Citation Nr: 1340628 Decision Date: 12/09/13 Archive Date: 12/20/13 DOCKET NO. 09-18 254 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an increased disability rating for posttraumatic stress disorder (PTSD), rated as 30 percent disabling prior to May 28, 2008. 2. Entitlement to an increased disability rating for PTSD, rated as 50 percent disabling from May 28, 2008 through May 31, 2011. 3. Entitlement to an increased disability rating for PTSD, rated as 70 percent disabling from June 1, 2011. 4. Entitlement to a total disability evaluation due to individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD D.S. Lee, Counsel INTRODUCTION The Veteran served on active duty from October 1967 through October 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. By way of history, service connection for PTSD was originally granted for the Veteran, effective August 8, 2006, with an assigned 30 percent initial disability rating. In May 2008, the Veteran filed a claim seeking a higher disability rating. Subsequently, the RO's July 2008 rating decision granted a higher 50 percent disability rating, effective May 28, 2008. From that decision, the Veteran filed a timely Notice of Disagreement (NOD) in which he asserted entitlement to a higher disability rating. The Veteran testified during an October 2010 Travel Board hearing that was held at the RO in St. Petersburg, Florida before the undersigned Veterans Law Judge. A transcript of this testimony is associated with the claims file. Subsequently, in April 2011, the Board remanded this matter for further development, to include efforts to obtain additional treatment records, to specifically include records from VA's New Port Richey Outpatient Clinic in Pasco County, and, to afford the Veteran a new VA examination of his PTSD. Efforts to comply with the Board's remand action were undertaken by the Appeals Management Center (AMC) in Washington, D.C. Over the course of the post-remand development, the AMC issued a March 2012 rating decision which awarded a higher 70 percent disability rating, effective June 1, 2011. Notwithstanding the staged grants outlined above, the Veteran has not expressed satisfaction with the assigned disability ratings for his service-connected PTSD. As such, the Board presumes that the Veteran is seeking the maximum available benefit and therefore maintains jurisdiction over the issues concerning the disability ratings assigned for the Veteran's PTSD. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); AB v. Brown, 6 Vet. App. 35, 38 (1993). This matter now returns to the Board in the foregoing procedural posture. The Board is satisfied that the remand action directed in the April 2011 remand has been performed and is prepared to proceed with its de novo consideration of this matter. The Board also notes that, in addition to the paper claims file, a paperless electronic claims file is associated with the claim on the Virtual VA and VBMS systems. These electronically stored records have been reviewed and considered as part of the evidentiary record. The issue of entitlement to TDIU is addressed in the REMAND below. FINDINGS OF FACT 1. Prior to May 28, 2008, the Veteran's PTSD was manifested by depression, anxiety, irritability, chronic sleep disturbances, and intrusive thoughts related to his in-service stressors; occupational and social impairment with reduced reliability and productivity is not shown during this period. 2. From May 28, 2008 through May 31, 2011, the Veteran's PTSD was manifested by occupational and social impairment with reduced reliability and productivity; occupational and social impairment, with deficiencies in most areas is not shown during this period. 3. From June 1, 2011, the Veteran's PTSD was manifested by occupational and social impairment, with deficiencies in most areas; total and occupational impairment is not show during this period. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 30 percent for PTSD prior to May 28, 2008 have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2013) 2. The criteria for a disability rating in excess of 50 percent for PTSD from May 28, 2008 through May 31, 2011 have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for a disability rating in excess of 70 percent for PTSD from June 1, 2011 have not been met or approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1), proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. Such notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). A June 2008 pre-rating letter provided the Veteran with notice of the information and evidence needed to substantiate his claim for an increased disability rating for PTSD. Consistent with Dingess, this letter included notice of the process in which VA assigns disability evaluations and effective dates. Subsequently, the Veteran's claim for a higher disability rating was adjudicated in the RO's July 2008 rating decision. Thus, because the VCAA notice in this case was legally sufficient, VA's duty to notify in this case has been satisfied. In addition, VA has fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claims. His service treatment records, claims submissions, lay statements, and VA treatment records have been obtained and associated with the record. VA examinations of his PTSD were conducted in June 2008, August 2009, and June 2011. Moreover, VA has not received any additional evidence since the June 2011 examination which indicates that the Veteran's PTSD has changed such as to warrant the scheduling of a new VA examination to reassess its symptoms and severity. Hence, these examinations, along with the other evidence of record, are fully adequate for the purpose of determining the extent of the Veteran's PTSD in light of the applicable diagnostic criteria. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Disability Ratings for PTSD Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations applies, 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 severity, it is necessary to consider the complete medical history of the veteran's disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Moreover, staged ratings are appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in the veteran's favor. 38 C.F.R. §§ 3.102, 4.3. Once the evidence is assembled, the Board is responsible for determining whether the preponderance of the evidence is against the claim. If so, the claim is denied; if the evidence is in support of the claim or is in equal balance, the claim is allowed. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). For all periods relevant to this appeal, the Veteran's PTSD has been rated in accordance with 38 C.F.R. § 4.130, DC 9411, which provides the rating criteria specifically for PTSD and requires that PTSD be rated under the General Rating Formula for Mental Disorders (General Formula). Under the General Formula, a 30 percent disability rating is assigned for PTSD that is manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation); due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; mild memory loss (i.e., forgetting names, directions, and recent events) A 50 percent disability rating is assigned for PTSD that is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as a 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; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is appropriate for PTSD that is manifested by 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 that is 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); or the inability to establish and maintain effective relationships. A 100 percent disability evaluation is granted where PTSD is productive of total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting himself or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time and place; or memory loss for the names of close relatives, own occupation, or own name. A. Prior to May 28, 2008 Subject to the procedural history noted in the introduction, the Board notes that the effective date for the assignment of an increased disability rating is generally the latter of either the date of receipt of the claim, or, the date on which entitlement to the higher disability rating arose. 38 C.F.R. § 3.400(o)(1). If, however, the claim for a higher disability rating is filed within one year of the date that the evidence shows that an increase in disability has occurred, the effective date is the earliest date as of which an increase is factually ascertainable (not necessarily the date of receipt of the evidence). 38 C.F.R. § 3.157(b)(1); 3.400(o)(2); see also Harper v. Brown, 10 Vet. App. 125, 126-27 (1997). In view of the foregoing law, and given that the Veteran's claim for an increased disability rating for PTSD higher than 30 percent was received on May 28, 2008, the earliest date on which the Veteran may be assigned a higher disability rating for his PTSD is May 28, 2007. Mindful of the same, and after careful review and consideration of the evidence of record, the Board finds that the Veteran is not entitled to a disability rating higher than 30 percent for PTSD at any time before May 28, 2008. In that regard, the overall disability picture associated with the Veteran's PTSD during that period corresponds with the assignment of a 30 percent disability rating. The only evidence pertinent to the severity of the Veteran's PTSD during the staged period before May 28, 2008 is the psychiatric findings noted in post-service VA treatment records dated in August 2007 and in April 2008. These records reflect ongoing complaints of depression, anxiety, irritability, sleep disturbances marked by nightmares and restlessness, and intrusive thoughts; all of which were managed by medication. Notably, the Veteran expressly denied having any suicidal or homicidal ideation. No opinion was given during either treatment as to the impact of the Veteran's symptoms on his occupational or social functioning, and indeed, the records do not indicate any subjectively reported occupational or functional impairment. Also, a Global Assessment of Functioning (GAF) scale score was not assessed during either treatment visit. The foregoing evidence shows that, for the period before May 28, 2008, the Veteran's PTSD was manifested by symptoms associated with the assignment of a 30 percent disability rating under the General Formula, to include: depression, anxiety, irritability, chronic sleep disturbances, and intrusive thoughts related to his in-service stressors. At the same time, the evidence does not suggest that the Veteran's PTSD was productive of other symptoms which may typically be associated with a higher disability rating. Similarly, there is no indication in the record that the Veteran was experiencing any impairment of occupational or social functioning that was more severe than that already contemplated by a 30 percent disability rating. Indeed, the Board gleans from later evidence (namely, occupational histories provided by the Veteran during August 2009 and June 2011 VA examinations) that the Veteran was employed during the staged period at issue as a municipal maintenance worker. Accordingly, the Board finds that the demonstrated symptomatology associated with the Veteran's PTSD during the period before May 28, 2008 is consistent with a 30 percent disability rating. To that extent, this appeal is denied. B. From May 28, 2008 through May 31, 2011 As noted in the introduction, the Veteran's PTSD has been rated as 50 percent disabling for the staged period from May 28, 2008 through May 31, 2011. Upon review and consideration of the pertinent evidence, the Board also finds that the Veteran is not entitled to a higher disability rating during that period. During a June 2008 VA examination, which the Board notes was the RO's primary basis for awarding a 50 percent disability rating effective from June 1, 2008, the Veteran reported that he has recently lost his job with the municipal government and was currently involved in an unlawful termination action against the city. He stated that he was currently working on a part-time basis as a furniture delivery person. Socially, he reported that he remained married to his current spouse of 22 years and described having stable relationships with his spouse and four children. The Veteran also related that he tried to get along well with others, attended church regularly, and socialized with others at church. Nonetheless, he stated that he received no visitors at his home. His only reported leisure activity was watching television. Regarding his symptoms, the Veteran reported having an increase in frequency of intrusive thoughts and nightmares about combat, depression, anxiety, irritability, and lability, and of being hyperalert with exaggerated startle responses. He also reported problems with anger management and irritability which caused him to become upset and yell. However, he continued to deny having any suicidal or homicidal ideation. A mental status examination revealed mildly impaired immediate memory and only fair impulse control but was otherwise normal. Based upon the Veteran's reported symptoms and findings from the mental status examination, the examiner assigned a Global Assessment of Functioning (GAF) scale score of 55 and opined that the Veteran's symptoms did not present total occupational and social impairment. In a July 2008 statement, the Veteran's spouse reported that the Veteran was whimpering, thrashing, jumping, and having crying episodes in his sleep. During VA treatment in October 2008, the Veteran reported ongoing symptoms as those noted above, as well as newly reported symptoms of poor concentration and being easily distracted. Again, he denied having any suicidal or homicidal ideation. Treating psychiatric staff characterized the Veteran's symptoms as being "severe" and opined that the Veteran was totally and permanently disabled and unemployable. A GAF score of 48 was assigned. During subsequent treatment in April 2009, the Veteran reported similar symptoms, as well as panic episodes. Once again, treating psychiatric staff opined that the Veteran was totally and permanently disabled and assigned a GAF score of 48. During an August 2009 VA examination, the Veteran reported that he remained married to his spouse. Although he intimated that he was having difficulties with his son, he nonetheless stated that he had good relationships and support from his family. The Veteran also continued to report that he was friendly with other members at his church, but, continued to report that he did not socialize with anybody outside of his family. Reported leisure activities continued to include watching television and working in the yard. Once again, the Veteran denied having any history of suicide attempts or violent or assaultive behavior. Regarding his current symptoms, the Veteran reported anxiety while driving or in situations where he was around other people. He stated that he preferred to be by himself and that he felt closed in and experienced increased anxiety while performing tasks such as going to the store. He related that he was presently unemployed, but otherwise enjoyed a stable life. As noted above, the Veteran stated that he continued to attend church regularly and that he tried not to become angry with others. Overall, he endorsed improvement in his anger management and irritability due to current medications. A mental status examination revealed that the Veteran had a depressed mood with constricted affect; sleep impairment marked by waking at night and occasional dreams about Vietnam; and panic attacks occurring once per month. Contrary to the prior June 2008 examination, remote, recent, and immediate memory were normal. Overall, the examiner summarized that the Veteran's PTSD appeared to be manifested by intense psychological distress and physiological reactivity at exposure to internal and external cues that symbolize or resemble and aspect of the traumatic event; efforts to avoid thoughts, feelings, or conversations associated with the Veteran's trauma; efforts to avoid places, activities, and people that arouse recollections of the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or estrangement from others; irritability or outbursts of anger; difficulty concentrating; and hypervigilence. The examiner noted further that that Veteran stayed to himself and was not emotionally expressive around others, became agitated and panicky around people of Asian descent, and experienced anxiety while driving. Functionally, the examiner concluded that the Veteran remained capable of managing his own finances and did not have total occupational and social impairment due to his PTSD. Although the examiner noted further that the Veteran had a history of working alone and did not work well with others, the examiner indicated that the Veteran did better in isolation performing independent tasks. Socially, the examiner concluded that the Veteran's ability to form loving relationships was impacted by his tendency toward isolation, emotional detachment, and difficulty forming relationships. A GAF score of 53 was assigned. Interestingly, the Veteran apparently sought VA treatment immediately following his August 2009 VA examination for an apparent anxiety attack resulting from his VA examination. In that regard, the Veteran reported anxiety related to the loss of his job and fear that VA would discontinue his disability benefits. He admitted that he was anxious during the VA examination and that he was afraid of making mistakes while answering the VA examiner's questions. In relation to his symptoms, the Veteran stated that he was sleeping OK and continued to deny having any suicidal or homicidal ideation. Nonetheless, the Veteran was unable to perform serial seven exercises, spell backwards, follow instructions, and demonstrated some memory impairment. A GAF score of 48 was assigned. Subsequent VA treatment records through September 2010 reflect ongoing depression, anxiety, irritability, intrusive thoughts, sleep disturbances, loss of concentration, inability to make decisions, and lack of interest and energy. During treatment in October 2009, the Veteran was noted as having difficulty adapting to stressful circumstances and difficulty establishing and maintaining effective relationships. During treatment in September 2010, the Veteran reported that his symptoms had worsened since the recent passing of his mother. Once again, a GAF score of 48 was assigned at that time. Throughout this period of treatment, the Veteran continued to deny having any suicidal or homicidal ideation. During his October 2010 Travel Board hearing, the Veteran complained of ongoing symptoms which included: anxiety, difficulty dealing with stress at work and in social situations, and dislike of crowded places. He and his spouse testified that they did not go on social activities except for occasional trips to a sandwich shop for a quick meal. Anecdotally, he recalled an incident at church when he became angry and cursed after someone touched his head. He also reported an incident in which he walked out of a previous job due to his inability to cope with work-related stress and that he was unemployed for a year and a half before beginning part-time employment for his church as a maintenance worker and custodian. In describing his current employment, he stated that he was paid for working 20 hours per week but was actually working more hours than that. He stated that he liked his job because he was allowed to work on his own. During the hearing, the Veteran's spouse testified that, while driving, the Veteran was afraid that other motorists might have a gun. She also testified that the Veteran had nightmares which caused him to jump in bed. Overall, the Veteran and his spouse described isolative behavior marked by having guests at their home infrequently. The Veteran's spouse testified further that even when their children came to visit, the Veteran would tolerate the situation briefly before going to his bedroom to watch television. She noted further that the Veteran appeared to demonstrate difficulty with concentration, particularly during conversations with others. She added that the Veteran became frustrated with work situations in which he was required to make fast decisions. Overall, the Veteran's spouse testified that the Veteran's symptoms were worsening and that she did not believe that the Veteran would not do well living independently. As examples, the Veteran's spouse noted that the Veteran would likely have difficulty paying his bills and going shopping. Subsequent VA treatment records through May 2011 reflect that the Veteran complained of ongoing anxiety, irritability, insomnia, and depression which were being managed by medications. Again, the Veteran denied having any suicidal or homicidal ideation. GAF scores of 50 were assigned during treatment in January and May of 2011. The foregoing evidence shows that, for the period from May 28, 2008 through May 31, 2011, the Veteran's PTSD was manifested by intrusive thoughts and nightmares about combat; depression; anxiety; irritability; being hyperalert with exaggerated startle responses; loss of concentration; lack of energy and interest, indicating decreased motivation and mood; intermittent memory loss; isolative behavior; and having few social or leisure interests. Although these symptoms appear to have been productive of some degree of social and occupational impairment, the evidence does not indicate the degree of impairment accompanied by the work and social deficiencies contemplated for a higher 70 percent disability rating. In that regard, the Board notes that the Veteran repeatedly denied having any suicidal or homicidal ideation and therefore did not pose a danger to himself or others. Similarly, the Veteran consistently stated that he attended church on a regular basis and remained generally friendly with other members of his church. Also, although the Veteran and his spouse reported isolative behaviors which included tolerating his family for only brief periods before retreating to his bedroom, the Veteran has maintained that he enjoys good relationships and good support from his family. Although the Board is mindful of the treating VA psychiatric staff's October 2008 and April 2009 opinions that the Veteran was totally disabled by his PTSD, such a finding is not consistent with the other evidence of record. Initially, the Board points out that these opinions are not accompanied by any rationale or discussion of specific symptoms or deficiencies which render the Veteran unable to perform his occupational tasks. Further, the Board notes that the Veteran was able to maintain periods of employment as a furniture deliveryman, and subsequently, as a custodian at his church. In relation to his latter period of employment with his church, the Veteran reported during his hearing that he enjoyed his job, and indeed, worked more than the 20 hours per week for which he was paid by his employer. Based upon the Veteran's psychiatric, social, and occupational history and the findings from the examinations, VA examiners concluded in their June 2008 and August 2009 opinions that the Veteran's symptoms did not present total social or occupational impairment. As these opinions appear to be supported by an accurate understanding of the Veteran's psychiatric history, gained from the Veteran's reported history, review of the claims file, and subjective findings from the examination, and moreover, are consistent with the Board's own review of the history, the Board is inclined to afford far greater probative weight to the VA examiner's June 2008 and August 2009 opinions than the VA medical staff's October 2008 and April 2009 opinions. Further, the Board acknowledges that the symptoms during the staged period at issue included some impaired impulse control (evidenced by irritability and anger towards others) and difficulty in adapting to stressful circumstances (evidences by the Veteran's difficulty in dealing with stressful situations in work and social situations, and, by his inability to make quick decisions), both of which are contemplated by the criteria for a higher 70 percent disability rating. Nonetheless, the Board finds that these symptoms, in particular the Veteran's impaired impulse control, do not reach the level of severity that would be consistent with a higher 70 percent disability rating. In that regard, the Board notes again that the Veteran has repeatedly denied having any suicidal or homicidal ideation. Moreover, the evidence simply does not indicate the presence of other symptoms typically associated with a higher disability rating. In view of the foregoing, the overall symptomatology associated with the Veteran's PTSD during the staged period at issue is most consistent with the criteria for a 50 percent disability rating. As noted above, the records pertinent to the period from May 28, 2008 through May 31, 2011 indicate assigned GAF scores which consistently range from 48 to 55. In assessing the degree of psychiatric disability, GAF scores are for application and reflect the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). According to the DSM-IV, a GAF score ranging from 51 to 60 is defined as indicating 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). GAF scores in the range of 41 to 50 denote serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). The Board admonishes that GAF scores are not conclusively dispositive as to a veteran's level of psychiatric impairment. Rather, they are merely parts of a whole body of evidence that must be considered by the Board. Overall, the symptoms demonstrated by the Veteran during the staged period at issue are grossly consistent with the assigned scores of 55 and 53, as assessed during the Veteran's VA examinations. In that regard, the evidence does demonstrate moderate social and occupational difficulty marked by having few friends and conflicts at work and in social settings. As noted above, however, there is no evidence of suicidal ideation, severe obsessional rituals, shoplifting or other legal problems, serious social or occupational impairment marked by having no friends or inability to keep a job. Under the circumstances, the Board finds that the GAF scores of 53 and 55, assigned during the June 2008 and August 2009 VA examination, are more consistent with the other evidence in the record, and moreover, are not in and of themselves inconsistent with the assignment of a 50 percent disability rating for the staged period at issue. Based upon the foregoing evidence and analysis, the Board finds that the demonstrated symptomatology associated with the Veteran's PTSD during the period from May 28, 2008 through May 31, 2011 is consistent with a 50 percent disability rating. To that extent, this appeal is denied. C. From May 31, 2011 Effective from May 31, 2011, the Veteran's PTSD was rated as 70 percent disabling. Upon review and consideration of the pertinent evidence, the Board also finds that the Veteran is not entitled to a higher disability rating during that period. During a June 2011 VA examination, which also served as the RO's basis for its award of a 70 percent disability rating, the Veteran reported that he remained in his marriage of 25 years and that he continued to have good relationships with his children. He continued to report that he had only a few friends, and in fact, described that they were more like acquaintances. In general, he stated that he was able to get along well with others, but preferred to isolate himself from people outside of his immediate family. He reported that he attended church three times a week with his spouse. Occupationally, the Veteran stated that he was still working 20 hours per week as a custodian at his church. Again, he stated that he liked his work because he was permitted to work by himself; however, did relate that he left work early on occasion due to anxiety and irritability. A mental status examination demonstrated anxious mood, but otherwise was within normal limits. Nonetheless, the examiner noted symptoms which included recurrent and distressing recollections of the Veteran's traumatic events; intense psychological distress at exposure to internal and external cues that symbolize or resemble an aspect of the traumatic events; efforts to avoid activities, places, or people that arouse recollections of the trauma; efforts to avoid thoughts, feelings, or conversations related to the trauma; diminished interest and participation in activities; feeling of detachment and estrangement toward others; restricted affect limited to being angry; irritability and outbursts of anger occurring ten to twelve times per week; moderate difficulty concentrating; and hypervigilence. The Veteran also endorsed mild panic attacks which occurred once every two weeks, most often while he was in traffic. He endorsed depression, stating that he had low motivation, low energy, and felt hopeless and worthless at times; however, continued to deny homicidality or suicidality. Overall, the examiner opined that the Veteran's symptoms resulted in significant distress and impairment in the Veteran's social, occupational, and other areas of functioning. Apparently tracking the language for the General Formula's criteria for a 70 percent disability rating, the examiner concluded that the Veteran's symptoms were causing occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and/or mood; however, concluded that the Veteran was not totally impaired either occupationally or socially. A GAF score of 51 was assigned. Subsequent VA treatment records through February 2012 reflect ongoing PTSD symptoms which were managed by medication. Essentially consistent with the GAF score assigned during the June 2011 VA examination, a GAF score of 50 was assigned during VA treatment in December 2011. Overall, however, these records do not indicate any new complaints or findings in regard to the Veteran's PTSD. The evidence for the period from May 31, 2011 shows that the Veteran's PTSD has been manifested by symptoms and occupational and social impairment which are consistent with a 70 percent disability rating, and no more. By contrast, the Veteran's PTSD was not manifested by any symptoms or impairment typically associated with a total 100 percent disability rating under the General Formula. In that regard, there is no evidence that the Veteran has experienced any gross impairment of thought process or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting himself or others; disorientation to time or place; or memory loss to the extent that he was unable to recall his own name or the names of close relatives or his own occupation. Moreover, the evidence does not support the finding that the Veteran has experienced total occupational or social impairment. In that regard, the Veteran reported that he continues to work as a part-time custodian at his church and that he continued to enjoy his work due to its solitary nature. Socially, the Veteran continued to be married to his spouse of over 25 years and described having good relationships with his family. Although the Veteran continued to demonstrate a degree of social impairment marked by having few friends, he reported that he was able to maintain friendly relations with others at his church, and indeed, continued to attend church three times per week. Overall, the symptomatology associated with the Veteran's PTSD simply is not consistent with that contemplated for a disability rating higher than 70 percent for the staged period at issue. Again, the Board notes that the Veteran was assigned GAF scores of 51 and 50 during his June 2011 VA examination and December 2011 VA treatment. For reference purposes, the Board reiterates that a GAF score ranging from 51 to 60 is defined as indicating 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). GAF scores in the range of 41 to 50 denote serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). See Carpenter v. Brown, 8 Vet. App. 240, 242-244 (1995). Under similar analysis as that undertaken above with respect to the Veteran's GAF scores, the Board notes that the evidence is consistent with findings of moderate social and occupational difficulty marked by having few friends and conflicts at work and in social settings. Again, there is no evidence of suicidal ideation, severe obsessional rituals, shoplifting or other legal problems, serious social or occupational impairment marked by having no friends or inability to keep a job. Nonetheless, the lower GAF scores assigned during the period from June 1, 2011 are consistent with progressing symptoms (such as the increased frequency of panic attacks and anger outbursts) which approach the more severe symptoms contemplated for GAF scores ranging from 41 to 50, and, which are consistent with the assignment of a 70 percent disability rating under the General Formula. Accordingly, the Board finds that the GAF scores assigned since June 1, 2011 are essentially consistent with the assignment of a 70 percent disability rating. Based upon the foregoing evidence and analysis, the Board finds that the demonstrated symptomatology associated with the Veteran's PTSD during the period from June 1, 2011 is consistent with a 70 percent disability rating. To that extent, this appeal is denied. D. Additional Considerations The Board has considered the potential application of various provisions of Title 38 Code of Federal Regulations, whether or not they have been expressly raised by the Veteran. Schafrath v. v. Derwinski, 1 Vet. App. 589, 594 (1991). In that regard, the Board has also considered the provisions under 38 C.F.R. § 3.321(b)(1), which govern the assignment of extra-schedular disability ratings. However, in this case, the Board finds that the record does not show that the symptomatology associated with the Veteran's PTSD 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 extra-schedular 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 regard, there must be a comparison between the level of severity and symptomatology of the claimant's service- connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule and the assigned schedular evaluation is therefore adequate, and no extra-schedular referral is required. Id., see also VAOGCPREC 6-96 (Aug. 16, 1996). Otherwise, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, VA must determine whether the claimant's exceptional disability picture exhibits other related factors, such as those provided by the extra-schedular regulation as "governing norms"(which include marked interference with employment and frequent periods of hospitalization). The evidence in this case does not show such an exceptional disability picture that renders inadequate the available schedular ratings for the service-connected disability. A comparison between the level of severity and symptomatology of the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe the disability level and symptomatology that are attributable to the Veteran's PTSD. As discussed above, higher schedular disability ratings are available under DC 9411 and the General Formula; however, the Veteran's disability simply is not productive of the manifestations necessary to warrant higher ratings during the periods contemplated above. As such, it cannot be said that the available schedular ratings are inadequate for purposes of rating the Veteran's disability. Based on the foregoing, the Board finds that the requirements for an extra-schedular evaluation for the Veteran's service-connected PTSD have not been met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995); Thun, 22 Vet. App. 111. The Board has also considered whether further "staged" disability ratings for the Veteran's PTSD are warranted by the evidence. The symptomatology shown upon examination and treatment, however, has been essentially consistent and fully contemplated by the assigned disability ratings. As such, there is no basis for further staged disability ratings for the Veteran's PTSD. ORDER An increased disability rating for PTSD, rated as 30 percent disabling prior to May 28, 2008, is denied. An increased disability rating for PTSD, rated as 50 percent disabling from May 28, 2008 through May 31, 2011, is denied. An increased disability rating for PTSD, rated as 70 percent disabling from June 1, 2011, is denied. REMAND In Rice v. Shinseki, the Court held that TDIU is part and parcel to a higher evaluation claim when the record reasonably raises the question of unemployability due to the disability for which the higher evaluation is sought. Id., 22 Vet. App. 447 (2009). Here, as noted above, treating VA psychiatric staff in October 2008 characterized the Veteran's symptoms as being "severe" and opined that the Veteran was totally and permanently disabled and unemployable. Likewise, during subsequent treatment in April 2009, treating psychiatric staff opined that the Veteran was totally and permanently. The Board observes that the Veteran has had part-time employment throughout the course of the appeal. Nevertheless, as his treating mental health providers have suggested that his unemployable due to his PTSD, the Board concludes that, pursuant to Rice, a claim for TDIU has been included as an issue on appeal. See Id. The Board has listed this issue as a separate claim for administrative purposes. On remand, the RO should provide VCAA compliant notice with respect to the TDIU issue and adjudication of the TDIU aspect of his claim. Accordingly, the case is REMANDED for the following action: 1. In accordance with any applicable policies, the temporary folders created at the RO should be consolidated with the Veteran's claim folder. 2. A letter should be sent to the Veteran explaining, in terms of 38 U.S.C.A. §§ 5103 and 5103A, the need for additional evidence regarding a TDIU claim under 38 C.F.R. § 4.16 for schedular and extra-schedular considerations. Any additional development should be undertaken as necessary. 3. Then adjudicate the TDIU claim. If the benefit sought on appeal is not granted, the RO should issue the Veteran and his representative a supplemental statement of the case and provide the Veteran an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims 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). ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs