Citation Nr: 1342417 Decision Date: 12/23/13 Archive Date: 12/31/13 DOCKET NO. 11-04 409 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an initial disability rating for posttraumatic stress disorder (PTSD) in excess of 30 percent. 2. Entitlement to a total disability rating based upon individual unemployability due to a service-connected disability (TDIU). REPRESENTATION Veteran represented by: T. Rhett Smith, Attorney ATTORNEY FOR THE BOARD J. Jenkins, Associate Counsel INTRODUCTION The Veteran had active service from October 1968 to March 1972. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas, which granted service connection for PTSD and assigned an initial rating of 30 percent effective August 25, 2008. An evaluation of 100 percent was assigned because of hospitalization over 21 days from January 5, 2009. An evaluation of 30 percent was assigned from March 1, 2009. The Veteran appealed the initial rating assigned in that decision. The claims file was subsequently transferred to the RO in Jackson, Mississippi. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO. VA will notify the Veteran if further action is required. FINDING OF FACT Throughout the entire period on appeal, the Veteran's service-connected PTSD has manifested by symptoms including nightmares, flashbacks, intrusive memories, and chronic sleep impairment, productive of functional impairment comparable to occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. CONCLUSION OF LAW The criteria for an initial disability rating in excess of 30 percent for PTSD have not been met. 38 U.S.C.A § 1155 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.4, 4.7, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist As required by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist veterans in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. § 3.159(b) (2013). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2013); 38 C.F.R. § 3.159(b) (2013); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, the United States Court of Appeals for Veteran's Claims Court (Court) held that VA must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the Veteran is expected to provide. 18 Vet. App. 112, 120-21 (2004). The appeal for a higher initial disability rating for the service-connected PTSD arises from a disagreement with the initial evaluation assigned following the grant of service connection. The Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA. VA has satisfied its duty to assist the Veteran in substantiating his claim pursuant to 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c). The Veteran's service treatment records, post-service VA and private medical records, and Social Security Administration (SSA) records are of record. VA provided the Veteran with medical examinations in March 2009 and April 2012. The VA examination reports reflect that the examiners reviewed the Veteran's claim file, recorded his current complaints, conducted an appropriate examination, and rendered an appropriate diagnosis and opinion consistent with the remainder of the evidence of record. Based on the foregoing, the Board finds that VA has satisfied its duties to notify and assist under the governing law and regulation. The Board will therefore review the merits of the Veteran's claims, de novo. Legal Criteria Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (West 2002 & Supp. 2013). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2013). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2013). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.4 (2013). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the "present level" of the Veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where VA's adjudication of an increased rating claim is lengthy, a claimant may experience multiple distinct degrees of disability that would result in different levels of compensation from the time the increased rating claim was filed until a final decision on that claim is made. Thus, VA's determination of the "present level" of a disability may result in a conclusion that the disability has undergone varying and distinct levels of severity throughout the entire time period the increased rating claim has been pending. Hart v. Mansfield, 21 Vet. App. 505 (2007). See also Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2013). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2013). The Veteran's service-connected PTSD has been rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013), which provides: A 10 percent is warranted when there is occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent disability rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is warranted when the Veteran experiences 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 disability rating is warranted when the Veteran experiences occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work-like setting); and inability to establish and maintain effective relationships. A 100 percent disability 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 ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130 (2013). One factor to be considered is the global assessment of functioning (GAF) score which is a scale reflecting the "psychological, social and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). A GAF score of 41-50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51-60 represents 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). A GAF score of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well and has some meaningful interpersonal relationships. While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130 (2013). Accordingly, GAF scores do not automatically equate to any particular percentage in the Rating Schedule. Rather, they are but one factor to be considered in conjunction with all the other evidence of record. In rendering a decision on appeal, the Board must also analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept and threshold factor in determining whether lay or medical evidence may be considered. In other words, competency addresses whether the evidence is admissible as distinguished from credibility and weight, which is a factual determination going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). 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 layperson. 38 C.F.R. § 3.159 (2013); see also Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (noting that 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). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159 (2013). Competency is a question of fact, which is to be addressed by the Board. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Analysis The Veteran contends that his service-connected PTSD is more disabling than currently rated. The Board has thoroughly reviewed all the lay and medical evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting that the Board must review the entire record but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). An August 2008 treatment record indicates that the Veteran was admitted to the Homeless Veteran's Program and Addiction Treatment Program. A subsequent August 2008 treatment record noted that the Veteran reported that he worked as a real estate and land developer from 1978 to 2003. The Veteran stated that he had been unemployed for three years and that he had played poker as a profession before giving it up after a four-month losing streak. The Veteran reported that he was married for approximately 30 years but divorced in 2003. He noted that he had two daughters born of that marriage. The social worker noted that the Veteran was alert, oriented, and cooperative. He was dressed in seasonally appropriate attire that was clean and neat in appearance, he maintained socially appropriate eye contact, was easily engaged, self-reported his mood as 4/10, and denied past or current suicidal or homicidal ideation. The Veteran indicated that he desired to get treatment and noted his belief that he had suffered from PTSD for many years. A September 2008 treatment record noted that the Veteran was well groomed and appropriately dressed, was oriented to person, time, and place, and displayed planned and appropriate behavior. It was also noted that the Veteran's speech was regular, his mood was irritable, and that his thinking was goal oriented and directed. No delusions or hallucinations were noted, his insight and judgment were good, and his GAF score was 45. In a subsequent treatment record, the Veteran stated that he had nightmares, particularly after watching war movies or talking about his experiences. He also reported intrusive thoughts about the violence, that he felt paranoid at times, had difficulty trusting people, or being in groups of people. The author of the record observed that the Veteran appeared anxious, that his thought process was a bit circumstantial, and his affect was, at times, intense. In subsequent a September 2008 social work note, the Veteran stated that reminders of Vietnam caused him psychological stress in the form of anxiety and feelings of paranoia. He reported that physically his heart rate increased, he felt tense, and his hands got clammy. He also stated that since Vietnam he tried to avoid large groups, had a hard time staying asleep, had problems with anger and aggression, had sporadic problems with concentration and attention, and was hypervigilant. He also noted that after returning from Vietnam he had flashbacks, but stated that they had stopped after approximately ten years. In a treatment record from February 2009, the Veteran reported that he was discharged from the PTSD program in Topeka, Kansas. He stated that he had been prescribed aripiprazole and that it decreased his anxiety and agitation. Upon mental status examination, the Veteran's thought process was clear and goal-directed, his mood was good with broad affect, no overt symptoms of psychosis were observed, and he denied thoughts of harming himself or others. A subsequent February 2009 social work note indicated that the Veteran reported that he had been hospitalized for inpatient psychiatric treatment from January to February 2009. The Veteran stated that his hobbies included playing pool, watching movies, and reading. During the interview, the Veteran was casually dressed and appropriately groomed, alert, oriented, cooperative, and maintained good eye contact. The Veteran was provided a VA examination in March 2009. The Veteran reported he was currently divorced, but that prior to his divorce his anxiety, paranoia, anger, and inability to feel affection impacted his marriage. He recalled episodes of paranoia where he would prop up guns by his front door at night. He reported that his then-wife encouraged him to get psychiatric treatment, but noted that he had not sought treatment other than emergency room visits for panic-type symptoms. The Veteran stated that he had two daughters and that he had a fair relationship with his older daughter, but did not have a relationship with his younger daughter. The Veteran noted that his ex-wife was vindictive and partially responsible for the lack of communication with his younger, minor daughter. The Veteran reported that he maintained communication with immediate family members and had a couple close friends. He noted that he had lost several friends during his divorce and when he traveled around playing poker. He noted that he avoided large crowds, but reported that he played pool with others at the domiciliary and made friends. He denied having any interests or hobbies. The Veteran stated that he worked as a real estate and land developer for many years until approximately 2003, when he had to sell off his assets and lost his business. He stated that he had attempted to work as a professional poker player, and had done well until he lost $250,000 in one game. The Veteran noted that he was currently employed part-time as a receptionist with the supportive employment program for seniors. The Veteran also reported that he had been homeless since 2007. The examiner noted that the Veteran described a history of abusive use of alcohol, diet pills/speed, and marijuana while in the military and briefly after discharge. However, the Veteran had denied problematic substance abuse after age 40. The examiner also noted that the Veteran had a history of gambling with problematic consequences, but opined that the Veteran did not meet the criteria for Pathological Gambling and opined that these behaviors were better accounted for by the Veteran's manic episodes. In regard to subjective complaints, the Veteran stated that he felt as if he had a diminished quality of life due to psychiatric issues. He reported that he failed his marriage and business due to his mood swings, inability to manage his stress, anger, and interpersonal relationships. The Veteran also reported concentration and chronic sleep problems. The Veteran stated that during the 1980's he had at one time had suicidal ideation, planning, and intent. In regard to treatment, the Veteran reported that he had numerous emergency room and doctors' visits throughout the 1980's and 1990's but had not obtained formal treatment until he entered the VA Health Care System in 2007. The Veteran reported that he was attending an outpatient PTSD group on a weekly basis. He also stated that he attended monthly psychiatry appointments. The Veteran indicated he completed a seven-week intensive PTSD program at the Topeka VAMC. The examiner opined that there did not appear to be any significant amount of time of remission from psychiatric symptoms. Upon mental status examination, the examiner noted that the Veteran was casually dressed with fair hygiene and grooming. His posture was rigid and he appeared tense. His eye contact was fair, his gait was steady, and neither psychomotor agitation nor retardation was noted. The Veteran's manner was guarded and anxious. His speech was rapid, pressured, soft spoken, and he answered questions fully and provided spontaneous information. His mood and affect were anxious. The Veteran admitted that he had a history of panic attacks, but indicated that he had not experienced any since his first VA admission. The Veteran reported obsessive and compulsive thinking around checking behaviors, and being overly neat and orderly with his room. The examiner also noted that the Veteran had a history of compulsive gambling and spending. The examiner reported that the Veteran's thought process was intact, linier, and goal directed. The examiner noted that the Veteran's paranoid content revolved mostly around early business dealings when he was in real estate and land development. The Veteran denied hallucinations, but described vivid memories, which appeared real to him at the time. During the examination the Veteran was oriented to time, place, and person. The Veteran's abstract thinking, concentration, and judgment were noted to be intact. The examiner reported that the Veteran's insight into his problems and need for treatment and continuing care was good. The examiner noted that the Veteran had a history of sleep problems, which were helped with medication. The examiner stated that the Veteran was administered measures designed to assess PTSD and that his scores were suggestive of an individual with PTSD. The examiner noted that the Veteran met the criteria for Bipolar Affective Disorder NOS. The examiner stated that the Veteran had uncontrolled bipolar disorder and had presented with mixed manic states. The examiner opined that the Veteran's periods of sleep deprivation were likely a large contributing factor to his overall symptoms. The examiner noted that the Veteran's manic behaviors included pressured speech, racing thinking, difficulty organizing his thoughts, and impulsivity. The examiner reported that the Veteran's medical records and reported history suggested that he experienced mild levels of depression. During the examination, the Veteran endorsed symptoms including sadness, pessimism, pass failure, loss of pleasure, guilty feelings, punishment feeling, self-dislike, self-criticalness, crying, loss of interest, indecisiveness, worthlessness, loss of energy, changes in sleep patterns, irritability, changes in appetite, concentration difficulty, and loss of interest in sex during the last two weeks. The examiner also noted that testing revealed symptoms of moderate to severe anxiety. The examiner found changes in the Veteran's functioning after military service. The examiner stated that changes in psychosocial functional status and quality of life following trauma exposure were noted in employment, family role functioning, physical health, and social/interpersonal relationships. The examiner noted that the Veteran had been homeless since 2007, and aside from attempts at professional gambling, had been unemployed since 2003. The examiner opined that the Veteran's PTSD symptoms appeared to be related to changes in functioning status and quality of life. The examiner stated that the extent of social and occupational impairment during the past 12 months was significant. The examiner stated that, at that time, it was not possible to differentiate between the effects of the Veteran's PTSD and his bipolar disorder on his functioning. The examiner assessed the Veteran's GAF score as 50, which indicated moderate to severe deficits in interpersonal, occupational, and emotional functioning. Treatment records from March 2009 consistently indicated that the Veteran was alert, oriented to time, place, and person, cooperative, displayed appropriate eye contact, was appropriately dressed, and maintained good hygiene. The Veteran's GAF score was 50. Another March 2009 treatment record indicated that the Veteran reported that his mood was pretty good, that he was sleeping well, and that his affect was good. The Veteran rated his anxiety as 3/10. Upon mental status examination, the Veteran's thought process was noted to be clear and goal-directed, his mood was good, his affect was broad, and he displayed no overt symptoms of psychosis. The Veteran denied any thoughts of harming himself or others. An April 2009 VA treatment record indicated that the Veteran reported his mood as 5/10. The record noted that the Veteran was alert, attentive, cooperative, reasonable in behavior, and groomed appropriately. His mood was depressed but his affect was bright. His speech, thought process and content, and memory were noted to be normal. His insight and judgment were good and he did not display homicidal or suicidal ideation. A subsequent April 2009 VA social work note indicated that the Veteran had left the domiciliary program to resume his gambling profession, but realized it was not for him and returned. The social worker noted that the Veteran appeared very anxious, was shaking, and did not look as though he felt well physically. The Veteran denied alcohol or drug use. A VA treatment record from November 2009 indicated that the Veteran had a positive score of 4/4 on a routine screen for PTSD. The Veteran did not report formal or informal suicidal or homicidal ideation and the record noted that he was alert and oriented to time, place, and person. In his December 2009 Notice of Disagreement, the Veteran reported he was not employable and that he was found to be totally disabled by the Social Security Administration (SSA). The Veteran stated that he believed that he qualified for an increased rating because he was receiving disability benefits from SSA and suffered from a permanent disability that made it impossible for an average person to follow a substantially gainful occupation. The Veteran stated that he had panic attacks, nightmares, and depression. He also stated that he had a difficult time dealing with people when riding the bus, buying food, and attending VA medical appointments. An April 2010 VA treatment record indicated that the Veteran felt less depressed but still had palpitations and anxiety. The Veteran reported that he had been treated for drinking and mental health problems at the Leavenworth, Kansas VA hospital. The Veteran stated that the treatment helped a great deal with his anger and his "other baggage from Vietnam." He reported that he was currently taking aripiprazole, buspirone, and lorazepam for his various symptoms. The Veteran stated that during the day he walked, listened to music, read, and went on shopping trips. He stated that when he was at home he felt okay, but that his anxiety increased slightly at night, and that he occasionally had trouble sleeping and had nightmares. He reported that his nightmares frequently related to experiences from Vietnam or to paranoid fantasies about aircraft problems. He stated that he rarely had flashbacks while awake. The Veteran reported that he felt pressured when he went out in public and that he had been on guard in public since the war. He noted that he was too vigilant to relax. The Veteran noted that he had two daughters whom he spoke with on the phone fairly often. He also noted that he had a few acquaintances. The VA psychiatrist observed that the Veteran was alert, neatly groomed, and that his affect was somewhat stiff, but within normal limits. The VA psychiatrist also noted that the Veteran's speech and thought process were normal but had a certain flatness of tone. The form of his thought process and contents of his thoughts were within normal limits, and the Veteran denied auditory hallucinations or thoughts of hurting himself or others. His GAF score was 48. SSA records received in September 2010 indicate that the Veteran was assessed for SSA disability in August 2008. The SSA examiner noted that the Veteran was able to perform activities of daily living. Specifically, the examiner noted that the Veteran read, did laundry, and used public transportation to shop. The examiner opined that the Veteran was capable of performing simple and intermediate tasks, but noted that residuals of his condition, be it PTSD, bipolar, or anxiety disorder, could make it difficult for him to consistently and efficiently learn complex detailed instructions in a reasonable period of time. The examiner noted that although the Veteran's mood fluctuations made it difficult to work with the general public, he should be able to work with others in the workplace. VA treatment records from September 2010 indicate that the Veteran participated in a psychotherapy-skills development group intended to reduce PTSD symptoms. However, the progress notes did not provide specifics as to the Veteran's subjective complaints or progress. VA treatment record from October 2010 noted that the Veteran had a history of bipolar disorder, anxiety, and PTSD, but had no formal or informal suicidal or homicidal ideation. The treatment record indicated that the Veteran was alert and oriented to time, place, and person. In his February 2011 substantive appeal, the Veteran reported that he suffered from anxiety, irritability, poor sleep, nightmares, flashbacks, intrusive memories, depression, and paranoia. A March 2011 private mental status evaluation report from Dr. E.H. indicated that the Veteran related to Dr. E.H. in a cooperative and reasonably well motivated manner. The Veteran reported that he worked as a real estate broker for 25 years but that he sold off 75 percent of his business in 2003, when he divorced, to satisfy the property settlement. The Veteran stated that he had used his remaining assets as a professional gambler for approximately 4 years, until he lost $150,000 over a seven-month period. The Veteran noted that he had been essentially homeless since that time. The Veteran also indicated that he applied for VA vocational rehabilitation but was recommended for a compensated work program instead, due to the severity of his PTSD. In regard to treatment for his PTSD, the Veteran indicated that he attended a PTSD Skills Development Group from September to December 2010, but stated that it was primarily a basic informational program and was not of much benefit to him. He also reported that he attended a Stress Disorder Treatment Program at the Topeka, Kansas VAMC in January and February of 2009 and felt that program was beneficial. The Veteran reported that he had problems staying asleep and noted that he experienced nightmares, some of which were related to Vietnam. He reported that he frequently awoke in a cold sweat with anxious feelings. The Veteran stated that he was able to maintain his hygiene and grooming independently. The Veteran noted that he was very uncomfortable around others and found riding the bus very difficult when it was crowded. He also noted that he often got off early if someone sat down in the seat next to him. Dr. E.H. noted that the Veteran appeared to possess basic communication and social skills, which allowed him to interact with others. Dr. E.H. noted that the Veteran was able to adequately relate to her but that he had difficulty with turn-taking in discourse. Dr. E.H. also indicated that the Veteran was able to initiate contact with the community to ensure that his needs were met, was able to handle money for routine purchases, and was able to schedule appointments and assumed the responsibility for keeping them. The examiner opined that any functional limitations described by the Veteran were causally related to the Veteran's physical or mental condition and were not self-imposed. Dr. E.H. noted that the Veteran's grooming and hygiene were adequate; he had no unusual mannerisms or gestures but was somewhat fidgety. Dr. E.H. noted that the Veteran's speech was intelligible and spontaneous but that he had occasional word-finding problems, that his speech appeared pressured, and that he had difficulty with turn-taking. He was oriented to time, place, and situation, and was alert and responsive to the examination process. In regards to his mood, Dr. E.H. noted that the Veteran appeared moderately anxious and dysphoric. The Veteran reported occasional suicidal thoughts, but denied any current threats. He also reported that he was often irritable and had problems with managing his anger. The Veteran also indicated that he felt useless and thought things would likely not get better. Dr. E.H. noted that the Veteran did not report any current manic behaviors, but had gone without sleep for several days in the past and had engaged in risky behaviors and displayed a significant degree of grandiosity, especially concerning his gambling skills. Dr. E.H. reported that the Veteran's thought process was logical and coherent, but that he had indications of tangential and circumstantial thinking. She stated that there was some evidence of impaired reality testing but the Veteran did not appear to have an underlying thought disorder or psychosis. Dr. E.H. noted that the Veteran reported that he was easily distracted, had some problems paying attention, acted impulsively, and did or said things without thinking them through. The Veteran also noted that his thoughts seemed to race and that he was nervous when a lot of people were around. He also indicated that he was not motivated to do things he enjoyed in the past, was suspicious of others, and carried grudges. The Veteran denied having delusional thoughts or hallucinations. Dr. E.H. opined that the Veteran's memory skills appeared somewhat poor and that his intellectual abilities, while above average, may have been declining. She noted that he was able to recall only two out of five objects after five minutes, but had no difficulty with simple mathematical calculations. She also noted that the Veteran's concentration appeared poor, but that he successfully sequenced four digits backwards and forwards. She opined that the Veteran's abstraction skills were normal and his judgment was fair, but that his insight was limited and he had limited empathy and awareness of the effect his behavior had on others. Dr. E.H. diagnosed the Veteran with Bipolar Disorder PTSD, personality disorder not otherwise specified, with narcissistic, paranoid, and antisocial traits. Dr. E.H. opined that the Veteran appeared to be able to perform simple routine and repetitive tasks but that his ability to perform complex tasks appeared poor. She also noted that his ability to interact with co-workers or receive supervision and maintain concentration and attention appeared to be poor. In an April 2011 letter, the Veteran's representative asserted that the medical evidence detailed significant functional limitation consistent with the inability to secure substantially gainful occupation due to service-connected psychiatric disabilities. The representative argued that this demonstrated a need for an increased disability rating. The representative noted that the Veteran had been charged with domestic violence and failure to provide support to his wife and children. The representative also indicated that the Veteran was uncomfortable around others and found riding the bus difficult due to his experiences in Vietnam. The representative also stated that the Veteran engaged in risky behaviors and tended to have a significant degree of grandiosity, especially concerning his gambling skills. The Veteran's representative argued that the Veteran's symptoms were more consistent with a 70 percent rating and that he had occupational and social impairment with deficiencies in most areas. VA treatment records from May 2011, noted that the Veteran endorsed problems with irritability, hypervigilance, nightmares, impaired sleep, some depression, and some forgetfulness. The Veteran attributed his depression to the isolating affects of his anxiety, and his forgetfulness to his impaired sleep and feelings of distractedness. The examining physician noted that the Veteran was anxious and irritable, his thought process was linear, he was appropriately dressed and groomed, displayed no suicidal or homicidal ideation, hallucinations, and his insight and judgment was good. His GAF score was 47. The Veteran was provided another VA examination in April 2012. At the examination, the Veteran endorsed chronic symptoms of anxious arousal, anger, irritability, depression, suicidal ideation, defensive avoidance, intrusive experiences, recurrent nightmares, feelings of detachment, tension reduction behaviors, and impaired self-reference. The Veteran reported that he was last employed for his own business, and that he had some employment with the VA transitional work experience program in April 2009. The Veteran stated that he abused marijuana and opiates in the 1970-19080's. He also noted that he had not used cocaine since the 1980's and that he had used marijuana only three or four times since then. The examiner noted that throughout the interview, the Veteran had difficulty maintaining his train of thought, his speech was pressured, and often he had to be redirected to answer the questions instead of going off on tangential and circumstantial stories. The examiner indicated that these behaviors were typical manifestations of bipolar disorder. The Veteran also reported that his mood was inconsistent, which the examiner noted was more in line with bipolar disorder than PTSD. The Veteran reported that he had problems with sleep and night sweats, and experienced anxiety attacks fairly regularly. The Veteran denied any recent thoughts of suicide. The Veteran reported that while going through his divorce, he lost his temper on a job site and was arrested for, but not convicted of, destruction of property and threatening with a firearm. The Veteran also reported numerous legal problems associated with his divorce and his failure to pay alimony. The examiner noted that the Veteran's scale score for trauma indicated mild distress as a result of his traumatic experiences. The Veteran reported persistently re-experiencing the traumatic event, persistent avoidance of stimuli associated with the trauma, and persistent symptoms of increased arousal. Specifically, the examiner found that the Veteran's PTSD symptoms included anxiety, suspiciousness, and problems with sleep. The examiner also diagnosed the Veteran with bipolar disorder, and noted that those symptoms included periods of depressive symptoms, periods of mania, and possible periods of mood dysregulation where depression and mania are experienced together. The Veteran's inclusive GAF score was 60 and his GAF score for PTSD alone was assessed as 70. The examiner stated that it was possible to differentiate what symptoms were attributable to the Veteran's bipolar disorder and which were attributable to his PTSD. The examiner noted that the Veteran's reported symptoms of depression, paranoia, anxiety, problems with sleep, and irritability were part of his bipolar disorder. In contrast, his nightmares, flashbacks, and intrusive memories were attributable to his PTSD. The examiner opined that the Veteran's combined mental health diagnoses resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally his functioning was satisfactory with normal routine behavior, self-care, and conversation. The examiner opined that the Veteran's PTSD symptoms alone would not prevent him from securing and maintaining gainful employment, nor did they impact his ability to engage in physical or sedentary employment if he chose to. In a VA treatment records from May 2012, the Veteran reported that he had significant anxiety, which made him uncomfortable leaving his home. The Veteran also noted that he felt depressed because he felt isolated. The Veteran stated that he experienced some grandiose type thoughts, which he attributed to a lack of sleep. The examining physician noted that no delusional thinking was noted and that the Veteran reported that his prior thinking now seemed ridiculous. The Veteran was observed to be anxious and irritable, but his thought process was linear, he was appropriately dressed and groomed, no suicidal or homicidal ideation was noted, his insight and judgment were good, and his GAF score was 47. Treatment records from August 2012 indicate that the Veteran requested inpatient psychiatric admission due to thoughts of harming others but stated that while he contemplated buying a gun he had not acted on that plan. He reported that he was under a great deal of stress due to his living situation and drug activity in his apartment complex. He stated that he felt wired and that he was not getting much sleep. Upon mental status examination the Veteran was appropriately groomed and dressed, his eye contact was good, he was oriented, his speech was normal, and his thought process was clear, logical, and circumstantial. Although the Veteran reported thoughts of harming others, the report noted that the Veteran's thought content revealed no suicidal or homicidal ideation and noted that the Veteran stated that he would not act on his violent thoughts. The record also indicated that the Veteran's memory was intact to recent and remote events, and that his judgment was good. A treatment record from September 2012 noted that the Veteran was appropriately dressed and groomed, that he was oriented, his speech was normal, and his thought process was clear, logical, linear, and goal directed. His thought content revealed no suicidal or homicidal ideation, or perceptual disturbance. His affect was a little tense, but his memory was intact and his judgment was good. The Veteran reported that his mood was better. A September 2012 mental health note indicated that the Veteran was appropriately dressed, oriented, maintained appropriate eye contact, displayed normal speech, memory recall, and thought process, and his GAF score was 55. The Veteran denied suicidal or homicidal ideation and did not endorse any psychotic symptoms. A subsequent treatment record noted that the Veteran reported that he felt good and that his sleep and mood had improved since his last session. The VA psychologist noted that the Veteran was appropriately dressed and groomed, he was pleasant and cooperative, his speech was normal, his thought process was appropriate, relevant, and logical, he was alert and oriented, his concentration and attention were fair, and that his GAF score was 60. As noted above, the Veteran is currently assigned a 30 percent rating for his PTSD. A 30 percent rating is warranted when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood; anxiety; suspiciousness; panic attacks (weekly or less often); chronic sleep impairment; and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). In consideration of the evidence of record, the Board finds that the Veteran's disability does not warrant an initial rating in excess of 30 percent. The Board finds that the Veteran's PTSD symptoms do not meet the majority of symptoms which are listed for a 50 percent evaluation, nor does he exhibit other symptoms which are of equal significance. The evidence does not reflect that the Veteran's PTSD has manifested by flattened affect, circumstantial, circumlocutory or stereotyped speech, panic attacks, difficulty in understanding complex commands, impairment of long-term memory, or abstract thinking. Id. To the contrary, VA treatment records indicate that the Veteran was consistently appropriately groomed and dressed, alert, oriented, his thought process was intact, linear, and goal directed, and his memory was within normal limits. The Board notes that in an August 2012 letter, the Veteran's representative asserted that the Veteran's GAF score of 70 for PTSD warranted a rating of at least 70 percent. The Board notes that GAF scores do not automatically equate to any particular percentage in the Rating Schedule. Rather, they are but one factor to be considered in conjunction with all the other evidence of record. As noted above, a GAF score of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well and the presence of some meaningful interpersonal relationships. As such, the Veteran's GAF score of 70 does not support his claim for a rating in excess of 30 percent. Although not determinative, the Board notes that throughout the appeal period the Veteran's GAF scores ranged from 45 to 70. As discussed above, GAF scores in this range indicate symptoms varying from serious to mild. The Board notes that only the April 2012 VA examiner provided a GAF score for both the Veteran's overall functioning and a separate score assessing only his PTSD symptoms. The other GAF scores encompass the Veteran's service-connected PTSD as well as his non-service-connected mental disorders. However, when not differentiated, the Board will consider the GAF scores in assessing the Veteran's level of functioning for rating purposes. The evidence reflects that the Veteran's PTSD is manifested by symptoms including nightmares, sleep impairment, recurrent and intrusive recollections, and hypervigilance. However, the evidence demonstrates that the Veteran was consistently fully oriented, and generally able to satisfactorily perform routine behavior, self-care, and normal conversation. Although the Veteran reported that he had experienced suicidal thoughts in the past, he denied having experienced suicidal ideation during the period on appeal. Additionally, while the Veteran reported that he had panic attacks, the evidence does not indicate that his attacks occur more than once a week. Furthermore, the April 2012 VA examiner stated that the Veteran's anxiety symptoms were attributable to his bipolar disorder, not his service-connected PTSD. In regard to social functioning, the evidence shows that the Veteran was married for approximately 30 years, maintained communication with immediate family members, and had a couple close friends. Additionally, the Veteran reported that he was able to make friends. In regard to occupational functioning, the Board notes that the Veteran was self-employed as a real estate and land developer for over 25 years, until he had to sell off the majority of his business to satisfy his divorce property settlement. Since that time, the Veteran has been unemployed. However, the evidence does not indicate that his unemployment is related to his PTSD symptoms. To the contrary, the SSA and VA examiners opined that the Veteran's mental health symptoms would not prevent him from securing and maintaining gainful employment. The Board acknowledges that the private examination report by Dr. E.H., noted that the Veteran had occasional word-finding problems, that his speech appeared pressured, and that he had difficulty with turn-taking. However, the Board notes that while Dr. E.H. diagnosed the Veteran with PTSD, Bipolar Disorder, and personality disorder not otherwise specified, she did not differentiate which symptoms were related to his service-connected PTSD and which were due to his non service-connected mental health disorders. In contrast, the April 2012 VA examiner was able to differentiate symptoms attributable to PTSD from those attributable to non-service-connected bipolar disorder. Like Dr. E.H., the April 2012 VA examiner also noted that Veteran exhibited pressured speech and exhibited difficulty maintaining his train of thought; however, the VA examiner indicated that these behaviors were typical manifestations of bipolar disorder. Accordingly, while the Board acknowledges that the Veteran has some cognitive and speech related symptoms, the Board finds that those symptoms are attributable to his non service-connected bipolar disorder rather than his service-connected PTSD. See 38 C.F.R. § 3.102 (2013); Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam) (noting that the Board may differentiate symptoms of a non-service-connected disability from a service-connected disability when supported by the competent evidence). Additionally, the Board acknowledges the Veteran's belief that his PTSD is more severe than currently rated. The Veteran and his representative are competent to report matters which they experience or observe, such as sleep disturbances, anger, irritability, and hypervigilance. 38 C.F.R. § 3.159 (2013); see also Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). However, the evidence of record has not shown that the Veteran or his representative has had any specialized medical training or expertise. Accordingly, they are not competent to provide an opinion of a medical matter, such as whether his PTSD symptoms satisfy a specific rating criteria. See Bostain v. West, 11 Vet. App. 124, 127 (1998). See also Routen v. Brown, 10 Vet. App. 183, 186 (1997) (stating that "a layperson is generally not capable of opining on matters requiring medical knowledge"). As such, the Veteran and his representative's assertions cannot constitute competent medical evidence that his PTSD warrants a specific rating. The Board finds that the VA examination reports are highly probative as to the current nature and severity of the Veteran's PTSD. Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (holding that factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion). The examination report addressed the Veteran's complaints of symptoms such as irritability, hypervigilance, and sleep impairment. The reports were based on a psychological examination and provided sufficient information to allow the Board to apply the schedular criteria. Thus, although the Veteran's competent and credible reports of symptoms have been considered and are probative, the Board attaches greater probative weight to the clinical findings of skilled medical professionals. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). In summary, the Veteran's psychiatric symptomatology manifested by his PTSD is encompassed by the 30 percent disability rating criteria. It does not meet the criteria for the next higher disability rating for any time on appeal. For these reasons, the Board finds that a preponderance of the evidence is against the claim for an initial rating in excess of 30 percent. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply, and the claim must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2013). ORDER Entitlement to an initial rating in excess of 30 percent for PTSD is denied. REMAND After a review of the record, the Board concludes that a remand of the issue of entitlement to TDIU for service-connected PTSD is necessary. During the pendency of the Veteran's appeal for an initial rating in excess of 30 percent, the Veteran submitted a completed VA Form 21-8940 (Veteran's Application for Increased Compensation Based on Individual Unemployability), claiming that he was unemployable due to his service-connected PTSD. In a February 2011 rating decision, the RO denied the Veteran's claim for TDIU due to service-connected PTSD. In April 2011, the Veteran's representative submitted a report of a private examination from Dr. E.H. and asserted that the report, in combination with the evidence of record, detailed a significant functional limitation that was consistent with the inability to secure substantially gainful occupation due to service-connected psychiatric conditions. The record does not reflect that the RO has considered this additional evidence in conjunction with the TDIU claim. There is no signed waiver of RO consideration of the additional evidence. The Court has held that a request for TDIU is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability. Rice v. Shinseki, 22 Vet. App. 447, (2009). If the Veteran or the record reasonably raises the question of whether the appellant is unemployable due to the disability for which an increased rating is sought, then whether a TDIU is warranted as a result of that disability is part and parcel to that claim. Id. at 455. The Board finds that entitlement to TDIU due to service-connected PTSD has been raised by the record and is part and parcel of the Veteran's claim for an increased rating. As such, the issue of entitlement to TDIU must be remanded, so that the RO can review the additional evidence in the first instance. 38 C.F.R. § 20.1304(c) (2013). Accordingly, the case is REMANDED for the following actions: 1. The RO should complete any additional evidentiary development necessary to adjudicate a claim for TDIU, to specifically include obtaining updated information concerning the Veteran's complete educational and occupational history. 2. Thereafter, adjudicate entitlement to a TDIU, to include with consideration of all evidence of record received since February 2011. If the benefit sought is not granted to the fullest extent, the Veteran and his representative should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further appellate review. The Veteran has the right to submit additional evidence and argument on the matter 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 2002 & Supp. 2013). ____________________________________________ U.R. POWELL Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013). Department of Veterans Affairs