Citation Nr: 1339355 Decision Date: 12/02/13 Archive Date: 12/13/13 DOCKET NO. 09-49 002 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana THE ISSUE Entitlement to increases in the ratings assigned for posttraumatic stress disorder (PTSD), currently assigned "staged" ratings of 30 percent prior to October 31, 2011, and 50 percent from that date. REPRESENTATION Appellant represented by: Wounded Warrior Project WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from September 1988 to September 1993. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision of the Indianapolis, Indiana RO. In October 2013, a videoconference Board hearing was held before the undersigned; a transcript of the hearing is included in the record. An interim (February 2013) rating decision increased the rating for PTSD to 50 percent, effective October 31, 2011. The issue is recharacterized to reflect that staged ratings are assigned, and that both "stages" are on appeal. The Board notes that the RO received updated VA treatment records that were associated with the claims file in August 2013, but the last supplemental statement of the case (SSOC) was issued in February 2013. The claims file was transferred to the Board in September 2013. Under 38 C.F.R. § 19.31, if the RO obtains pertinent evidence prior to certifying or transferring the case to the Board, such as in this situation, it must issue a SSOC. The Board concludes a SSOC was not needed here, however, because the additional evidence was either duplicative or not pertinent. As for the new VA outpatient records, they reflect continuing mental health treatment for PTSD, but they show symptomatology largely similar to the records and examinations in evidence prior to February 2013. The additional records do not reflect any worsening of the Veteran's symptoms since that time, so it would be pointless to remand the Veteran's case for issuance of a SSOC. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). The matter of entitlement to a total disability rating based on individual unemployability (TDIU) is being REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action on his part is required. FINDINGS OF FACT 1. Prior to March 11, 2010, the Veteran's PTSD was manifested by symptoms productive of impairment no greater than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks; occupational and social impairment with reduced reliability and productivity due to PTSD symptoms was not shown. 2. From March 11, 2010 (but not earlier) it is reasonably shown that the Veteran's PTSD has been manifested by symptoms productive of occupational and social impairment with reduced reliability and productivity; at no time during the period under consideration is the PTSD shown to have been manifested by symptoms productive of occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW The Veteran's PTSD warrants a 50 percent rating from (the earlier effective date of) March 11, 2010; a rating in excess of 30 percent prior to March 11, 2010 and a rating in excess of 50 percent for any period of time under consideration are not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code (Code) 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). As the rating decision on appeal granted service connection and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). A November 2009 SOC provided notice on the "downstream" issue of entitlement to an increased initial rating, and a February SSOC readjudicated the matter after the Veteran responded and further development was completed. 38 U.S.C.A. § 7105; see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). The Veteran has not alleged that notice was less than adequate. See Goodwin v. Peake, 22 Vet. App. 128, 137 (2008) ("where a claim has been substantiated after the enactment of the VCAA, the Veteran bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream issues"). The Veteran's pertinent treatment records have been secured. He was afforded VA examinations in February 2008, March 2010, and October 2011; those examinations are reported in greater detail below, and are cumulatively adequate for rating purposes, as the reports contain the information necessary for consideration of the applicable criteria. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. 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). 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. PTSD is rated under the General Rating Formula for Mental Disorders. A 30 percent evaluation is warranted when the evidence demonstrates 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 is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory or stereotyped speech; panic attacks more than once a week; difficulty 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; difficulty in establishing and maintaining effective work and social relationships. 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 evaluation 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. With respect to the rating of his PTSD, the Veteran has been assigned various Global Assessment of Functioning (GAF) scores. 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). A score from 21 to 30 is indicative of behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. Lesser scores reflect increasingly severe levels of mental impairment. See 38 C.F.R. § 4.130 [incorporating by reference VA's adoption of the American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM-IV), for rating purposes]. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remissions. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. 38 C.F.R. § 4.126(b). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, and in Virtual VA, with an emphasis on the evidence relevant to this appeal. 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 relevant evidence, as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or does not show, as to the claim. On October 2005 VA treatment, the Veteran reported that he was a full time student working toward a Bachelor's degree in ministry and communication with counseling. He reported symptoms including nightmares, daytime intrusive memories with significant physiological and emotional re-experiencing symptoms, hypervigilance with significant volatility and startle reflex, and depression. He reported difficulty trusting others. He reported needing to have his back to the wall in restaurants. He reported initial and middle insomnia, restless sleep, and recurrent feelings of sadness with spontaneous crying at times while watching television. He reported recurrent feelings of guilt. He denied any passive or active suicidal or homicidal ideation or any psychotic symptoms. He denied any history of suicide attempts or physical violence. On mental status examination, the Veteran was well oriented and had good eye contact. He was pleasant, warm and superficially jovial, although he fought tears on several occasions while discussing his military experiences. His speech was normal in pace and tone, clear, coherent, and purposeful. His affect was broad and well modulated and his mood was dysphoric. His thought processes were logical, goal oriented, and free of any passive or active suicidal or homicidal ideations as well as any delusions. No major cognitive impairment was noted; his insight and judgment were adequate. The diagnoses included severe and chronic PTSD, recurrent mild to moderate major depressive disorder, a history of alcohol dependence in remission, and a history of polysubstance abuse in remission. A GAF score of 60 was assigned, and it was noted that the risk of suicide was low. On January 2006 VA treatment, the Veteran reported significant improvement in his PTSD and depressive symptoms with Citalopram, with a significant decrease in nightmares. The frequency of daytime intrusive memories and flashbacks was also much improved as they were less disruptive. His only residual symptom was initial insomnia, as his middle insomnia was much improved and he denied any significant restlessness. He was aware of being less defensive and impulsive. He reported only intermittent sadness and feelings of guilt; he remained irritable and at times had fleeting homicidal rage, but he denied any persisting homicidal ideations, plans, or intent. On mental status examination, he was well oriented with good eye contact and his speech was within normal limits. His affect was broad and well modulated and his mood was euthymic. His thought process was logical, goal oriented, and free of any passive or active suicidal or homicidal ideation or any delusions. His insight and judgment were adequate and his cognition was grossly intact. The impressions included PTSD and mild recurrent major depressive disorder; a GAF score of 65 was assigned. On August 2006 VA treatment, the Veteran had relocated, he was employed, and he was adjusting well to his new situation. He denied significant sadness, significant anxiety or any panic attacks. He reported some increase in PTSD symptoms when he began applying for service connection benefits the previous month. He reported an increase in hypervigilance, e.g., checking the house and walking the perimeter at night. He reported interrupted sleep and an increase in vivid violent dreams. He reported decreased frequency and intensity of the intrusive vivid memories and flashbacks in the daytime. He was less irritable and yelled less often. He denied any active or passive suicidal or homicidal ideations or any psychotic symptoms. On mental status evaluation, he was alert and well oriented, pleasant and cooperative. His speech was within normal limits. His affect was broad and well-modulated, and his mood was dysphoric. His thought process was logical, goal oriented, and free of any passive or active suicidal or homicidal ideation as well as any delusions. His insight and judgment were adequate, and his cognition was grossly intact. The impressions included chronic PTSD with recent exacerbation, and recurrent mild major depressive disorder; a GAF of 55 to 60 was assigned as the Veteran was struggling with residual symptoms of PTSD and depression. On July 2007 VA treatment, the Veteran reported being married for 18 years; he reported it was a good marriage with good communication and similar interests. He was employed. He reported that he enjoyed doing "family things". On mental status examination, he showed no psychomotor agitation or retardation, and his behavior was appropriate. His speech was within normal limits, his mood was calm, and his affect was euthymic. He denied any suicidal or homicidal ideation and any auditory or visual hallucinations or delusions. His thought processes were logical, sequential, and goal directed with no flight of ideas or loosening of associations. He showed no psychotic symptoms and reported no dangerousness to himself or others. His concentration was intact as was his memory. His judgment and insight were good and he was highly motivated for treatment. The diagnosis was chronic PTSD, and a GAF score of 58 was assigned. On February 2008 VA examination, the Veteran reported taking medications including Citalopram, Gabapentin, and Prazosin, which he described as very helpful in reducing his agitation and the frequency and intensity of nightmares; he was not participating in individual or group therapy. He reported recurrent nightmares, agitation, and hypervigilance, although many of his symptoms were better controlled compared to before he began treatment. He reported having a good marriage with no significant problems since he began treatment, and he had no problems in his relationships with his two children. He denied any close relationships with his extended family due to geographical limitations and his religious beliefs; his mental health symptoms did not appear to have significantly affected his relationship with his extended family. He reported feeling depressed about once a week. He reported having one close friend and difficulty making new friends, as many people find him too extreme, loud, or easily fired up. He reported having largely superficial relationships with people in his congregation. He denied any significant loss of interest in hobbies or activities. He denied any history of suicide attempts and reported no episodes of violence in recent years. The examiner opined that the Veteran's overall level of psychosocial functioning was fair; he was employed full time and had positive relationships with his wife and children, but he denied having significant social contacts outside of his family. On mental status examination, the Veteran's psychomotor activity and speech were unremarkable, and his attitude was cooperative, friendly, relaxed, and attentive. His affect was normal and his mood was good. His attention was intact and he was oriented to all spheres. His thought process and thought content were unremarkable. He reported no delusions. His judgment and insight were intact. He reported trouble falling asleep most nights as well as waking up during the night most nights. He reported hypersensitivity to noises and nightmares once to twice per week; he reported that the frequency of nightmares had been consistent for years but the medication had helped to reduce the intensity. He denied any visual hallucinations and there was no evidence of obsessive or ritualistic behavior. He reported having panic attacks about once per month, lasting from a half-hour to a couple of hours; he denied any specific triggers. He denied any homicidal or suicidal thoughts. He reported good impulse control and no episodes of violence, although there was a significant anger outburst one month earlier in which he threatened to kill the family dog in front of his children. His remote, recent, and immediate memory was normal. He reported no problem with the activities of daily living. The examiner noted that, overall, the Veteran showed no visible signs of anxiety or depression during the examination, and appeared very at ease. The examiner opined that the level of symptom severity reported by the Veteran was consistent with a diagnosis of PTSD of mild severity; a GAF score of 68 was assigned. Based on these findings, the March 2008 rating decision on appeal granted service connection for PTSD and assigned an initial 30 percent rating. On September 2008 VA treatment, the Veteran reported increased professional and financial pressure. He stated that his prescribed medications were helpful in reducing his nightmares but he still struggled with irritability and overall tension. His mood was mostly stable with Celexa and Neurontin, though he reported fatigue, irritability, and poor sleep. On mental status examination, he was pleasant, polite, and cooperative, with speech within normal limits and good eye contact. His affect was mobile and appropriate. His thought processes were logical, sequential, and relevant. He showed no overt signs of delusions or paranoia. His concentration and memory were grossly intact, his judgment was appropriate, and his insight was good. He denied any suicidal or homicidal ideation. A GAF score of 58 was assigned. On April 2009 VA treatment, the Veteran complained of irritability, nightmares, and flashbacks. His insight was intact and he expressed motivation for change. He was employed and had supportive family and/or friends. He reported having leisure or recreational interests and was interested in vocational development. He was found to pose no risk to himself or others. A GAF score of 60 was assigned for the diagnosis of PTSD. On January 2010 VA treatment, it was noted that the Veteran had expressed suicidal ideation over the phone to a VA employee who then called the police; he was brought to the emergency department for treatment. He reported increased depression recently due to having just moved his family to a new state to live with his younger brother, because he was unable to financially provide for them. He reported having a difficult time keeping a job due to his anxiety and tendency to overreact. He reported a lack of interest in things he normally would enjoy. He had a history of suicidal ideation but no previous reported attempts. He reported sleeping poorly and erratically. He reported having nightmares and was sometimes unable to distinguish his dreams from reality. On mental status examination, the Veteran's mood was depressed and anxious. He was very talkative and his speech was clear and coherent. His thought process was organized with no reports of audio or visual hallucinations. He admitted to sometimes feeling paranoid. His insight was impaired and his judgment was poor. His concentration and eye contact were good, and he was pleasant and cooperative. The diagnoses included recurrent severe major depression without psychosis, and PTSD, and a GAF score of 32 was assigned. [In an April 2010 statement, the Veteran clarified that he was hospitalized for four days at this time under the Baker Act.] On March 11, 2010 VA examination, it was noted that the Veteran had been hospitalized for suicidal ideation in January 2010. The Veteran reported that he was taking Klonopin, Gabapentin, and Celexa, which reduced his depression and anxiety; he was not participating in group or individual therapy. He reported moderate depressed mood twice per week, sleep of 6 hours per night with medication, poor energy, decreased concentration, and decreased self esteem. He reported that recent suicidal ideation resulted in psychiatric hospitalization, though he denied any actual attempts. The examiner found no evidence of mania or hypomania. The Veteran reported being married for 20 years with two children and having one friend; he enjoyed spending time with his family, reading, and watching television. He denied any history of suicide attempts or violence/assaultiveness. On mental status examination, the Veteran was noted to be clean, neatly groomed, and casually and appropriate dressed. His psychomotor activity was unremarkable, and his speech was unremarkable, spontaneous, clear, and coherent. His attitude was attentive, his affect was full, and his mood was "crappy". His attention was intact, and he was oriented to person, time, and place. His thought process and thought content were unremarkable, and he reported no delusions or hallucinations. His judgment was intact, and his insight was fair. His behavior was appropriate. He reported no obsessive or ritualistic behavior or panic attacks. He denied any homicidal thoughts. He reported a recent hospitalization for suicidal thoughts but no attempts. His impulse control was fair and he reported no episodes of violence. He had no problem with the activities of daily living. His remote, recent, and immediate memory were normal. He reported that he was unemployed; he had lost his most recent job approximately one year earlier due to extreme behavior and poor people skills. Although he contended that his unemployment was due to his PTSD, the examiner opined that the Veteran's psychological issues were not severe enough to prevent him from working. The diagnoses were chronic PTSD and alcohol abuse, and a GAF score of 62 was assigned. The examiner opined that the reported irritability, sleep, and concentration problems could be due to either the alcohol abuse or the PTSD. The examiner opined that there was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but there was generally satisfactory functioning; the symptoms included relatively mild social detachment and anhedonia. On April 2010 VA treatment, the Veteran reported flashbacks twice per week, avoidance of war content on television, avoidance of public places, and hypervigilance. He reported anxiety attacks associated with muscle tension, palpitations, cold sweats, precipitants, and a sense of doom with emergency room visits; he reported these occur three times per week with a duration of up to several hours, with increased intensity during the first 5 to 10 minutes. He reported sleeping approximately 6 hours per night with initial and middle insomnia two to three times per night, and morning fatigue. He reported taking 3 to 4 hour daytime naps 4 times per week. His appetite was good, and his libido was decreased after beginning to take Klonopin. He reported that taking Celexa for 4 years helped with his energy level and tendency to become overwhelmed, and taking Prazosin for the past year helped with his nightmares and dizziness. Gabapentin helped to reduce his nightmares and insomnia as well. He denied any dysthymia or suicidal attempts, although he admitted to suicidal ideation as recently as two weeks earlier, with no plan. He was unemployed and reported that he had been terminated from five jobs in 10 years for interpersonal difficulties with others. On mental status examination, the Veteran was alert and oriented to all spheres, and his affect was within normal limits. He denied any suicidal or homicidal ideation. He showed no perceptual disturbance, and his thought process was organized. The impressions included chronic PTSD, recurrent major depressive disorder, alcohol dependence, and cannabis and nicotine dependence by history, as well as a personality disorder not otherwise specified. A GAF score of 60 was assigned. On July 2010 VA treatment, the Veteran had a 5 year history on medications that helped his PTSD symptoms including Gabapentin, Celexa, and Prazosin, with some success. He was also placed on Klonopin, which had significantly reduced his anxiety and irritability. He reported weekly combat nightmares, but he also frequently had "positive dreams" unrelated to combat. His daytime flashbacks were largely managed on his medication regimen. He was less irritable and his avoidance was down as well. He had been unemployed for over a year but had plans to work as a pastor in a new church. On mental status examination, he was cooperative and very extroverted. No unusual psychomotor activity was noted. His affect was appropriate and full range and his mood was good. His speech was slightly pressured and rapid, and his processing was logical and sequential though at times circumstantial. His thought content revealed no homicidal or suicidal ideation, plan, or intent. He was future oriented. No auditory or visual hallucinations were reported, and he had no paranoia or signs of hypomania or mania other than pressure speech. He reported no panic attacks. Cognitively, he was fully oriented; his memory was grossly intact, his concentration was within normal limits, and his judgment and insight were fair. The diagnoses included chronic PTSD, dysthymic disorder, and alcohol dependence in sustained partial remission, and a GAF score of 62 was assigned. On February 2011 VA treatment, the Veteran reported being very busy with his new position as a pastor; he loved it and felt like it was a good fit. He reported occasional dips in mood which caused him to spend more time in bed, and he had some occasional trouble with energy and motivation. He still had occasional nightmares and avoided watching the news or war movies to avoid any hyperarousal and intrusive memories. On mental status examination, the Veteran was cooperative and presented with good hygiene. No unusual psychomotor activity was noted. His affect was appropriate and full range, and his mood was described as very good most of the time. His speech was slightly pressured and rapid and he was very talkative and sometimes hard to direct. His thought process was logical and sequential and circumstantial. His thought content revealed no homicidal or suicidal ideation, plan, or intent. He was future oriented. He reported combat nightmares, and occasional intrusive thoughts associated with symptoms of hyperarousal. His judgment and insight were fair. The diagnoses included chronic PTSD, dysthymic disorder, and alcohol dependence in sustained remission; a GAF score of 65 was assigned. On October 31, 2011 VA examination, the Veteran reported that he had a "pretty decent" relationship with his wife of 22 years; they were not close physically, which he attributed more to her than to himself. He reported having good relationships with his two children, although he still overreacted to things. He denied having friends outside of his family. He was involved with teaching in the church but sometimes found it overwhelming. He reported that he enjoyed helping people and that his wife told him he had a hero complex. He enjoyed carpentry, watching his children ride their dirt bikes, camping, and traveling despite not having the time or money to do so. The Veteran reported that he was unemployed from December 2008 to June 2010; he then worked for a temp agency for two months until he was asked to leave due to lack of attendance, which he attributed to being overwhelmed. He was currently working as a church minister, since September 2010. On mental status examination, the Veteran was well groomed and appropriate dressed, his activity was within normal limits, and his attitude was cooperative. His speech was fluent and sequential. His mood was depressed and his affect was flat. He reported having hallucinations, feeling that sometimes he was being followed. His thought process was logical and coherent. His most recent suicidal ideation was about one month earlier, but he had no intent or plan because he loved his family. He reported fleeting homicidal thoughts about twice per month, thinking about hurting someone when he is angry, but he denied having any intent to harm others. He reported having memory issues. His attention was within normal limits, and his judgment and insight were fair. He reported having nightmares once a week and estimated that he slept 6 to 7 hours per night. He reported having a violent temper and becoming easily frustrated but he denied any physical aggression toward others. His symptoms included depressed mood, anxiety, suspiciousness, mild memory loss such as forgetting names, directions or recent events, flattened affect, and disturbances of motivation and mood. He also reported that he communicates in an extreme manner, he is hypervigilant, and he has difficulty in large crowds. He reported that since the last examination, his personal relationships had deteriorated, and he had a harder time managing his anger. The diagnoses included PTSD as well as cluster B traits on Axis II. A GAF score of 62 was assigned. The examiner opined that the Veteran's PTSD caused occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner opined that the Veteran's symptoms appeared largely unchanged since his last examination; he reported increased irritability and frustration in dealing with people, but he had meaningful relationships with his family and had maintained his position as a local minister of a small congregation. The examiner noted that the cluster B personality traits contributed to his interpersonal difficulties; he generally had poor coping skills in dealing with his anger and frustration that was not considered to be associated with, or in response to, his PTSD symptoms. In September 2012, the Veteran was hospitalized for five days due to homicidal ideation related to his recent termination from church employment. For the diagnoses of PTSD and history of alcohol dependence, a GAF score was assigned upon admission and a GAF score of 50 was assigned at discharge. Upon discharge, the Veteran reported that he felt decompressed; he was still irritable about the recent events involving the people at church but he had no thoughts of interacting with them or harming them in any way. He had no thoughts of harming himself either. He was trying to find a better job. On January 2013 treatment, the Veteran reported that he suffered a loss of his pastorship due to "congregation issues" in September 2012, and he was very angry with homicidal ideations for which he was admitted for treatment. On treatment, he reported irritability as his most troublesome symptom. He was employed with CarMax and felt underutilized and underpaid. He described job difficulties due to impatience and irritability. His nightmares were well managed with medication. He had no further anger or homicidal ideation toward the church members but still felt he needed a break from church pastoring. His medication compliance was noted to be "patchy". On mental status examination, the Veteran was cooperative and casually dressed. He appeared tired with a more constricted affect, and his mood was "okay at home" but with irritability surfacing easily. His thought content revealed no homicidal or suicidal ideation. No related behaviors were evident and he did not appear to be at risk of harming himself or others; he was future oriented. His judgment was fair but his medication compliance was poor, and his insight was fair. The diagnoses included chronic PTSD, dysthymic disorder, and alcohol dependence in partial remission, and a GAF of 58 was assigned. Based on such evidence, a February 2013 rating decision increased the rating for PTSD to 50 percent effective October 31, 2011, the date of a VA examination. On June 2013 VA treatment, the Veteran denied any homicidal thoughts or fantasies. He endorsed symptoms of depression, and he presented with an inflated self-image. He reported being unable to hold steady jobs because of his problem with authority. He stated that he had no friends because people grew tired of him. He reported that his role in ministry soured due to personality conflicts. He denied any acute plan or intent for self harm and denied any current thoughts of harm to others. He denied any symptoms of psychosis. He reported occasional nightmares and intrusive thoughts and he had problems with sleep. The diagnoses included PTSD, depression not otherwise specified vs. dysthymia, and alcohol abuse, with a rule-out diagnosis of a personality disorder; a GAF score of 50 was assigned. In a July 2013 statement, the Veteran stated that he had recently lost his job due to his PTSD symptoms. At the October 2013 Board hearing, the Veteran testified that he experiences flashbacks, nightmares, and anxiety, and he alienates people and has no close friends. He testified that he often wakes up disoriented. He testified that he has suicidal and homicidal thoughts but his wife has been very helpful regarding keeping him from getting into trouble with the law or hurting himself or anybody else. He testified that he loses concentration and repeats things, and he overreacts and is too intense. He testified that he recognizes some of the triggers of his anxiety attacks. He testified that he goes to church on a regular basis. He testified that he has been treated by a psychologist for brief periods at various times, and he sees a psychiatrist several times per year in addition to in case of an emergency, which happens a couple of times per year. He testified that at the time of the [March 2010] VA examination, he and his family were living with his brother because they had nowhere else to go; he testified that he was "emotionally fried" at the time of the examination, reporting that his wife had to drive him there, he was wearing pajamas at the time, and he could not think straight, yet the examiner did not record the severity of his symptoms. He testified that he was hospitalized in 2012 due to having homicidal ideation and plans. He testified that it was recommended he enter a 4-week or 12-week inpatient PTSD program at a long term treatment facility. Regarding the 2010 VA examination, the Veteran's wife testified that he was very anxious and functioning very poorly, and she had to pull him out of bed that morning, unshowered and unshaved, in his pajamas to attend the examination; she testified that this behavior happened once or twice per month and would last for 2 to 4 days. She testified that being in a large group of people or in the city for any extent of time sends him over the edge. She testified that he sought vocational rehabilitation and was denied twice. She testified that he has never been physically abusive to her or to their children. The Veteran has identified/submitted VA treatment records through September 2013. Such records, in addition to those cited above, reflect symptoms similar to those noted on the VA examinations cited above. At the outset, the Board notes that the record reflects that the Veteran has been assigned psychiatric diagnoses other than PTSD (most notably major depressive disorder, dysthymic disorder, and alcohol abuse) which are not service connected. While symptoms/impairment due to disability that is not service connected generally may not be considered in rating a psychiatric disability, governing caselaw provides that where it is not possible to distinguish the effects of a nonservice-connected disability from those of the service-connected disability being rated, the reasonable doubt doctrine dictates that all symptoms be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App, 181 (1998). In the instant case, the examiners have generally not distinguished symptoms due to the Veteran's PTSD from those due to other co-existing and nonservice-connected psychiatric diagnoses. Therefore, for the limited purposes of this appeal only, the Board will consider all psychiatric symptoms shown as due to the service-connected PTSD. Notably, in assigning the ratings on appeal the RO also did not exclude any symptoms from consideration as due to nonservice-connected disability. Taken as a whole, the medical evidence prior to March 11, 2010, shows that the impairment from the Veteran's PTSD more nearly approximated occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, contemplated by a 30 percent rating, rather than the reduced reliability and productivity required for a 50 percent evaluation. For example, on February 2008 VA examination, the Veteran reported recurrent nightmares, agitation, and hypervigilance, although many of his symptoms were better controlled on medication compared to before he began treatment. He reported having a good marriage with no significant problems since he began treatment, and he had no problems in his relationships with his two children. He denied any close relationships with his extended family, but his mental health symptoms did not appear to have significant affected his relationship with his extended family. He denied any significant loss of interest in hobbies or activities or history of suicide attempts and he reported no episodes of violence in recent years. The examiner opined that the Veteran's overall level of psychosocial functioning was fair; he was employed full time and had positive relationships with his wife and children, but he denied having significant social contacts outside of his family. The examiner opined that the level of symptom severity reported by the Veteran was consistent with a diagnosis of PTSD of mild severity; a GAF score of 68 was assigned. In short, the Board finds that the evidence prior to March 11, 2010 is indicative of no greater impairment than that contemplated by the 30 percent rating assigned for PTSD at that time. However, the Board finds that from March 11, 2010, symptoms of the Veteran's PTSD are shown to have more nearly approximated the criteria for a 50 percent rating. On examination on that date, he reported moderate depressed mood twice per week, sleep of 6 hours per night with medication, poor energy, decreased concentration, decreased self esteem, and recent suicidal ideation that had resulted in a brief psychiatric hospitalization, though he denied any actual attempts. On mental status examination, he reported that he was unemployed as he had lost his most recent job approximately one year earlier due to extreme behavior and poor people skills. The impressions included chronic PTSD and alcohol abuse, and a GAF score of 62 was assigned. The GAF scores of 50 to 65 assigned since that date continue to reflect moderate impairment due to his PTSD symptoms including flattened affect; circumstantial and pressured speech; mild memory loss; impaired abstract thinking; and disturbances of motivation and mood. Accordingly, the Board finds that a substantial number of the criteria for a 50 percent rating are met or approximated, and that the rating for the Veteran's PTSD warrants increase to 50 percent throughout from (the earlier effective date of) March 11, 2010. The evidence of record does not show that symptoms that meet (or approximate) the above-listed criteria for a 70 percent rating were manifest at any time during the evaluation period. At no time during the appeal period is it shown that the Veteran had occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: 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; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships, or any other symptoms of similar gravity; no such symptoms have been shown. Notably, for example, the Veteran has maintained family relations (as evidenced by a long-standing marriage, good relations with children, and the ability to turn to a brother for temporary shelter). While he has had periodic flare-ups, inability to maintain routine or daily activities is not shown. Consequently, the Board finds that the criteria for a 70 percent rating are not met or approximated for any period of time under consideration. The Board finds that the GAF scores assigned do not provide a separate basis for an award of a rating in excess of 50 percent. The symptoms and level of impairment represented by the GAF scores assigned reflect moderate disability, but not severe disability so as to warrant a 70 percent rating. The Board notes the lay statements submitted by the Veteran and his wife in support of this claim. Those statements detail the types of problems that result from the Veteran's PTSD symptoms (nightmares, irritability, anger flare-ups, difficulty maintaining employment, occasional suicidal ideation (but not intent) etc.). The levels of functioning impairment described are consistent with the criteria for the staged ratings assigned. Thus the lay statements do not support that a higher rating is warranted. The matter of entitlement to a total rating based on unemployability is addressed below. ORDER A rating in excess of 30 percent for the Veteran's PTSD prior to March 11, 2010 is denied. A 50 percent rating is granted for the Veteran's PTSD, effective from (the earlier effective date of) March 11, 2010, subject to the regulations governing payment of monetary awards; a rating in excess of 50 percent is denied. REMAND In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims 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. Here, entitlement to a TDIU rating [on an extraschedular basis] has been raised by the record. The Veteran testified that he cannot keep a job; he testified that he has held four jobs in the past five years, two of which he quit, and the other two from which he was fired. He testified that he was too often absent or late to work due to his PTSD or the medications he takes for it. He testified that he lost his most recent job as a mechanic technician in July 2013 due to his PTSD; over a nine month period, he was written up 12 times for being late or absent. Although a[n unappealed] January 2012 rating decision denied the Veteran TDIU, the matter is raised again as part and parcel of the instant claim for increase. Therefore, it must be remanded for development and adjudication. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). Expedited handling is requested.) The RO should fully develop and adjudicate the matter of the Veteran's entitlement to a TDIU rating [on an extraschedular basis]. If it is denied, the Veteran should be so advised, and advised of his appellate rights. If he files a notice of disagreement and a substantive appeal after an SOC is issued, such matter should be returned to the Board, if in order, for appellate review. He should be advised that this matter will not be before the Board unless he initiates, and perfects, an appeal as to any negative determination by the RO regarding his entitlement to a TDIU rating. The appellant 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs