Citation Nr: 1340412 Decision Date: 12/06/13 Archive Date: 12/20/13 DOCKET NO. 09-32 088A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an initial increased rating for posttraumatic stress disorder (PTSD), evaluated as 30 percent disabling from August 1, 2006 to June 6, 2012, and 50 percent disabling from June 7, 2012. 2. Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION The Veteran had active service from June 1967 to January 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the April 2008 and March 2010 rating decisions of the Department of Veterans Affairs Regional Office (RO) in St. Petersburg, Florida. The April 2008 rating decision granted service connection for PTSD and assigned a 30 percent disability rating for this disorder. The March 2010 rating decision denied entitlement to TDIU benefits. During the current appeal, and specifically in April 2011, the Veteran also testified at a Travel Board hearing at the RO conducted before the undersigned Veterans Law Judge (VLJ), who was designated by the Chairman to conduct the hearing pursuant to 38 U.S.C.A. § 7107 (c) (West 2002 & Supp. 2012). A transcript of the testimony has been associated with the Veteran's claims file. This matter was previously before the Board in December 2011 at which time it was remanded for additional development. It is now returned to the Board. As will be discussed further herein, as to the issue being decided herein, the Board finds that the agency of original jurisdiction substantially complied with the remand orders, and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). During the pendency of the Veteran's appeal, and specifically in a June 2012 rating action, the Veteran's disability evaluation for his service-connected PTSD was increased to 50 percent, effective from June 7, 2012. See Fenderson v. West, 12 Vet. App. 119, 126 (1999) (where evidence indicates that the degree of disability increased or decreased during the appeal period following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found). The Veteran also has a Virtual VA paperless claims file, which is a highly secured electronic repository that is used to store and review documents involved in the claims process. The paperless file includes VA treatment records dated through June 2012, most of which are not located in the paper claims file, as well as the Appellant's Post-Remand Brief, which has been submitted on behalf of the Veteran by his representative. All these records have been considered by the Board in adjudicating this matter. 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. FINDINGS OF FACT For the entire duration of the appeal, the Veteran's PTSD has been productive of sleep impairment, suicidal ideation, intrusive thoughts, social isolation, paranoia, nightmares, hypervigilance, anger problems, avoidant behavior, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control, difficulty in adapting to stressful circumstances and Global Assessment of Functioning scores of 41 and 50; those manifestations overall are indicative of serious, but not total, impairment in occupational and social functioning. CONCLUSION OF LAW For the entire duration of the appeal, the schedular criteria for a rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist At the outset, the Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2012). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). (The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008, during the pendency of the appeal. See 73 Fed. Reg. 23353 -56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the Veteran to provide any evidence in the Veteran's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1).) The Board finds that all notification and development action needed to render a decision on the claim on appeal has been accomplished. Through a May 2007 notice letter, the RO notified the Veteran of the information and evidence needed to substantiate his underlying service connection claim. Thereafter, the Veteran was afforded the opportunity to respond. In addition, the Veteran was provided notice concerning the assignment of rating criteria and effective dates via the May 2007 letter. Hence, the Board finds that the Veteran has received notice of the information and evidence needed to substantiate his claim that is the subject of this decision, and has been afforded ample opportunity to submit such information and evidence. The Board also finds that the May 2007 notice letter satisfies the statutory and regulatory requirement that VA notify a claimant what evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). In the letter, the RO notified the Veteran that VA was required to make reasonable efforts to obtain medical records, employment records, or records from other Federal agencies. The RO also requested that the Veteran identify any medical providers from whom he wanted the RO to obtain and consider evidence. Thus, the Board finds that "the appellant [was] provided the content-complying notice to which he [was] entitled." Pelegrini v. Principi, 18 Vet. App. 112, 122 (2004). In addition, the Veteran was given the opportunity to respond following the May 2007 notice letter. In any event, as is the case here, once a veteran disagrees with an initial determination, other provisions apply to the remainder of the adjudication process, particularly those pertaining to the issuance of rating decisions and statements of the case. See 38 U.S.C.A. §§ 5104(a), 7105(d) (West 2002); 38 C.F.R. §§ 3.103(b)(1), 19.29 (2010); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); see also Dunlap v. Nicholson, 21 Vet. App. 112, 119 (2007). Nothing about the evidence or any response to the RO's notification suggests that the rating issue must be re-adjudicated ab initio to satisfy the requirements of the VCAA. The Board also points out that there is no indication that any additional action is needed to comply with the duty to assist in connection with the claim decided herein. The Veteran's service treatment records as well as all identified and available VA medical records pertinent to the years after service are in the claims file and were reviewed by both the RO and the Board in connection with the Veteran's rating claim. Also, the Veteran's Social Security Administration (SSA) records have been retrieved and associated with the claims file. In addition, the Veteran testified before the Board in April 2011. Indeed, at no time has the Veteran or his representative referenced outstanding records that they wanted VA to obtain or that they felt were relevant to his claim. Moreover, pursuant to the December 2011 remand, the Veteran was afforded a VA psychiatric examination to determine the current level of severity of his PTSD in June 2012. There is no objective evidence indicating that there has been a material change in the severity of his service-connected disorder since the Veteran was last examined. See 38 C.F.R. § 3.327(a) (2013). The duty to assist does not require that a claim be remanded solely because of the passage of time since otherwise adequate VA examinations were conducted. See VAOPGCPREC 11-95. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examination obtained in this case is more than adequate, as it was predicated on a review of the Veteran's medical records, an interview with the Veteran, and a discussion of his medical history and because the examination fully addresses the rating criteria that is relevant to rating the disability in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination in connection to the increased rating issue on appeal has been met and the requirements of the December 2011 remand were ultimately accomplished. See Stegall v. West, 11 Vet. App. 268 (1998). Thus, there is adequate medical evidence of record to make a determination in this case. Under these circumstances, the Board finds that VA has complied with all duties to notify and assist required by 38 U.S.C.A. §§ 5103(a), 5103A and 38 C.F.R. § 3.159. Analysis Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Turning to the rating criteria for PTSD, the Board first observes that the symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). An evaluation of 30 percent is warranted for PTSD with occupational and social impairment with occasional decreased 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, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. An evaluation of 50 percent is warranted for PTSD with 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. See Id. A 70 percent evaluation is warranted for PTSD with 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 work-like setting); inability to establish and maintain effective relationships. See Id. A 100 percent evaluation is warranted for PTSD with total occupational and social impairment, due to symptoms such as the following: 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. See Id. For purposes of considering the evidence in connection with the PTSD issue, the Board notes that the Global Assessment of Functioning (GAF) scale is a scale from 0 to 100, 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) ("DSM-IV") (100 representing superior functioning in a wide range of activities and no psychiatric symptoms). See also 38 C.F.R. §§ 4.125, 4.126, 4.130. A GAF score of 31-40 indicates some impairment in reality testing or communications or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. A GAF of 41-50 denotes serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning. A GAF of 51-60 denotes moderate symptoms (e.g. flat affect, circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or coworkers). A GAF of 61-70 denotes 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 interpersonal relationships. The record includes VA outpatient treatment records dated from 2004 to 2012, the June 2012 VA examination report, lay statements submitted by the Veteran, as well as his family members, friends and former employers, as well as hearing testimony provided by the Veteran and his spouse. All of these records have been reviewed by the Board, although they will not all be discussed in assessing the rating assigned to the Veteran's PTSD. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that the clinical evidence for the entire duration of the appeal more closely assesses the Veteran's occupational and social impairment around the 70 percent rating. In this regard, the Veteran has received ongoing psychiatric treatment at the VA Medical Center (VAMC) in Tampa, Florida. These records demonstrate that throughout the course of the appeal, the Veteran's PTSD symptoms have included suicidal ideation, near continuous depression and panic attacks, difficulty concentrating, sleep disturbances, flashbacks, social isolation, and difficulty adapting to stressful circumstances. Initially, the Board observes that the record on appeal demonstrates that, in addition to the Veteran's service-connected PTSD, he has also been diagnosed with anxiety disorder not otherwise specified (NOS) (See July 2006 VA treatment report) and bipolar disorder (see June 2012 VA examination report). However, service-connection has not been established for these disorders and it is unclear from some of these records whether or not symptoms of these disorders are intertwined with his PTSD. The Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102 (2008); Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so). Accordingly, the Board will consider the psychiatric symptoms as depicted by the evidence as a whole in rating the service-connected PTSD unless clearly attributed to the other nonservice connected disorders. In this regard, VA outpatient records reflect that the Veteran was admitted to a VA medical facility with worsening PTSD symptoms of three weeks duration in November 2004. It was noted that the Veteran's psychiatric condition had been deteriorating since his birthday, which is the anniversary of the date his friend and former fellow serviceman committed suicide many years ago. On admission, the Veteran endorsed symptoms of flashbacks, as well as suicidal and homicidal ideations. Although the Veteran's affect was constricted and his thought process was positive for suicidal ideation and auditory hallucinations, his thought form was described as linear, logical and goal directed and his insight and judgment were described as fair. During his April 2011 hearing, the Veteran testified that he assaulted a few of the other patients as well one of the physicians at the hospital during his November 2004 hospitalization. See April 2011 Hearing Transcript (T.) p. 10. After changing his medication and undergoing routine monitoring for twenty-four hours, the Veteran showed signs of improvement, and he denied any suicidal or homicidal ideations at the time of discharge. Subsequent records reflect that the Veteran was admitted to the VA medical center (VAMC) in Tampa, Florida in July 2006 with reports of suicidal ideation and worsening PTSD symptoms. Upon admission, the Veteran reported to experience a myriad of symptoms, to include flashbacks, hypervigilance, nightmares, and avoidant behavior. According to the Veteran, he had been doing well for the past two years and it was only recently that his PTSD symptoms had started to degenerate. He reported to experience a depressed mood as well as panic attacks which he likened to periods of nausea, anxiety, chills and shortness of breath of three to four weeks duration. The VA staff psychiatrist noted that the Veteran was thereafter placed on a new medication which helped improve a number of his symptoms. Prior to his discharge, the Veteran underwent a mental examination, wherein he was shown to be cooperative, his speech was described as fluent, coherent and relevant, and his thought processes were described as linear, logical and goal oriented. The VA staff psychiatrist described the Veteran's mood as depressed and his affect as constricted and assigned the Veteran a GAF score of 60 at discharge. Subsequent VA treatment records reflect that the Veteran was hospitalized once again in February 2007. Upon admission, the Veteran was assessed with a GAF score of 25, and he described deteriorating PTSD symptoms, to include increasing nightmares, flashbacks, decreased concentration, impaired sleep, anxiety, and suicidal thoughts and intent. According to the Veteran, his symptoms had worsened over the past three months without any precipitating stressors. In the May 2007 letter, the Veteran's psychologist at the VA, J.L, Ph.D., reviewed his military and medical history and described how certain traumatic in-service and post-service events had affected the Veteran's ability to function both occupationally and socially. According to Dr. L., the Veteran had few close friends and experienced intense guilt related to the loss of his friends in service. Occupationally, Dr. L. noted that the Veteran was once successfully employed as an installer of window blinds and draperies, but in the years following September 11th, and the development of his PTSD symptoms, his business declined. Dr. L. noted that the Veteran's "[a]rousals symptoms" were particularly disruptive to his ability to continue his business with the level of proficiency and success he attained in the past. The Veteran also reported to experience dissociative symptoms, to include a "subjective sense of numbing and detachment as well as reduction in awareness of surroundings, [that had] negatively impacted his ability to maintain his business." According to Dr. L., the Veteran had a GAF score no higher than 41, and his ability to function had been seriously impacted by his psychiatric symptoms, as he had few friends and was unable to keep a job. Although the Veteran's September 2007 hospitalization was attributed to his bipolar disorder, the Veteran did allude to occasional suicidal thoughts during his hospitalization. See September 2007 Nursing note. During a June 2007 VA treatment visit, the Veteran reported to experience ongoing difficulty sleeping, and further noted to struggle significantly with his memory. According to the Veteran, he had poor concentration, and was unable to focus. The Veteran also endorsed symptoms of paranoia and stated that he did not like to leave his house or visit places. He also reported to experience feelings of guilt and hopelessness, and added that he worried about not being able to provide for his family. At a January 2008 VA outpatient visit, the Veteran reported to have nightmares three times a week, and further reported to get about 5.5 hours of sleep every 24 hour period. According to the Veteran, "between Desert Storm, 9-11, and the Iraqi War," he had been feeling worse in recent years. A July 2007 SSA Disability Determination and Transmittal form reflects that the Veteran was granted disability benefits for his psychiatric disorder, effective July 1, 2007. In the Explanation of Determination letter, it was determined that the Veteran was disabled as a result of his PTSD. During a May 2009 VA treatment visit, the Veteran reported to have occasional dreams about suicide, and stated that the last time he had suicidal ideation was two to three months prior. A March 2010 VA outpatient report documents the Veteran's complaints of feeling depressed 70 to 75 percent of the time. In a June 2010 statement, the Veteran's wife, J.S. explained how the Veteran's psychiatric condition began to decline in 2000. According to J.S., prior to the deterioration of his psychiatric condition, the Veteran led a successful business working as a window cover installer. However, as explained by J.S., around the year 2000, the Veteran began to go into spells wherein he would spend the night alone in his car and ask not to be bothered by anyone, or wake up afraid that someone was coming after him. According to J.S., even though they continued working, they started cancelling various jobs due to the fact that the Veteran was afraid to leave his house. She noted that the Veteran's symptoms steadily worsened and in 2004, he had what she described as a "very large breakdown" which led to his hospitalization. Although the Veteran's condition improved by the end of his hospitalization, he was back in the hospital one month later, and had since been in and out of the hospital five times as a result of his PTSD. She stated that the Veteran was no longer the same person as before as he is scared to leave the house and go out in public, and he does not sleep beside her at night for fear he may hurt her due to violent manner in which he awakens from his ongoing nightmares. As a result of the Veteran's deteriorating condition, and her fear of leaving him by himself, J.S. explained that they were forced to cancel all their jobs and assignments, and have since lost all their previous accounts as well as their home. In December 2010, the Veteran presented at the VAMC with a two to three month history of worsened depressed mood and persistent suicidal thoughts. Upon admission to the hospital, the Veteran endorsed symptoms of depression, anhedonia, poor sleep, low concentration, and suicidal thoughts with a plan to overdose on his medication. After he was admitted and assessed by the inpatient psychiatric team, he was re-started on a new medication regimen. After two days, the Veteran's mood and symptoms improved significantly and he was discharged several days later with a GAF score of 55. However, in February 2011, the Veteran presented at the Zephyrhills Community-Based Outpatient clinic (CBOC), at which time he admitted to feeling depressed for the past two months. The Veteran also endorsed feelings of worthlessness, helplessness and hopelessness and admitted to occasional crying spells. According to the Veteran, he was not sleeping and had nightmares two to three times a week that were combat related. On examination, his speech was shown to be taciturn and quiet, his mood was described as depressed, and his affect was described as resigned and restricted. During a November 2011 VA outpatient visit, the Veteran explained that he got into an argument with his neighbor the day before which resulted in him becoming violent and pushing his neighbor down. VA treatment records dated in January 2012 also demonstrated a worsening in the Veteran's symptoms. During this follow-up visit, the Veteran reported to have passive suicidal thoughts without intent or plan and stated that he was having hallucinations upon awakening from his nightmares. The Veteran described seeing "dead friends" at the foot of his bed briefly, and reported to be "more impulsive and verbally hostile towards others, especially his wife." The Veteran also reported to experience increased depression, anxiety, intrusive thoughts and nightmares. On examination, the Veteran's mood was described as anxious and depressed, and his affect was shown to be congruent to his mood. The treatment provider also noted that the Veteran exhibited passive suicidal ideation without plan or intent and that the Veteran agreed he would go to the acute recovery center (ARC) at the VAMC emergency room if necessary. After attending a February 2012 PTSD group session where the topic of conversation focused on certain events related to a recent murder-suicide, the Veteran met with the clinical psychologist afterwards at which time he reported to experience increasing flashbacks and thoughts of suicide triggered by discussion this topic. During a May 2012 follow-up visit, the Veteran reported to feel "very depressed" over the past month, and the treatment provider noted that he had not been showering or shaving on a regular basis. According to the Veteran, he goes days without sleep and has nightmares whenever he does sleep. The Veteran further reported to experience panic attacks several times a week as well as a lack of motivation or desire to go anywhere or do anything. The Veteran indicated that he had been considering applying for the Bay Pines residential treatment program for PTSD, but was hesitant to do so because he did not want to leave his wife home alone for six weeks. On mental examination, the treatment provider described the Veteran's mood as anxious and depressed, and assigned him a GAF score of 50. The Veteran was afforded a VA psychiatric examination in June 2012, at which time the examiner reviewed the Veteran's medical, social and employment history, and noted that the Veteran had been married to his current wife since 1995. The Veteran described his marriage as "OK" and explained that he had been married five times and had one son from his first marriage, with whom he maintained a good relationship. With regard to his social activities, the Veteran reported that he is not able to interact with others "but does like groups since [2005]." The Veteran also reported to sleep in the afternoon and noted that he sleeps better in the day, and tends to stay on his Citizens band (CB) radio at night. According to the Veteran, he does not go out to restaurants or to the movies, and while he used to work as a window cover installer, he had not worked since 2005-2006 due to the fact that "he started making many expensive mistakes" and was eventually dropped by his clients. After reviewing the Veteran's medical records and evaluating the Veteran, the examiner diagnosed the Veteran with PTSD and bipolar disorder, most recent episode (MRE) depression, and assigned him a GAF score of 50. According to the examiner, the Veteran's PTSD is manifested through recurrent and distressing recollections of the traumatic in-service event, including images, thoughts or perceptions; recurrent distressing dreams of the event; and intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event - symptoms that he experiences on a daily or near-daily basis. The examiner also noted that the Veteran attempts to avoid thoughts, feelings or conversations associated with the trauma, as well as activities, places or people that arouse recollections of the trauma on a daily basis. The examiner further noted that the Veteran's hyperarousal, avoidant behavior and intrusive memories serve to exacerbate his anxiety, depression and irritability, all of which interferes with his social and occupational functioning. Upon mental evaluation, the examiner observed the Veteran to be neatly groomed and appropriately dressed, and further noted that the Veteran was oriented times four. The examiner also described the Veteran's mood as sad and lethargic and his affect as blunted and lethargic. With regard to the Veteran's current symptomatology, the examiner noted that the Veteran endorsed a depressed mood, anxiety, chronic sleep impairment, a flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships as a result of his PTSD. The examiner further concluded that the Veteran experiences occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, as a result of his PTSD. The Board finds that in this case, the clinical evidence throughout the entire duration of the appeal more closely approximates the level of occupational and social impairment contemplated by a 70 percent rating. Specifically, the Veteran is socially withdrawn and housebound, has frequent panic attacks, experiences a depressed mood and ongoing suicidal thoughts, and has anger issues, intrusive thoughts, and avoidant behavior which results in few to no interpersonal relationships with people outside of his own family. Indeed, the record reflects that the Veteran's PTSD has steadily deteriorated throughout the years, and has resulted in at least five hospitalizations from 2004 to 2010. In addition, the Veteran testified at his hearing that he has been unemployed since 2004 (see T. p. 15), and prior to that he was forced to cancel various assignments and projects due to his difficulty concentrating at work, his fear of leaving his house, and his inability to perform the necessary tasks required of him - tasks he was once able to fulfill. This coupled with the fact that he has been divorced four times, and does not interact with any friends or participate in hobbies or social activities in his community is reflective of criteria enumerated under the 70 percent evaluation for PTSD. Suicidal ideation, near continuous panic or depression affecting the ability to function independently, appropriately and effectively and difficulty in adapting to stressful circumstances (including work or a work like setting) are listed under the criteria for the evaluation of a 70 percent evaluation for PTSD. Additionally, VA treatment records dating from November 2004 to June 2012 reflect that the Veteran has been assigned multiple GAF scores ranging from 41 to 60, by various VA psychologists and VA treatment providers, which indicate that the Veteran has moderate to severe impairment. The Board notes that GAF scores are just one component of the Veteran's disability picture, and there is no set 'formula' followed in assigning evaluations. Rather, the Board considers the Veteran's entire disability picture, including GAF scores, when rendering its determination. Under such circumstances, Veterans with identical GAF scores may be assigned different evaluations based on each individual's symptomatology and level of functioning. Furthermore, the Board need not accept a GAF score as probative. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 492, 433 (1995) (it is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others). The Board acknowledges that multiple VA treatment providers assigned the Veteran GAF scores ranging between 55 to 60 which reflect that the Veteran suffers from 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). However, the Veteran was also assigned a GAF score of 41, as reflected in the May 2007 letter issued by Dr. J.L., a VA psychologist who had the opportunity to meet with and evaluate the Veteran on multiple occasions. In addition, the more recent VA treatment records dated in December 2010, January 2012, and May 2012, as well as the June 2012 VA examination report, indicate that the Veteran was assigned GAF scores of 50 which reflects more serious symptoms, or any serious impairment in social, occupational or school functioning. The Board finds that the GAF scores indicating more severe symptoms are more consistent with the medical evidence of record. Accordingly, such characterization more closely approximates the scheduler criteria associated with a 70 percent evaluation for the Veteran's PTSD. The Board observes that a higher rating is not warranted because the competent evidence of record does not demonstrate that the Veteran's symptomatology most closely approximates a 100 percent evaluation or higher. In this regard, the Board notes that the Veteran's medical records do not contain evidence which support a finding that he has gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living, or disorientation as to time or place. The Board acknowledges VA treatment records which demonstrate that the Veteran has experienced occasional auditory and visual hallucinations. This was reaffirmed at his hearing when the Veteran testified that he hallucinates at night which is why he tries to sleep during the day. See T. p. 5. However, the Board notes that upon review of the Veteran's entire medical history, reports of hallucinations were mentioned or discussed on an infrequent basis. Indeed, the majority of the VA recent treatment records, as well as the June 2012 VA examination report, are either negative or absent for any complaints or signs of auditory or visual hallucinations, and are therefore better reflective of the Veteran's current symptomatology. Indeed, the record establishes that the Veteran has maintained fairly steady relationships with family members, and further reflects that he currently resides with his wife and has described his marriage as a good one. The record also demonstrates that the Veteran continues to perform his activities of daily living independently. Other than one isolated occasion in May 2012, he has consistently maintained his personal appearance and hygiene to a socially acceptable level, without any indication of grossly inappropriate behavior and has been described as someone who is neatly and appropriately groomed, logical and goal-oriented. The overall picture based on the medical evidence of record corresponds more closely with the 70 percent disability evaluation. Therefore, the Board finds that the criteria for a 100 percent schedular evaluation are not met, and a total schedular evaluation is not warranted. Resolving reasonable doubt in the Veteran's favor as to the severity of his service-connected PTSD, the Board concludes that the criteria for a 70 percent evaluation are met throughout the appeal period. However, the criteria for a 100 percent schedular evaluation are not met, as the Veteran continues to maintain some social relationships. The GAF score assigned reflects severe, but not totally incapacitating, PTSD. Thus, while the criteria for a 70 percent evaluation have been met throughout the appeal period and the appeal is granted to this extent, the criteria for a total schedular evaluation for PTSD are not met. In essence, the preponderance of the evidence is against an evaluation in excess of 70 percent for PTSD. Since the evidence is not in equipoise, the provisions of 38 U.S.C.A. § 5107(b) regarding resolution of reasonable doubt are not applicable to warrant an evaluation in excess of 70 percent. The above determinations are based upon application of the pertinent provisions of VA's rating schedule. The Board finds that the record does not reflect that the Veteran's disability is so exceptional or unusual as to warrant the assignment of a higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the Board finds that the rating criteria used to evaluate the Veteran's PTSD reasonably describes his disability level and symptomatology and he has not argued to the contrary. There is no indication that the Veteran's disability picture is so exceptional or unusual to render the schedular criteria inadequate. Consequently his disability level is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate. For these reasons, the Veteran's disability picture is contemplated by the rating schedule and no extraschedular referral is required. 38 C.F.R. § 3.321(b)(1); Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). ORDER An initial increased rating of 70 percent, but no higher, for the service-connected PTSD is granted for the entire duration of the appeal, subject to laws and regulations governing the award of monetary benefits. REMAND The Veteran contends that he was unable to continue working as an installer of window blinds and draperies, and ultimately lost his business, as a result of his worsening PTSD symptoms. He further contends that he is unable to secure or follow a substantially gainful occupation as a result of his PTSD. The Veteran is currently service-connected for PTSD, which as determined above, is evaluated as 70 percent disabling. Accordingly, the Veteran meets the schedular percentage requirements for eligibility for TDIU. See 38 C.F.R. § 4.16(a). In the December 2011 remand, the Board instructed the AOJ to schedule the Veteran for a VA examination to determine the current extent and severity of his PTSD. The remand directives also instructed the VA examiner to address whether the Veteran's PTSD renders him unable to secure or follow a substantially gainful occupation. At the June 2012 VA examination, the VA examiner did not find that the Veteran had total occupational and social impairment and explained that the Veteran's ability to understand and follow instructions, as well as his ability to retain instructions and sustain enough concentration to perform simple tasks was not considered impaired. The VA examiner did find that the Veteran's ability "to sustain concentration to task persistence and pace," as well as his ability to respond appropriately to coworkers, supervisors, or the general public was considered moderately impaired. The VA examiner also noted that the Veteran had "marked impairment" when it came to his ability to respond appropriately to changes in the work setting. It appears that the Veteran's claims file was subsequently reviewed by another VA examiner several hours later, and this examiner determined that the Veteran's medical condition did prevent him from securing or following a substantially gainful occupation. The examiner also noted that the Veteran's conditions were likely to be permanently disabling. See June 2012 General VA examination report. However, when asked to provide an opinion as to whether the Veteran was unemployable as a result of his PTSD, this VA examiner indicated that the Veteran was scheduled for a VA examination in connection to his PTSD claim, and explained that he would defer to the opinion issued by the mental healthcare provider with regard to this issue. Indeed, this examiner did not conduct a psychiatric evaluation of the Veteran, and it does not appear that he reviewed the examination findings generated at the June 2012 VA mental examination when arriving at his conclusion. The June 2012 VA examiner who did conduct a mental evaluation of the Veteran, did not mark that the Veteran had total occupational and social impairment as a result of his PTSD, but did observe moderate impairment in the Veteran's ability to concentrate on certain tasks as well as his ability to respond appropriately to coworkers, supervisors, or the general public. She also noted that the Veteran's ability to respond appropriately to changes in the work setting was considered "marked[ly] impaired." Despite these findings, the examiner did not discuss the type of employment the Veteran was capable of performing in light of his educational and occupational history, and in light of the fact that some of the cognitive abilities necessary to function in the work environment were deemed impaired as a result of his PTSD. Furthermore, this examiner did not clearly address whether the Veteran is unable to obtain and/or maintain another of form of employment consistent with his education and occupational experiences, as a result of his service-connected disorder. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In light of the contradictory medical findings, and the inadequate information provided, the Board finds that another VA examination and clarifying medical opinion is necessary for the purpose of determining whether the Veteran is capable of obtaining and maintaining substantially gainful employment. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be scheduled for another VA psychiatric examination. The purpose of this examination is to determine the effect of the Veteran's service-connected PTSD on his employability. The claims folder, a copy of this REMAND, and a copy of all medical records on the Virtual VA claims file must be made available to, and reviewed by, the examiner(s) in conjunction with the examinations. Any and all studies, tests, and evaluations deemed necessary by the examiner(s) should be performed. The examiner(s) is/are requested to elicit from the Veteran, and record for clinical purposes, his full educational and employment history. The examiner(s) is then requested to review all pertinent records associated with the claims file, to include the more recent VA treatment records, and to conduct a mental evaluation of the Veteran. The examiner(s) should then comment on the effect of the service-connected PTSD on the Veteran's ability to engage in any type of full-time employment consistent with his education and occupational experiences, including whether any form of 'light duty' is possible and whether, in the examiner's opinion, this service-connected disability is of such severity as to result in an inability to obtain and to maintain employment. If the Veteran is capable of performing 'light duty', the examiner(s) should specifically discuss what 'light duty' type work encompasses and provide examples of the type of light duty the Veteran could secure employment in, in light of his education and previous work experiences. When rendering his or her opinion, the examiner(s) should take into consideration the severity of the Veteran's service-connected PTSD. If the examiner(s) finds that the Veteran is employable, he or she should explain how the Veteran is capable of obtaining or maintaining any type of employment in light of the mental restrictions resulting from his service-connected disabilities. Clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the examiner(s) feel that the requested opinion cannot be rendered without resorting to speculation, the examiner(s) should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 2. The AOJ should ensure compliance with the remand instructions. After the above development has been completed, review all the evidence of record and readjudicate the Veteran's claim of entitlement to TDIU. If the issue on appeal remains denied, provide the Veteran and his representative a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. No action is required of the Veteran until he is notified by the AOJ; however, the Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2013). The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (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. A. MARKEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs