Citation Nr: 1342910 Decision Date: 12/26/13 Archive Date: 01/07/14 DOCKET NO. 04-35 616 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Wilmington, Delaware THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD) for the period prior to November 24, 2008. 2. Entitlement to an initial rating in excess of 70 percent for PTSD for the period from November 24, 2008. 3. Entitlement to a total rating based on unemployability due to service connected disability (TDIU) for the period prior to November 24, 2008. REPRESENTATION Appellant represented by: Joseph R. Moore, Attorney at Law ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The Veteran had active service from November 1966 to October 1968. This matter came before the Board of Veterans' Appeals (Board) from a February 2004 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which granted service connection for PTSD and assigned a 30 percent evaluation. Jurisdiction over the Veteran's claims file has since been transferred to the Wilmington, Delaware RO. In a September 2006 decision, the Board increased the initial rating to 50 percent. The Veteran appealed to the U.S. Court of Appeals for Veterans Claims (Court). In May 2007 the Court granted the parties joint motion for remand, vacating the September 2006 decision to the extent that it denied a rating in excess of 50 percent for PTSD. The Board remanded the appeal for additional development of the record in November 2007. While the appeal was in remand status, the RO issued a January 2009 rating decision which assigned a 70 percent evaluation for PTSD, effective November 24, 2008. In July 2010, the Board again remanded the appeal. In a September 2011 decision, the Board again denied the Veteran's claim for increase. The Veteran appealed to the Court. In May 2012 the Court granted the parties' joint motion for remand. The appeal was returned to the Board for action consistent with the terms of the joint motion. The Board notes that in a November 2013 statement, the Veteran's attorney specified that the Veteran was satisfied with the rating assigned to his PTSD from November 24, 2008. The issue of entitlement to a TDIU for the period prior to November 24, 2008 is addressed in the REMAND portion of the decision below and is REMANDED to the RO. FINDINGS OF FACT 1. On November 7, 2013, prior to the promulgation of a decision in the appeal, VA received notification from the appellant, through his authorized representative, that a withdrawal of the appeal is requested with respect to the issue of entitlement to an initial rating in excess of 70 percent for PTSD, for the period from November 24, 2008. 2. For the period prior to November 24, 2008, PTSD was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as: sleep disturbance, intrusive thoughts, flashbacks, difficulty concentrating, memory problems, irritability, avoidance, and isolation. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the appellant (or his or her authorized representative) have been met. 38 U.S.C.A. § 7105(b) (2), (d) (5) (West 2002); 38 C.F.R. § 20.204 (2013). 2. The criteria for an initial rating in excess of 50 percent prior to November 24, 2008 have not been met or approximated. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Evaluation of PTSD from November 24, 2008 The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2002). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2013). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the appellant, through his authorized representative, has withdrawn the appeal with respect to the issue of entitlement to a higher initial rating for PTSD for the period from November 24, 2008. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal regarding this issue and it is dismissed. Evaluation of PTSD prior to November 24, 2008 The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the Court have been fulfilled. In this case, the Veteran filed his service connection claim in March 2003. He was notified of the provisions of the VCAA by the RO in correspondence dated in May 2003 and December 2007. These letters notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claim, identified the Veteran's duties in obtaining information and evidence to substantiate his claim, and provided other pertinent information regarding VCAA. Subsequently, the claim was reviewed and a supplemental statement of the case (SSOC) was issued in April 2011. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a); Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Kent v. Nicholson, 20 Vet. App. 1 (2006), Mayfield v. Nicholson (Mayfield III), 499 F.3d 1317 (Fed. Cir. 2007). During the pendency of this appeal, the Court in Dingess v. Nicholson, 19 Vet. App. 473 (2006), found that the VCAA notice requirements applied to all elements of a claim. Notice as to this matter was also provided in the December 2007 letter. The Veteran has been made aware of the information and evidence necessary to substantiate his claim and has been provided opportunities to submit such evidence. A review of the claims file also shows that VA has conducted reasonable efforts to assist him in obtaining evidence necessary to substantiate his claim during the course of this appeal. His service treatment records, post-service VA treatment records, and Social Security Administration records have been obtained and associated with his claims file. The Veteran was also provided with VA medical examinations in October 2003, July 2005, and November 2008 to assess the current nature of his PTSD. The Board finds that the examinations are adequate in that they were conducted by neutral, skilled providers who reviewed the record, interviewed the Veteran, and performed appropriate physical examinations prior to providing their conclusions. The Board finds the case is adequately developed for appellate review. Factual Background During an October 2003 VA examination, the Veteran's history was reviewed. He stated that his parents were deceased and that he kept in touch with a sister. He noted that he married in 1979 but had been separated for the previous nine years. When asked why the marriage dissolved, the Veteran stated that his wife was a shop-aholic and they lost their house. He indicated that he had not worked since 2001, and was on disability. Regarding legal history, he related that he had been charged with assault for hitting a fellow employee on the job; he indicated that he received probation. With respect to medical history, the Veteran reported that he had a minor cerebrovascular accident four or five years previously. He noted that he had been admitted to a psychiatric hospital following a suicide attempt in 1973; he indicated that he had not received psychiatric treatment since then. On mental status examination, the Veteran complained of trouble sleeping, nightmares, minimal appetite, recurrent and intrusive distressful thoughts about Vietnam, flashbacks, difficulty concentrating, irritation, and avoidance of thoughts, feelings, crowds, and parties. He indicated he had one friend and felt detached from other people. He stated that he was unable to feel any emotion. He also complained of irritability and reported he got mad very easily. The diagnosis was chronic PTSD, with an assigned GAF score of 50. VA medical treatment records dated from September 2003 to August 2004 note that the Veteran was repeatedly found to be alert and oriented. In July 2004, the Veteran complained of memory loss. During neuropsychology consultation in August 2004, various tests were administered. The provider noted that the Veteran had been referred given reports of memory difficulties, alcohol abuse, and past head injuries. The Veteran reported both memory and organization problems, noting that it was common for him to forget what he had been asked to purchase at a store when he arrived there. With respect to previous head injuries, the Veteran indicated that he was injured in a drunken driving accident in addition to five other motor vehicle accidents. He indicated that he had suffered a stroke five or six years previously. He also reported that he had rolled a concrete truck and was thrown into the dashboard and experienced loss of consciousness. He noted that since that incident, he had been unable to work. Upon examination, the examiner reported that the Veteran was casually dressed, very pleasant throughout the evaluation and easily established rapport with the examiner, was able to maintain a socially appropriate conversation, and responded well to both verbal and nonverbal cues. The examiner noted that at times the Veteran took a little longer than normal to fully "process" what he was being instructed to do, but that he did not seem to become frustrated by his presented tasks, and worked rather calmly on each presented task. After multiple tests, the examiner found that the Veteran's overall intellectual abilities, general memory functions, and neuropsychological evaluations were in the average range of performance. He concluded that based on the reported history, the Veteran was functioning at a much higher cognitive level than what might be expected. He noted that as a whole, the Veteran's deficits were subtle. In January 2005 the Veteran was noted by a VA physician to be alert and oriented, and in no acute distress. During a July 2005 VA examination, the Veteran reported that since his October 2003 examination, he had not had any psychiatric or medical hospitalizations, and that he was not engaged in treatment for PTSD. He reported that he liked living alone, did not like social gatherings, and avoided crowds and loud places. He reported that his sleep was interrupted with nightmares occurring once per month. He endorsed flashbacks occurring when he saw certain programs such as on the History Channel. He noted that certain smells or seeing the Brandywine River triggered intrusive thoughts. He stated that he had no social life and he preferred it that way. He noted that he had one friend from alcoholics anonymous. He related that he had never had trouble getting jobs and that he was fired for missing time due to his drinking. He also reported that he was violent in the workplace in 2000 and was charged with an assault and had to undergo anger management and one year probation. He indicated that he was independent in his activities of daily living. He denied any particular hobbies. Upon examination, the examiner reported he was groomed and neat in appearance, oriented and cooperative. Affect was constricted and almost flat and moody as claimed by the Veteran. There was no evidence of psychosis. Thinking was goal directed and relevant. The Veteran had no trouble with serial sevens; concentration was good. He was fully oriented and was able to abstract. He did not exhibit any significant cognitive defects. He denied any suicidal or homicidal ideations. The diagnosis was PTSD, with an assigned GAF score of 50, which the examiner noted was evidenced by his serious impairment in social function, and inability to have committed relationships. A January 2006 VA social worker note indicates that the Veteran was seen for a PTSD session. The social worker noted that the Veteran's inconsistent sleep cycles dictated what he did and did not do on a daily basis. A January 2006 VA mental health consultation note indicates that the Veteran had not slept since awakening the previous morning. He also endorsed times when he talked too much and got on peoples' nerves as well as racing thoughts. Mental status examination revealed no signs of mania, depression, severe anxiety, or psychosis. The assessment was PTSD and rule out bipolar disorder. In February 2006 the Veteran reported to his VA social worker that his sleep disturbance and intrusive thoughts increased during the summer of 2005 and he could not figure out why. In February 2006, the Veteran asserted that he had highs and lows and sometimes could not stop talking when into a subject that interested him. He reported that he was socially isolated, though he did enjoy being in "some" company of others under limited situations, such as when he chose the encounter. In May 2006, a VA primary care annual evaluation included a PTSD screen. The Veteran indicated that in the previous month, he had not had nightmares, intrusive thoughts, or avoidant behaviors. He denied having been constantly on guard, watchful, or easily startled. He also denied feeling numb or detached from others. The provider concluded that the PTSD screen was negative. The Veteran was noted to be alert and oriented by a medical provider in May 2006. During a May 2007 VA follow-up, the Veteran denied suicidal intent, but admitted to feelings of depression and wanting to give up. He had no active suicide plan. The Veteran was noted to live alone with limited support networks. A June 2007 VA social worker's note indicates that the Veteran kept himself busy driving friends to medical appointments so that he could get out of his apartment for stimulation. He was noted to be very passionate about his political and war related viewpoints and was also very knowledgeable about past and current world events. He reported that he enjoyed attending group therapy when he was able. He denied suicidal ideation and noted that he would not be capable of such, but admitted to not caring whether he died. In a June 2007 VA medical progress note, the Veteran reported that he did not care if he woke up in the morning, but that he had no suicidal ideations. He related that he was too "scared" of doing that. October and November 2007 VA medical records indicate that the Veteran was alert and oriented, and in no acute distress. In a January 2008 letter, the Veteran's friend, J. B., indicated that he is in contact with the Veteran on a daily basis, and that he had noticed in the previous several years that the Veteran continually talked about Vietnam. The author noted that the Veteran's mind would turn to Vietnam in the middle of a conversation. He also related that the Veteran had told him about his nightmares. In March and September 2008 the Veteran was noted to be alert, oriented, and in no acute distress. During a November 2008 VA examination, the Veteran's history was reviewed. He reported having a hard time feeling close to others and that he was a "loner" who preferred to be alone at home. He noted that he got along with his step son. He stated that if someone asked him for help, he would make an effort to leave the home. He reported that he was easily angered and provoked, and he worried that he could lash out physically. He indicated that he was more withdrawn in the last several years and that he made a point to avoid crowds and public events. He noted that he had once bowled on a league, but that he had lost interest and motivation to do many things and had no hobbies or interests. He indicated that he watched television most of the day. He reported that he had a single suicide attempt in the 1970s and that he hit a coworker and was arrested for assault in 2000, but had no episodes of violence during this review period. Upon examination, the Veteran was casually dressed, in disheveled clothes and with poor eye contact. He displayed psychomotor activity including a hand tremor. He was oriented, with unremarkable thought process, no delusions, average intelligence, and partial insight. He had mumbled speech. He was cooperative. His affect was blunted and his mood was agitated and dysphoric. He endorsed inappropriate behavior such as yelling at others in grocery stores and experiencing road rage and poor impulse control; however, he denied episodes of violence. He endorsed auditory hallucinations. He denied obsessive/ritualistic behavior and panic attacks. He endorsed some homicidal and suicidal thoughts; he denied that he would act on his homicidal thoughts, noting that he had an appreciation for the consequences. He also denied plan or intent with respect to his suicidal thoughts, noting that he wished he would die in his sleep. The examiner noted that the Veteran's impulse control was poor, noting that the Veteran was verbally and behaviorally impulsive with incidents of yelling at others and episodes while driving. He indicated that there were some problems with activities of daily living such as severe interference with household chores and recreational activities, and moderate impairment of grooming, shopping, self-feeding, bathing, dressing, exercise, and driving. He noted normal remote and recent memory and mildly impaired immediate memory. He further noted recurrent and intrusive distressing recollections of events, recurring distressful dreams, recurrence of traumatic events, and intense psychological and physiological distress at exposure to internal or external cues that symbolize the traumatic event. The Veteran reported symptoms most days of a moderate to severe intensity. The examiner diagnosed PTSD and assigned a GAF score of 35 based on serious symptoms and major impairment in several areas of functioning to include social and family relationships, judgment, thinking, and mood. The examiner further noted there was not total occupational and social impairment due to PTSD signs and symptoms. In August 2013, a private physician, M.L.C., M.D., conducted a two-hour diagnostic interview with the Veteran. He noted that prior to the interview, he completed a comprehensive review of the medical and service records as well as ancillary information. Dr. C. stated that the Veteran had experienced intractable symptoms of PTSD since at least 2003 when he was first diagnosed, but in reality, far earlier. He indicated that his review of the record and interview with the Veteran indicated that he had a pervasive and severely impairing mental illness for many decades, and certainly between the dates of March 17, 2003 and November 24, 2008. He noted that the Veteran's symptoms during that period were essentially unchanged and continued to be severe through the present day. He related that the medical record was extremely convincing on that point, and his interview with the Veteran confirmed the fact that the Veteran was, during the period in question, severely mentally ill and incapable of functioning in any employment setting due to his PTSD alone. Dr. C. noted that although the Veteran appeared to have been reluctant to participate in regular mental health treatment, such was not a reflection of the severity of his symptoms. He indicated that it was quite common for the pervasively and severely mentally ill to decline or refuse engagement in comprehensive mental health care service due to impairment in judgment, insight, and functioning. He stated that treatment records existing for the period between 2003 and 2008 showed that the Veteran had been not only completely occupationally impaired, but also extremely socially isolated, detached from others, unable to display any affect, and prone to volatile, angry, and potentially dangerous behavior. He stated that those records also showed cognitive impairments marked by loss of focus, concentration, and attention to basic details of day to day life due to the Veteran's psychiatric illness. He pointed out the Veteran's report of having assaulted a coworker in 2000, as well as extended periods of unemployment, and difficulty maintaining meaningful and gainful positions. He pointed to reports dated in July 2005 and February 2006 as indicating that the Veteran was isolated, incapable of appropriate interactions, and minimal contact with family and friends. He interpreted the November 2008 VA examination report as evidence of incapacity to work and complete impairment from psychiatric illness since the previous 2005 examination. He acknowledged the Veteran's other injuries, but stated that even if the Veteran never had a single other injury or medical illness, he would still have been 100 percent disabled from PTSD as the totally impairing symptoms were present from at least 2003 when he was diagnosed, but likely far earlier. He encouraged that there was ample documentation that before the motor vehicle accident that initially forced him to stop working, the Veteran had poor impulse control on the job, had assaulted a coworker, and failed to function in even the most basic aspects of day to day society. In summarizing the relevant records, Dr. C. discussed the August 2004 neuropsychological evaluation. He noted that the Veteran's cognitive functioning was not affected by his head injuries. He also discussed the 2003 VA examination report, and pointed out that the diagnoses of chronic PTSD and substance dependence disorder, translated into 2013 nomenclature would be equivalent to the diagnosis of chronic PTSD, delayed onset, with dissociative symptoms and alcohol use disorder. Dr. C. also noted that the 2008 VA examiner recorded a reported history marked by problem attendance, frequent firings, and difficulty establishing and maintaining cooperative relationships with coworkers. He also noted that the 2008 examiner recorded a history of chronically irritable and depressed moods interfering with the Veteran's ability to bathe, dress, eat, maintain his home, leave the house, and socialize with others; as well as an inability to maintain a regular schedule of mental health care. Dr. C. noted that in his extensive evaluation of the Veteran he described the same symptoms dating to far earlier than the date of the 2008 report, prior to his diagnosis of PTSD in 2003. He noted that the Veteran described himself on the jobsite as volatile, dangerous, and unpredictable, with homicidal and suicidal thoughts. On interview, the Veteran described longstanding suicidal thoughts and the strong desire to be dead after his return from service. He indicated that he had frequent thoughts of harming others, and had actually done so on more than one occasion, although only one was officially reported. He reported that he disliked himself intensely, felt he had no meaningful existence, and had extensive despair, hopelessness, guilt, and shame, which he reported feeling since the early 1970s. In summary, Dr. C. stated that the Veteran's current symptoms did not miraculously appear at such a level of severity in 2008, but were present far earlier, likely dating back to 1973 when he was hospitalized after a suicide attempt, but at least since the official diagnosis of PTSD in 2003. He pointed out that the history showed that as far back as 2000 the Veteran's symptoms of PTSD were so severe that he was "assaulting coworkers and behaving in a fashion that was completely untenable in a workplace or in society." He urged that as of his 2003 diagnosis he was equally as impaired as he was in 2008. He stated that while the Veteran functioned in an occupational environment since his discharge from active duty service until 2001, he was volatile, dangerous, mentally ill, and significantly impaired. He speculated that if the Veteran had not experienced other medical problems he likely would have been forced to stop working due to his volatile and inappropriate behaviors, and by the time he began receiving even minimal treatment after his 2003 PTSD diagnosis, he would have been equally as unable to find and maintain gainful employment as he was currently strictly from his PTSD. He further stated that the Veteran's symptoms were just as impairing in 2003 as they were in 2008. Analysis Disability evaluations are determined by the application of a schedule of ratings, which is based on average industrial impairment. 38 U.S.C.A. § 1155. A proper rating of the Veteran's disability contemplates its history, 38 C.F.R. § 4.1, and must be considered from the point of view of a Veteran working or seeking work. 38 C.F.R. § 4.2. 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. The Board observes that in cases where the original rating assigned is appealed, consideration must be given to whether a higher rating is warranted at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). The Board has considered whether staged ratings are warranted for the period considered. It has determined that the Veteran's PTSD did not significantly change during this period, and that a uniform rating is for application. Under the rating criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013), a 100 percent evaluation is provided for PTSD where 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. A 70 percent evaluation is provided where 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 or hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 50 percent evaluation is appropriate where there is 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. In evaluating psychiatric disorders, it must be shown that industrial impairment is the result of actual manifestations of the service-connected psychiatric disorder. The severity of a psychiatric disability is based upon actual symptomatology, as it affects social and industrial adaptability. Two of the most important determinants of disability are time lost from gainful employment and decrease in work efficiency. 38 C.F.R. § 4.130 (2013). In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet.App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical 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 younger children, is defiant at home, and is failing at school). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as indicating moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Upon careful consideration of the evidence pertaining to this claim the Board has determined that for the entire appellate period under consideration herein, the current 50 percent evaluation is appropriate for the Veteran's PTSD. The Secretary, acting within his authority to "adopt and apply a schedule of ratings," chose to create one general rating formula for mental disorders. 38 U.S.C. § 1155; see 38 U.S.C. § 501; 38 C.F.R. § 4.130. By establishing one general formula to be used in rating more than 30 mental disorders, there can be no doubt that the Secretary anticipated that any list of symptoms justifying a particular rating would in many situations be either under-or over-inclusive. The Secretary's use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each Veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. This construction is not inconsistent with Cohen v. Brown, 10 Vet.App. 128 (1997). The Board acknowledges that evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the rating specialist is to consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the DSM-IV. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436 (1992). In this case, the Board observes that the Veteran's reported symptoms include sleep disturbance marked by nightmares; flashbacks; intrusive thoughts; avoidance of cues that symbolize or resemble an aspect of the traumatic event; avoidance of activities, people, and places that arouse recollection of trauma; passive suicidal and homicidal ideation; restricted affect; and irritability and outbursts of anger. Moreover, the Board accepts that the Veteran's PTSD impacted his relationships and social and occupational functioning during the period considered. There is evidence of restricted affect, mood disturbance, and some difficulty concentrating and focusing. The evidence also shows difficulty with respect to establishing and maintaining effective social relationships. However, the evidence does not demonstrate impaired judgment, thought disturbance, or complete inability to establish and maintain effective relationships. In essence, the evidence reflects symptoms that are best contemplated by the criteria for a 50 percent evaluation. The Board has also determined that an evaluation in excess of 50 percent is not warranted. The Board acknowledges that the Veteran's PTSD is manifested by disturbances in affect and mood, passive suicidal and homicidal ideation, isolative behaviors, and sleep problems, which were already considered in assigning the 50 percent evaluation. However, the evidence does not demonstrate deficiencies in most areas. Rather, as noted by providers during the period considered, the Veteran has been shown to be fully alert and oriented by both medical and psychological providers. In August 2004, he was able to maintain appropriate conversation, and although he took longer than normal to complete instructed tasks, he did not appear to become frustrated. In July 2005 the Veteran reported that he did not have trouble getting jobs, and that he had been fired because he missed work due to his drinking. His thought process at that time was goal directed and relevant. There were no significant cognitive defects. While he has reported violence on the job in 2000, he denied any such episodes during the period under consideration. There has been no demonstration of symptoms such as obsessive rituals interfering with routine activities; intractable panic or depression to the extent that if affects the ability to function independently, appropriately and effectively; speech disturbance; or spatial disorientation. Judgment and insight are intact. The Veteran's hygiene has been noted to be adequate. There is no indication that any of the Veteran's psychiatric symptoms affect his ability to function independently, appropriately, and effectively. While there has reportedly been an impact on the Veteran's social functioning, the record does not reflect the difficulty contemplated by the diagnostic criteria for a higher rating. In that regard, the Veteran reported in February 2006 he did enjoy some company, and indicated in June 2007 that he busied himself by driving friends to appointments, and noted that he enjoyed group therapy. The Board acknowledges that the report by Dr. C. suggests that the Veteran's psychiatric symptoms caused total occupational and social impairment during the period from 2003 to 2008. However, as discussed above, the Board finds that the objective evidence of record reflects symptoms more closely approximating the criteria for a 50 percent evaluation. While Dr. C. urges that the Veteran had pervasive and severely impairing mental illness for the period under consideration, and that such was based on his review of the record as well as interview of the Veteran, the Board notes that his discussion fails to account for records indicating that the Veteran was alert, oriented, and capable of functioning appropriately. The August 2004 examiner concluded that the Veteran's overall intellectual ability, general memory functions, and neurological evaluations were in the average range and indicated that the Veteran's deficits were subtle. Dr. C's conclusion that the Veteran was socially isolated and detached from others does not account for the Veteran's own reports to VA providers that he enjoyed attending group therapy, and that he assisted friends by driving them to appointments. This does not demonstrate that the Veteran was incapable of appropriate interaction, or that overall, he was volatile, dangerous, and significantly impaired. In sum, while the Board accepts that the Veteran's PTSD has effects on his functioning, the lay and medical evidence of record does not demonstrate the impairment in judgment, abstract thinking, motivation and mood, or the difficulty in establishing and maintaining effective work and social relationships contemplated by the criteria for a higher evaluation. Rather, the Veteran has repeatedly been found to be oriented with intact thought processes, and while he has, at times, endorsed suicidal ideation and thoughts of harming others, he has denied any plan with respect to those thoughts. Moreover, those symptoms were already considered in determining that a 50 percent evaluation was warranted. As such, the Board finds that the record as a whole does not support the existence of symptoms such that the criteria for a 70 percent evaluation are approximated. The Board acknowledges that VA records for the period from 2003 to 2008 include GAF scores of 50. The Board notes that a GAF score does not automatically equate to any particular percentage in the Rating Schedule. Rather, it is but one factor to be considered in conjunction with all the other evidence of record. 38 C.F.R. §§ 4.2, 4.6. As discussed above, after considering the symptoms manifested, and the duration and severity thereof, the Board finds that the criteria for a 50 percent rating, but no higher, are met. While the Veteran's symptoms have been assessed as severe and the Veteran experiences suicidal thoughts, the overall level of psychiatric impairment more nearly approximates occupational and social impairment with reduced reliability and productivity as a result of the psychiatric symptoms manifested. In summary, the overall disability picture does not more nearly approximate the criteria for a schedular evaluation of 50 percent. As such, the Board concludes that a 50 percent evaluation for the Veteran's PTSD for the entire period on appeal is appropriate. See Fenderson v. West, 12 Vet. App. 119 (1999). Extraschedular Consideration The Board has also considered whether the Veteran's PTSD presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted. Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the Veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the Veteran's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology. In particular, the Veteran's symptoms as described in detail above are specifically contemplated by the rating criteria. Consequently, the Board has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. Since the available schedular evaluation adequately contemplates the Veteran's level of disability and symptomatology, the second and third questions posed by Thun become moot. Even still, the record does not show that the Veteran has required hospitalization, or has lost significant periods of work, due to his diabetes mellitus or lower extremity peripheral neuropathy. In short, the evidence does not support the proposition that the Veteran's service connected disabilities present such an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards and warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2013). ORDER Entitlement to an initial rating in excess of 50 percent for PTSD, for the period prior to November 24, 2008, is denied. REMAND Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to a total rating for compensation purposes based on individual unemployability (TDIU). Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). TDIU may be a part of a claim for increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Here, the Veteran's representative points out that the issue of a TDIU for the period prior to November 24, 2008 should be considered. A total disability rating may be assigned where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disability; provided that, in pertinent part, if there is only one such disability, the disability shall be rated at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability rated 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341(a), 4.16(a) (2013). Where these percentage requirements are not met, entitlement to benefits on an extraschedular basis may be considered when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, and consideration is given to the Veteran's background including his or her employment and educational history. 38 C.F.R. §4.16(b). The Board does not have the authority to assign an extraschedular total disability rating for compensation purposes based on individual unemployability in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. The Board observes that while this appeal was before the Court, the agency of original jurisdiction (AOJ) in March 2012 granted service connection for coronary artery disease with a 60 percent evaluation from March 8, 2004 through July 8, 2007 and a 10 percent evaluation from July 9, 2007 through March 12, 2012. Thus, his combined rating from March 3, 2003 to March 7, 2004 was 50 percent, from March 8, 2004 to July 8, 2007 was 80 percent, and from July 9, 2007 to November 24, 2008 was 60 percent. Because the Veteran did not meet the schedular requirements for a TDIU for the entire period prior to November 24, 2008, and the Board does not have the authority to assign an extraschedular total disability rating in the first instance, the Board concludes that this issue must be remanded for such consideration on the part of the AOJ. 1. Provide the Veteran corrective VCAA notice which informs him of the evidence necessary to establish a TDIU for the period prior to November 24, 2008. Forward a VA Form 21-8940 to the Veteran, and subsequently forward a VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefit, to the former employers listed on the Veteran's submitted VA Form 21-8940. 3. Then, adjudicate the issue of entitlement to a TDIU for the period prior to November 24, 2008. If the benefit sought on appeal is not granted to the Veteran's satisfaction, the AOJ should furnish to the Veteran and his representative a supplemental statement of the case and afford them the requisite opportunity to respond before the case is returned to the Board for further appellate action. 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). ____________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs