Citation Nr: 1343501 Decision Date: 12/31/13 Archive Date: 01/07/14 DOCKET NO. 08-20 149 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating by reason of individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Vietnam Veterans of America WITNESSES AT HEARINGS ON APPEAL Appellant (the Veteran) and his daughter ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from July 1969 to July 1971. This case comes to the Board of Veterans' Appeals (Board) on appeal of a November 2007 rating decision of the Detroit, Michigan, Regional Office (RO) of the Department of Veterans Affairs (VA), which granted service connection for PTSD, assigning a 30 percent rating, effective March 8, 2006. In July 2010, a videoconference Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. The case was remanded by the Board in November 2010 and April 2013 for further development of the evidence. That has been accomplished and the case has been returned for further appellate consideration. It is noted that the November 2010 Board remand included the issue of entitlement to an effective date earlier than March 8, 2006, for an award of service connection for PTSD. By rating decision in May 2012, the RO awarded an effective date of November 22, 2004 for service connection for PTSD. This represents the date of receipt of the Veteran's informal claim, which is earlier than the effective date requested by the Veteran. The Veteran has not further appealed this award. The issue of 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 his part. FINDING OF FACT Throughout the appeal the Veteran's PTSD has been shown to be primarily manifested by mood disturbances, passive suicidal ideation, low energy, sadness, poor concentration, diminished interest in formerly enjoyable activities, feelings of alienation, sleep disturbances with recurrent nightmares, intrusive recollections, flashbacks, and avoidance behavior; the disability is productive of difficulty in establishing and maintaining effective work and social relationships. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for an initial rating of 50 percent, but no higher, for PTSD has been met throughout the appeal period. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code (Code) 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative 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). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between a veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). As the rating decision on appeal granted service connection and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess 19 Vet. App. at 490. A June 2008 statement of the case (SOC) provided notice on the "downstream" element of initial rating; while a July 2013 supplemental SOC (SSOC) most recently readjudicated the matter after the Veteran and his representative responded and further development was completed. 38 U.S.C.A. § 7105 (West 2002); see Mayfield v. Nicholson, 20 Vet. App. 537, 542 (2006). In addition, the Veteran was advised of VA's duties to notify and assist in the development of the claim in an additional November 2010 letter that explained the evidence necessary to substantiate the claim, the evidence VA was responsible for providing, and the evidence the Veteran was responsible for providing. With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records, including records utilized in a disability determination by the Social Security Administration (SSA), have been secured or certified as being unavailable. The Veteran was afforded VA medical examinations, most recently in February 2012. The Board finds that the opinions obtained are adequate. The opinions were provided by qualified medical professionals and were predicated on a full reading of all available records. The examiners also provided a detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the representative has challenged the adequacy of the examination obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2013). Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C.A. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2013). Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 4.3 (2013). In this case, the Board has considered the entire period of initial rating claim from November 2004 to see if the evidence warrants the assignment of different ratings for different periods of time during these claims, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). The Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Board is required to render a finding with respect to the competency and credibility of the lay evidence of record. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competent, credible lay evidence could be, in and of itself, sufficient to establish an elemental fact necessary to support a finding of service connection. Jandreau v. Nicholson, 492 F.3d 1372, 1376 (2007). As a fact finder, the Board is obligated to determine whether lay evidence is credible in and of itself. The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence, but it may consider a lack of contemporaneous medical evidence as one factor in determining the credibility of lay evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Credibility is a factual determination going to the probative value of the evidence, to be made after the evidence has been admitted or deemed competent. Cartwright v. Derwinski, 2 Vet. App. 24 (1991). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994). A veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived, that is, experienced, were directly through the senses. 38 C.F.R. § 3.159 (competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.); Layno, 6 Vet. App. at 469-71 (lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses; lay testimony is competent only so long as it is within the knowledge and personal observations of the witness, but lay testimony is not competent to prove a particular injury or illness); see Barr 21 Vet. App. at 303 (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d at 1377. Also, a veteran as a layperson is competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (citing Jandreau). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus; however, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the layman is competent and does not otherwise require specialized medical training and expertise to do so, i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F.3d at 1316 (recognizing that, under 38 U.S.C.A. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition; the person is reporting a contemporaneous medical diagnosis; or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional). PTSD Service connection for PTSD was granted by the RO in a November 2007 rating decision. The 30 percent initial disability rating was awarded under the provisions of Code 9411 from the date of claim in November 2004. The Veteran contends that his PTSD is more disabling than currently evaluated. During the Board hearing before the undersigned, he stated that he attended group and individual therapy sessions several times per week in order to manage his PTSD symptoms. He related that he suffers from symptoms such as hypervigilance and that he has particular difficulties on occasions such as the fourth of July, when fireworks cause flashbacks of his time in Vietnam. He also stated that he took several medications that help him to relax and to sleep. It was noted that the Veteran had recently separated from his spouse of over 29 years as a result of his PTSD symptoms. A 30 percent rating is warranted for PTSD with occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events). 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for 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 ideations; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or worklike settings); inability to establish and maintain effective relationships. A 100 percent rating is warranted for 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. 38 C.F.R. § 4.130, Code 9411 (2013). The regulations establish a general rating formula for mental disorders. 38 C.F.R. § 4.130. Ratings are assigned according to the manifestation of particular symptoms. In this decision, the Board considered the rating criteria not as an exhaustive list of symptoms, but as examples of the type and degree of the symptoms, or effects, that would justify a particular rating. The Board has considered the symptoms indicated in the rating criteria as examples or symptoms "like or similar to" the Veteran's PTSD symptoms in determining the appropriate schedular rating assignment. Ratings are assigned according to the manifestation of particular symptoms. The Board has not required the presence of a specified quantity of symptoms in the Rating Schedule to warrant the assigned rating for PTSD. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). 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 (1996). A score of 21 to 30 reflects that behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends). A score of 31-40 is assigned where there is "[s]ome 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)." DIAGNOSTIC AND STASTICAL MANUAL OF MENTAL DISORDERS (DSM-IV) 47 (4th ed. 1994). A score of 41-50 is assigned where there are "[s]erious 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 score of 51-60 is appropriate where there are "[m]oderate 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." Scores ranging from 61 to 70 reflect mild symptoms (e.g., depressed mood and mile insomnia) or difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household). Id. An examination was conducted by VA in December 2006. At that time, it was reported that the Veteran had worked for 36 years for a steel company and was currently on extended sick leave. He noted that during his time at work he had been repeatedly moved among departments and frequently been given disciplinary actions for poor attendance, tardiness, arguing, sleeping on the job, and substance abuse. He had never been admitted to a hospital for psychiatric care, but had been followed as an outpatient in the Mental Health Clinic for the past two years. The Veteran was noted to be casually dressed and neatly groomed. He was alert and fully oriented. Speech was fluent and goal directed. Thought content reflected logical processes and intact critical judgment and fair insight. Memory functioning was compromised, with immediate recall and short-term memory impaired, significantly impacting new learning. He had neither a thought disorder nor delusions and denied auditory and visual hallucinations. Mood was bland and range of affective responsiveness was attenuated. He admitted to both suicidal and homicidal ideation, but denied present plan or intent. In this regard, he reported that he had no firearms and that his religious beliefs precluded suicide as an option. He endorsed low energy and amotivation, episodes of sad mood, spontaneous weepiness, poor concentration, diminished interest in formerly enjoyable activities, discomfort with crowds and experiencing a sense of alienation. He stated that he preferred to be alone. He stated that he had an enclosed porch on the back of his home that he referred to as his "bunker" or safe place. Sleep patterns were characterized by initial insomnia and frequent night awakenings. He stated that he slept from three to six hours per night, with recurrent nightmares of specific events from Vietnam that occurred at least weekly. He experienced uninvited intrusive recollections of his service in Vietnam daily. These occurred spontaneously; however, he identified cues such as the smell of gunpowder, rain, explosive sounds, or helicopters. He avoided reminders of war and combat such as media coverage of the continued combat in Southwest Asia. He was fully independent in all activities of daily living and compliant with medications and outpatient appointments. He was not working, but attempted to fill his time with Bible classes, church activities, and visiting his mother. The diagnoses were PTSD, chronic, and depressive disorder, not otherwise specified. His GAF score was 58. His current level of symptoms was considered moderate, with impairment in social and occupational functioning due to psychiatric symptoms being mild to moderate. In statements from VA social workers, received in November 2008, it was related that the Veteran had symptoms of PTSD that included anxiety, depression, isolation, memory flooding, nightmares with sweating, flashbacks, guilt-grief feelings, hypervigilance, hyperstartle response, and feelings and episodes of anger and rage. These symptoms were said to have greatly complicated and damaged his personal and work life experiences. In a February 2009 statement, a social worker from the Dearborn, Michigan, Vet Center stated that the Veteran had been attending weekly PTSD anger management group sessions since February 2007 and last attended in October 2008. Progress notes accompanied this statement. An examination was conducted by VA in July 2009. At that time, it was noted that the Veteran was now attending group therapy sessions twice monthly and individual therapy once per month. He had recently applied for treatment in a long term inpatient PTSD program, but had not been hospitalized for his PTSD. Symptoms of PTSD were described as an irritable and depressed mood, with periodic crying spells that were triggered by such things as July 4th fireworks. He stated that he was about to separate from his wife and had no relationship with his older daughter. He fished and went to movies by himself. He had no history of suicide attempts, but did have a history of violence and of being assaultive four or five times in the past three years. He reported minimal contact with others, but had some minimal activities such as church. He avoided alcohol because intrusive thoughts took over and he believed he would be in less control if he drank. On mental status evaluation, he was appropriately and casually dressed. He was lethargic and tense. Speech was unremarkable, slow and clear. He was cooperative, but suspicious and guarded. His affect was constricted and blunted. Mood was depressed and dysphoric. Attention disturbance was noted in that he was easily distracted. He was oriented to person and place, but not to time as he thought it was noon when it was actually 9:30 am. He did arrive at the facility timely for his interview. Thought process was subdued, withdrawn, and guarded. Content was unremarkable, but he did have ruminations. There were no delusions. Judgment and insight were intact in that the Veteran understood the outcome of his behavior and that he had a problem. He usually slept about four hours per night. He had no hallucinations or inappropriate behavior. His thinking was concrete. There were no ritualistic behaviors observed. He had panic attacks with stimulus such as July 4th, and helicopter sounds. These usually abated after moments when the trigger was removed. He did not have homicidal thoughts, but did report having suicidal thoughts. These were passive such as wishing he would not awaken from sleep, but not active because of his participation in church. He had intrusive thoughts and episodes of violence toward his spouse. He was able to maintain minimum personal hygiene. He did not have problems with his activities of daily living. Memory was intact, both remotely and recently. Specific PTSD symptoms included recurrent and intrusive recollections of events, including images, and perceptions. He also had recurrent distressing dreams of the event and was in intense psychosocial distress at exposure to internal or external cues that symbolized or resembled an aspect of the events. He had markedly diminished interest or participation in significant activities, feelings of detachment or estrangement of others. He had difficulty falling or staying asleep, irritable outbursts of anger and an exaggerated startle response. He had weekly nightmares and had self-medicated with alcohol until 1994. He reported auditory hallucinations of hearing the sound of crickets. He had limited interactions with others, conflicts with his family, panic attacks, and crying spells. He had worked as a general mechanic for a steel company but had retired in 2005 due to psychiatric problems. The diagnosis was PTSD. The GAF score was listed at 55. It was noted that, while a depressive disorder did exist, the Veteran's psychosocial adjustment was more related to severe symptoms of PTSD rather than depression. In an April 2010 private psychological evaluation, it was noted that the Veteran persistently re-experienced past traumatic events at least four or five times per day. He had recurrent distressing dreams of Vietnam combat six to seven times per week. He reported complete flashbacks of Vietnam from which he had a hard time bringing himself back. He had feelings of anger, sadness, and depression. He reported physiological reactivity to the traumatic cues and had been blocked from expressions about his trauma in that he never spoke of Vietnam or his PTSD until he started VA counseling over the past year. He avoided trauma triggers such as fireworks or military events and reported memory problems in that he was no longer able to remember the names of soldiers with whom he served. He had feelings of detachment and estrangements from others and reported a poor relationship with his two adult daughters. He also reported a poor marriage with his wife, stating that he had moved out of their bedroom. He had persistent sleep problems, persistent symptoms of irritability, and persistent difficulty concentrating. He had chronic hypervigilance and an exaggerated startle response. The diagnosis was PTSD. His GAF score was listed as 45. VA outpatient treatment records as well as February and August 2011 statements from a Vet Center social worker, show that the Veteran continued to attend therapy sessions for his PTSD. In August 2011, it was noted that the Veteran's symptoms included depression, intrusive thoughts, hypervigilance, nightmares, relationship dysfunction due to isolations and stimulus avoidance, flashbacks and difficulties with focus and concentration that made it difficult to engage in work activities. In a July 2011 psychosocial assessment and employability evaluations the Veteran's current symptoms of PTSD were reportedly difficulty falling and staying asleep and physical reactions such as sweating. He did not remember his nightmares because of the medication that he was taking for this symptoms. He had daily intrusive thoughts regarding Vietnam and experienced flashbacks triggered by loud noises such as gun shots or by the sight or sound of helicopters. He became extremely upset when around places, people or events that reminded him of the military. He avoided such reminders as much as possible. He had felt emotionally numb and void of feelings since his return from the military. He had difficulty trusting others. He had blanks in his memory regarding certain aspects of his traumas. He had frequent bouts of irritability and outbursts of anger, not always related to the issues at hand, stating that he often overreacted. His concentration was impaired and his mind wandered easily. He was hypervigilant and stated that he preferred to sit with his back to the wall. He had an alarm system and often got up to check his doors and windows. He exhibited an exaggerated startle response. He saw his current therapist once per week and attended Vet Center group therapy twice per month. He sometimes went to the Vet Center for additional therapy. It was noted that throughout his career, he had had consistent difficulties with figures of authority, supervisors, and co-workers. The diagnosis was PTSD, chronic, severe. His GAF score was listed at 42. An examination was conducted by VA in February 2012. At that time, the diagnosis was PTSD, with an assigned GAF score of 55. His occupational and social impairment was described as being mild or due to transient symptoms that decreased work efficiency and ability only during periods of significant stress, or they were controlled by medication. It was reported that he lived alone, having left his wife more than a year ago after 30 years of marriage. He stated that he still loved her and missed her, but at times it was a relief to not be arguing anymore. He had two daughters with whom he had an "OK" relationship. He stated that he had some activities with which he kept himself busy, such as church meetings and fishing during the summer months. He noted that he was taking the medication Bupropion that helped him somewhat in that "I am functioning." He was not able to watch TV because he got angry about "what is going on." He denied any psychiatric hospitalizations and his sleep patterns seemed erratic. He stated that he had nightmares all the time and had to change his clothing. He woke up one to six times per night. He reported anger management problems stated that he was going to two Veteran's meetings and seeing an outside therapist. He reported feeling sad and got emotional easily. There were no manic or psychotic symptoms reported. The examiner noted that the Veteran met the PTSD traumatic event criteria and had recurrent, distressing dreams of the event. He made efforts at avoidance of thoughts and activities associated with the trauma and restricted range of affect. He had difficultly falling or staying asleep and irritability or outbursts of anger. The symptoms caused significant distress and impairment in social, occupational or other areas of function and included depressed mood, anxiety, sleep impairment, and inability to establish and maintain effective relationships. At the time of the December 2006 examination on which the initial rating of PTSD was made, it was noted that the Veteran's memory was compromised and his mood was bland. At that time, the Veteran admitted to both suicidal and homicidal ideation, but not action. He also described symptoms of low energy, sadness, poor concentration, diminished interest in formerly enjoyable activities and feelings of alienation. He had sleep disturbances with recurrent nightmares of events from Vietnam that occurred weekly, intrusive recollections almost daily, and avoidance behavior. Although the examiner opined that the symptoms caused only moderate disability, the Board finds that the symptoms noted, particularly those of impaired memory, intrusive thoughts, and mood disturbances, are more nearly productive of the criteria outlined for a rating of 50 percent. Given the GAF score of 58, which denotes only moderate disability, and lack of symptoms demonstrating deficiencies in most areas such as illogical speech, near-continuous panic, or depression affecting the ability to function independently, a rating in excess of 50 percent is not shown to be warranted. To this extent, the appeal is allowed. Additional private and VA examination continue to demonstrate approximately the same level of disability, which warrants a continuation of the 50 percent rating. In this regard, it is noted that symptoms in July 2009 included a constricted and blunted affect, attention disturbances, lack of orientation as to time, sleep disturbances, concrete thinking, panic attacks with certain stimuli, suicidal thoughts, intrusive thoughts, episodes of violence toward his spouse, recurrent and intrusive thoughts, distressing dreams, diminished interest or participation in significant activities, feelings of detachment and estrangement from others, and an exaggerated startle response. The GAF score was listed at 55. It was noted that, while a depressive disorder did exist, the Veteran's psychosocial adjustment was more related to severe symptoms of PTSD rather than depression. Similar symptoms such as flashbacks and additional examinations of avoidance behavior were reported on each succeeding examination report, but while the GAF scores varied from 42 to 55, the symptomatology itself remained basically static. A 50 percent rating is shown to have been warranted throughout, but again, a rating in excess of this is not shown, as the combination of symptoms is not shown to cause deficiencies in most areas occupationally or socially. Extraschedular Considerations The Board must also consider whether an extraschedular evaluation may be warranted for PTSD. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2013). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has 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 for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. Turning to the first step of the extraschedular analysis, the Board finds that the symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, Diagnostic Code 9411, specifically provide for disability ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested difficulty sleeping, panic attacks, anxiety, irritability, passive suicidal ideation, and depression. These symptoms are part of the schedular rating criteria. In addition, the level of occupational and social impairment are explicitly part of the schedular rating criteria. In addition, the GAF scores are incorporated as part of the schedular rating criteria as they tend to show the overall severity of symptomatology or overall degree of impairment in occupational and social functioning. Moreover, all the Veteran's psychiatric symptomatology is contemplated by the schedular rating criteria, which rates by analogy psychiatric symptoms that are "like or similar to" those explicitly listed in the schedular rating criteria. Mauerhan, 16 Vet. App. at 443. The schedule is intended to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. "Generally, the degrees of disability specified [in the rating schedule] 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." 38 C.F.R. § 4.1. In this case, the problems reported by the Veteran are specifically contemplated by the criteria discussed above, including the effect on his daily life. In the absence of exceptional factors associated with PTSD, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). ORDER An initial rating of 50 percent, but no higher, for PTSD is granted during the entire appeal period, subject to controlling regulations applicable to the payment of monetary benefits. REMAND It is noted that the Veteran's combined service-connected disability rating was 80 percent prior to the award herein of a 50 percent rating for PTSD. Recently received correspondence from the Veteran, dated in August 2013, includes contentions that he is not able to work as a result of his service-connected disabilities. Thus, it appears that he has contended that he could not secure and follow a substantially gainful occupation, by reason of service-connected disability. Such evidence in the record suggesting unemployability constitutes an informal claim for TDIU. 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) (2013) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the veteran is entitled to TDIU. See Roberson v. Principi, 251 F.3d 1378, 1384 (Fed. Cir. 2001) (VA to "determine all potential claims raised by the evidence, applying all relevant laws and regulations"). See also Rice v. Shinseki, 22 Vet. App. 447 (2009) (suggesting, in an effective date appeal, that an appeal for higher rating somehow includes TDIU, or that a TDIU must arise from an increased rating claim, unless it is the veteran who raises the TDIU claim). While it is noted that TDIU was denied during the pendency of this appeal, in rating decision of May 2010, since that decision, service connection has been awarded for ischemic heart disease and, as noted, the rating for his PTSD has been increased to 50 percent. Accordingly, the case is REMANDED for the following action: Develop as necessary and adjudicate the issue of entitlement to a TDIU. If the decision remains unfavorable to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the claim to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs