Citation Nr: 1337535 Decision Date: 11/18/13 Archive Date: 11/26/13 DOCKET NO. 11-33 850 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for tinnitus. 2. Entitlement to a higher initial disability rating for posttraumatic stress disorder (PTSD), in excess of 30 percent for the period prior to December 20, 2012, and in excess of 50 percent for the period on and after December 20, 2012. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). ATTORNEY FOR THE BOARD E. Blowers, Associate Counsel INTRODUCTION The Veteran, who is the appellant, had active service from July 1969 to July 1971. He served in the Republic of Vietnam and was awarded the Combat Infantryman Badge (CIB). This matter came before the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision of the Oakland, California, Regional Office (RO) which, in pertinent part, granted service connection for PTSD, assigned a 30 percent rating for that disability, effectuated the award as of June 29, 2010, and denied service connection for tinnitus. In January 2013, the RO assigned a 50 percent disability rating for the period from December 20, 2012, thus creating a "staged" initial rating. The Board has reviewed the physical claims file and both the Veterans Benefits Management System (VBMS) and "Virtual VA" files so as to insure a total review of the evidence. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. The Veteran has appealed from the initial rating assigned for the service-connected PTSD. In Fenderson v. West, 12 Vet. App. 119 (1999), the United States Court of Appeals for Veterans' Claims (Court) addressed a similar appeal and directed that it was specifically not a claim for an increased disability rating. The Court also directed that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. The Board has, therefore, framed the issue as entitlement to a higher initial disability rating for PTSD in excess of 30 percent for the period prior to December 20, 2012, and in excess of 70 percent for the period on and after December 20, 2012. FINDINGS OF FACT 1. The Veteran engaged in combat with the enemy and was exposed to loud combat-related noise in service. 2. The Veteran has a current disability of tinnitus. 3. Tinnitus originated during active service. 4. For the entire rating period, PTSD was productive of no more than significant occupational and social impairment with deficiencies in most areas including work, judgment, thinking, and mood due to symptoms including recurrent recollections and nightmares of Vietnam; an attempted suicide; a major depressive episode; substance abuse; anxiety; disturbed mood; social isolation and detachment; sleep impairment; irritability or outbursts of anger; hypervigilance; and no delusions, hallucinations, grossly inappropriate behavior, or persistent danger to himself or others. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, tinnitus was incurred in active service. 38 U.S.C.A. §§ 1110, 1154(b), 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304(d), 3.326(a) (2013). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for a 70 percent rating for PTSD for the entire rating have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for a rating in excess of 70 percent for PTSD for any period have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this decision, the Board grants service connection for tinnitus. As such action represents a complete allowance of the Veteran's claim, no further discussion of VA's duty to notify and to assist is necessary as to that issue. In July 2010, VA issued the Veteran a VCAA notice which informed him of the evidence generally needed to support a claim of service connection and the assignment of a rating and effective date for an initial award of service connection, what actions he needed to undertake, and how VA would assist him in developing his claim. The July 2010 VCAA notice was issued to the Veteran prior to the December 2010 rating decision from which the instant appeal arises. The issues on appeal were readjudicated in the October 2011 statement of the case (SOC) and the October 2013 supplemental statement of the case (SSOC). Therefore, there was no defect with respect to timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Moreover, because this appeal arises in part from the Veteran's disagreement with the initial rating following the grant of service connection for PTSD, no additional notice is required regarding this downstream element of the service connection claim for PTSD. The United States Court of Appeals for the Federal Circuit (Federal Circuit) and the Court have similarly held that regarding the downstream element of the initial rating that, once service connection is granted the claim is substantiated, additional notice is not required, and any defect in notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) (noting that, once an initial VA decision awarding service connection and assigning a disability rating and effective date has been made, 38 U.S.C.A. § 5103(a) notice is no longer required); 38 C.F.R. § 3.159(b)(3) (no VCAA notice required because of filing of notice of disagreement (NOD)). Regarding the duty to assist in this case, the Veteran was afforded multiple VA examinations, including October 2010 and December 2012 VA PTSD examinations. The examination reports are of record. To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The October 2010 and December 2012 examination reports reflect that relevant records were reviewed and all relevant issues were answered. All relevant documentation, including VA and private PTSD treatment records, has been secured. It was not necessary to obtain the Veteran's California Department of Rehabilitation treatment records, as the July 2012 closure report thoroughly explains the impact of the Veteran's mental picture on his ability to receive rehabilitation services. All relevant facts have been developed. There remains no issue as to the substantial completeness of the Veteran's appeal for a higher initial rating for PTSD. 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). Any duty imposed on VA, including the duty to assist and to provide notification, has been met as set forth above. Service Connection for Tinnitus Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). The condition at issue, tinnitus, is not a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) do not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In the case of any veteran who engaged in combat with the enemy in active service with a military, naval, or air organization of the United States during a period of war, campaign, or expedition, the Secretary shall accept as sufficient proof of service connection of any disease or injury alleged to have been incurred in or aggravated by such service satisfactory lay or other evidence of service incurrence or aggravation of such injury or disease, if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the fact that there is no official record of such incurrence or aggravation in such service, and, to that end, shall resolve every reasonable doubt in favor of the veteran. Service connection of such injury or disease may be rebutted by clear and convincing evidence to the contrary. The reasons for granting or denying service-connection in each case shall be recorded in full. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The Veteran asserts that service connection for tinnitus is warranted as he engaged in combat in the Republic of Vietnam and initially experienced ringing of the ears during active service. In his June 2010 claim and his January 2011 NOD, the Veteran advanced that tinnitus began during combat in the Republic of Vietnam. The report of a September 2010 VA audiological examination conveys that the Veteran reported the ringing as occurring monthly. After a review of all the evidence, lay and medical, the Board finds that the Veteran engaged in combat with the enemy and was exposed to loud combat-related noise in service. His service personnel records reflect that he served in the infantry in the Republic of Vietnam and was awarded the CIB. Excessive noise exposure is consistent with the circumstances, conditions and hardships of the Veteran's combat. The Veteran's in-service noise exposure is presumed. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The Veteran has a current disability of tinnitus. He was diagnosed with tinnitus by the VA examiner at the September 2010 VA audiological examination for compensation purposes. The Board finds that the evidence is in equipoise on the question of whether the Veteran's tinnitus is related to his period of active service. The Veteran's service treatment records reflect no complaint, finding, or diagnosis of tinnitus. The September 2010 VA audiological examination report conveys that the VA examiner concluded that the Veteran's tinnitus was not related to his active service. She based her opinion solely upon the fact that the Veteran's "service treatment records indicated normal hearing at entrance and then separation from service." The absence of service treatment records showing in-service evidence of tinnitus is not fatal to a claim for service connection. 38 C.F.R. § 3.303(d). No specific cause for the tinnitus was advanced by the VA examiner. Neither the Veteran's in-service combat-related noise exposure, nor his previous contention that the ringing in his ears began in service were addressed by VA the examiner. The opinion, therefore, holds little probative value. See Barr, 21 Vet. App. at 312 (when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate). For such reasons, the Board concludes that the September 2010 audiological examination opinion is of little probative value. The Veteran was awarded the CIB and was exposed to loud combat-related noise in service. He has a diagnosed disability of tinnitus. He conveyed that his tinnitus originated during active service and has continued to the present. Tinnitus is a condition capable of lay observation and diagnosis. See Charles v. Principi, 16 Vet. App. 370, 374 (2002) ("ringing in the ears is capable of lay observation"). The Veteran's statements are competent, credible and probative. Resolving reasonable doubt in the Veteran's favor, tinnitus was incurred in active service. The Board finds that the criteria for service connection for tinnitus have been met. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Initial Disability Rating for PTSD In December 2010, the RO granted service connection for PTSD, assigned an initial 30 percent rating for that disability, and effectuated the award as of June 29, 2010. The Veteran entered a NOD to the initial rating in January 2011. In January 2013, the RO assigned a 50 percent initial rating for the period beginning December 20, 2012, thus effectuating a "staged" initial rating for PTSD. Disability ratings are determined by comparing a veteran's current symptomatology with the criteria set forth in the Schedule For Rating Disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. A 30 percent rating will be assigned for PTSD which is productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating will be assigned for PTSD which is productive of occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks occurring 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 or forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating will be assigned for occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and an inability to establish and maintain effective relationships. A 100 percent rating will be assigned for total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting herself or others, an 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. 38 C.F.R. § 4.130, Diagnostic Code 9411. Where there is a question as to which of two disability ratings shall be applied, the higher rating 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. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Global Assessment of Functioning (GAF) is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994). A score of between 1 and 10 is defined as persistent danger of severely hurting self or others (e.g., recurrent violence) or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death. A score of between 11 and 20 conveys that there is some danger of hurting self or others (e.g., suicide attempts without clear explanation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). A score of between 21 and 30 is assigned when behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). A score of between 31 and 40 denotes some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A score of between 41 and 50 denotes serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning, (e.g., no friends, unable to keep a job). A score of between 51 and 60 reflects moderate difficulty in social, occupational, or school functioning. A score of between 61 and 70 indicates the presence of mild symptoms and/or some difficulty in social, occupational, or school functioning, but a generally satisfactory level of functioning. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). The Secretary of VA, acting within his authority to adopt and apply a schedule of ratings, chose to create one general rating formula for mental disorders. 38 U.S.C.A. § 1155; see 38 U.S.C.A. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 psychiatric disorders, there can be no doubt that the Secretary of VA anticipated that any list of symptoms justifying a particular rating would in many situations be either under- or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet. App. 128 (1997). See Mauerhan v. Principi, 16 Vet. App. 436, 442 (1992). The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. § 4.126. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. The schedular rating criteria rate by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The Federal Circuit has embraced the Mauerhan interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). Initial Rating for PTSD The Veteran contends that his PTSD is manifested by significant occupational and social impairment. Among other symptoms, the Veteran has reported Vietnam-related recurrent, intrusive, and distressing memories. In his January 2011 NOD, the Veteran advanced that he met the criteria for a 50 percent PTSD rating. In his December 2011 substantive appeal, he asserted that VA "doesn't understand my affliction level." His October 2012 statement in support of claim conveys that a 30 percent PTSD rating is too low because his "symptoms and affliction cause both significant occupational and social impairments." After a review of all the evidence, lay and medical, the Board finds that for the entire rating period PTSD was productive of no more than significant occupational and social impairment with deficiencies in most areas including work, judgment, thinking, and mood due to symptoms including recurrent recollections and nightmares of Vietnam; an attempted suicide; a major depressive episode; substance abuse; anxiety; disturbed mood; social isolation and detachment; sleep impairment; irritability or outbursts of anger; hypervigilance; and no delusions, hallucinations, grossly inappropriate behavior, or persistent danger to himself or others. The Veteran's psychiatric disability picture had been found to render vocational rehabilitation infeasible. The Veteran's GAF score ranged from approximately 10 to 65. These symptoms and degree of occupational and social impairment more nearly approximate the criteria for a 70 percent disability rating. The criteria for a rating in excess of 70 percent for PTSD have not been met or more nearly approximated for any period. 38 U.S.C.A. §§ 1155; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411; Hart v. Mansfield, 21 Vet. App. 505 (2007). Medical evidence received by VA includes the report of an October 2010 VA PTSD examination. The Veteran complained of Vietnam-related recurrent, intrusive, and distressing memories. He was diagnosed with PTSD. The Veteran was found to exhibit poor social interaction and detachment from others. He did report having a good relationship with his wife of 30 years and most of his children. A GAF score of 65 was assigned. Treatment records from the Vet Center reflect ongoing psychiatric treatment for PTSD and a major depressive episode. A September 2011 Vet Center treatment record reported a history of substance abuse, sleep impairment, recurrent recollections and nightmares of Vietnam, and no delusions, hallucinations, grossly inappropriate behavior, or persistent danger to himself or others. He was found to be oriented to time, place and person, and his memory was normal. The GAF score was 58. An October 2011 Vet Center treatment record noted that the Veteran had provided inconsistent information between the Vet Center counselors and his psychiatrist. An August 2011 VA treatment record reflects that the Veteran was diagnosed with PTSD and depression. He stated that he had no suicidal ideation. A GAF score of 55 was assigned. A September 2011 VA treatment record noted that the Veteran complained of a depressed mood. The examiner diagnosed the Veteran with mood disorder NOS, and ruled out major depressive disorder. The GAF score was 55. VA clinical documentation dated October 2011 reflects that the Veteran ingested 30 capsules of a prescription painkiller in a possible suicide attempt. The level of suicidal intent was assessed to be "moderate/ambivalent." A July 2012 California Department of Rehabilitation closure report conveyed that the Veteran's mental health picture rendered vocational rehabilitation infeasible. The counselor reported that the Veteran's "mental health is so problematic that employment is no longer on the agenda. . . . without ongoing therapy and possibly psychotropic medication, it is not likely [the Veteran] will be able to be a productive member of the work force." The report assessed that the "GAF score could be rated as low as 10, due to his recent serious suicidal act with clear expectation of death." The report of a December 2012 VA PTSD examination notes that the Veteran was socially isolated and detached from others; suffered recurrent recollections and nightmares of Vietnam; had irritability or outbursts of anger; was hypervigilant; and suffered from chronic sleep impairment, anxiety, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. A GAF score was 60 was assigned. Little lay evidence has been received beyond the Veteran's statements found in the records discussed above. In his January 2011 NOD, the Veteran advanced that he met the criteria for a 50 percent PTSD rating. In his December 2011 substantive appeal, he asserted that VA "doesn't understand my affliction level." His October 2012 statement in support of claim conveys that a 30 percent PTSD rating is too low because his "symptoms and affliction cause both significant occupational and social impairments." As the Veteran's lay statements do not discuss his actual PTSD symptoms, but merely assert that his symptoms entitle him to a higher rating, his statements have minimal probative value. The Board acknowledges that the Veteran is not the most accurate historian, as noted in the October 2011 Vet Center treatment record. He has denied suicidal ideation on multiple occasions; however, the Veteran ingested 30 painkillers in October 2011. The Board finds this to be a suicidal gesture. The California Department of Rehabilitation has also assessed that the Veteran's current mental picture has significantly impacted his potential for employment. A PTSD rating of 50 percent represents reduced reliability and productivity in occupational and social life, while a 70 percent rating represents significant deficiencies in occupational and social life. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. Resolving reasonable doubt in the Veteran's favor, his PTSD symptomatology, which includes an attempted suicide and significant impact on his employment opportunities, has been shown to be productive of significant occupational and social impairment most closely approximating the criteria for a 70 percent rating for the entire period, which includes the period prior to December 20, 2012. 38 U.S.C.A. §§ 1155; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411; Hart v. Mansfield, 21 Vet. App. 505 (2007). The California Department of Rehabilitation counselor in July 2012 advanced that the Veteran "could" have a GAF score as low as 10. A GAF score of between 1 and 10 includes a persistent danger of severely hurting oneself or others, persistent inability to maintain minimal personal hygiene, or serious suicidal act with clear expectation of death. The GAF score assigned is supported only by the single act of suicide attempt, without consideration of context (symptoms and occupational impairment soon before and after this single incident), and without consideration of persistence of any suicidal thoughts, or of any other evidence as to the Veteran's symptoms or degree of occupational functioning. Such one day assessment a 10 GAF that "could" have been assigned is not only unsupported by, but is inconsistent with, the weight of the other lay and medical evidence of record that shows that the Veteran is able to maintain his personal hygiene, and is not a persistent danger to self or others. While the Veteran did attempt suicide in October 2011 by ingesting 30 prescription painkillers, there has been no subsequent indication of any suicidal ideation or attempt. Prior to the suicide attempt, the Veteran's GAF scores ranged from 55 to 65. Subsequent to the suicide attempt, at the December 2012 VA PTSD examination, the examiner assigned a GAF score of 60. Thus the speculation that the Veteran could have warranted a GAF score as low as 10 is an outlier, and, therefore, the speculated GAF score of 10 has less weight than the other assigned GAF scores and other, specific evidence demonstrating actual symptomatology and degree of actual occupational and social impairment. The record does not establish, and the Veteran has not advanced, that his PTSD disability picture encompassed symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting himself or others, an 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 evidence does not show that the symptoms are productive of total occupational and/or social impairment, given that he is able to maintain some personal relationships and attend counseling. Given these findings, a 100 percent rating for any period is not warranted. 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. Extraschedular Consideration The Board has also evaluated whether the Veteran's claim should be referred for consideration of an extra-schedular rating for PTSD under 38 C.F.R. § 3.321(b)(1). Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). The Court has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extra-schedular rating. Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. Second, if the schedular rating does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Thun v. Peake, 22 Vet App 111 (2008). With respect to the first prong of Thun, the evidence in this instant appeal does not establish such an exceptional disability picture as to render the schedular evaluation inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria found in 38 C.F.R. § 4.130, Diagnostic Code 9411, reflects that the diagnostic criteria reasonably describes the Veteran's disability level and symptomatology. The diagnostic criteria convey that compensable ratings will be assigned for PTSD which is manifested by various levels of occupational and social impairment. The Veteran's disability picture has been shown to encompass significant occupational and social impairment and symptoms which falls squarely within the diagnostic criteria for a 70 percent evaluation for all relevant periods. Prior to and after December 20, 2012, the Veteran's PTSD was productive of occupational and social impairment with deficiencies in most areas including work, judgment, thinking, and mood due to symptoms including recurrent recollections and nightmares of Vietnam; an attempted suicide; a major depressive episode; substance abuse; anxiety; disturbed mood; social isolation and detachment; sleep impairment; irritability or outbursts of anger; hypervigilance; vocational rehabilitation infeasibility; and no delusions, hallucinations, grossly inappropriate behavior, or persistent danger to himself or others; and GAF scores ranging from approximately 10 to 65. All the impairment and symptoms are either explicitly part of the schedular rating criteria or are like or similar to examples or symptoms in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. In addition, the GAF scores, which are incorporated into the schedular rating criteria as part of the DSM-IV, assesses the degree of overall occupational and social impairment. For these reasons, the Veteran's PTSD has not been shown to be productive of an exceptional disability picture. Therefore, the Board determines that referral of this case for extra-schedular consideration pursuant to 38 C.F.R. § 3.321(b)(1) is not merited. ORDER Service connection for tinnitus is granted. A 70 percent evaluation, but no higher, for PTSD for the entire period is granted. REMAND The Court has directed that when entitlement to a TDIU is raised during the adjudicatory process of evaluating the underlying disability, it is part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). Entitlement to a TDIU requires an accurate assessment of the functional impairment associated with all the veteran's service-connected disabilities. 38 C.F.R. § 4.16(b) (2013). The October 2012 letter from the California Department of Rehabilitation conveys that the Veteran's current mental health picture renders employment infeasible. The issue of entitlement to a TDIU has not been previously adjudicated or considered. A determination as to entitlement to a TDIU requires an accurate assessment of the functional impairment associated with all the Veteran's service-connected disabilities. Given the above awards of service connection for tinnitus and a higher initial rating of 70 percent for PTSD for one period, the Board remands the issue of entitlement to a TDIU to the RO for evaluation. Accordingly, the issue of TDIU is REMANDED for the following action: Adjudicate the issue of TDIU. If the benefit sought on appeal is denied, the Veteran should be provided a SOC. An appropriate period of time should be allowed for response before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs