Citation Nr: 1340765 Decision Date: 12/11/13 Archive Date: 12/20/13 DOCKET NO. 11-15 957 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to compensation under 38 U.S.C.A. § 1151 for left eye blindness. 2. Entitlement to increased ratings for posttraumatic stress disorder (PTSD) with major depressive disorder, rated 30 percent prior to January 5, 2010 and 70 percent from that date. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Young, Counsel INTRODUCTION The Veteran had active duty service from July 1972 to July 1975. These matters come before the Board of Veterans' Appeals (Board) on appeal from September 2008 and April 2010 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). In the September 2008 rating decision, the RO denied entitlement to compensation under 38 U.S.C.A. § 1151 for left eye blindness. The Veteran filed a notice of disagreement in October 2008; a statement of the case (SOC) was issued in November 2009, and a substantive appeal was received in December 2009. In the April 2010 rating decision, the RO continued a 30 percent rating for PTSD with major depressive disorder. The Veteran filed a notice of disagreement in May 2010. An interim, May 2011, rating decision increased the rating for PTSD to 70 percent effective January 5, 2010; an SOC was issued concurrently with the May 2011 rating decision. As the Veteran is presumed to be seeking the maximum benefit allowed by law and regulation, it follows that his claim remains in controversy as less than the maximum benefit available has been awarded and he contends as recently as March 2013 that a higher rating is warranted. See AB v. Brown, 6 Vet. App. 35 (1993). A substantive appeal was received in June 2011. In March 2013, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge; a transcript of the hearing is included in the claims file. By rating decision in December 2011, the RO awarded a total rating based on individual unemployability, effective from June 8, 2011. The issue of entitlement to compensation under 38 U.S.C.A. § 1151 for left eye blindness is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. For the period prior to January 5, 2010, the Veteran's service-connected PTSD has more nearly approximated occupational and social impairment with reduced reliability and productivity; his PTSD was not manifested by occupational and social impairment, with deficiencies in most areas. 2. For the period from January 5, 2010, the Veteran's service-connected PTSD has been manifested by occupational and social impairment, with deficiencies in most areas; his PTSD has not been productive of total occupational and social impairment; the record has not demonstrated symptoms on par with those contemplated in the maximum, 100 percent criteria, such as: gross impairment in thought processes or communication; persistent delusions or hallucinations, 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. CONCLUSIONS OF LAW 1. For the period prior to January 5, 2010, the criteria for a rating of 50 percent (but no higher) for PTSD with major depressive disorder have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). 2. For the period from January 5, 2010, the criteria for a rating in excess of 70 percent for PTSD with major depressive disorder have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As provided for by the VCAA, the VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Duty to Notify Upon receipt of a complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). The notice requirements apply to all five elements of a service connection claim: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In a claim for increase, the VCAA requirement is generic notice, that is, the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO provided VCAA notice by letter dated in January 2010. The notice included the type of evidence needed to substantiate the claim for a higher rating, namely, evidence to show that the disability was worse and the effect the disability had on employment. The Veteran was notified that VA would obtain service records, VA records, and records of other Federal agencies and that he could submit other records not in the custody of a Federal agency, such as private medical records, or that, with his authorization, VA would obtain any such records on his behalf. The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has not demonstrated any prejudice with regard to the content of the notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). See also Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The RO has obtained the Veteran's VA and private treatment records. Social Security Administration (SSA) records have been associated with the claims file. The Veteran was afforded VA examinations in July 2010, April 2011, July 2011 and August 2011. The Veteran was afforded the opportunity to testify before the undersigned VLJ in March 2013. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) has held that 38 C.F.R. 3.103(c)(2) requires that the VLJ who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the undersigned essentially elicited testimony necessary to determine the current severity of the Veteran's claim regarding a higher rating for his service-connected PTSD with major depressive disorder. In addition, the undersigned sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claim. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor has identified any prejudice in the conduct of the Board hearing. By contrast, the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim for benefits. As such, the Board finds that, consistent with Bryant, the undersigned complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record. As there is no indication of the existence of additional evidence to substantiate the claim, the Board concludes that VA has complied with the notice and assistance requirements and that the Veteran is not prejudiced by a decision on the claim at this time. Neither the Veteran nor his representative has identified any other pertinent records for the RO to obtain on his behalf. VA's duty to assist is met. Legal Criteria, Factual Background and Analysis The present appeal involves the Veteran's claim that the severity of his service-connected PTSD with major depressive disorder warrants a higher disability rating. 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). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Under the criteria for PTSD (set forth at 38 C.F.R. § 4.130, Diagnostic Code 9411), a 30 percent rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment, with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g. retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. A 100 percent schedular rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relative, own occupation, or own name. The Global Assessment of Functioning (GAF) scale reflects the psychological, social and occupational functioning under a hypothetical continuum of mental illness. See American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown , 8 Vet. App. 240, 243 (1995). According to the DSM-IV, a GAF score between 41 and 50 is indicative of serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job); a GAF score between 51 and 60 is indicative of 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 coworkers). The Board recognizes that the Court in Mauerhan v. Principi, 16 Vet. App. 436 (2002), stated that the symptoms listed in VA's general rating formula for mental disorders is 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. However, the Court further appears to have acknowledged that without those examples, differentiating between evaluations would be extremely ambiguous. Id. at 442. The Board notes that it has reviewed all of the evidence in the Veteran's claims file, as well as in "Virtual VA", with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. Prior to January 5, 2010 The Veteran appealed the April 2010 rating decision that continued a 30 percent rating for PTSD. A March 2009 VA PTSD examination noted the Veteran had been diagnosed with depression and PTSD since 2008. He was prescribed citalopram and Trazodone, which the Veteran reported, helped him to sleep and with the anxiety he experienced. He attended counseling twice a month. He last worked in 1993 as an additive room operator and stop working that job because of medical disabilities associated with a car accident. He had been married and divorced and has four children. He stated that he is not close to his older son, or his grandchildren, but is fairly close to his three younger children, who he sees once a week, and they talk about twice a week. He lived alone and was not dating. He had a close friend, who he talked to twice a week and would see one to two times a month. He had no casual friends. He watched television, cleaned his house, and cooked. He is close to his mother and sees her once a week. On mental status examination, the Veteran was alert, oriented and attentive. His mood was depressed and his affect was constricted and sad. His speech was somewhat slow and there was some evidence of psychomotor retardation. He became tearful during the evaluation. His thought process was logical and coherent. His thought content was devoid of current auditory or visual hallucinations, there was no evidence of delusional content. He denied current thoughts of hurting himself or others. He denied a history of suicide attempts and denied a history of being physically aggressive with others. His memory was mildly impaired for immediate information. He was fairly intact for recent and remote events. He was not able to concentrate well enough to spell world backwards, but he was able to interpret a proverb. He had average intelligence, and fair insight into his current condition. The diagnoses under Axis I were PTSD, major depressive disorder, alcohol dependence in remission, and cannabis abuse in remission. His GAF score was 52. The examiner noted that the Veteran had exhibited considerable symptoms associated with PTSD. Specifically, the Veteran reported having intrusive thoughts one to two times a month and nightmares almost every night. He also had night sweats. He described psychological and physiological reactivity to seeing any kind of open flame. His affect was constricted. He described emotional detachment from others and noted decreased interest in activity. He got eight hours of sleep, but it was mostly during the day and he never got more than to two three hours at a time. He reported problems with irritability and concentration. He described an exaggerated startle reaction to loud noises or unexpected approaches. He noted that he stays to himself all of the time. He reported a hypervigilant style and was very aware of his surroundings. He reported depression with low energy, low motivation, fatigue and decreased feelings of hope and worth. He had an increased appetite and had gained 100 pounds in the past six years. The examiner further noted that the Veteran's social adaptability and interactions with others was considerably impaired. In terms of his ability to maintain employment and perform job duties in a reliable, flexible and efficient manner, this appeared to be considerably impaired. Overall the Veteran's disability was in the considerable range. The Veteran submitted a March 2009 statement from his therapist, S. McClam, who had treated him since September 2008. S. McClam noted that the Veteran had diagnoses of PTSD, major depression disorder and alcohol abuse. She requested that the Veteran's award of 30 percent for PTSD be reconsidered based on the facts that he had struggled with severe drinking problems prior to beginning therapy; and he had been diligent in his efforts to stop drinking. He was very depressed over his status and inability to adequately provide for his children. He had a history of an inability to maintain positive relationships with others. He was withdrawn, he isolated himself and found little joy in his life, and until he progressed in therapy, he presented with an unkempt appearance and hygiene. Moreover, his "small" progress was not sufficient for him to re-enter the work force. The evidence in this case shows that prior to January 5, 2010 the Veteran exhibited symptoms that more nearly approximate the criteria for a 50 percent rating. See 38 C.F.R. § 4.130, Diagnostic Code 9411. For example, the Veteran experienced occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Furthermore, his GAF score on March 2009 VA examination was 52. A GAF score of 52 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, or occupational, functioning (e.g., few friends, conflicts with peers or co-workers), which more nearly approximate the criteria for a 50 percent rating under Diagnostic Code 9411. It is noted that a disability rating depends on evaluation of all the evidence, and an examiner's classification of the level of a psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage disability rating to be assigned. 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (1995). In this case, the Board finds that the record satisfactorily indicates that the Veteran's overall PTSD symptomatology is essentially consistent with the types of symptoms listed for a 50 percent rating. After carefully reviewing the totality of the evidence and with consideration given to 38 C.F.R. § 4.7, the Board believes that for the period prior to January 5, 2010, the criteria for entitlement to a disability evaluation of 50 percent, but no higher, for the Veteran's service-connected PTSD with major depressive disorder have been met. The Board has considered whether a rating in excess of 50 percent (for the period prior to January 5, 2010) is warranted, and finds it is not. His PTSD symptoms during the stated period were not manifested by deficiencies in most areas, as required for the next higher (70 percent) rating under Diagnostic Code 9411. From January 5, 2010 The Board finds that the current 70 percent rating adequately reflects the level of impairment for the Veteran's service connected PTSD for the period from January 5, 2010. To meet the criteria for the next higher (100 percent) rating, the evidence must show total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of closest relatives, own occupation, or own name. On February 2010 VA PTSD examination, the Veteran reported that he had difficulty with sleep. He had nightmares and night sweats almost on a nightly basis. His mood was depressed; he felt hopeless at times and had thoughts of suicide; he denied any current suicidal or homicidal ideations. He primarily stayed at home and described avoidance and isolation. He had intrusive thoughts and flashbacks on a daily basis. He had problems with anger and irritability, hypervigilance, exaggerated startled response and difficulty being in crowds. He had a history of panic attacks, but had not had any in two years. He reported that he started drinking again in January 2010, and was drinking a quart of liquor daily. He stated that drinking "helps me forget." He reported having decreased energy, and socialization. He had difficulty trusting others and he isolated himself. He spent his day watching television and eating. He had decreased motivation to provide for his hygiene; he shaved and bathed once a week, and brushed his teeth every other day. He primarily ate fast food and junk food. He managed his finances independently. He had minimal engagement in cooking and cleaning. On mental status examination, the Veteran was alert and oriented to person, place, day, date and time. His thought process was linear. His history was adequate. His affect was blunted. Insight was demonstrated. His spontaneous speech was full, grammatical and free of paraphasia. He presented with mild difficulty with attention and memory. He did not report any overt symptoms of psychosis. He denied a history of suicide attempts, although he did report a history of suicide thoughts. The diagnoses under Axis I were PTSD, major depressive disorder, and alcohol abuse. His GAF score was 50. The examiner noted that the Veteran had decreased motivation including with basic hygiene. He presented with mild difficulty with attention and memory, and with moderate-to-severe impairment of functioning related to social and occupational functioning. In February 2011 the Veteran underwent inpatient mental health treatment (for approximately 9 days) at a VA hospital. His chief complaint at the time of admission was "I feel like I wanted to hurt myself." He had no specific plan, but had considered using the kitchen knives. He reported that his symptoms exacerbated about a year ago when his three young children began living with him. On mental status examination, he was alert and oriented to all spheres. His hygiene was fair. His affect was somewhat constricted, sad at times, but overall congruent with content of speech. His speech was a normal rate and rhythm, logical and goal directed. There was no evidence of a formal thought disorder. He endorsed thoughts of suicide, with such plans as using the kitchen knives. He denied homicidal ideations. His judgment and insight were fair. The diagnoses were alcohol dependence, substance abuse, mood disorder, and PTSD with a GAF of 55. On April 2011 VA PTSD examination, the Veteran reported having some difficulty with his family relationships. He reported that his children's mother left and he does not have close friends outside of family. He does not belong to any organization, group, or church. He had decreased motivation and energy to complete his basic hygiene; he bathed once a week. He performed very minimal cooking and cleaning tasks. He was unemployed; and reported having a history of difficulty with decreased productivity and efficiency related to mental health and problems getting along with co-workers. He had problems with anger and difficulty relating to others on the job. On mental status examination, his affect was blunted. His memory was mildly impaired. His insight was fair. His thought process was generally linear. His speech was generally fluent, grammatical, and free of paraphasia. He denied any auditory or visual hallucinations. He reported that at times he had seen something in his peripheral vision when nothing was there. The diagnoses under Axis I were PTSD, and alcohol dependence in early sustained remission. His GAF score was 48. The examiner noted that the Veteran's overall level of impairment due to PTSD was severe with severe impairment in social and occupational functioning. In a June 2011 letter by the Veteran's therapist, S. McClam, it was noted that his diagnoses were PTSD and major depressive disorder. It was further noted that he was unable to work in any capacity due to his severe physical and psychological problems. At the time of the July 2011 VA PTSD examination, the Veteran was alert and oriented to person, place, day, date, and time. His thought process was linear; and his history was adequate. His affect was blunted, and his insight was demonstrated. His spontaneous speech was fluent, and free of paraphasia. His attention was intact. He had mildly impaired memory. He denied current auditory or visual hallucinations. There were no suicidal or homicidal ideations, plans, or intent. The diagnoses under axis I were PTSD, alcohol dependence, and major depressive disorder. His GAF score was 48. The examiner noted that the overall level of impairment due to mental health was severe, with severe impairment in social and occupational functioning, which would render him unable to obtain and maintain employment. However, the impairment due to the PTSD alone related to the service-connected training incident does not render him unable to obtain and maintain employment, and is a mild to moderate level of impairment. This is based on the Veteran's history of performance prior to the nonservice-connected motor vehicle accident in 1989. On August 2011 VA (review) examination for PTSD, the examiner was asked to review the claims file and the evaluation by the July 2011 VA examiner. The Veteran was also present for the examination. The examiner noted that based on interviewing the Veteran and reviewing the claims file, she did not wish to make any changes to the evaluation conducted by the July 2011 VA examiner, and that she agreed with the conclusions drawn by the July 2011 VA examiner. At his March 2013 Travel Board hearing, the Veteran testified that it had been a while since he sought treatment for his PTSD; even though he was currently taking medication for PTSD. He stated that since 1989, he had not tried to get employment. He receives SSA benefits. He noted that his SSA benefits were not based on his PTSD, but on non-service-connected disabilities. He stated that he was last examined by VA for PTSD about two years ago. He disclosed that he copes with stressful event by drinking, and that his memory was not good. He is able to care for himself. He pays his own bills. He does not go out and do anything with family and friends. He stays at home all the time, but stays in touch via the telephone. He was able to take care of his hygiene. He stated that he had thoughts of hurting himself, but he had never called anybody on the suicide hotlines or anything. He stated that he deals with it and talks to his mother. He had a panic attack almost every day. He stated that he would sometimes go out and ride around in his car. When asked if any other doctor or therapist indicated that his PTSD had gotten worse, he responded "No, no." To the extent that the Veteran's PTSD symptomatology manifests in some occupational and social impairment, as demonstrated by episodes of depression, difficulty with loud noises and crowds, flashbacks, intrusive thoughts, anger, and irritability, such symptoms were described as severe and is well within that contemplated by the 70 percent disability rating currently assigned. However, the Board acknowledges the Veteran's statements that he had adequate employment until he had a motor vehicle accident in 1989 and then went out on disability for that reason. VA examiner noted that he did not have significant impairment in employability due to PTSD at that time, but that he subsequently presented with an overall severe level of impairment due to mental health, some of which is related to his nonservice-connected disabilities and limitations since the motor vehicle accident in 1989. Based on the evidence of record, to include the Veteran's ability to maintain successful family relationships (his children and his mother), his essentially normal mental status, and the medical evaluations that impairment due to PTSD alone do not render him unable to obtain and maintain employment (and is a mild to moderate level of impairment), the Board finds that the Veteran's PTSD does not manifest in total occupational and social impairment due to the types of symptoms comparable to those contemplated by the criteria for a 100 percent disability rating. Thus an increased 100 percent rating under Diagnostic Code 9411 is not warranted. The Board has considered the Veteran's PTSD symptoms and acknowledges that they result in significant impairment. However, with consideration of all of the numerous items of evidence presenting competent findings concerning the Veteran's psychiatric health, the evidence does not indicate gross impairment in thought processes or communication; the Veteran has been repeatedly observed to be without such impairment by trained professionals for the period from January 5, 2010, on appeal. Trained professionals have described his thought processes as linear. Furthermore, the evidence repeatedly indicates that the Veteran is without hallucinations during psychiatric evaluation. The Veteran has not manifested grossly inappropriate behavior as characterized by any trained medical professional. Although he has clearly experienced significant difficulties with suicidal thoughts, intrusive thoughts, sleep, anxiety and depressed mood, these symptoms are expressly contemplated by the assigned 70 percent disability rating. The evidence simply does not indicate that these symptoms have risen to the level of making the Veteran a persistent danger of hurting self or others. Although the Veteran indicated that he had some difficulty with family relationships and he had no friends, the evidence shows that he does have close relationships with his mother and his children. The evidence further indicates that the Veteran has remained consistently able to take care of himself and perform activities of daily living and maintenance. While it had been reported (on VA examinations in 2011 that he had decreased motivation and energy to complete his basic hygiene (bathing once a week), he apparently improved in that area as he stated at his 2013 hearing that he was able to take care of his hygiene. He has consistently been determined (as expressly noted in numerous reports) to be alert and oriented to person, time and place. Finally, although the Veteran has reported having some difficulty with his memory (described as mild), these descriptions correspond to the severity of memory loss contemplated by the currently assigned disability rating (as described in criteria for lower ratings); the evidence in this case directly address the Veteran's memory function and show no memory loss comparable to forgetting the names of his closest relatives, his own occupation, or his own name. To the extent that the Veteran's significant PTSD symptomatology manifests in occupational and social impairment with deficiencies in most areas, such level of disability is expressly contemplated by the 70 percent disability rating assigned. To the extent that some evidence indicates that the Veteran is unemployable due in part to his PTSD symptoms, and acknowledging that the Veteran has been granted a total rating on the basis of unemployability, such information pertains to a determination of employability which is separate and distinct from the schedular evaluation of the Veteran's PTSD under the applicable rating criteria. The Board finds that the Veteran's PTSD does not manifest in total occupational and social impairment due to the types of symptoms matching or comparable to those contemplated by the criteria for a 100 percent disability rating. The evidence simply does not show that the Veteran's PTSD disability picture more nearly approximates the level of impairment and types of symptoms listed for a 100 percent rating. The Board has considered the GAF scores assigned by various mental health medical professionals during the period from January 5, 2010. His GAF scores during that period ranged from 48 to 55. This documented range of GAF scores denote, at the lowest end, serious symptoms such as suicidal ideation or any serious impairment in social, or occupational, functioning. The higher end of the range of the Veteran's GAF scores is indicative of some 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 coworkers). These GAF scores, consistent with the breadth of the probative and detailed evidence in this case, most nearly match the severity of disability contemplated by the criteria for a 70 percent disability rating and do not demonstrate severity of symptomatology meeting the criteria for a 100 percent disability rating. The Board stresses to the Veteran that a significant level of impairment due to the PTSD has already been recognized by assignment of the 70 percent rating. However, the Board is bound to apply the regulatory criteria for rating PTSD, and for the reasons set forth above the Board finds that the preponderance of the evidence is against assignment of a rating in excess of 70 percent. Staged ratings have been applied in this case. See Hart , 21 Vet. App. 505. In sum, the Board concludes that the preponderance of the evidence is against entitlement to a rating in excess of 70 percent for the period from January 5, 2010. As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C.A. § 5107(b). The Board has considered whether this case presents an exceptional or unusual disability picture, with such related factors as marked interference with employment or frequent periods of hospitalization, so as to render impractical application of regular schedular standards and warrant referral for extraschedular consideration. See 38 C.F.R. § 3.321(b)(1). However, after reviewing the record in this case, the Board finds that the symptoms described by the Veteran, for each of the respective periods, fit squarely within the criteria found in the Diagnostic Code for the disability at issue. In short, the rating criteria contemplate not only his symptoms but the severity of his disability prior to and from January 5, 2010. For these reasons, the Board finds that referral for extraschedular consideration is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008). ORDER Entitlement to a 50 percent rating (but no higher) is warranted for PTSD, for the period prior to January 5, 2010. To this extent, the appeal is granted, subject to laws and regulations applicable to payment of VA monetary benefits. Entitlement to a rating in excess of 70 percent for PTSD from January 5, 2010, is denied. REMAND The Veteran claims entitlement to compensation under 38 U.S.C.A. § 1151 for left eye blindness. At his March 2013 Travel Board hearing he stated that his last medical procedure [regarding the left eye] was "Last week." As the report from that medical procedure may be pertinent to the Veteran's claim, they must be sought. See 38 C.F.R. § 3.159; see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following action: 1. The RO should secure for the record any outstanding VA ophthalmology/eye treatment reports or other data (not already associated with claims file or Virtual VA), to specifically include the report of the February/March 2013 medical procedure. If such report(s) are unavailable, it must be so noted in the record, with explanation. 2. The RO should review the record and ensure that all development sought is completed. Then the RO should readjudicate the claim. If it remains denied, the RO should issue an appropriate SSOC and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board. 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013). ______________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs