Citation Nr: 1342895 Decision Date: 12/26/13 Archive Date: 01/07/14 DOCKET NO. 12-02 887 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability (TDIU). ATTORNEY FOR THE BOARD J. Gladney, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1970 to January 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision dated in June 2011 of the Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for PTSD and assigned a 30 percent rating, effective August 14, 2008. On appeal, a subsequent rating decision was issued in January 2012 which increased the Veteran's disability rating for PTSD from 30 percent to 50 percent, effective August 14, 2008. The United States Court of Appeals for Veterans Claims (Court) has held that on a claim for an original or increased rating, the appellant will generally be presumed to be seeking the maximum benefit allowed by law or regulations, and it follows that such a claim remains in controversy where less than the maximum benefit is allowed. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Board is cognizant of the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the United States Court of Appeals for Veterans Claims held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran submitted a letter in March 2013 stating that he was terminated as a result of his PTSD. Accordingly, the Board concludes that a claim for TDIU has been raised and will be discussed further in the remand portion of the discussion. The issues of entitlement to TDIU is addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. From August 14, 2008 to December 20, 2011, the Veteran's PTSD was manifested by symptoms like depression, anger outbursts, irritability, delusions or hallucinations, recurrent intrusive recollections, sleeping disturbance with nightmares, flashbacks, anxiety, panic attacks, hypervigilance, exaggerated startle response, impaired judgment, social isolation, difficulty in adapting to stressful circumstances, difficulty in establishing and maintain effective work and social relationships, avoidance behaviors, mild memory loss, and flattened affect productive of occupational and social impairment with reduced reliability and productivity. Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood has not been shown. 2. From December 20, 2011, forward, the Veteran's PTSD has been manifested by symptoms like depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintain social and work relationships, difficulty adapting to stressful circumstances, and persistent delusions and hallucinations productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Total occupational impairment has not been shown. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 50 percent for PTSD, from August 14, 208 to December 20, 2011 have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code 9411 (2013). 2. The criteria for a 70 percent disability rating, and no higher, for PTSD, from December 20, 2011, forward have been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002) redefined VA's duties to notify and to assist the veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper notice from VA must inform the claimant of any information and 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. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Here, the Veteran is appealing the initial rating assignment as to his PTSD. In this regard, because the June 2011 rating decision granted the Veteran's claim of entitlement to service connection, such claim is now substantiated. His filing of a notice of disagreement as to the June 2011 determination does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). Rather, the Veteran's appeal as to the initial rating assignment triggers VA's statutory duties under 38 U.S.C.A. §§ 5104 and 7105, as well as regulatory duties under 38 C.F.R. § 3.103. As a consequence, VA is only required to advise the Veteran of what is necessary to obtain the maximum benefit allowed by the evidence and the law. This has been accomplished here, as will be discussed below. In the January 2012 statement of the case (SOC), under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," the relevant diagnostic code for rating the disability at issue were set forth, and a description of the rating formulas for all possible schedular ratings under this diagnostic code were included. The appellant was thus informed of what was needed not only to achieve the next-higher schedular rating, but also to obtain all schedular ratings above the initial evaluation that the RO assigned. Therefore, the Board finds that the appellant has been informed of what was necessary to achieve a higher rating for the service-connected disability at issue. The duty to assist the Veteran has also been satisfied in this case. The RO has obtained the Veteran's service treatment records (STRs), private medical evidence, as well as his post service medical records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. VA examinations were conducted in July 2010 and December 2011. 38 C.F.R. § 3.159(c)(4). Each examiner conducted an interview of the Veteran, and mental status examination, recorded clinical findings, and documented the Veteran's subjective complaints. As these examinations included sufficient detail as to the current severity of his service-connected disability, the Board concludes that these examinations are adequate for evaluation purposes. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). The Board has had the opportunity to review medical and lay evidence as to the severity of the Veteran's service-connected PTSD. Thus, the Board finds that in this case the available evidence of record provides sufficient information to evaluate the level of severity of this disability. In any event, the Veteran has neither advanced an argument that any VA examination of record was deficient in any respect, nor that he was prejudiced thereby. Barr, 21 Vet. App. at 312. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also, Dingess/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). II. Legal Criteria The Veteran seeks an initial disability rating in excess of 50 percent for his service-connected PTSD, contending that his currently assigned disability rating does not adequately reflect the severity of his disorder. He believes his rating for PTSD should be at 100 percent. The Board evaluates PTSD using the criteria in the General Rating Formula for Mental Disorders. 38 C.F.R. §§ 4.1, 4.130 (2013); Diagnostic Code 9411 (2013). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries encountered as a result of or incident to military service and their residual conditions in civil occupations. 38 C.F.R. § 4.1 (2013). Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1 (2013). Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Generally, the degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). In this case, the rating decision on appeal was the initial rating decision granting service connection for the disability at issue. Therefore, separate ratings can be assigned for separate periods of time based on facts found, a practice known as staged ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). However, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Ratings are assigned according to the degree of occupational and social impairment resulting from the manifestations of the disability at issue. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as the type and degree of symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16. Vet. App. 436 (2002). Under Diagnostic Code 9411, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). A 70 percent rating is warranted when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessive 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. Id. Finally, a 100 percent disability 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 relatives, own occupation, or own name. Id. The Board notes that when 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 (2013). As the United States Court of Appeals for the Federal Circuit recently explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan, 16 Vet.App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms [,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas"-i.e., "the regulation ... requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a) (2013). In addition to evidence regarding the Veteran's symptomatology and its impact on his social and occupational functioning, a Global Assessment of Functioning (GAF) score is another component considered to determine the entire disability picture for the Veteran. The GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)). The Board notes that the evidence includes GAF scores ranging from 40 to 56. GAF scores ranging from 31-40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). The explanation of GAF scores ranging from 41 to 50 reflects 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). The explanation of GAF scores ranging from 51 to 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 coworkers). The Board notes that a GAF score need not be accepted as probative if it is determined that the score does not reflect the overall psychiatric disability picture at the time of the examination. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995) (it is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others). However, the probative value of the GAF scores will be considered in light of the other evidence of record. Finally, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (2013); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). III. Factual Background The Veteran submitted his claim for service connection for PTSD in August 2008. VA outpatient notes associated with the claims file show the Veteran was treated for PTSD from April 2008 to December 2008 at VAMC Columbia. Those outpatient records indicate a positive PTSD screening in April 2008. Thereafter, from May 2008 to December 2008, the Veteran's records reflect a diagnosis of PTSD. Records state the Veteran's PTSD symptoms include anxiety, depression, insomnia, and substance abuse. Records also note the Veteran's kinetics were normal, mood/affect anxious, sensorium normal, and orientation x4. The Veteran's concentration and recent and remote memory were all noted as good. A GAF score of 55 was assigned in May 2008. His affect and mood were anxious and his thoughts were linear, goal-directed, content without hallucinations or delusions. His insight, judgment, memory, and concentration were intact and adequate. Records note the Veteran's sleep was non-restorative, appetite was adequate, and energy was fatigued. The Veteran was noted to have experienced irritability/anger, depressive/anxiety symptoms, and nightmares several times a week that caused him to wake up in a cold sweat and were "worsened by stress at work." Records also noted the Veteran experiences flashbacks occasionally with no identified triggers. Subsequent mental health outpatient notes from September 2009 were provided. These notes indicated that the Veteran continued to have difficulty achieving restful sleep which was disrupted by sounds and nightmares. Symptoms listed in the outpatient records included non-restorative sleep, temper outbursts that were not out of control, and depression. The Veteran denied having manic or hypomanic symptoms, delusions, or drug abuse. Notes indicated that the Veteran experiences anxiety, specifically excessive worrying and tension. The examiner described the patient as cooperative, clean and casually dressed, and tired. The examiner stated the affect was constricted and the mood was dysthymic, anxious. The Veteran's speech was noted as spontaneous, normal tone, and he elaborated well. The Veteran denied auditory or visual hallucinations and denied experiencing delusions. The examiner determined the Veteran was alert and attention and concentration were noted as "good." The examiner stated the Veteran's "short term and long term memories appeared in tact but not formally tested." The examiner noted the Veteran's judgment was intact, insight into illness was fair, and thoughts were goal oriented, logical and coherent. The Veteran denied having any suicidal or homicidal thoughts or plans. The examiner also noted the Veteran had an isolative social life. The Veteran stated he experienced flashbacks once a month, nightmares 4-5 times a month, and night sweats. He also described feeling depressed 3-4 times per week and stated the medication reduced his irritability but he still loses his temper. Thereafter, in support of his claim, the Veteran submitted a January 2010 psychological evaluation from his private psychologist, Dr.W.J.D. The Veteran provided a copy of his DD-214 for the evaluation. He described having difficulties with anger control, verbal outbursts, but no physical altercations. At the time of the evaluation, the Veteran had been employed for 37 years. The Veteran stated that he began to drink heavily during his military service and continued post service. He denied any legal history and stated he stopped smoking marijuana in 1975. Dr. W.J.D noted the Veteran experience intrusive thoughts and flashbacks related to service. He had recurrent nightmares one to two nights per week and night sweats. The Veteran has cognitive and physiological responses to smells that remind him of Vietnam. Dr.W.J.D. determined the Veteran has a history of intensive effort geared toward the avoidance of thoughts, feelings, conversations, activities, places, and people associated with his traumatic experiences. The Veteran was also found unable to remember aspects of trauma to which he had been exposed. He had markedly diminished interest and participation in significant activities. Dr.W.J.D determined he had a restricted range of affect. The Veteran also experienced insomnia, intermittent waking and terminal waking, irritability, angry verbal outbursts, trouble with concentration, hypervigilance, and exaggerated startle response. The Veteran noted experiencing significant fatigue and loss of energy, and suicidal ideation. He also described a history of homicidal ideation, though denied current ideation. Dr.W.J.D. found the Veteran's impulse control fell below normal limits. She determined his speech fell within normal limits as well. His thought process was consistent with the presence of suicidal ideation. Dr.W.J.D. described the Veteran's affect as stable. She also determined he was oriented to person, place, and time. Dr.W.J.D. found the Veteran's concentration and immediate memory abilities fell below normal limits. She also determined the Veteran's recent memory fell within normal limits, recent past events fell below normal limits, and remote memory was intact. She found his intelligence and fund of information fell within the average range and judgment and insight fell below the normal limits. Dr.W.J.D. diagnosed the Veteran with PTSD and assigned a GAF score of 40 based upon his difficulties including social and employment functioning, family relationships, judgment related issues, thinking difficulties, and mood. Specifically, Dr. W.J.D. noted a marked pattern of isolation post service, problems with authority figures and coworkers in his work environment, and conflict with his wife. Dr. W.J.D stated that the Veteran's symptoms "likely substantially negatively impact his employability" and "symptoms are service-connected and severe." In July 2010, the VA provided the Veteran a mental health examination. The examination report indicated that the Veteran stated he had been receiving treatment for PTSD through the VA and had never been hospitalized for psychiatric problems. The Veteran stated he had been having symptoms of PTSD since he served in Vietnam. The examiner noted that the Veteran was alert and oriented to person, place, day, date, and time; thought process was linear, and history was adequate. The examiner stated the Veteran's affect was euthymic, he demonstrated insight, and his spontaneous speech was full, grammatic, and free of paraphasias. The examiner reported that the Veteran's attention and memory were mildly impaired. He noted that the Veteran endorsed auditory and visual hallucinations. The Veteran described hearing "noises", hearing "sounds", and seeing people and animals, primarily at night. The Veteran denied experiencing any hallucinations during the examination. The examiner diagnosed the Veteran with PTSD with a GAF score of 56. He noted a review of the claims file. The examiner noted the Veteran presents with a diagnosis of PTSD, his history of treatment for PTSD with the VA, and an independent examiner's diagnosis of PTSD. The examiner stated it was as least as likely as not that the Veteran's PTSD was related to his tour of duty in Vietnam and his reported in service stressors. The examiner determined the Veteran moderate impairment in functioning including social and occupational due to his PTSD symptoms. The examiner also diagnosed the Veteran with alcohol abuse secondary to his diagnosis of PTSD. Thereafter, in April 2009, the RO granted service connection for PTSD and assigned a disability rating of 30 percent. The Veteran contends his PTSD is more disabling and filed a timely notice of disagreement. Subsequently, the VA afforded the Veteran an additional mental health examination in December 2011. The examiner noted review of the claims file and that the Veteran's PTSD has psychosocial and environmental problems regarding his family, socialization, and occupation. The examiner assigned a GAF score of 48. The examiner noted no other diagnoses of mental disorders or traumatic brain injuries. The examiner determined the Veteran has occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported increasing auditory hallucination, marked increase in irritability, and feelings that his PTSD symptoms are dominating his life and affecting his job stability. The examiner noted the Veteran had suicidal ideations in the past, but not presently, and has been feeling more depressed in the past year. The Veteran stated that his relationship with his family had deteriorated significantly. The Veteran noted his continued consumption of alcohol and denied having a criminal history. The examiner found that the Veteran's aforementioned PTSD symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Furthermore, the examiner found the Veteran experiences depressed mood, anxiety, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events; flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, and persistent delusions or hallucinations. The examiner stated no other symptoms attributable to PTSD were found other than those listed and the Veteran is capable of managing his own financial affairs. In January 2012, the RO increased the rating for the Veteran's PTSD from 30 percent to 50 percent disabling. The Veteran timely filed a substantive appeal to his PTSD disability rating in February 2012. In his substantive appeal, the Veteran states that the VA did not consider all of the medical evidence. He contends that the VA failed to consider Dr. W.J.D.'s report in the rating decisions. He also contends that the VA accepted Dr. W.J.D's symptoms as evidence and believes the private doctor's report has more probative value than the VA PTSD examinations. He asserts that he is 100% disabled by his PTSD. A. Initial Rating from August 14, 2008 to December 20, 2011 After reviewing all the evidence, the Board finds that, for the initial rating period from August 14, 2008 to December 20, 2011, the Veteran's PTSD was productive of moderate impairment of occupational and social functioning, depression, anger, irritability, a history of delusions or hallucinations, recurrent intrusive recollections, sleeping disturbance with nightmares, flashbacks, anxiety, panic attacks, hypervigilance, exaggerated startle response, impaired judgment, social isolation, difficulty in adapting to stressful circumstances, difficulty in establishing and maintain effective work and social relationships, avoidance behaviors, mild memory loss, flattened affect, euthymic mood; mildly impaired concentration and memory; intact insight; linear thought process; and understandable speech which approximates the criteria for a 50 percent disability rating. The criteria for a rating in excess of 50 percent for PTSD for the period from August 14, 2008 to December 20, 2011 have not been met or more nearly approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326(a), 4.3, 4.7, 4.130, Diagnostic Code 9411. The appellant's impairment was found to be represented by GAF scores of 55, 40, and 56. GAF scores are considered and given great probative value as they reflect a picture of the Veteran's psychiatric disability at the time of examination. The Veteran exhibited PTSD symptoms indicate impairment in several areas, including work, family relations, thinking, and mood. Noted above, the Veteran's PTSD symptomatology is more accurately described by GAF scores ranging from 51-60 which 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 coworkers). As previously stated, a GAF score of 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). At the time these scores were assigned, the examiners noted some social and occupational impairment which included irritability, arguments with coworkers, and a history of panic attacks, but the Veteran maintained employment and relationships with his family and a few friends. The Veteran's examinations failed to show the severity of symptoms reflected by a GAF score of 40. As such, the Board finds greater probative value in the GAF scores of 55 and 56 than the score of 40. The Board recognizes the conflicting opinions of severity between the VA mental health examiners and the Veteran's private physician, DR. W.J.D. The Board finds that Dr. W.J.D. is competent and credible to assess the Veteran's psychiatric disability and has considered the probative value of the mental evaluation provided. However, the Board finds the VA medical evidence and VA PTSD examination conducted in July 2010 have greater probative value in determining the Veteran's overall disability picture. The VA examiners were provided and reviewed the Veteran's entire claims file which included the Veteran's in service and post service medical records and the Veteran's lay statements over a number of months. Dr. W.J.D. was only provided the Veteran's DD-214 which is not reflective of the Veteran's medical history during or post service. Furthermore, it is unclear whether Dr. W.J.D. has a history of treating the Veteran for his psychiatric disability or engaged with him for the sole purpose of evaluating his PTSD contentions. As the VA examiners were able to review a more complete picture of the Veteran's medical history and psychiatric disability, the Board finds greater value in the consistently similar findings, opinions, and GAF scores of the VA examiners. In sum, the evidence of record prior to December 20, 2011 demonstrates that the Veteran was able to function independently and manage his finances. He had been married and employed for nearly four decades, maintained relationships with his wife and children, continued to social with friends, and enjoyed hobbies. He was able to control his anger, not prone to violence, and experienced moderate social and occupational functional impairment. During this time he did not experience cognitive impairment. Examiners did determine, however, that the Veteran did exhibit depressed mood, irritability and anger issues, hypervigilance, and sleep impairment due to occasional nightmares, and delusions. Based on the foregoing, the Board finds that the Veteran's PTSD prior to December 20, 2010 most closely approximates the criteria for a 50 percent rating and no higher. 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. IV. Initial Rating on and after December 20, 2011 While the Board determined that the Veteran's PTSD disability rating prior to December 20, 2010 was properly rated at 50 percent, the Board has also determined that the initial rating period on and after December 20, 2011 should be rated at 70 percent disabling and no higher. Upon examination, in December 2011, the Veteran's PTSD was productive of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, difficulty in adapting to stressful circumstances (including work or work like setting), depressed mood, anxiety, chronic sleep impairment, mild memory loss, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintain social and work relationships, and persistent delusions and hallucinations which more adequately reflected in a 70 percent disability rating. The criteria for a rating in excess of 70 percent for PTSD for the rating period on and after December 20, 2011 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.326(a), 4.3, 47, 4.130, Diagnostic Code 9411. The December 20, 2011, VA mental health examination determined the Veteran has occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner assigned a GAF score of 48. The Veteran reported increasing auditory hallucination, marked increase in irritability, and feelings that his PTSD symptoms are dominating his life and affecting his job stability. The examiner noted the Veteran had a history of suicidal ideations and increasing depression in the past year. The Veteran stated that his relationship with his family has deteriorated significantly. The examiner found that the Veteran's aforementioned PTSD symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Furthermore, the examiner found the Veteran PTSD symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events; flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, and persistent delusions or hallucinations. Given the documented deterioration in the Veteran's PTSD disability picture as manifested by the lower GAF score, the objective evidence of occupational and social impairment, and the Veteran's PTSD symptoms, the Board finds that a 70 percent disability rating more adequately reflects the appellant's PTSD symptomatology for the period on and after December 20, 2011. The Board has also determined that the criteria for a 100 percent rating are neither met nor more nearly approximated as there is no evidence of total occupational and social impairment and does not exhibit symptoms such as gross impairment in thought processes or communication, grossly inappropriate behavior, a persistent danger of hurting himself or others, an intermittent 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, 38 C.F.R. §§ 4.3, 4.7. The Board has applied the benefit of the doubt doctrine in determining the criteria for a rating of 70 percent are met since December 20, 2011, but finds that the preponderance of the evidence is against an assignment of a higher rating. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102, Gilbert v. Derwinski, 1. Vet. App. 49, 53 (1990). IV. Extraschedular Rating When deciding extraschedular rating considerations, the Board must determine whether referral is warranted for a rating outside of the schedule for the Veteran's PTSD. To accord justice in an exceptional case where the schedular standards are found to be inadequate, the field station is authorized to refer the case to the Chief Benefits Director or the Director, Compensation and Pension Service for assignment of an extraschedular evaluation commensurate with the average earning capacity impairment. 38 C.F.R. § 3.321(b)(1) (2013). Extraschedular consideration involves a three step analysis. Thun v. Peake, 22 Vet. App. 111 (2008). First, the Board or the RO must determine whether the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology. Id. at 115. If the schedular rating criteria do reasonably describe the Veteran's disability level and symptomatology, the assigned schedular evaluation is adequate, referral for extraschedular consideration is not required, and the analysis stops. Id. If the RO or the Board finds that the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology, then either the RO or the Board must determine whether the Veteran's exceptional disability picture includes other related factors such as marked interference with employment and frequent periods of hospitalization. Id. at 116. If this is the case, then the RO or the Board must refer the matter to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for the third step of the analysis, determining whether justice requires assignment of an extraschedular rating. Id. Here, the schedular rating criteria reasonably describe the Veteran's disability level and symptomatology, so referral for extraschedular consideration is not required. The Veteran's reported symptomatology, such as suicidal ideation, difficulty adapting to stressful circumstances, occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, and inability to establish and maintain effective relationships, are contemplated by the regulations, and they do not indicate that a higher rating of 70 percent is warranted. Thus, the extraschedular analysis ends here, and referral for consideration of an extraschedular rating is not required. ORDER Entitlement to an initial rating in excess of 50 percent for PTSD prior to December 20, 2011 is denied, and a rating of 70 percent, but no higher, on and after December 20, 2011 is granted. REMAND The claim for TDIU required remand for an addendum opinion. In March 2013, the Veteran has asserted that he was terminated from his employment as a result of his PTSD. The Veteran's employer noted he was terminated as a result of "permanent restrictions." The Board cannot determine such restrictions are a result or indicative of the Veteran's PTSD. No examiner has found that the Veteran's PTSD symptoms render him unemployable; therefore, a remand is required to determine whether the Veteran's PTSD interferes with his occupational functioning such that it renders him unemployable. Accordingly, the case is REMANDED for the following action: 1. Inquire as to whether the Veteran receives SSA disability benefits. Update the VA medical record from September 2011 forward. Ask the Veteran if he has received private treatment for PTSD from Dr. Wende Anderson since February 2010. Obtain records if the response is positive. Ask the Veteran if he has received any other treatment for PTSD from any other private provider, and obtain those records if the answer is positive. 2. Send a VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, to the Veteran's previous employer. Any response received should be associated with the claims folder or Virtual VA eFolder. 3. Request an addendum opinion to determine the Veteran's total disability rating based on individual unemployability. The claims folder must be available for review by the examiner. Additionally, all relevant medical records must be made available to the examiner for review, either in the Virtual VA eFolder, or if the eFolder is not available, then via paper copies. An explanation for all opinions expressed must be provided. If an opinion cannot be provided without resort to speculation, it must be noted in the examination report, and an explanation provided for that conclusion. The examiner is specifically requested to discuss how the Veteran's PTSD impacts his ability to obtain and/or maintain substantially gainful employment and to provide an opinion as to whether the Veteran's PTSD is of sufficient severity to produce unemployability. 4. Reconcile the VA examiner's opinion with the Veteran's statement regarding his termination and any VA Form 21-4192 response from the Veteran's previous employer. 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 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). ____________________________________________ MARJORIE. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs