Citation Nr: 1336586 Decision Date: 11/08/13 Archive Date: 11/22/13 DOCKET NO. 09-44 344 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder for the time period from March 16, 2006, to March 4, 2013. 2. Entitlement to an increased evaluation for posttraumatic stress disorder, currently evaluated as 70 percent disabling for the time period from March 5, 2013. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability for the time period prior to March 5, 2013. ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The Veteran served on active duty from March 1968 to October 1969. This matter come before the Board of Veterans' Appeals (Board) on appeal from July 2007, August, 2009, and September 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. FINDINGS OF FACT 1. From March 16, 2006, the medical evidence of record shows that the Veteran's PTSD was manifested by near-continuous depression affecting the ability to function independently, appropriately and effectively, social withdrawal, nightmares, fatigue, low motivation, suicidal ideation, panic attacks, decreased concentration, anxiety, irritability, sleep impairment, difficulty adapting to stressful circumstances, total occupational impairment, and almost total social impairment, that results in occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood; total occupational and social impairment has not been shown. 2. From March 16, 2006, the Veteran is precluded from securing or following substantially gainful employment as a result of his service-connected PTSD. CONCLUSIONS OF LAW 1. From March 16, 2006, to March 4, 2013, the criteria for an evaluation of 70 percent, but no more, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). 2. From March 5, 2013, the criteria for an evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). 3. From March 16, 2006, the criteria for entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claims herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2013). The Veteran's claims of entitlement to initial increased evaluations for PTSD arises from his disagreement with the initial evaluation assigned following the grant of service connection. Once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed. The duty to assist the Veteran has been satisfied in this case. The RO has obtained the Veteran's service treatment records, records from the Social Security Administration (SSA), and his identified private and VA outpatient and inpatient treatment records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. Moreover, the Veteran has been afforded multiple VA examinations and medical opinions in April 2007, February 2010, March 2011, May 2012, and March 2013 that are adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Specifically, the VA examiners took into account the Veteran's statements and treatment records, which allowed for fully-informed evaluations of Veteran's service-connected PTSD during the appeal period. Id. As such, there is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini, 18 Vet. App. at 120. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); see also Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2013). The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2013). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2013). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Historically, in March 2006, the Veteran submitted a claim of entitlement to service connection for PTSD, which was granted in July 2007. An initial 30 percent rating was assigned for the Veteran's service-connected PTSD, effective March 16, 2006. In an August 2009 rating decision, a 50 percent evaluation was assigned, effective March 16, 2006. In March 2011 and January 2013, the Board remanded this matter for additional development, to include obtaining VA examinations. In March 2011, the Board determined that the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) was part and parcel of the determination of the evaluation for the Veteran's service-connected PTSD and was properly before the Board. See Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009) (holding that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities; if the claimant or the record reasonably raises the question of whether the veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for an increased rating is whether a total rating based on individual unemployability as a result of that disability is warranted). In a March 2013 rating decision, the RO granted entitlement to a TDIU as well as assigned a 70 percent evaluation for the Veteran's PTSD, each effective from March 5, 2013. After issuing a supplemental statement of the case in March 2013, this matter was returned to the Board for adjudication. Where a Veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous. . . ." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id.; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). Pursuant to Diagnostic Code 9411, PTSD is rated 50 percent when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty 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. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). A 70 percent disability 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. Id. A 100 percent disability rating is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; gross 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, Diagnostic Code 9411 (2013). The symptoms listed in Diagnostic Code 9411 are not intended to constitute an exhaustive list, but rather 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). In addition, in Mittleider v. West, 11 Vet. App. 181 (1998), the U.S. Court of Appeals for Veterans Claims (Court) held that VA regulations require that when the symptoms and/or degree of impairment due to a veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF of 31 to 40 is defined as 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. Id. A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Id. A GAF of 51 to 60 is defined as 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). Id. A GAF of 61 to 70 is defined as some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful relationships. Id. VA regulations require that when the symptoms and/or degree of impairment due to a veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. Mittleider v. West, 11 Vet. App. 181 (1998). As discussed in detail below, a VA examiner in a March 2011 examination report indicated that the Veteran's MDD was not secondary to his PTSD given that he did not report symptoms of MDD until about 5 years before, when he stopped working and stopped using drugs and alcohol. Another VA examiner in a May 2012 medical opinion stated that there was "some" symptom overlap between PTSD and MDD, including sleep disturbance, difficulty concentrating, and loss of interest, indicating that the MDD and PTSD had a degree indistinguishable symptomatology. However, in a March 2013 examination report, after a thorough review of the entirety of the record, a VA examiner specifically opined that the Veteran's MDD and PTSD were at least as likely as not inter-related (not separate and distinct disorders). The March 2013 VA examiner highlighted that evidence of record showed that the Veteran's symptoms of depression, PTSD, and alcohol dependence were all present at the same time and that his report of history suggested that the onset of all three disorders was at the same time. Based on the foregoing, the Board will attribute all the Veteran's psychiatric symptoms to his service-connected PTSD residuals. A longitudinal review of the claims file showed the Veteran filed his claim for entitlement to service connection for PTSD in March 2006. An April 2006 letter and DSM IV Criteria for PTSD checklist from the Vet Center were associated with the record. A therapist indicated that the Veteran presented with marked verbal and physical anxiety and had suppressed memories for many years. It was noted that the Veteran remained highly sensitive to smells of fuel and death, that reexperiencing was clear during his interview, and that he endorsed as positive for PTSD. A DSM IV Criteria for PTSD checklist showed that the Veteran complained of distressing recollections of events, dreams of events, anxiety (physiological reactivity on exposure to external or internal cues), avoidance of thoughts/feelings/conversations, feeling of detachment or estrangement from others, sense of foreshortened future, difficulty falling or staying asleep, irritability or outbursts of anger, difficulty concentrating, and exaggerated startle response. Post-service private treatment records dated from November 2006 and August 2007 showed findings of PTSD, insomnia, and anxiety state NOS (not otherwise specified). The Veteran complained of past depression and anxiety, anhedonia, panic attacks, fatigue, decreased motivation, feeling depressed, concentration problems, crying spells, decreased appetite, decreased sleep, guilt, low self esteem, sadness, short temper, nightmares, and suicidal ideation. Psychological examination findings were listed as appropriate affect and mood, normal interaction, good eye contact, reasonable judgment, alert, oriented, and anxious demeanor. In an April 2007 VA examination report, the Veteran indicated that he last worked seven months before and reported that he had angry outbursts often on the job. He was noted to be poorly treated with anti-anxiety medications and complained of severe anhedonia as well as some alternating psychomotor agitation or retardation. On psychiatric examination, the Veteran was noted to have neat grooming, hand wringing, spontaneous speech, cooperative attitude, full affect, hopeless mood, intact attention, orientation to person, time, and place, overabundance of ideas, suicidal ideation, understand outcome of behavior, above average intelligence, insight, sleep impairment, panic attacks, fair impulse control, normal remote and recent memory, mildly impaired immediate memory, and be able to maintain minimum personal hygiene. It was noted that he had no hallucinations, inappropriate behavior, obsessive/ritualistic behavior, homicidal thoughts, or episodes of violence. The examiner indicated that the Veteran was able to function reasonably well and to work fulltime until this past year. It was indicated that his depression, anxiety, sleeplessness, and nightmares were worse over the past year. It was noted that his drinking had increased to the point that his wife had conflicts with him over the last few years and that he had more angry episodes several times a week. The examiner diagnosed delayed-type PTSD, major depression with melancholia without psychosis, and continuous alcohol dependency, assigning a GAF score of 40. The examiner further commented that the Veteran voiced active suicidal feelings with plans but no active intentions on the day of the examination. It was noted that the Veteran could not work at this time because of multiple untreated psychiatric condition, that his depression and anxiety problems had clearly worsened over the last year, and that his PTSD symptoms and alcoholism had been intertwined for many years. The examiner commented that the Veteran could not work at present and for six months to possibly two years while he recuperated from his alcoholism, severe melancholic depression, and moderate PTSD. Records from SSA dated in July 2007 listed a primary diagnosis of anxiety related disorders and secondary diagnosis of affective disorders with a disability onset date in September 2006. When asked to report the conditions that limited his ability to work, the Veteran reported that he easily got upset and very nervous, had difficulty breathing, got dizzy, was an active alcoholic, and was tired all the time but could not sleep. On psychiatric review, the Veteran was noted to have feelings hopelessness and suicidal ideation; have anger outbursts several times a week; have dreams of Vietnam several times a week; have severe anhedonia with no energy; and have severe problems completing tasks, getting along with others, and with concentration. The consultant noted that the Veteran's alcohol abuse was directly related to his PTSD and could not be isolated. Private treatment records from St. Luke Hospital showed the Veteran was admitted with chief complaints of alcohol dependency and recreational cocaine use in August 2007. The Veteran reported that he was retired due to disability. The examiner indicated that the Veteran had multiple psychiatric conditions, including PTSD, depression, and anxiety. A September 2007 VA suicide assessment outpatient note showed the Veteran was not at current risk of suicide. A September 2007 VA mental health intake summary revealed that the Veteran was looking for help to maintain sobriety after being successfully discharged from a rehabilitation program. A VA social worker diagnosed PTSD, alcohol dependence, and depression NOS, assigning a GAF score of 49. In an October 2007 VA mental health note, the Veteran complained of panic attacks one to two times a week, depressed mood, periods of irritability or agitation, no psychomotor abnormalities, insomnia, anergia secondary to decreased sleep, anhedonia, amotivation, difficulties with concentration, and feelings of guilty/hopelessness/helplessness. On mental status examination, the Veteran was casually dressed, cooperative, had normal speech, depressed mood, congruent and anxious affect, goal-directed thought processes, and oriented as well as exhibited intact memory/concentration, good insight, and intact judgment. The examiner indicated that there was no evidence of current delusions, paranoia, suicidal ideation, and homicidal ideation. The examiner noted that the Veteran presented with a significant neurovegetative burden in addition to his PTSD symptoms and other anxiety. It was noted that reported panic attacks did not meet the criteria for panic disorder and did appear to be related to depression and/or PTSD symptoms. The examiner diagnosed severe, recurrent MDD (major depressive disorder) without psychotic features, PTSD, anxiety NOS, ETOH dependence in early full remission, and nicotine dependence, assigning a GAF score of 50. In additional VA mental health notes, the examiner assigned GAF scores of 55 (November 2007), 50 (January 2008), and 50 (March 2008). In November 2007, the Veteran reported some improvement in neurovegetative burden in addition to his PTSD symptoms and insomnia but continued to report frustration with anhedonia and amotivation. VA mental health notes dated in June 2008, November 2008, February 2009, and June 2009 showed complaints of irritability and distractibility as well as continued reports of improvement in insomnia, depressed mood, lack of motivation, difficulties with concentration, and feelings of guilt/hopelessness/helplessness. The Veteran also denied active suicidal ideation and homicidal ideation, intent and plan. The examiner listed the same psychiatric diagnoses, mental status findings, and assigned GAF scores of 50. Additional VA mental health notes dated in October 2009 and January 2010 showed the Veteran reporting he was feeling better, did not feel depressed, and felt his medications were helping him. While he indicated that he still feels guilty, hopelessness, and helplessness, he reported improvement in motivation and concentration as well as sleeping better. He denied active suicidal ideation and homicidal ideation, intent and plan but admitted to having intermittent nightmares, flashbacks, reexperiences, avoidance, and hypervigilance. On mental status examination in October 2009, the Veteran was noted to be casually groomed, oriented, and cooperative as well as exhibit normal speech and psychomotor activity, congruent and somewhat anxious affect, normal thought content, goal directed thought processes, grossly intact memory, good insight, and intact judgment. In a February 2010 VA examination report, the Veteran denied prior history of suicide attempts and any recent psychiatric hospitalization. He reported being unemployed for the past three years, being fired from or quitting jobs in the past, and being argumentative with supervisors and fellow employees. The Veteran indicated that his leisure activities included watching television, spending time on the computer, and reading. He denied having any regular friends and reported socializing pretty much just with his family. On mental status examination, the Veteran exhibited casual grooming, anxious and somewhat depressed affect, overall logical and sequential thought processes, no hallucinations or delusions, anxious and fidgety behaviors, and fairly good eye contact. He denied suicidal and homicidal ideations, had adequate activities of daily living, was alert and oriented, and exhibited intact memory but no significant psychomotor agitation or retardation. The Veteran reported experiencing a panic attack about once per month, indicating that he developed acute onset chest pain, shortness of breath, anxiety, feelings of rage, tremors, and irritability. He indicated that things were not as bad now that he was receiving medications. The Veteran noted that he had erratic sleep patterns, sometimes waking up in cold sweats, had nightmares, and had trouble sleeping at all at times. He informed the examiner that he was chronically anxious and chronically irritable. The VA examiner listed a diagnostic impression of PTSD, major depression, alcohol dependence (reportedly in full remission), and cocaine/opiate abuse (also reportedly in remission), assigning a GAF score of 55. The examiner indicated that the assigned GAF of 55 was for both PTSD and depression, opining that "[the Veteran's] MDD is not felt to be caused by, or a result of, his military service." Thereafter, the examiner highlighted that the Veteran's symptoms appeared to have approved with medications and therapy with a VA treatment provider as compared to his last VA examination in 2007. It was indicated that alcohol and substance abuses were not felt to be associated problems but instead were due to "willfulness conduct", as there was no significant impairment in thought processes or communication and his activities of daily living were felt to be "quite adequate". Finally, the examiner indicated that PTSD resulted in reduced reliability and productivity. In a May 2010 VA mental health treatment record, the Veteran denied complaints of depressed mood, interrupted sleep, irritability, and anxiety. His treatment provider noted that he was coping with PTSD triggers with medications. An August 2010 VA mental health record showed the Veteran continued to endorse improvement in his symptomatology but acknowledged he still suffered from nightmares, sleep problems, feelings of worthlessness, reclusiveness, fatigue, suicidal thoughts, and depressed mood. The examiners continued to assign GAF scores of 50. In March 2011, the Board initially remanded this matter to obtain a medical opinion as to whether the Veteran was precluded from gainful employment due to his service-connected PTSD. Accordingly, a VA examination was conducted in March 2011. The Veteran reported being married for 41 years and described the relationship as "fair", noting that he was verbally abusive and lost his temper once a week with his spouse. He further indicated that he had good relationships with his sons. The Veteran reported that he had trouble getting out of bed and off the couch each day and denied engaging in any formal social activities. He detailed that his mood over the past month was depressed, lonely, and helpless most days. On mental status examination, the Veteran was casual, clean, appropriately dressed, alert, fully oriented, and cooperative. He exhibited fidgety psychomotor activity; fair eye contact; normal speech and limited but fair communication due to a tendency for vague explanations; very anxious mood but no disturbances in motivation; congruent and appropriate affect; unremarkable thought content and processes; no difficulty understanding of complex commands; no impairment of memory, judgment, or abstract thinking; no delusions or hallucinations; denials of suicidal or homicidal ideation, plan, or intent; and no obsessional rituals that interfered with routine activities. The examiner noted that the Veteran did seem to have near continuous depression affecting the ability to function independently, appropriately, and effectively. It was indicated that the Veteran's level of motivation was low and felt worthless. He continued to describe having sleep impairment, mild memory problems, difficulty with attention and concentration, passive suicidal ideation weekly without plan or intent, visual illusions when waking from a nightmare, daily panic attacks, feelings of detachment or estrangement from others, difficulty adapting to stressful experiences, daily irritability, and occasional anger outbursts towards his family. The examiner indicated that the Veteran was not in persistent danger of hurting himself or others, was independent with activities of daily living, and did not neglect personal hygiene or appearance. The March 2011 VA examiner diagnosed PTSD, MDD, alcohol dependence in sustained full remission, anxiolytic dependence in sustained full remission, and polysubstance abuse in sustained full remission. Thereafter, the examiner opined that while the Veteran's service-connected PTSD had a moderate impact on social and occupational functioning as reflected by his GAF score of 60, his symptoms of MDD currently had a more significant impact his functioning. To that effect, the examiner assigned a separate and lower GAF score of 45. These findings were based on the Veteran's report that it was his symptoms of feelings of hopelessness and loss of interest that had been the primary reason that prevented him from seeking employment since he was fired from his last job in March 2006. The examiner found these symptoms were due to MDD. In this regard, the examiner also stated "[i]t is my opinion his MDD is not secondary to his PTSD given that he did not report symptoms of MDD until about 5 years ago, when he stopped working and stopped using drugs and alcohol." The examiner indicated that symptoms of PTSD would cause the Veteran to have mild difficulty tolerating stress, leading to a mild decrease in work efficiency and productivity. It was further noted that PTSD may also have a mild impact on the Veteran's ability to maintain positive working relationships with coworkers and supervisors. The examiner opined that those potential impacts were judged to be within mild range and not of sufficient severity to prevent him from securing and maintaining substantially gainful employment. Additional VA mental health notes dated in March 2011, June 2011, and November 2011 showed the Veteran reporting having nightmares and feeling depressed as well as anxious. While he indicated that he still feels guilty, hopelessness, and helplessness, he reported improvement in motivation and concentration and improved sleep. The examiner listed same psychiatric diagnoses, mental status findings, and GAF scores of 50 as documented above. Subsequent to the March 2011 VA examination, the Veteran submitted a March 2012 statement asserting that his MDD was a symptom of his PTSD which he masked with the use of drugs and alcohol, which was made evident by the onset of MDD at the time he quit using drugs and alcohol. The Veteran further stated that his use of drugs and alcohol was a self-medicating form of treatment for his service-connected PTSD. Moreover, although the March 2011 VA examiner stated that the Veteran's MDD was not secondary to the Veteran's PTSD, the examiner failed to provide an opinion as to whether the Veteran's service-connected PTSD aggravated his MDD. Thereafter, the Board remanded this matter to obtain a supplemental opinion addressing the relationship between the Veteran's service-connected PTSD and his MDD in April 2012. A May 2012 VA Disability Benefits Questionnaire (DBQ) contained a supplemental VA medical opinion provided by the same examiner that conducted the March 2011 VA examination. After reviewing the Veteran's claims file and Virtual VA file records dated up to March 2012, the VA examiner again opined that the Veteran's MDD was not proximately due to his service-connected PTSD. The rationale for that opinion simply included a quote from the prior March 2011 examination report that "[w]hereas his PTSD is service-connected, his MDD does not appear to be military-related. It is my opinion his MDD is not secondary to his PTSD given that he did not report symptoms of MDD until about 5 years ago, when he stopped working and stopped using drugs and alcohol." The VA examiner then commented that there was "some" symptom overlap between PTSD and MDD, including sleep disturbance, difficulty concentrating, and loss of interest. However, the VA examiner again reiterated that symptoms, including suicidal ideation, were unique to MDD and appeared to have been the primary symptoms contributing to the Veteran's reported increase in subjective distress in the last five to six years. The VA examiner then opined that MDD was not aggravated by the Veteran's PTSD based on the fact that they were separate disorders and there was no evidence that his PTSD had increased in severity. The VA examiner cited to the Veteran's previous GAF scores, noting that they were in moderate range and not suggestive of significant differences in functioning. Thereafter, the VA examiner again opined that MDD was most likely masked by the Veteran's use of alcohol and drugs given that the Veteran reported that his MDD developed when he stopped using drugs and alcohol. The VA examiner noted that medical literature indicated a link between MDD and substance abuse, where the substances are used to mask or cope with symptoms of MDD. Finally, the examiner cited to the March 2011 VA examiner's findings on unemployability, indicating that there was no new evidence in the file or VA medical records to suggest any changes in the impact of the Veteran's PTSD on unemployabililty since the time of the last examination. Subsequent to the May 2012 VA medical opinion, the RO added additional VA treatment records to the Veteran's Virtual VA file dated up from March 2012 to March 2013. Those records included treatment notes pertaining the Veteran's service-connected PTSD and MDD, dated in March 2012, May 2012, September 2012, December 2012 that reflected continued findings of severe, recurrent MDD (major depressive disorder) without psychotic features, PTSD, anxiety NOS, anxiety disorder, ETOH dependence in early full remission, and nicotine dependence as well as assigned GAF scores of 50. In May and September 2012, the Veteran reported feeling somewhat depressed and anxious and sometimes becoming agitated. In December 2012, he discussed being stressed as well as depressed and anxious due to his son's divorce and relocation at his home as well as prior cancellations of mental health appointments. The Veteran and his spouse submitted statements in December 2012 again asserting that he used drugs and alcohol to mask unpleasant feelings associated with PTSD and that once the substances were eliminated, his PTSD symptoms increased and depression began to occur. He further asserted that the May 2012 VA examiner provided no rationale as to how the examiner separated the symptoms of PTSD and MDD. The Veteran also highlighted the examiner's opinion regarding the issue of entitlement to a TDIU, noting that the examiner failed to properly consider that the Veteran was fired from his last job due to anger management issues, which he contended was a symptom of PTSD. The Board determined again remanded this matter to obtain a supplemental opinion addressing the relationship between the Veteran's service-connected PTSD and his MDD in January 2013. In a March 2013 VA Review PTSD DBQ examination report, the examiner listed diagnoses of PTSD, MDD, and alcohol dependence in sustained full remission as well as assigned a GAF score of 50. The examiner specifically indicated that it was not possible to differentiate what symptoms were attributable to each diagnosis. As there was significant overlap between the Veteran's depressive and PTSD symptoms, the examiner opined that the conditions were related. The examiner also determined that occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood best summarized the Veteran's level of occupational and social impairment with regards to all mental diagnoses. After discussing a thorough review of the evidence of record, the examiner discussed the Veteran's relevant social, marital, family, and occupational history. The Veteran reported that he has been married for 44 years and had good relationships with his spouse and children. He indicated that he was not sure what he enjoys and had little interest in things as well as denied having any friends. Other reported symptomatology included: mood over the past month had been "not good" most days; history of panic attacks that did not appear to be of issue with current medication; significant anxiety and appeared highly anxious during examination; level of interest in things was reportedly low most days; energy level was reportedly variable from fair to terrible, which he felt related to mood; poor sleep unless he takes medication; problems with irritability and depressed mood most days; independent with activities of daily living; no major problems with hygiene or self care; does household chores "on good days" as well as manages his finances; problems with memory, attention, and concentration; denied having suicidal or homicidal ideation, plan, or intent; and denied having hallucinations but discussed some perceptual illusions (e.g., mistaking a coat rack for a person in the dark). The examiner marked that the following symptoms applied to the Veteran's diagnoses: depressed mood and anxiety; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; circumstantial, circumlocutory or stereotyped speech; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner also specifically indicated that the following symptoms were not present: 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. The examiner opined that the Veteran's MDD and PTSD were at least as likely as not inter-related (not separate and distinct disorders), highlighting that evidence of record showed that the Veteran's symptoms of depression, PTSD, and alcohol dependence were all present at the same time and that his report of history suggested that the onset of all three disorders was at the same time. The examiner indicated a GAF score of 50 was assigned to reflect that the Veteran has some serious symptoms (such as depressed mood and chronic anxiety most of the day, nearly every day) as well as serious impairment in social and occupational functioning. The examiner commented that the Veteran reported having no friends, some marital strain at times due to his irritability, and being fired for anger-related issues at his last job. Thereafter, the examiner opined that the Veteran was not able to engage in sedentary or physical labor when considering his service-connected PTSD, as the Veteran's current ability to perform day to day activities, especially in a work setting is moderately to severely impaired. Considering the evidence in light of the criteria noted above, and with resolution of all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's PTSD meets the severity of occupational and social impairment contemplated for a 70 percent rating for the time period from March 16, 2006, to March 4, 2013. 38 C.F.R. § 4.130, Diagnostic Code 9411. Regarding the time period from March 5, 2013, the Board finds that the service-connected PTSD disability symptomatology does not meet the severity of occupational and social impairment contemplated for a rating in excess of 70 percent. Id. Collectively, the evidence reflects that during his appeal the Veteran's PTSD has been manifested by near-continuous depression affecting the ability to function independently, appropriately and effectively, social withdrawal, nightmares, fatigue, low motivation, suicidal ideation, panic attacks, decreased concentration, anxiety, irritability, sleep impairment, difficulty adapting to stressful circumstances, total occupational impairment, and almost total social impairment, that results in occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood. At no point during the appeal period did the Veteran's PTSD symptomatology meet the criteria for a rating in excess of 70 percent. As noted above, a 100 percent rating requires total social and occupational impairment; however, the Board finds that this level of occupational and social impairment has not been shown during the appeal period. While the Veteran complained of near continuous depression, irritability, and suicidal ideation without plan or intent during the appeal period and has been found to have total occupational impairment due to PTSD, he has maintained current familial relationships as well as exhibited intact thought processes, judgment, and insight. The Board further points out that the assigned GAF scores ranging from of 40 to 55 during the appeal period are indicative of moderate to major symptomatology and moderate to major but not total impairment in social and occupational functioning due to service-connected PTSD. While there have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD, the evidence shows no other distinct periods of time from March 16, 2006, to the present during which the Veteran's PTSD has varied to such an extent that a rating greater than the 70 percent evaluation currently assigned would be warranted. Cf. 38 C.F.R. § 3.344 (2013) (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). Based on the foregoing discussion, the Board finds that there is no basis for assignment of an evaluation in excess of 70 percent for PTSD during the entire appeal period from March 16, 2006 to the present. In this case, the Veteran's statements are competent evidence to report his increased PTSD symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. He is also credible in his belief that he is entitled to higher ratings. However, the more probative evidence of record does not indicate that the assignment of any additional increased evaluation is warranted. In so finding, the Board notes that it weighed the lay and medical evidence and finds more probative certain opinions rendered by medical professionals given their expertise in evaluating mental disorders. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. 38 C.F.R. §§ 4.20, 4.27 (2013). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. Nonetheless, in exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available scheduler evaluations for that service-connected disability are inadequate. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008), aff'd, 572 F.3d 1366 (2009); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned scheduler evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's disability picture is not so unusual or exceptional in nature as to render the assigned ratings inadequate. The Veteran's service-connected PTSD is evaluated pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. During the appeal period, evidence of record shows that the Veteran's PTSD has been manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds that the Veteran's experiences are congruent with the disability picture represented by the assigned 70 percent disability ratings. A higher 100 percent rating is provided for by the regulations for certain manifestations of PTSD, but the medical evidence for the time periods from March 16, 2006, to March 4, 2013, and from March 5, 2013, demonstrates that those manifestations are not present. The criteria for the assigned 70 percent evaluations reasonably describe the Veteran's disability levels and symptomatology throughout the pendency of this appeal. Consequently, the Board concludes that the scheduler evaluations are adequate and that referral of the Veteran's case for extraschedular consideration is not required. See 38 C.F.R. § 4.130, Diagnostic Code 9411; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). In reaching this decision the Board considered the doctrine of reasonable doubt; however, as discussed above, the preponderance of the evidence is against the assignment of an initial evaluation in excess of 70 percent from March 16, 2006, to March 4, 2013, and from March 5, 2013, the doctrine is not for application. The Board further notes that the issue of entitlement to TDIU has been found to be part and parcel of the determination of the evaluation for the Veteran's service-connected PTSD and is properly before the Board. See Rice v. Shinseki, 22 Vet. App. 447, 453-55 (2009). The Board is cognizant that the RO has already granted entitlement to TDIU, effective from March 5, 2013, in a March 2013 rating decision of record. However, due to determinations by the Board in this decision, the Veteran now meets the schedular criteria for a TDIU under 38 C.F.R. § 4.16(a) as of March 16, 2006. Evidence of record discussed in detail above also shows the Veteran has not been able to engage in sedentary or physical labor when considering his service-connected PTSD during the appeal period. Thus, entitlement to TDIU is also warranted during the entire appeal period from March 16, 2006, to the present. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); see also Fenderson, 12 Vet. App. at 126; see also Hart, 21 Vet. App. at 507. ORDER Entitlement to an initial evaluation of 70 percent for PTSD, but no more, for the time period from March 16, 2006, to March 4, 2013, is granted, subject to the controlling regulations applicable to the payment of monetary benefits. Entitlement to an evaluation in excess of 70 percent for PTSD for the time period from March 5, 2013, is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is granted from March 16, 2006, subject to the controlling regulations applicable to the payment of monetary benefits. ____________________________________________ JOY A. MCDONALD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs