced Diagnostic Code under which the disability is rated). Where, as here regarding PTSD (and TDIU as it flows from that claim), service connection has been granted and an initial disability rating has been assigned, statutory notice no longer required because the purpose that the notice was intended to serve has been fulfilled. The Veteran was properly notified (by statement of the case (SOC) and supplemental SOC) regarding the downstream issue of entitlement to an increased initial rating. Furthermore, VA has made reasonable efforts to identify and obtain relevant records in support of the claim for a higher rating for PTSD. 38 U.S.C.A. § 5103A(a), (b) and (c). The RO has obtained VA records and Social Security Administration records. The Veteran has furnished private psychological evaluation reports and opinions from Dr. Tripi and Dr. Goran. He has not identified any additionally available evidence for consideration in his appeal. Also, VA has afforded the Veteran VA examinations to assist him to substantiate his claim for a higher rating. 38 U.S.C.A. § 5103A(d). He underwent VA examinations to determine the severity of his PTSD in October 2008 and March 2011. As there is no indication of the existence of additional evidence to substantiate the claim, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claim is required to comply with the duty to assist. Legal Criteria Disability ratings are determined by applying the criteria in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes which outline the criteria specific for each disability. 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 required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. With the initial rating assigned following a grant of service connection, separate (staged) ratings may be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). When evaluating the level of disability from a mental disorder, the rating agency shall consider the extent of social impairment, but shall not assign an evaluation based solely on the basis of social impairment. The focus of the rating process is on industrial impairment from the service-connected psychiatric disorder, and social impairment is significant only insofar as it affects earning capacity. 38 C.F.R. §§ 4.126, 4.130. PTSD is evaluated under 38 C.F.R. § 4.130, Code 9411. 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 from PTSD under 38 C.F.R. § 4.130 is not restricted to the symptoms in Code 9411. 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 DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). PTSD is rated under the General Rating Formula for Mental Disorders (General Formula). A 70 percent rating is warranted when 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; 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); inability to establish and maintain effective relationships. 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. 38 C.F.R. § 4.130, Code 9411. The Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM-IV at 32. GAF scores ranging from 51 to 60 reflect more 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). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Scores ranging from 31 to 40 reflect 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 other children, is defiant at home, and is failing at school). Lesser scores reflect increasingly severe levels of mental impairment. See 38 C.F.R. § 4.130 [incorporating by reference VA's adoption of the DSM-IV, for rating purposes]. A total disability rating may be assigned where the schedular rating is less than 100 percent, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more such disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Factual Background The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal, as summarized in large part above. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000.) Hence, the Board will summarize the evidence as deemed appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claim. During the appeal period (since August 1, 2008), the Veteran was assigned two periods of temporary total evaluation for PTSD with major depressive disorder based on hospitalization (from mid-June through July 2009 and from late June through July 2010), and that such periods are not for consideration herein. On July 2008 VA inpatient discharge (just prior to the start of the relevant period for consideration in this appeal), the diagnosis was PTSD; a GAF score of 32 was assigned. On October 2008 VA examination, the examiner noted that the Veteran had been in treatment with primary care and psychiatry for PTSD groups; he had been resistant to attending VA groups but had been attending Vet Center groups regularly. The examiner noted that the most recent (2006) VA examination had resulted in a GAF score of 50. The Veteran reported that he had been divorced since 1986 (and later had "some girlfriends"). He lived with his younger daughter; he had been living with an older daughter and son-in-law but "was asked to leave because he was not contributing to the household." He reported a stable relationship with both daughters. He had a few friends, but no close friends; he had difficulty trusting others. He reported getting up in the morning to go to McDonald's for coffee then returning home to watch television and surf the internet. His daughter did not want him to do anything in the house; he just had to live there. He went to the mall to walk early in the morning, but never when it was busy because crowds and people troubled him. He went to group meetings at the Vet Center weekly. He reported he was twice (in 2006 and in 2008) admitted to a PTSD recovery unit, and would probably go again because it helped him to better understand himself; he felt the problem was that he was down and having trouble coping; he would leave the unit feeling great, only to worsen again. He reported feeling depressed five to six days out of the week. He reported feeling lost ever since he left Vietnam. He felt somewhat better when he was working and distracted though he was aware that the depression was still there. He reported feelings of suicidal ideation and plans at times, though he clearly denied intent; he distracted himself from the suicidal feelings by going for a ride, changing the TV channel, surfing the internet, or visiting with a Vietnam veteran who lived across the street to refocus his mind. He reported feelings of suicidal ideation two to three times per week, particularly on cloudy/rainy days. He denied ever making any suicidal attempt or any history of assaultive behavior. He reported being able to take care of his routine responsibilities of self-care, including doing his own laundry. He reported having a great deal of difficulty socializing with others, and that he found it difficult to hold conversations with others as he was disinterested in what they were saying and had nothing in common [with them]. He reported avoided violence on television. He did not attend church, as he found them hypocritical. He had no feeling of purpose or direction but was trying to find one. He had no interest in socializing. He reported problems with sleep disturbance, endorsing middle insomnia and the need for naps during the day. He reported anhedonia, and did not look forward to holidays or significant events. On mental status examination, the Veteran was casually dressed, neatly groomed, and pleasant and cooperative with good eye contact. He was marked by psychomotor retardation. He displayed a range of affect including becoming tearful several times when recalling Vietnam or discussing his ongoing struggles with depression. His thought process was intellectualized and "a bit plodding"; he was aware of this, stating that he overanalyzed things. His intelligence and fund of knowledge appeared above average. His recent and remote memory was intact; immediate memory was not tested. His cognition was felt to be grossly intact; though he reported difficulty with concentration, focus and distractibility. His mood was depressed and anxious, and his affect was flat. He denied auditory or visual hallucinations or paranoia, but reported general mistrust of others and discomfort with crowds and social engagements. There was no evidence of substance abuse or characterological problems. There was no evidence of any formal thought disorder. He admitted to periodic suicidal thoughts but no attempts, and denied any active suicidal or homicidal ideation, intent, or plan. His thought processes were goal-directed, and his insight and judgment were fair to good. The diagnosis was chronic PTSD and moderate recurrent major depressive disorder related to PTSD and ongoing adjustment difficulties. A GAF score of 45 was assigned, reflective of severe persistent psychological symptoms (depression, anxiety, intrusive thoughts, and sleep disturbance) with moderate impairment in social and occupational functioning. The examiner opined that the Veteran's mental health symptoms would likely cause severe discomfort when interacting with other people, and moderate to severe reduced communication effectiveness; the examiner opined that the Veteran's level of frustration, apathy, isolation, and inner turmoil would likely cause moderate to severe work inefficiency and lack of productivity, and his fatigue, frustration, and motivation problems would likely cause difficulty with reliability. The examiner opined that the amount of avoidance of social contact and confrontation shown would likely interfere severely with his ability to interact effectively. The examiner opined that the Veteran had some moderate reduction in ability to adapt to stressful circumstances such as workplace, classroom, or other social environments. The examiner opined that the Veteran was not an immediate danger to himself or others. On April 2009 VA treatment, the Veteran reported attending individual VA therapy and two outpatient groups, in addition to psychiatric care. His medications included Terazosin and Bupropion. He denied any history of suicidal attempts but admitted to ideation in prior months. He reported calling other veterans and talking when he thinks that way, and the ideation goes away; he also reported getting rid of his guns "a long time ago." He denied any current ideation of harming himself. He had been living with his daughter and son-in-law for the previous several years. His PTSD symptoms included re-experiencing, intrusive memories, and flashbacks triggered by helicopters; his nightmares related to war events had increased. He reported trouble falling asleep and staying asleep. His anxiety was very high and he felt unable to go to the store unless nobody else was there shopping. He felt irritable and was having more anger dysregulation. He reported social isolation and depressed mood; he found it hard to be around his veteran friends for coffee at McDonald's and felt forced by his anxiety to leave. He reported wanting to not isolate himself so much. On August 2009 private psychosocial evaluation, psychologist Dr. Tripi reviewed the Veteran's personal, employment, and treatment history. He was noted to be receiving treatment from a VA social worker and a psychiatrist as well as weekly Vet Center group sessions. The Veteran reported difficulty staying asleep, waking after two to three hours even with medication, and sometimes with physical reactions such as sweating. He reported problems with feeling frightened or confused in the past. He reported that he used to have frequent nightmares but could not recall having any currently. He reported daily intermittent intrusive, involuntary thoughts, and flashbacks regarding his military experiences, which would be triggered by the sight or sound of helicopters or airplanes, loud noises, or news of the war in Iraq. He became very upset around people, places, or events that reminded him of the military. He reported feeling emotionally numb and void of feeling since his separation from service. He reported difficulty trusting others, having no close friends, and having rocky interpersonal relationships. He tried to avoid thinking or talking about traumas over the years, and had difficulty remembering certain aspects of his traumas due to blanks in his memory. He reported feeling alienated from others, and had a sense of doom and negativity, noting that he felt like he had no purpose. He had lost interest in things he previously enjoyed. He reported frequent bouts of irritability and outbursts of anger, not always related to issues at hand. He reported that his concentration was affected, as his mind would wander and he became bored easily. He reported being hypervigilant; he preferred sitting with his back to the wall, checked doors and windows and scanned the environment, and had an exaggerated startle response. Dr. Tripi opined that the Veteran experienced severe social, personal, and occupational impairment due to symptoms including difficulty concentrating and completing tasks in a timely fashion, generalized anxiety with three to four panic attacks per week, waves of short and long term memory loss, flashbacks and intrusive thoughts, sleep disturbance, overwhelming feelings of anger and sorrow with crying spells, feeling withdrawn and isolative, and bouts of severe depression. The diagnosis was chronic delayed severe PTSD and a GAF score of 42 was assigned. Dr. Tripi opined that, although the Veteran was on medication and in therapy, his symptoms were severe and very active. She opined that, based on his education, training, work history, and level of symptoms, he was not a viable rehabilitation candidate, nor was he capable of sustaining substantial gainful work activity. On January 2010 VA treatment, the Veteran reported difficulty expressing emotions as he had learned to "turn them off" in the military. He reported that it felt weak crying in front of someone else, and he cried when he was alone. He reported war-related nightmares and attempted to process two specific dreams involving feelings of guilt, regret, and helplessness. On mental status examination, the Veteran was appropriately dressed and groomed with good eye contact. His demeanor was talkative and pleasant. His speech was within normal limits. His affect was normal, tearful at times and joking at other times, and his mood was stable. He was fully oriented and his thought process and content were coherent and logical. He denied any suicidal or homicidal ideations, and his insight and judgment were good. On February 2010 VA treatment, the Veteran reported living with his daughter and son-in-law. He continued to have problems and symptoms related to trauma in service. He reported intrusive thoughts, nightmares, exposure distress with physiological reaction, avoidance of thoughts and feelings and related situations, anhedonia at times, emotional numbing, sleep difficulty, irritability, hypervigilance, and an exaggerated startle response. He was receiving psychiatric treatment as well as individual and group therapy. He denied any alcohol or drug use. He denied any history of suicide attempts, and he was not currently suicidal or homicidal. His mood was "mellow" and he was open and cooperative, logical and focused. He reported no hallucinations. In an August 2010 statement, the Veteran's treating psychologist, Dr. Goran, noted that she had been treating the Veteran for PTSD since May 2010. He was clean but ungroomed and poorly dressed, and he was very anxious and intense. He had brought numerous documents with him to validate his history as though he did not expect to be believed. He was polite and cooperative and answered all questions thoughtfully. He reported having more than 20 different jobs from 1969 to 2005, with his longest position as a self-employed computer consultant from 1985 to 1990. He reported that he had been fired from one job after having an altercation with his boss. He reported that he had been unable to find and keep work since October 2005. Regarding treatment, Dr. Goran noted a history of multiple VA hospitalizations for PTSD and treatment at several other VA medical centers and Vet Centers. Dr. Goran noted the Veteran's recent release from another inpatient hospitalization, prior to which he had been living with his daughter and avoiding all other social contact as much as possible. He frequently felt suicidal, slept poorly and had frequent intrusive thoughts, and was hypervigilant and irritable with no sense of connection to anyone but his daughters. The diagnoses were PTSD and recurrent major depressive disorder. Dr. Goran opined that the Veteran was unable to obtain and maintain gainful employment (including sedentary types) and this inability was directly related to his service-connected condition. The opinion was based on the Veteran's symptoms and history and the multiple statements, records, and other opinions examined. On August 2010 discharge from VA inpatient treatment, a GAF score of 31 was assigned for PTSD. The Veteran was noted to be stable for discharge with euthymic mood and no evidence of psychosis; he was not considered a suicidal or homicidal risk. In a September 2010 summary statement, the Veteran's treating Vet Center therapist noted that the Veteran had been receiving counseling at the Vet Center since March 2007, initially individually and then in group therapy. The therapist noted that the Veteran struggled with nightmares, sleep difficulty, irritability, high stress levels, anxiety, depression, and crying spells, with daily intrusive memories of the war, emotional numbness, and difficulty getting close to others. The therapist noted that the Veteran had difficulty with trust and had very limited social interaction. The therapist noted that the Veteran avoided crowds and calculated the right time to leave home in order to perform necessary obligations without facing crowds. The therapist noted that the Veteran was awarded Social Security disability benefits in August 2007. The therapist opined that the Veteran's chronic PTSD had impaired his ability to function productively. On November 2010 VA treatment for medication management, the Veteran was noted to be taking Bupropion and Prazosin, with no side effects. He reported that he spent most of his time at home but did not elaborate. On mental status examination, he was alert with fairly good grooming and good eye contact. His speech was fluent and spontaneous. His affect was brighter and his thinking was logical. He denied any suicidal or homicidal ideation at that time. The diagnoses were chronic PTSD and recurrent major depressive disorder in partial remission; a GAF score of 45 was assigned. On further November 2010 VA treatment, the Veteran reported his ongoing issues with his PTSD and symptoms of depression. He reported intrusive thoughts, nightmares, avoidance, arousal, and depression. He was attending group therapy regularly and receiving psychiatric care, as well as attending a group at the Vet Center. He was motivated for treatment but understood that he would "never be like [he] was before Vietnam." He denied active suicidal or homicidal ideations or any plan of harm. On mental status examination, he was well groomed, attired appropriately for the weather, pleasant and cooperative. His speech was within normal limits. His mood was stable and his affect was euthymic. He was fully oriented. His thought process and content were coherent, logical, and goal-directed, and his insight and judgment were good. On February 2011 VA treatment, the Veteran reported that he was living with his daughter and her husband after losing his own home several years earlier. He became emotional when discussing his PTSD and his feelings about how much it had cost him. He reported that about two months earlier, he had a "realization" of all that he had lost due to his problems related to his service; he was focused on these problems and struggled with grief and sadness. He denied any active suicidal or homicidal ideations or plan of harm. On mental status examination, he was well groomed and appropriately attired for the weather, and he was pleasant and cooperative. His speech was within normal limits. His affect was euthymic, and his mood was stable though tearful at times. He was fully oriented, and his thought process and content were coherent, logical, and goal-directed. His insight and judgment were good. On later February 2011 VA treatment for medication management, the Veteran was noted to be taking Bupropion and Prazosin. He reported that his nightmares were greatly diminished with these medications and he was sleeping much better with no reported side effects. He reported that he was seeing a new PTSD counselor and it was going well. He reported having flashbacks the previous December about how his life had been for the previous 25 years and he became very emotional; he clarified that he had been thinking intently about his mental illness and viewed these years as a waste due to his PTSD. On mental status examination, the Veteran had fairly good grooming and good eye contact. His speech was fluent and spontaneous. His affect was appropriate and his thinking was logical. He denied any suicidal or homicidal ideation. The diagnoses were chronic PTSD and recurrent moderate major depressive disorder in partial remission; a GAF score of 45 was assigned. On March 2011 VA examination, it was noted that the Veteran had been treated in intensive PTSD in-patient programs in 2006, 2008, 2009, and 2010, and that his GAF score at the time of his last discharge was 31. The examiner noted that the Veteran continued to receive treatment for PTSD and depression and his most recent GAF score of 45 on February 2011 treatment. The examiner reviewed the history of diagnoses and treatment for depression, then dysthymia, then PTSD and major depression. The Veteran denied any history of assault, violence, or suicide attempt since his previous [2008] VA examination; however, he did report recurrent frequent suicidal ideation. There was no history of substance abuse; the Veteran reported a history of alcohol abuse, and that he had cut back drinking on his own when he realized it was "not taking him to good places"; he had not had a drink since 2006. The examiner noted that the Veteran was being seen by the VA clinic psychiatrist approximately every three months, and attended monthly VA individual therapy and weekly PTSD and smoking cessation group therapy, in addition to a PTSD group at the Vet Center. The Veteran reported that each PTSD hospitalization reduced his symptoms but the reduction was short-lived and the symptoms increased again within a month or two. The Veteran reported improved sleep initiation and maintenance, getting eight hours of restful sleep per night, and improved anxiety on his current medications of Wellbutrin and Prozac, with no side effects. He reported chronic symptoms of depression, anxiety, and PTSD, ranking his depression at five or six out of 10 in severity and his anxiety at five out of 10. He reported having panic attacks two to three times per week, brought on by stress and traumatic cues; he reported severe panic attacks once per month. He reported chronic difficulties with irritability and poor frustration tolerance, and he tended to become quiet when angry; on rare occasions, he would take his anger out on inanimate objects. He reported periodic road rage. He denied impulsivity but reported chronic serious difficulties with hypervigilance; he reported that he needed to sit with his back to the wall, repeatedly checked doors and windows, and did perimeter checks when up at night. He reported increased startle response, frequent crying spells, and chronic difficulties with motivation and apathy. He reported serious difficulty with discomfort when exposed to crowds, and no longer went to malls, sporting events, movie theaters, or crowded stores or restaurants; he would go to less crowded restaurants or stores with moderate to severe discomfort. He reported difficulty with mistrust and suspiciousness as well as social withdrawal and periods of social isolation. He reported that he had no friends, and that he kept to himself in his own part of the house despite living with his daughter and son-in-law. He denied any difficulty with energy but reported chronic difficulties with interests and chronic serious difficulties with hopelessness, helplessness, excessive guilt, concentration, focused attention, and distractibility. He reported that he was no longer able to read on a regular basis due to poor concentration, and that he had some difficulty with word processing programs, even though he had worked in programming for much of his career. He denied any appetite problems. He reported daily suicidal thoughts but denied any current active suicidal or homicidal ideation, intent or plan. He was divorced with two adult daughters, with whom he had good relationships and regular contact. He had no close friends and did not socialize with neighbors; his socializing was limited to his children and veterans in his PTSD group. He reported being able to attend to activities of daily living, such as shopping, cooking, cleaning, or laundry without difficulty. He reported being neglectful of personal hygiene, showering twice per week and shaving only once per week. He reported that he had withdrawn from activities he previously enjoyed such as reading or going to the mall to walk. He spent much of his time watching movies and surfing the internet. He had been unemployed since 2005. On mental status examination, the Veteran was timely, pleasant, and cooperative with good eye contact. He was periodically tearful, especially when discussing his traumas and the impact of his PTSD on his life. His speech was regular in rate and rhythm, relevant, spontaneous, articulate, and coherent. He appeared able to advocate well for himself, presenting the examiner with many organized documents chronicling his work history, where he had lived, and accounting for his symptoms, traumatic cues, and medications. He was noted to have a tendency to be over-inclusive, and he was difficult to disengage at the end of the interview, as he continued to list additional symptoms and difficulties he was having. His hygiene was adequate; he was unshaven, and his clothing was clean and weather-appropriate. He was alert and oriented to all spheres. His memory was intact for recent and remote; immediate memory was not tested. His cognition was felt to be grossly intact without noticeable difficulties in concentration, focused attention, or distractibility. His intelligence and fund of knowledge appeared average. His mood was depressed and anxious; his affect was blunted but easy to engage in that he was initially guarded but was able to establish a rapport with the examiner. He reported mistrust and suspiciousness. He denied auditory or visual hallucinations, delusions, or paranoia, and there was no evidence of any formal thought disorder. He denied any symptoms of mania, hypermania, or obsessive compulsive disorder. He reported chronic difficulties with discomfort in crowds as well as frequent panic attacks but denied impulsivity. He reported irritability, poor frustration tolerance, and outbursts of anger but denied any assaults or violence. He reported hypervigilance, crying spells, and difficulties with motivation, apathy, depression, anxiety, interests, hopelessness, helplessness, guilt, and concentration. His thought processes were goal-directed with some tendencies toward over-inclusiveness and tangentiality. He reported daily distressing recollections and feeling as if the event were recurring with intense psychological distress and physiological reactivity on exposure to cues. He reported avoidance symptoms, marked diminished interests in participating in significant activities, feelings of detachment and estrangement form others, a restricted range of affect, and a sense of a short future. There was no evidence of any substance abuse or underlying personality disorder. Insight and judgment were good. The March 2011 examination diagnosis was PTSD with severe recurrent major depression; a GAF score of 35 was assigned. The examiner explained that the Veteran presented with serious symptomatology and his depression was felt to be due to his chronic PTSD symptoms and psychosocial functioning difficulties due to PTSD, noting that the PTSD and depressive symptoms could be considered collectively as there was such an overlap between the two that it would be speculative to try to differentiate which symptoms would be due to any one condition. The examiner opined that the Veteran had serious difficulties with interpersonal functioning, as evidenced by his lack of friends, social withdrawal, social isolation, chronic difficulties with mistrust, and withdrawal from activities which he previously enjoyed. The examiner noted that the Veteran had moderate difficulty interacting socially and serious discomfort in crowds, and presented as someone who would have moderate difficulty adapting to stressful situations in a work, classroom, or social setting. The examiner noted moderate difficulty establishing and maintaining effective work relationships and serious difficulty maintaining social relationships. The examiner noted that the Veteran's thinking processes were logical and would not adversely affect his social or vocational functioning, though his communication was somewhat reduced due to circumstantiality, over-inclusiveness and emotional detachment. The examiner noted chronic difficulties with concentration, focused attention, distractibility, inner turmoil, apathy, and motivation which would as likely as not lead to periodic missed days from work and moderate to serious reduction in occupational productivity, reliability, efficiency, or work performance. The examiner noted that, despite therapeutic and pharmacological interventions, the Veteran's symptoms remained quite severe and would likely remain chronic with some periodic worsening in response to additional stressors or losses. On March 2011 VA treatment, the Veteran denied any thoughts of suicide or homicide. He reported that he wanted to be less concerned about getting "ticked off" and angry, and his anger was still a significant problem for him; he reported being afraid of going places that might set him off. His insight was fair in that he was aware of his illness and expressed a desire and motivation for change. He reported having a supportive family and/or friends; he reported that he lived with family but was not necessarily happy with his living situation, though he was wary of getting his own place because he knew how much he isolated himself from others. His treatment plan priorities included reducing the frequency and intensity of his irritability and outbursts of anger, and establishing the skills needed for building trust and managing emotions in relationships to reduce his feelings of detachment from others. The treatment plan included monthly individual therapy for six months and weekly PTSD group therapy for six months. The diagnoses included PTSD and major depression; a GAF score of 45 was assigned. The Veteran has also submitted lay statements chronicling his symptoms. VA and Vet Center treatment records through March 2011 reflect findings largely similar to those noted above. At an October 2011 Board hearing, the Veteran's representative noted that from 2008 to the present the Veteran's GAF scores have ranged from 31 to 45, and no higher. The Veteran testified that he frequently became irritable to the point where he could not work. He testified to having impulse control problems such as angry outbursts that would affect his ability to be employed. He testified that he was not able to maintain effective relationships. He was able to go out to public places such as the grocery store, but testified that he went at times when there were no crowds. He had been told by Dr. Goran that he was not employable due to his PTSD symptoms; the Veteran's representative referred to Dr. Goran's statement as well as vocational rehabilitation documents indicating that the Veteran's occupational functioning is impacted by his PTSD to the point that employment is not feasible. The Veteran testified that he was able to communicate with people to a certain extent, but not very well; he was able to write only short emails. He denied having any persistent hallucinations or delusions, though he testified that he used to have them. He testified that he had felt like he was a danger to himself or others, so he isolated himself "so not to get into trouble" or harm people. He had not had any homicidal ideation, but often had suicidal ideation (though with no attempts). He testified that he had had outbursts in public, such as when he believed someone was not telling the truth and he argued and screamed in response. He testified that he neglected his personal hygiene because he just did not care, but was able to perform activities of daily living including maintenance of minimal personal hygiene if he wished to do so. He testified that he was oriented to place, time, and day, and knew his immediate family. On April 2012 private psychosocial reassessment and employability reevaluation, Dr. Tripi reviewed the Veteran's employment history and noted that the Veteran was receiving psychiatric treatment at the VA to include group therapy at the Vet Center. Her review included VA treatment records dated up to March 2012. Of his current symptoms, the Veteran continued to have difficulty sleeping. He had daily intermittent intrusive and involuntary thoughts regarding his military experience. He had flashbacks. He became extremely upset around places, people, and events that reminded him of the military. He continued to feel emotionally numb and void of feeling since his return from the military. He had difficulty in trusting others and had no close friends and rocky interpersonal relationships. He avoided thinking or talking about his traumas. He felt alienated and separate, and had a sense of doom and negativity. He lost interest in things he previously enjoyed and had difficulty remembering certain aspects of his traumas as there were blanks in his memory. He continued to have bouts of irritability and outbursts of anger, and his concentration was affected. He was hypervigilant and checked doors and windows and scanned his environment. He exhibited exaggerated startle response. Dr. Tripi stated that the following symptoms caused severe social, personal, and occupational impairment in the Veteran: difficulty concentrating and completing tasks in a timely fashion, generalized anxiety with three to four panic attacks per week, waves of short and long-term memory loss, flashbacks/intrusive thoughts, sleep disturbance, overwhelming feelings of anger and sorrow with crying spells, withdrawn and isolative, and bouts of severe depression. The diagnosis was PTSD, severe; a GAF score of 40 was assigned. In conclusion, Dr. Tripi found the Veteran's PTSD symptoms to be severe, despite the medication he took and the frequent therapy. Based on his education, training, work history, and current level of symptoms, it was Dr. Tripi's opinion that the Veteran was "not a viable rehabilitation candidate, nor is he capable of sustaining substantial gainful work activity." She stated the Veteran was not employable. On December 2012 VA examination, the examiner diagnosed continuing severe PTSD and major depressive disorder, and stated that new environmental stressors and a change in psychotropic medication regime may be playing a role in the escalation of PTSD symptoms. Of note was the Veteran's report of increased irritability and anger outbursts, difficulties in concentration (cannot remember conversations), and severe panic symptoms. The Veteran also reported hearing noises but not voices, and sometimes he saw things that were not there but believed that they may be flashbacks. They did not appear to be psychotic events. The examiner assigned a GAF score of 31, later highlighting (in a January 2013 addendum report) that the GAF indicated a decrease from the private April 2012 assessment of a GAF score of 40. On mental status examination, the Veteran was casually dressed and slightly disheveled/unkempt. He cooperated fully and maintained good eye contact. He was oriented to person, place, and time. His speech was of normal rate and flow. His mood endorsed depressive and anxious symptoms; no panic symptoms were reported. His affect was anxious, sad, and tearful. His thought content endorsed suicidal ideation periodically but not currently; he denied homicidal ideation, delusions, and auditory/visual hallucinations. His thought process was coherent, focused, and organized; he denied obsessive thoughts. His attention and concentration was characterized by distractibility, forgetgfulness, and difficulty concentrating. Short term memory loss was noted due to inattention; long term memory was intact. Insight/judgment was intact. The examiner concluded that the level of occupational and social impairment of the Veteran was best summarized by impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood [as is described in the criteria for a 70 percent rating under Diagnostic Code 9411], and not total occupational and social impairment [as is described in the criteria for a 100 percent rating under Code 9411]. PTSD Rating The issue at hand is whether the evidence supports the Veteran's claim for a 100 percent schedular rating for PTSD with major depressive disorder for the period of August 1, 2008 to December 20, 2012. After evaluating the evidence, the Board finds that the Veteran's symptoms of PTSD with major depressive disorder are clearly productive of severe impairment, but they are not so severe as to affect his everyday life and his ability to function to a degree that more nearly approximates the schedular criteria for a 100 percent rating. That is, for the period in question, as will be explained the Veteran's PTSD with major depressive disorder, while causing severe occupational and social impairment, is not characterized by symptoms of similar type and degree as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting himself or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives/own occupation/own name. Private and VA medical evidence shows that the Veteran lived a rather isolated life, with no interest in socializing. He had no close friends and lived with one of his daughters. Any socializing was limited to his children and veterans in his PTSD group. Nonetheless, his thought processes were not disordered and were generally goal-directed, although sometimes marked by over-analysis of things as noted by the October 2008 VA examiner, or by a tendency toward over-inclusiveness and tangentiality as noted the March 2011 VA examiner. In VA treatment records (in January 2010 and February 2011, e.g.) his thought process and content were noted to be coherent and logical. He was cooperative during examinations, with good eye contact, and his speech and communication abilities were not shown to be grossly deficient. His speech was fluent and spontaneous and his thinking was logical on a November 2010 VA treatment record. On the March 2011 VA examination, his communication was reduced only "somewhat" due to circumstantiality, over-inclusiveness, and emotional detachment. As for grossly inappropriate behavior, the Veteran felt irritable and reported anger outbursts, yet there is no evidence that he posed a persistent danger to himself or to others. The Veteran has denied any history of assault or violence, as noted on a VA examination in March 2011, although he did then also report having taken his anger out on inanimate objects (but on rare occasions) and having periodic road rage (yet he at the same time denied impulsivity, and maintains a license to drive). He frequently reported suicidal thoughts, but there was never any plan or intent to carry out his thoughts, as noted on the October 2008 VA examination. The medical reports also do not show any intent to carry out any homicidal thoughts. Thus, there is no evidence to demonstrate the Veteran presented a persistent danger to himself or others, as the October 2008 examiner noted. Moreover, the Veteran does not have persistent delusions or hallucinations. VA and private reports do not reflect that his PTSD with major depressive disorder has been marked by any psychotic episodes or behavior. He denied hallucinations and paranoia on VA examinations in October 2008 and March 2011. Even when records reflect GAF scores of 40 or less, such as when he was discharged from VA inpatient care in July 2008 and in August 2010, there are no particular findings of any delusions or hallucinations. In fact, in August 2010 he was noted to have a euthymic mood and no evidence of psychosis after his inpatient treatment. The Veteran himself has readily admitted, as on VA examination in March 2011, that following VA inpatient treatment his PTSD symptoms were improved. The evidence also reflects that the Veteran does not lack the ability to perform activities of daily living. He was usually dressed appropriately and neatly, even if at times, such as in August 2010 with Dr. Goran, he was found to be ungroomed but clean, and from all reports he tended to his own personal needs without the requirement of the assistance of another. He took care of his routine responsibilities of self-care including doing his own laundry. On VA examination in March 2011, although he indicated that he could be neglectful of personal hygiene (e.g., showering twice a week and shaving once a week), he appeared to maintain basic, minimal hygiene (his hygiene on examination was noted as adequate); he also related that he could shop, cook, clean, and do laundry without difficulty. Mental status examinations show that the Veteran generally was cooperative, alert, and oriented. As noted on some VA outpatient treatment records, his demeanor was talkative and pleasant, with normal speech. For Dr. Goran in August 2010, he answered all questions thoughtfully. The Veteran's attention, concentration, and focus were impaired, which appears to have affected his memory (the VA examiner in December 2012 observed that short term memory loss was due to inattention). Recent and remote memory was usually assessed as intact or fair, although Dr. Tripi noted in her reports that the Veteran had "waves" of short and long term memory loss. Nevertheless, such memory loss is not shown to have been so severe that the Veteran could not recall his own name or those of close family. On VA examination in March 2011, his recent and remote memory was intact. Furthermore, the Board finds that the GAF scores assigned during the period at issue do not provide a separate basis for a rating higher than 70 percent. The symptoms and level of impairment represented by the GAF scores of 31 to 45 reflect moderate to serious disability, which does not warrant a 100 percent schedular rating. The lowest GAF scores of 31 and 32 were assigned at the time of discharge from VA inpatient PTSD treatment, but as noted previously the Veteran himself had described his symptoms as being improved (reduced) upon discharge. The Veteran's GAF scores are not indicative of a type of behavior that is considerably influenced by delusions or hallucinations, serious impairment in communication or judgment, or inability to function in almost all areas. For the reasons articulated above, the symptoms of the Veteran's PTSD with major depressive disorder more closely approximate the type and severity of symptomatology associated with the criteria for a 70 percent rating under Code 9411 for throughout the entire period from August 1, 2008 to December 20, 2012. The findings do not more nearly approximate a disability picture of total occupational and social impairment so as to warrant a 100 percent rating. The preponderance of the evidence is against a schedular rating in excess of 70 percent for PTSD with major depressive disorder; therefore, the benefit-of-the-doubt provisions do not apply. 38 U.S.C.A. § 5107(b). Extraschedular Consideration Although the Board is precluded by regulation from assigning an extraschedular rating under 38 C.F.R. § 3.321(b)(1) in the first instance, the Board is not precluded from considering whether the case should be referred to the Director of VA's Compensation and Pension Service for a rating. The threshold factor for extraschedular consideration is a finding that the evidence presents such an exceptional disability picture that the available schedular ratings for that service-connected disability are inadequate. This is accomplished by comparing the level of severity and symptomatology of the service-connected disability with the established criteria. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the Rating Schedule, and the assigned schedular evaluation is, therefore, adequate and referral for an extraschedular rating is not required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology, and provide for a higher rating for the most severe symptoms. As the disability picture is encompassed by the Rating Schedule, the assigned schedular rating is, therefore, adequate. Consequently, referral for extraschedular consideration is not required under 38 C.F.R. § 3.321(b)(1). TDIU In March 2012, the Board remanded the case so that the RO could fully develop and adjudicate the matter of the Veteran's entitlement to a TDIU rating. As was noted in the remand, the Court has held, in essence, that when the matter of entitlement to a TDIU rating is raised by the record in a claim for increase, such matter becomes part of the increased rating claim. Rice v. Shinseki, 22 Vet. App. 447 (2009) (a request for a TDIU rating, either stated or implied by a fair reading of the claim or of the evidence of record, is not a separate claim for benefits, but part of the claim for increase). Further, where a veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a TDIU rating. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). In the Board remand, it was acknowledged that in this case a TDIU rating had been expressly raised by the Veteran, when he submitted VA Form 21-8940, Application for Increased Compensation Based on Unemployability, in July 2011. It was also acknowledged that on various VA treatment records and examinations before he filed VA Form 21-8940, the Veteran had reported he had not worked since 2005 and believed his PTSD and major depressive disorder contributed to his inability to obtain and maintain a job. He obtained medical opinion letters, specifically from Dr. Tripi and Dr. Goran, to support his position. Thereafter, in a June 2013 rating decision, the RO granted a TDIU rating, effective July 28, 2011, which is the date of receipt of the application for TDIU. However, as previously noted in caselaw, the Veteran's TDIU rating issue became part of his claim for a higher rating for PTSD when it was raised by the record, which pre-dates the effective date of July 28, 2011. In other words, entitlement to a TDIU rating for the period prior to July 28, 2011 is still for appellate consideration. At his October 2011 hearing, the Veteran asserted that he was only pursuing the matter of a rating higher than 50 percent for PTSD from August 1, 2008. Given such intent, as well as the fact that a rating higher than 70 percent for PTSD is not established until after July 28, 2011, the Board will consider whether the Veteran is entitled to a TDIU rating for the period of August 1, 2008 to July 28, 2011. At the outset, the Board notes that for the period of August 1, 2008 to July 28, 2011, the Veteran meets the schedular criteria for a TDIU rating, as he has two or more disabilities for that period and at least one disability is ratable at 40 percent or more, with sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). His service-connected PTSD with major depressive disorder alone is rated 70 percent disabling from August 1, 2008. The Board finds that the Veteran meets the criteria for a TDIU rating for the period from August 1, 2008 to July 28, 2011; that is, the evidence shows during the period he was unable to pursue substantially gainful employment due to service-connected disability. Twice during the period at issue, in June 2009 and June 2010, the Veteran was admitted to an inpatient VA program for treatment of his PTSD symptoms. Also during the period at issue, the Veteran's GAF scores were generally in the range of 35 to 45, which represents impairment in functioning to the extent that the Veteran would be unable to work or unable to keep a job due to his service-connected mental disability. Additionally, the Veteran has submitted written reports, dated in August 2009 and August 2010, from two different clinical psychologists, Dr. Tripi and Dr. Goran, who interviewed him, conducted psychological testing, reviewed his treatment records including VA records, and rendered diagnostic impressions based on the information obtained. Dr. Tripi and Dr. Goran were in agreement that based on the Veteran's education, training, work history, and level of symptoms related to his service-connected mental disability, he was not a viable rehabilitation candidate, nor was he capable of sustaining substantial gainful work activity, to include sedentary types of employment. While VA examiners in October 2008 and March 2011 assessed the Veteran's service-connected mental disability as productive of moderate impairment in social and occupational functioning, they nonetheless described the Veteran's PTSD with major depressive disorder in such terms that it is reasonable to find the Veteran was essentially rendered unemployable by his mental disability. For example, the VA examiner in October 2008 believed that the Veteran's level of frustration, apathy, isolation, and inner turmoil would probably cause moderate to severe work inefficiency and lack of productivity, and that his fatigue, frustration, and motivation problems would probably cause difficulty with reliability. The VA examiner in March 2011 believed the Veteran's chronic difficulties with concentration, focused attention, distractibility, inner turmoil, apathy, and motivation would probably lead to periodic missed days from work and moderate to serious reduction in occupational productivity, reliability, efficiency, or work performance. Moreover, the Veteran's Vet Center therapist in September 2010 noted that the Veteran was receiving Social Security disability from 2007 and that his PTSD impaired his ability to function productively. Such assessments are persuasive in demonstrating that the Veteran would be unable to both obtain and maintain substantially gainful employment. After consideration of all the relevant evidence, the Board finds that the Veteran was unemployable due his service-connected disabilities for the period of August 1, 2008 to July 28, 2011, and that a TDIU rating for that specific period is warranted. ORDER The appeal seeking a rating in excess of 70 percent for PTSD with major depressive disorder for the period from August 1, 2008 to December 20, 2012 is denied. A TDIU rating is granted for the period of August 1, 2008 to July 28, 2011, subject to the regulations governing payment of monetary awards. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs