Citation Nr: 1341663 Decision Date: 12/17/13 Archive Date: 12/31/13 DOCKET NO. 06-14 467 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) with anxiety disorder and depression, for the period prior to April 4, 2005. 2. Entitlement to an initial rating in excess of 50 percent for PTSD with anxiety disorder and depression, for the period from June 1, 2005. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD B. Thomas Knope, Counsel INTRODUCTION The Veteran served on active duty from September 1966 to September 1968. He died in July 2012, and the appellant is his surviving spouse. This matter is on appeal from a November 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Jurisdiction over the appeal is currently with the RO in Des Moines, Iowa. After the Veteran's death in July 2012, the appellant requested that she be substituted for the Veteran in her capacity as his surviving spouse. See 38 U.S.C.A. § 5121A (West Supp. 2013) (a surviving spouse may be substituted in place of a Veteran who has died on or after October 10, 2008). As there is no dispute that she is the Veteran's surviving spouse and is a person eligible for substation, the Board may proceed to adjudicate this claim on this basis. Id. (a person eligible for substitution will include "a living person who would be eligible to receive accrued benefits due to the claimant under 38 U.S.C.A. § 5121(a)" The appellant retains the Veteran's docket number before the Board. This appeal was remanded by the Board in December 2010 for further development and is now ready for disposition. The issue of entitlement to 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. VA will notify the appellant if additional action is required on her part. FINDING OF FACT For both periods on appeal, the Veteran's PTSD was characterized by isolation, nightmares, flashbacks and some suicidal ideation; total occupational and social impairment, due to such symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, inability to perform activities of daily living, disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name was not shown. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent rating, but no higher, for PTSD with anxiety disorder and depression, for the period prior to April 4, 2005, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9411 (2013). 2. The criteria for an initial 70 percent rating, but no higher, for PTSD with anxiety disorder and depression, for the period from June 1, 2005, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, DC 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSIONS VA Duty to Notify and Assist 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 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Here, neither the Veteran, nor the appellant (or either of their representatives) has alleged prejudice with respect to notice, as is required, and none is found by the Board. Indeed, the claim arises from the Veteran's disagreement with the initial rating following the grant of service connection. Once service connection is granted, the claim is substantiated. Therefore, additional notice is not required and any defect in notice is not prejudicial. See Shinseki v. Sanders, 556 U.S. 396 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Next, VA has a duty to assist a veteran and/or an appellant in the development of the claim. This duty includes assisting him or her in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2013). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). First, the RO has obtained the Veteran's service treatment records and VA outpatient treatment records and records submitted in conjunction with a claim to the Social Security Administration (SSA). Further, the Veteran and appellant submitted statements in support of the claim. VA examinations with respect to the issue on appeal were also obtained in October 2004, November 2006, July 2006, November 2007 and January 2012. 38 C.F.R. § 3.159(c)(4) (2013). To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As noted below, the Board finds that the VA examinations obtained in this case are more than adequate, they are predicated on a full understanding of the Veteran's medical history, and provide a sufficient evidentiary basis for the claim to be adjudicated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion concerning the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4) (2013). Finally, it is noted that this appeal was remanded by the Board in December 2010 in order to obtain a new VA examination to evaluate the Veteran's PTSD symptoms. The Board is now satisfied there was substantial compliance with this Remand. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Specifically, the Veteran was provided a new VA examination in January 2012, which the Board finds adequate for adjudication purposes. After the required development was completed, this issue was readjudicated and the Veteran was sent a supplemental statement of the case in April 2012. Accordingly, the Board finds that the Remand directives were substantially complied with and, thus, there is no Stegall violation in this case. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2013). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the veteran. 38 C.F.R. § 4.3 (2013). In cases where the veteran's claim arises from a disagreement with the initial evaluation following the grant of service connection, the Board shall consider the entire period of claim to see if the evidence warrants the assignment of different ratings for different periods of time during the claim a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Here, the Veteran submitted a claim seeking service connection for PTSD in May 2004. Service connection was initially granted in a November 2004 rating decision with a 10 percent disability rating, to which he submitted a timely appeal to the assigned rating. Since the time of the November 2004 decision, his assigned disability rating was increased on a number of occasions. Most recently, a December 2010 rating decision increased his rating to 50 percent for the entire period on appeal. However, the RO also granted a temporary 100 percent rating for a period of psychiatric hospitalization, from April 4 to May 31, 2005. See 38 C.F.R. § 4.29 (2013). As such, this short period of time is no longer on appeal. Even so, the remaining periods on appeal are still in appellate status, as he did not receive the maximum benefit available. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Psychiatric disorders such as PTSD are evaluated through the application of symptoms to a general rating formula that addresses essentially all psychiatric disorders. Under the general rating formula, a 50 percent rating is warranted 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 effective work and social relationships. A 70 percent rating is warranted when the psychiatric disorder results in occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, 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 an unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. A total schedular rating of 100 percent is warranted when the disorder results in 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 mental and personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. §4.130, DC 9411 2013). Based on the evidence of record, the Board determines at the outset that a 70 percent rating is warranted for both periods on appeal. In this regard, the number of psychiatric evaluations the Veteran has received during the course of this appeal has been very large. However, the symptoms observed by various physicians were relatively constant and, notably, very few of the symptoms specifically listed in the general rating formula were clinically observed. For example, when the Veteran underwent a VA examination in October 2004, he stated that he lived in his own trailer home and that he "moped around a lot and helped his wife a little." While he generally stayed in with his wife in the evenings, he indicated that he had difficulty concentrating. He also stated that he had experienced suicidal ideation on a number of occasions in the past, as well as some anxiety-related sexual dysfunction. Upon examination, he appeared "unfocused," but was fully oriented, with adequate memory and concentration for purposes of the examination. Based on examinations such as this, and the many others, there do not appear to be true indications of symptoms such as spatial disorientation, unusual speech patterns, obsessional rituals or impaired impulse control. However, the Board stresses that the appropriate rating should not be based solely on the criteria mentioned in the general rating formula, but should encompass all symptoms that may be relevant to his psychiatric functioning. See Mauerhan, 16 Vet. App. 436 (2002). This being the case, the Board notes three aspects of this claim that suggest that the Veteran's symptoms may have been more severe than what is represented by a 50 percent rating. First, throughout the course of this appeal, the Veteran's Global Assessment of Functioning (GAF) scores have varied dramatically on a relatively consistent basis. For example, while he had GAF scores of 45-55 in 2003 and 2004, he was also assigned GAF scores of as low as 30 in 2005. For the period from 2005 to 2008, his GAF scores continued to vary from as low as 38 (in August 2005) to 50 (in October 2006 and June 2008). The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV)). For example, a GAF of 51-60 reflects "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), while a GAF of 41-50 would indicate "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 ranging from 31-40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). Clearly, despite the fact that the Veteran's symptoms were observed to be largely consistent, at least some treating psychiatrists believed that his symptoms were quite severe. Next, although the Veteran received a temporary 100 percent rating for a period of hospitalization in April and May 2005, the evidence indicates that he was also hospitalized in February of that year and again in May 2008. While these periods may be too short to warrant a separate total disability rating under 38 C.F.R. § 4.29 (2013), it is evidence of worsening psychiatric symptoms. Finally, the Board cannot ignore the fact that the Veteran died of a self-inflicted gunshot wound, which the RO recognized in October 2013 was attributable to his PTSD. While it is difficult to specifically quantify the amount of psychiatric impairment that led to this unfortunate conclusion, it at the very least rebuts the observations of many psychiatrists who did not observe any suicidal ideation. Therefore, based on these factors, the Board determines that a 70 percent rating is warranted for both periods on appeal. Next, the Board considers whether a rating in excess of 70 percent is warranted for either period on appeal. In order to be assigned the next-higher 100 percent disability rating for PTSD, 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 inability to perform activities of daily living (including maintenance of minimal personal hygiene); * disorientation to time or place; and/or * memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, DC 9411 (2013). After a review of the competent evidence, the Board concludes that a rating in excess of 70 percent is not warranted. As an initial matter, the evidence does not indicate the existence of manifestations such as gross impairment in thought processes, persistent delusions or hallucinations, grossly inappropriate behavior or any other similar types of symptoms. For example, at a private evaluation in January 2004, the evaluating psychologist did not even observe an identifiable psychiatric disorder. Notably, the Veteran was unable to identify any psychiatric symptoms and he was depressed only on occasion. In fact, the psychologist appeared to doubt the veracity of the Veteran's statements, considering that his mental status testing would "indicate a profound dementia" which would preclude simple daily tasks he normally does. The Veteran was also evaluated in June 2004 in conjunction with a claim for benefits with the SSA in order to assess his cognitive functioning and to rule out a suspicion of malingering. On that occasion, the Veteran stated that his mood was "terrible." He appeared only mildly distracted and complained of memory problems, but denied hallucinations or delusions, although it was also observed that he had "extensive somatic concerns." His speech was fluent, well-articulated and normal in rate and volume. After undergoing a number of psychiatric tests, the examiner diagnosed generalized anxiety disorder with obsessive features with excessive concern on his alleged memory and mental deficiencies. The examiner noted that there were "many instances during this exam where underperformance appeared evident." When the Veteran underwent a VA examination in October 2004, he indicated that he lived in a trailer and was unemployed. He reported that he was "jumpy," "easily startled," and he preferred to avoid reminders of Vietnam. He thought his energy level was satisfactory and appeared to experience some sexual dysfunction that was thought to be anxiety-related. Upon examination, he appeared "unfocused," but his speech was seen as logical with no indication of hallucinations, delusions or formal thought disorder. While he did not experience compulsive thoughts, he was very compulsive in his work habits, where he worked a great deal of overtime at his job. During this same time, the Veteran underwent a number of shorter psychiatric evaluations, where many symptoms were not observed. For example, in October 2003, as well as May and July 2004, he denied any suicidal or homicidal ideation. His appearance, speech, thought process, associations and insight were normal. The evidence indicates that he was hospitalized from February to March 2005. During a psychiatric examination in March 2005, he was observed to have a depressed mood and anxious affect, but did not indicate any suicidal or homicidal ideation. He was not considered a danger to himself or to others, and was released ahead of schedule in "fair" condition. While the Veteran was again hospitalized in April to May 2005, there are no evaluations of record from this period of time. However, he underwent a second VA examination in November 2005. On this occasion, he stated that he had very little patience and never wanted to go anywhere. He also complained of flashbacks on a fairly regular basis. However, upon examination, his manner appeared characterized by anger and impatience, and "appears to take little responsibility for his own problems." His speech was mostly logical, and there was no indication of hallucinations, delusions or a formal thought disorder. His affect appeared to be inconsistent with the circumstances of his interview. The outpatient psychiatric evaluations from 2005 through 2007 were again relatively consistent, and did not reveal any significant symptoms. During this time, he regularly attended a PTSD therapy group (called a "rap group") where he actively participated. At an evaluation in January 2006, he reported nightmares and some sleep disturbance. He denied any suicidal or homicidal ideation. Similar symptoms were observed in May and June 2008. At a June 2006 VA examination, the Veteran continued to indicate that he has depressive symptoms. The examiner noted that he "appears to engage in a good deal of counterproductive brooding," and sometimes has suicidal ideation. Upon examination, he appeared calmer than he had at his prior examination in November 2005. While he displayed compulsive personality traits, there was no flight of ideas or loosening of associations. He was oriented in all areas and his concentration was adequate. At another VA examination in November 2007, the examiner observed that the Veteran's memory testing yielded results that were so atypical as to strongly suggest malingering. His responses to the examiner's questions were coherent and goal-directed. While he was wary of others, he denied visual hallucinations. However, he did state that he heard voices "off and on." Since his November 2007 VA examination, the Veteran underwent a number of outpatient evaluations which did not indicate significant observable psychiatric symptoms. For example, in May 2008, his speech and thought processes were observed to be within normal limits, and this thought content did not include any hallucinations or homicidal or suicidal ideation, but was limited to intrusive thoughts related to his PTSD. The Board notes that, at a separate evaluation on that same day, he indicated that he had suicidal ideation on a number of occasions during the past 7 years, even though he denied suicidal ideation on that particular occasion. However, even if his reported history of suicidal ideation was accurate, it had been sporadic in nature, and the Board does not conclude that this symptom alone would warrant an increased rating. By 2009 and 2010, it appeared as if the Veteran's psychiatric symptoms had actually improved. For example, at an evaluation in June 2009, he described symptoms of low motivation and "not having a purpose in life," but denied any suicidal or homicidal ideation. Upon examination, his speech and thought process were again within normal limits, and his insight and judgment were also normal. While his thought content was observed to be abnormal, there was no indication of hallucinations or delusions. Similar observations were made in October 2009. At more recent evaluations in April and August 2010, the Veteran was on both occasions alert and attentive. His thought process was normal and coherent, and there was no unusual thought content observed. His insight and judgment appeared to be good, and he denied any suicidal or homicidal ideation. Finally, at his most recent VA examination in January 2012, the Veteran stated that he preferred to not go out shopping or to restaurants and that he didn't feel like he slept well. He also complained of combat-related nightmares which caused him to wake up at night. Upon examination, he appeared adequately groomed and appeared alert. However, his speech was short, and his affect constricted. Overall, the Board does not conclude that the Veteran's psychiatric symptoms, as observed by various medical professionals, warrant a rating in excess of his current 70 percent rating. While he displayed some symptoms, such as a blunted affect and some occasional suicidal ideation, these symptoms were not to the level characterized by "gross impairment in thought processes or communication" or a "persistent danger of hurting self or others." Significantly, no psychiatric professional indicated that such symptoms were very severe. Moreover, other symptoms such as persistent delusions or hallucinations, grossly inappropriate behavior, an intermittent inability to perform activities of daily living or disorientation to time or place, for the most part, were not demonstrated. Next, although the general rating formula provides specific examples of symptoms that may result from various acquired psychiatric disorders, the Board emphasizes that its analysis should not be limited to only these symptoms, but should also consider any other relevant criteria outside of the rating code in order to determine the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). As such, the Board has also considered the extent to which there are other indications of occupational and social impairment, and whether these rendered him totally impaired from an occupational and social standpoint. In this regard, although the Veteran was not employed and did display some symptoms that impaired his ability to interact with others (as described above), his overall level of social functioning was actually much better than what is required for an increased rating on this basis. Specifically, through the numerous VA examinations the Veteran underwent, it is clear that he maintained a small but strong circle of associates. For example, at his VA examination in October 2004, he indicated that he had been married to his spouse for 38 years and, until the store he worked at closed in 2002, he had been employed for 32 years. By this time, he lived in a trailer with his spouse, and helped her with chores, and they ate together at night. While he did not participate in more strenuous activity, it appeared that this was due to non-psychiatric disorders. Overall, the examiner noted that the Veteran indicated a "close, loving relationship with his family and participation in his children's upbringing." At his VA examination in November 2005, the Veteran was accompanied by his spouse, with whom he lived. He claimed that he typically aided his wife with the housework, but mostly sat at home. His two children visited periodically with his grandchildren, which he appeared to enjoy. He also indicated that he was fairly regimented about his daily routine. During his July 2006 VA examination, the Veteran again indicated his desire to isolate himself and typically did not drive, although he could if he had to. His spouse indicated that she had to take care of her father, and sometimes the Veteran accompanied her. While he had apparently become estranged from some of his relatives, he also appeared to have some longer-term friends. At a VA examination in November 2007, the Veteran stated that his day consisted mostly of remaining around the house. However, he also stated that he attended stock car races once or twice a year and that he also traveled to a local casino periodically with his spouse. He also would accompany his wife shopping, so long as the stores were not too crowded. At his most recent VA examination in January 2012, he stated that he lived with wife of 45 years. He reported minimal contact with his neighbors and rarely left the house. However, he again stated that he and his wife went out to the casino or out to eat approximately once per month. His daughter also visited often. Finally, while the Veteran had undergone a number of psychiatric evaluations during the course of the appeal, none of these evaluations contradict the findings of the VA compensation examinations. Indeed, he often attended group counseling, and appeared to be engaged in these sessions. Overall, the Board acknowledges that the Veteran did have some social impairment. However, the evidence does not suggest that his impairment could reasonably be considered "total." Specifically, even though he often isolated himself from others, the evidence clearly establishes that he still had some level of social functioning. This weighs against a finding that his social functioning was so impaired as to warrant a rating in excess of 70 percent. As discussed previously, the Board has been particularly conscious of the fact that the Veteran died in July 2012 following a self-inflicted gunshot wound. It has also been established in an October 2012 rating decision that his death was at least as likely as not attributable to his service-connected psychiatric symptoms. However, the fact that his death was caused by an event indicative of substantial psychiatric impairment does not establish total impairment, per se. Rather, the Board must weight this factor against the other evidence of record. In this case, the evidence does not indicate that the Veteran's social functioning was so impaired that a total disability rating is warranted until the time of his death in July 2012. Moreover, while there were occasions where suicidal ideation was shown, there was never any indication of actual intent. In fact, on a number of occasions, he specifically stated that he restricted his own access to firearms in order to prevent this possibility. The Board also notes the occasions where his symptoms were the least severe were near the latter end of the period on appeal. Next, as mentioned above, the Board has considered the Veteran's GAF scores when assigning the appropriate disability rating for his PTSD. Here, his GAF scores have varied dramatically on a relatively consistent basis. For example, while he had GAF scores of 45-55 in 2003 and 2004, he was also assigned GAF scores of as low as 30 in 2005. For the period from 2005 to 2008, his GAF scores continued to vary from as low as 38 (in August 2005) to 50 (in October 2006 and June 2008). On two occasions in 2010, his GAF scores were as high as 70. The Board is willing to give the appellant the benefit of the doubt by placing more probative value on the occasions where the Veteran's GAF scores were in the 31-40 range. However, as low as these scores are, they do not represent symptoms necessary for a rating in excess of 70 percent. Namely, although there may have been occasions where he had shown "major impairment" (as is associated with GAF scores in the 31-40 range), even his lowest GAF scores do not indicate that there was "total" impairment. The Board has also considered the Veteran's and appellant's statements that his PTSD was worse than his assigned ratings indicate. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In this case, the Veteran and the appellant are competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno, 6 Vet. App. at 470. However, neither he nor the appellant is competent to identify a specific level of disability of his PTSD according to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran's PTSD has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports) directly address the criteria under which these disabilities are evaluated. The Board has also considered whether referral for an extraschedular evaluation is warranted. The question of an extraschedular rating is a component of a claim for an increased rating. Bagwell v. Brown, 9 Vet. App. 337 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular rating when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). To determine whether referral for such consideration is warranted, VA must first determine whether the available applicable schedular rating criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology. If the rating criteria are inadequate, VA must then determine whether the Veteran exhibits an exceptional disability picture indicated by other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for extraschedular consideration. Thun v. Peake, 22 Vet. App. 111 (2008). In this case, the evidence does not indicate that Veteran's disability picture could not be adequately contemplated by the applicable schedular rating criteria. Specifically, the relevant diagnostic code and general rating formula address both symptoms and social and occupational impairment. Moreover, as was established in Mauerhan, 16 Vet. App. at 444, a schedular rating for psychiatric disorders is not necessarily limited to the enumerated symptoms in the general rating formula, and no relevant symptoms have been excluded in the Board's analysis. Therefore, referral for consideration of the assignment of a disability evaluation on an extraschedular basis is not warranted. Thun, 22 Vet. App. at 111; Bagwell, 9 Vet. App. at 337; Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). Based on evidence of record, the Board determines that a 70 percent rating, but no higher, is warranted for both periods on appeal. The appeal is granted to this extent. ORDER An initial 70 percent rating, but no higher, for PTSD with anxiety disorder and depression, for the period prior to April 4, 2005, is granted, subject to the laws and regulations governing the payment of monetary benefits An initial 70 percent rating, but no higher, for PTSD with anxiety disorder and depression, for the period since June 1, 2005, is granted, subject to the laws and regulations governing the payment of monetary benefits REMAND The Board notes that the Veteran also filed a claim for TDIU, which was denied by the RO in an August 2008 rating decision, and he did not appeal. However, when a veteran submits a claim seeking an increased rating for a service-connected medical disability, it is construed as a claim for the highest rating possible to include entitlement to TDIU. See Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). Thus, although his TDIU claim was previously denied, it may be effectively re-raised when the evidence is added to the record which may support a claim of unemployability that was not previously considered. Evidence in the record so raises the issue. In this case, given the above and that the Board has determined that a 70 percent rating is warranted for the two periods remaining on appeal, he now meets the schedular requirements for TDIU as set forth by 38 C.F.R. § 4.16(a) (2013). Therefore, the issue of entitlement to TDIU, as it is encompassed in his increased rating claim, should be remanded for consideration by the RO/AMC. Accordingly, the case is REMANDED for the following action: 1. Send a letter to the appellant's last known address informing her of the evidence required to establish entitlement to TDIU under 38 C.F.R. §§ 3.340 and 4.16. She should be advised that this pertains to evidence relevant to the Veteran's employability prior to his death in 2012. 2. If the Veteran underwent any VA or private treatment relevant to his employability where the records of such treatment are not in the claims file, the RO should attempt to obtain them after acquiring any necessary authorization. 3. Any further development deemed necessary should be undertaken, to including obtaining any medical opinion. 4. Thereafter, readjudicate the issue of entitlement to TDIU for the period on appeal. If the benefit sought on appeal remains denied, the appellant and her representative should be furnished a supplemental statement of the case and provided the opportunity to respond. Then, the case should be returned to the Board for further appellate consideration, as appropriate. 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. 2013). ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs