Citation Nr: 1428051 Decision Date: 06/20/14 Archive Date: 06/26/14 DOCKET NO. 00-16 200 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to March 21, 2012. 2. Entitlement to a disability rating in excess of 50 percent for PTSD from March 21, 2012. 3. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Appellant represented by: Joseph R. Moore, Attorney at Law ATTORNEY FOR THE BOARD T. Matta, Associate Counsel INTRODUCTION The Veteran had active service from March 1966 to February 1970. This matter comes to the Board of Veterans' Appeals (Board) from rating decisions of a Department of Veterans Affairs Regional Office (RO). FINDINGS OF FACT 1. Prior to March 21, 2012, the Veteran's PTSD was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 2. From March 21, 2012, to June 7, 2013, the Veteran's service-connected PTSD has been manifested by symptoms productive of occupational and social impairment with reduced reliability and productivity. 3. From June 7, 2013, the Veteran's service-connected PTSD has been manifested by symptoms productive of occupational and social impairment with deficiencies in most areas. 4. The Veteran is unable to engage in substantially gainful employment due to service-connected disability. CONCLUSIONS OF LAW 1. Prior to March 21, 2012, the criteria for entitlement to a disability evaluation in excess of 30 percent for the Veteran's service-connected PTSD were not met. 38 U.S.C.A. § 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.130 and Diagnostic Code (Code) 9411 (2013). 2. From March 21, 2012, to June 7, 2013, the criteria for entitlement to a disability evaluation in excess of 50 percent for the Veteran's service-connected PTSD were not met. 38 U.S.C.A. § 1155, 5107; 38 C.F.R. Part 4, including § 4.130 and Code 9411. 3. From June 7, 2013, the criteria for entitlement to a disability evaluation of 70 percent (but no higher) for the Veteran's service-connected PTSD have been met. 38 U.S.C.A. § 1155, 5107; 38 C.F.R. Part 4, including § 4.130 and Code 9411. 4. The criteria for entitlement to a total rating based on individual unemployability have been met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. Duty to Notify 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). 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). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). This appeal arises from the Veteran's disagreement with the initial evaluation following the grant of service connection for PTSD. 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). No additional discussion of the duty to notify is therefore required. Duty to Assist VA also has a duty to assist the Veteran in the development of the claim, which is not abrogated by the granting of service connection. In this case, the Veteran's service treatment records are on file, as are post-service VA and private medical records, VA examination reports, and statements from the Veteran and his ex-wife. The Veteran has been afforded VA examinations regarding the issues on appeal. The examination reports obtained are thorough and contain sufficient information to decide the issues on appeal. See Massey v. Brown, 7 Vet. App. 204 (1994). For all the foregoing reasons, the Board concludes that VA's duties to the Veteran have been fulfilled with respect to the issues on appeal. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on his claims at this time. The Veteran submitted additional records in support of his claim after the November 2012 statement of the case was issued. The additional evidence consisted of private treatment records dated between 2007 and 2013, a private examination report, and a statement from the Veteran's ex-wife. A remand for preparation of a supplemental statement of the case is not necessary as the Veteran waived initial RO consideration of the newly submitted evidence. 38 C.F.R. § 20.1304(c). Posttraumatic Stress Disorder The present appeal involves the Veteran's claim that the severity of his service-connected PTSD warrants a higher disability rating. The Veteran filed his initial claim of service connection for PTSD on August 5, 1999. A January 2011 rating decision granted service connection and assigned a 30 percent disability rating effective August 5, 1999. The Veteran expressed disagreement with the disability rating assigned. An August 2012 rating decision assigned a 50 percent disability rating effective March 21, 2012. Consequently, the issue before the Board is entitlement to a disability rating in excess of 30 percent prior to March 21, 2012, and a disability rating in excess of 50 percent from March 21, 2012. Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where, as in the instant case, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board notes that DSM-V (the latest version of the DSM) has now been officially released. However, 38 C.F.R. § 4.130 still explicitly refers to the DSM-IV. The regulation legally requires the Board to continue considering this prior version of the DSM until such time as the regulation is changed. While there is a regulation change in the works that would change the regulation to reference "the current version of the DSM," it is unclear when that proposed change will be published. Turning to the rating criteria, the Board first observes that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The service-connected PTSD disability has been assigned an initial 30 percent rating under 38 C.F.R. § 4.130, Diagnostic Code 9411, for the period prior to March 21, 2012. Under the general rating formula for mental disorders, 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, mild memory loss (such as forgetting names, directions, recent events). An evaluation of 50 percent is warranted for PTSD with occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. See 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation is warranted for PTSD with 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 a work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for PTSD with total occupational and social impairment, due to symptoms such as the following: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). 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. The Board has reviewed all of the evidence of record included in the Veteran's claims file, including such evidence contained in Virtual VA and VBMS, with an emphasis on the evidence relevant to this appeal. 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). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. In reviewing the claim, the Board notes that the evidence covering the period under review consists of VA clinical records, private treatment records, December 1999, November 2004, November 2010, and March 2012 VA examination reports, and the Veteran's allegations of increased disability, supported by a statement from his former spouse. During the December 1999 VA examination, the Veteran reported trouble sleeping, anxiety, hearing voices, nightmares, flashbacks, irritability, anger, and isolation since returning from the Vietnam War. He complained of nightmares and reported that loud noises, helicopters, and Vietnamese people remind him of Vietnam. The Veteran reported that he has no close friends and cannot get close to anyone. The VA examiner noted that the Veteran was married twice and has two children. He was in the middle of a divorce at the time of examination, and appeared "somewhat sad looking" but fairly groomed, cooperative but irritable. He was alert and oriented. The examiner also noted that the Veteran's immediate memory was reduced although his memory for recent and remote was intact. His insight and judgment were intact, and the examiner noted that the Veteran was competent to manage his money. He diagnosed the Veteran with PTSD and assigned a Global Assessment of Functioning (GAF) score of 50. GAF scores ranging from 41 to 50 reflect 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). See 38 C.F.R. § 4.130 (incorporating by reference VA's adoption of the American Psychiatric Association: Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV), for rating purposes). The claims file also consists of records from the Veteran's private treating psychiatrist. Overall, the Veteran was generally non-suicidal and non-homicidal. A November 2009 record notes that the Veteran and his psychiatrist talked extensively about suicide and its consequences after the Veteran attended a funeral for his stepson's roommate who possibly overdosed. The private treatment records also show a gradual improvement. Treatment records from August to December 1999 show that the Veteran was stable and able to sleep, despite family problems. According to a January 2000 record, he experienced a setback due to the holidays and family issues. A March 2000 private treatment record noted that the Veteran's PTSD symptoms, including nightmares and anger issues, have become much calmer since treatment began. The examiner noted that the Veteran's general presentation and behavior was fair; his speech was normal; he would experience ups and downs with respect to affect and mood; and his intellectual functioning was slow. The Veteran has no current, recent, or past suicidal tendencies; he did have past homicidal tendencies and periods of violence, but no current or recent tendencies. In April 2000, the Veteran moved out of the family home after an altercation with his wife. In May 2000, he began experiencing trouble after seeing Vietnam paintings. The Veteran's psychiatrist noted lots of family dysfunction in a May 2000 record. In June 2000, the psychiatrist noted that the Veteran appeared stable despite chronic marital conflict. An October 2000 follow-up report shows the Veteran was stable. A January 2001 record noted that the Veteran "looks real good" and was stable despite lots of issues. A February 2001 report notes that the Veteran was experiencing sleeping problems and would experience stress after hearing motors, helicopters, and planes. The examiner questioned whether the Veteran was agoraphobic, but did not provide an opinion as to that issue. By March 2001, the Veteran was sleeping better and was taking daily naps. The examiner noted that he looked his usual self. An April 2001 note indicates the Veteran was struggling with PTSD, but by May, he was doing a lot better with the mediations. A June 2001 treatment request form noted that the Veteran was on antipsychotic, hypnotic, anti-anxiety, and anti-depressant medications. The Veteran's academic or work inhibition was noted as severe, while his depressed mood was described as moderate; none showed improvement with treatment. The Veteran's physical symptoms, sleep disturbances, and anxiety were also severe, but showed improvement with treatment. The psychiatrist described the Veteran's following symptoms as mild: antisocial, destructive, disorganized, and social withdrawal behavior; impaired judgment; and panic attacks. He described the following symptoms as moderate: decrease in energy or fatigue; impulsivity/recklessness; psychomotor agitation; restlessness; aggression or rage; anger/hostility; apathy; helplessness; hopelessness; irritability; and low self-esteem. The Veteran's psychiatrist assigned a GAF score of 68, indicating mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with meaningful interpersonal relationships. By August 2001, the Veteran complained that his PTSD stress returned; the treatment notes indicate that the Veteran had been taking care of children who were hyperactive and who would wake him up at night. By late August, he was stable and sleeping well. In September 2001, his PTSD was exacerbated; the treatment notes do not indicate why. In December 2001, the examiner noted that the Veteran seemed to take too many pills. The Veteran's treatment records from January to August 2002 show the Veteran was non-suicidal and non-homicidal. In an October 2002 private treatment record, the Veteran's psychiatrist noted a "clear" need for Valium. The Veteran's treatment then became more sporadic. In January 2003, the treatment records reflect a "super stressful situation" relating to two house payments that were due. In March 2004, the Veteran reported not sleeping well. During a November 2004 VA examination, the Veteran described himself as being tense and anxious a lot of the time. He described having a quick temper when people are "messing around with him." He mentioned being depressed, but denied recent suicidal ideation (although he did so in the past). His medications help him sleep, although he still has occasional nightmares. He experiences intrusive thoughts regarding his Vietnam War experiences approximately three to four times per week. He avoids crowds. If he goes to a restaurant, he will sit with his back to a wall, facing the door. He tends to visually scan an area in which he is moving and rechecks doors and windows to make sure they are locked. He is startled by loud noises and would become "very upset," although not violent, if someone approached him from the rear and touched him on the shoulder. The Veteran has very few friends, but considers one or two people to be "real friends." He reported staying home most of the time as his PTSD symptoms made it difficult for him to attend work and/or to function effectively. The Veteran described his marriage as "pretty decent" and felt reasonably close to his current wife, despite their considerable disagreements and verbal fights. He was married twice before, with the first marriage resulting in two children. He reported that one marriage ended with the death of his wife and the other ended, in part, due to his PTSD issues, including his irritability, quick temper, and poor sleeping habits. The VA examiner noted that the Veteran was casually and appropriately dressed, and oriented times four. The Veteran maintained good eye contact throughout most of the session and was cooperative. His mood was within normal limits and he had a fair level of short-term memory. The examiner noted no thought disorder in the sense of derailment, tangentiality, or circumlocution. He also noted no hallucinations or delusions. The Veteran had good verbal abstracting skills and the examiner noted no impairment of thought process or communication that would have a significant impairing effect on his social functioning or work capacity. The examiner diagnosed the Veteran with PTSD and assessed a GAF score of 56, which is indicative of moderate symptoms, or moderate difficulty in social, occupational, or school functioning. The examiner noted that the Veteran met the increased arousal part of the PTSD diagnosis by virtue of his irritability, hypervigilance, and exaggerated startle response. He also noted the Veteran's limited social relationships and social activities. The examiner concluded that the Veteran's PTSD produces a moderate degree of dysfunction in his social activities and capacity for work. The August 2005 treatment record reported "lots of stressors" without identifying any. A March 2006 record notes that the Veteran does not have homicidal or suicidal thoughts. A December 2007 treatment note indicates that the Veteran was struggling with a divorce. Treatment records in June and December 2010 and September 2012 show that the Veteran had no homicidal or suicidal thoughts. A January 2013 treatment record notes lots of stress with respect to family problems. The Veteran was not suicidal. On November 2010 VA examination, the Veteran presented with having recurrent nightmares about a number of different combat-related experiences in Vietnam-his nightmares used to occur frequently, but now occur once per month. The Veteran avoids events involving fireworks since the noise reminds him of combat. The Veteran also reported being verbally aggressive and having a violent temper. The Veteran stated that he had recently pulled his granddaughter's boyfriend out of the car by his hair and almost hit him with a steel pipe because he was talking to another girl and not helping the Veteran change the oil. The Veteran again discussed his marital status noting that his first wife divorced him because he changed too much, referring to his anger, when he came back from Vietnam. The Veteran reported having a good relationship with the two children born during that marriage. He divorced his second wife, but they are currently back together. He reportedly has a good relationship with her but becomes irritable and angry with her because she talks too often. He described his marriage to his third wife as very volatile, on the part of the ex-wife. He described himself as someone who has always had friends "and currently has friends[.]" He noted a problem with angry outbursts and reportedly had a number of physical altercations with people in the past. The Veteran fixes appliances for friends and family, has been working on restoring a 1952 pick-up truck, enjoys going to a restaurant for coffee most days of the week, and enjoys visiting friends. The examiner noted that the Veteran appeared casually dressed, but mildly disheveled with fair hygiene. He was oriented times four and made eye contact with the examiner, although he was mildly fidgety during the examination. The Veteran's mood and affect were congruent; the Veteran appeared either sad or anxious at certain points during the examination. He admitted to having occasional suicidal thoughts when he becomes frustrated and angry with other people, but denied any suicidal or homicidal ideation or intent. The VA examiner noted no evidence of a thought disorder in terms of derailment, tangentiality, or circumlocution. The Veteran denied hallucinations and delusions. There was no impairment with thought processes or communication, although the Veteran needed to be redirected to stay on topic a number of times during the interview. The Veteran complained of problems with short-term memory and concentration, and found himself not remembering the names of people he has known for a long time. The examiner noted that the Veteran's short-term memory was good, but he made several errors with respect to serial sevens. The examiner noted the "only inappropriate behavior" as having a short temper with his girlfriend and granddaughter, as well as being physically threatening to his granddaughter's boyfriend. The Veteran was diagnosed with mild PTSD and assigned a GAF score of 65, which is indicative of some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well with some meaningful interpersonal relationships. The examiner noted that the Veteran described a foreshortened future. He also noted that persistent symptoms of increased arousal included irritability and angry outbursts as well as difficulty concentrating and an exaggerated startle response. He also noted that the Veteran has recurrent and intrusive memories and nightmares of a number of different combat experiences, and persistently tried to avoid thoughts, feelings, and activities that remind him of such events. The VA examiner concluded that the Veteran has moderate impairment with respect to social and occupational functioning. He noted that the Veteran has long-term relationships with family and friends, but also has a history of becoming easily verbally aggressive. In February 2011 correspondence, the Veteran's physician again noted the Veteran's irregular sleep patterns and unscheduled naps during the day. He further noted that the Veteran is awakened at night by loud noises and dreams due to his experiences in Vietnam. Although he was able to block such noises from his sleep in the past, the psychiatrist noted that the Veteran's problems have returned due to his age. The psychiatrist further noted that the Veteran is depressed and reclusive due to his inability to provide for his family. During a March 21, 2012, VA examination, the Veteran reported that he has a good relationship with his girlfriend of four years, as well as his two sons. The examiner noted that the Veteran re-experiences his traumatic events by recurrent and distressing recollections and dreams of the event, acting and feeling as if the traumatic event was recurring, and intense psychological distress at, as well as physiological reactivity to, exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. The Veteran undertakes efforts to avoid thoughts, feelings, or conversations associated with the trauma; avoids activities, places, or people that arouse recollections of the trauma; has an inability to recall an important aspect of the trauma; has markedly diminished interest or participation in significant activities; has feelings of detachment or estrangement from others; and has a restricted range of affect and a sense of a foreshortened future. The Veteran also experiences persistent symptoms of increased arousal as indicated by the following: difficulty falling or staying asleep; irritability or outburst of anger; difficulty concentrating; hypervigilance; and exaggerated startle response. These symptoms last more than one month and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. He noted the following symptoms with respect to the Veteran's PTSD: anxiety, suspiciousness, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting. The examiner diagnosed the Veteran with PTSD and assigned a GAF score of 56, indicating moderate symptoms. He noted occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although functioning satisfactorily, with normal routine behavior, self-care, and conversation. He also concluded that the Veteran was capable of managing his own financial affairs. In a July 2012 addendum opinion, the VA examiner concluded that the Veteran's mental problems make it difficult for him to complete and perform the task required by an employer. He also noted that the Veteran's social problems make him unable to adapt in most social atmospheres. The VA examiner concluded that the Veteran has moderate difficulty obtaining and/or maintaining employment. In a June 2013 statement, the Veteran's ex-wife stated that she and the Veteran married in 1982. She described their relationship as normal most of the time, although the Veteran exhibited extreme protection of family. She described "explosive situations" involving their daughter and granddaughter, as well as being awoken by the Veteran's nightmares and outbursts of anger and violence. She mentioned that she sought counseling for her husband for his suicidal thoughts. They divorced in 1994 but reconnected in 2007. She stated that his war memories and side effects of the war "seem to be worsening with age." She described anger, short tempers, impatience, and increasing dreams. She also described the following as triggers: confrontational conversations, loud or unsuspecting noises, threats, and "authority rules." She stated that sometimes simple, everyday situations can be a trigger. She also stated that the Veteran still experiences flashbacks and nightmares of war. The Veteran submitted an August 2013 private opinion from Dr. Michael Cesta, a psychiatrist. Although Dr. Cesta noted that the Veteran's treating psychiatrist "does not write expansive and prolific progress notes," Dr. Cesta was able to determine that the Veteran has had prominent symptoms of PTSD with secondary symptoms of depression, irritability, anger, insomnia, hostility, agitation, periods of psychosis, and persistent thoughts of violence. He noted violent behavior with respect to the Veteran pulling his granddaughter's boyfriend out of a car by his hair, and his anger issues which ended at least one of his marriages. Dr. Cesta noted "a history of violent thoughts directed at family, coworkers and others" as well as persistent suicidal thoughts during periods of agitation and anger. Dr. Cesta notes in his report that the VA has consistently underestimated the severity of the Veteran's symptoms and consistently described him as having a moderate degree of dysfunction in his social activities and capacity for work, despite his aggressive, and potentially violent, behaviors, and isolation from most family members. Dr. Cesta concluded that the Veteran exhibits extremely severe dysfunction consistent with chronic and pervasive mental illness and is incapable of having appropriate interactions with even the most intimate people in his life. The Veteran consistently avoids any stimuli associated with the traumatic events and has experienced negative alterations in his arousal in reactivity associated with his experience in Vietnam. He also experiences periods of dissociation, depersonalization, and derealization. Dr. Cesta noted that the Veteran was reasonably cooperative and appropriate during the examination and maintained fair impulse control, although he had periods of mood lability, anger, and the incapacity to control his emotions. There were times during the interview when the Veteran became agitated and angry, and shouted at the examiner, regarding his experiences in Vietnam. There were also multiple crying spells associated with his recollection of the traumatic events. Dr. Cesta concluded that the Veteran's thought content was positive for intermittent passive suicidal ideation without plan or intent. The Veteran also discussed prior episodic homicidal ideations occasionally directed at individuals, but he did not have specific thoughts of hurting another individual. A mini-mental status examination suggested somewhat impaired cognitive function. The Veteran no longer experienced auditory, visual, or tactile hallucinations. Dr. Cesta concluded that the Veteran's PTSD symptoms have been "profound, severe, and unremitting" since 1998 and likely for decades prior. Dr. Cesta notes that the Veteran has contemplated homicide and suicide, and has experienced severe neurovegetative symptoms of depression and anxiety associated with this PTSD. According to Dr. Cesta, the Veteran consistently experiences severe nightmares, flashbacks, physiological and psychological reactivity, hopelessness, despair, thoughts of violence, suicide, and cognitive impairments directly related to PTSD. He characterized the Veteran as "severely mentally ill, socially isolated, and [] completely dysfunctional in any occupational or social setting." Dr. Cesta diagnosed the Veteran with PTSD, with dissociative symptoms, with delayed onset. Because Dr. Cesta used the DSM-V, he did not assign a GAF score. Turning to the question of whether the 30 percent rating assigned by the RO beginning August 5, 1999, is proper, the Board is compelled to conclude that a rating in excess of 30 percent is not warranted for the period prior to March 21, 2012. During that period, the Board finds that the Veteran's PTSD was characterized by the following signs or symptoms: sleep impairment marked by nightmares, flashbacks, irritability, anger, hearing voices, isolation, anxiety, panic attacks, impaired judgment, and depressed mood. The Board finds that these symptoms are similar to many of those contemplated by the currently assigned 30 percent rating. In particular, the General Rating Formula lists, inter alia, panic attacks occurring weekly or less often, anxiety, depressed mood, and chronic sleep impairment among the types of symptoms associated with a 30 percent rating. These are not unlike those the Board finds to be associated with the Veteran's PTSD for this period. 38 C.F.R. § 4.130. Although the 50 percent rating criteria contemplate reduced reliability and productivity, such must be "due to" the symptoms listed for that rating level, "or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). While some of the symptoms experienced by the Veteran (including panic attacks, impaired impulse control, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships) approximate those listed in the 50 percent criteria, the Board finds that, overall, the symptoms experienced by the Veteran are of similar duration, frequency, and severity as those described for the 30 percent rating, for the period prior to March 21, 2012. The Veteran's own treating physician described the Veteran's antisocial, destructive, disorganized, and social withdrawal behavior, his impaired judgment, and his panic attacks as mild. He also described the Veteran's impulsivity and recklessness, restlessness, aggression or rage, anger/hostility, apathy, and irritability as moderate. He assigned a GAF score of 68 which overall reflected mild symptoms. The Veteran was assigned several GAF scores throughout his treatment and VA examinations. During the December 1999 VA examination, he was assigned a GAF score of 50, indicating serious symptoms. During the June 2001 VA examination, the Veteran was assigned a GAF score of 68, indicating mild symptoms. At the November 2004 VA examination, he was assigned a GAF score of 56, indicating moderate symptoms, and at the November 2010 VA examination, he was assigned GAF score of 65, indicating mild symptoms. Accordingly, although the Veteran's GAF score in 1999 indicated serious symptoms, the Veteran's condition has exhibited generally mild or moderate symptoms. While it is noted that the Veteran had some disturbances of motivation and mood and some anger and irritability issues, the overall disability picture more correctly aligns with a 30 percent rating. There was no evidence to suggest that the Veteran had occupational and social impairment with reduced reliability and productivity as required by a 50 percent rating. Turning to the question of whether a rating in excess of 50 percent rating is proper from March 21, 2012, and affording the Veteran all reasonable doubt, the Board is compelled to conclude that a staged rating is warranted. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007) (where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary). The Board particularly finds that, for the reasons explained below, a 50 percent rating is warranted from March 21, 2012, through June 7, 2013, and a 70 percent rating is warranted from June 7, 2013. The Board finds that, from March 21, 2012, to June 7, 2013, the Veteran's PTSD was characterized by the following signs and symptoms: anxiety, suspiciousness, chronic sleep impairment, irritability, difficulty concentrating, hypervigilance, exaggerated startle response, restricted range of affect, isolation, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work-like setting. The Board finds that these symptoms are similar to many of those contemplated by the 50 percent rating. In particular, the General Rating Formula lists, inter alia, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The 70 percent rating criteria contemplate deficiencies in "most areas," including work, school, family relations, judgment, thinking, or mood. Although the Veteran has difficulty in adapting to stressful circumstances, and because the 70 percent level contemplates such difficulty, this does not mean that the Veteran's PTSD rises to the 70 percent level. The Board is required to look to the frequency, severity, and duration of the impairment. Vazquez-Claudio, 713 F.3d at 117. On March 2012 VA examination, the Veteran reported having a good relationship with his four living brothers, his current girlfriend of four years, and his two sons. Accordingly, the Veteran did not experience an inability to establish and maintain effective relationships. The VA examiner assigned a GAF score of 56, indicating moderate symptoms. Here, the examiner, in evaluating all of the evidence and after examining the Veteran, concluded that the Veteran's symptoms more nearly approximated the 50 percent rating. The Board finds that the objective findings paint a disability picture more consistent with PTSD productive of social impairment with reduced reliability and productivity. 38 C.F.R. § 4.119; Fenderson, 12 Vet. App. at 126. The Board finds that a June 7, 2013, statement from the Veteran's ex-wife provides additional information concerning the Veteran's PTSD symptoms that provides a basis for the assignment of a 70 percent rating. The June 2013 statement provides information concerning the following symptoms: anger, short tempers, impatience, and increasing nightmares. Although she specifically identified certain triggers for the Veteran, she also noted that sometimes simple, everyday situations can be a trigger. The August 2013 private examination provides further evidence of the need for a higher rating. The report shows that the Veteran consistently experiences severe nightmares, flashbacks, physiological and psychological reactivity, hopelessness, despair, thoughts of violence, suicide, and cognitive impairments directly related to his PTSD. Although he no longer experiences hallucinations, his behavior during the interview, including crying spells, shouting at the examiner, and other examples of incapacity to control his emotions, show increasing PTSD symptoms. The Board finds that such symptoms most nearly approximate one of occupational and social impairment with deficiencies in most areas, and warrants the assignment of a 70 percent rating from June 7, 2013, the date of his ex-wife's statement. Although the August 2013 private examiner reported that the Veteran has thoughts of violence and suicide, and the 100 percent rating contemplates a persistent danger of hurting self or others, the Board finds that this is not enough to conclude that the Veteran's PTSD rises to the 100 percent level. Indeed, the 70 percent rating contemplates suicidal ideation. During the August 2013 examination, the Veteran discussed prior episodic homicidal ideations but denied any current thoughts of hurting another individual. Additionally, the Veteran's thought content was positive for intermittent passive suicidal ideation, as he was without plan or intent. Given that the rating is to be assigned, not solely on the presence or absence of particular symptoms, but rather, the frequency, severity, and duration of such symptoms, as well as the length of remissions, and the Veteran's capacity for adjustment during periods of remission, the Board finds that the Veteran's current suicidal ideation is more closely analogous to that contemplated by the 70 percent rating. The Veteran is in a long-term relationship and has a good relationship with his children and brothers. The Veteran reported that he enjoys rebuilding his 1952 pick-up truck, enjoys going to a restaurant for coffee most days of the week, and enjoys visiting friends. Accordingly, the Board finds that the Veteran's symptoms do not more closely approximate total occupational and social impairment contemplated by a 100 percent rating, and therefore a 100 percent rating is not warranted. Given the frequency, nature, and duration of those symptoms, the Board finds that they result in no more than occupational and social impairment with deficiencies in most areas. See Vazquez-Claudio, 713 F.3d at 114. The Board notes that the August 2013 private examiner has challenged the November 2010 VA examiner's diagnosis of mild PTSD, contending that the qualifier of "mild" is technically inaccurate. The Board has considered this argument, but in light of the evidence discussed above, has concluded that a 30 percent disability rating is appropriate for the period prior to March 21, 2012, a 50 percent disability rating is appropriate for the period of March 21, 2012, to June 7, 2013, and a 70 percent disability rating is appropriate for the period from June 7, 2013. Finally, the Board has considered whether extraschedular consideration is warranted. The symptoms and resulting impairment demonstrated with regard to PTSD fall within the schedular criteria. The rating criteria contemplates a higher rating for PTSD than those assigned, but as explained above, the evidence does not show that the Veteran has manifestations of the PTSD disability that meet the next higher rating criteria. The discussion above reflects that the rating criteria reasonably describes and contemplates the severity and symptomatology of the Veteran's service-connected PTSD. See Code 9411. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). TDIU A request for a total rating based on individual unemployability due to service-connected disability (TDIU), whether expressly raised by the Veteran or reasonably raised by the record, is not a separate "claim" for benefits, but rather, can be part of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In other words, if the claimant or the evidence of record reasonably raises the question of whether the Veteran is unemployable due to a disability for which an increased rating is sought, then part and parcel with the increased rating claim is the issue whether a TDIU is warranted as a result of that disability. Id. A TDIU rating for compensation purposes may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more; or if there are two or more service-connected disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Disabilities affecting both upper or both lower extremities, disabilities resulting from a common etiology or a single accident, and disabilities involving a single body system are considered as one disability. 38 C.F.R. § 4.16(a). Entitlement to TDIU requires an impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Substantially gainful employment is defined as work which is more than marginal and which permits the individual to earn a living wage. Moore v. Derwinski, 1 Vet. App. 356 (1991). The central inquiry is whether the Veteran's service-connected disability(ies) alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In making this determination, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. Service connection has been established for neurodermatitis, currently rated as 30 percent disabling, tinnitus, currently rated 10 percent disabling, cortical chip fracture, currently rated 10 percent disabling, and PTSD, rated as 30 percent disabling prior to March 21, 2012, 50 percent disabling from March 21, 2012, through June 7, 2013, and 70 percent disabling from June 7, 2013. The percentage requirements of 38 C.F.R. § 4.16(a) have been met as of March 21, 2012 (70 percent combined rating when the Veteran received a 50 percent disability rating for PTSD as of that date). The remaining question is whether the Veteran is unable to engage in substantially gainful employment because of his service-connected disabilities. In several correspondences dating back to August 2001, the Veteran's treating psychiatrist has stated that the Veteran has not been able to work since June 1996 due to the Veteran's PTSD symptoms and service connected skin disorder. In a May 2004 statement, the Veteran reports that he has been unable to find and maintain gainful employment to support his family of four. In an August 2004 mental medical source statement, the Veteran's treating psychiatrist noted the Veteran had moderate limitation with respect to remembering locations and work-like procedures; understanding and remembering, as well as carrying out, very short and simple instructions; sustaining ordinary routine without special supervision; making simple work related decisions; asking simple questions or requesting assistance. He noted marked interference with the following: understanding and remembering, as well as carrying out, detailed instructions; maintaining attention and concentration for extended periods; completing a normal work day and work week; interacting appropriately with the general public; getting along with coworkers or peers; maintaining awareness of normal hazards and taking appropriate action; traveling in unfamiliar places; and setting realistic goals. The examiner also noted severe interference with respect to the following: performing activities within a schedule, maintaining regular attendance, being punctual within customary tolerances; working in coordination with or proximity to others without being distracted; accepting instructions and responding appropriately to criticism from supervisors; maintaining socially appropriate behavior and adhering to basic standards of neatness and cleanliness; and responding appropriately to changes in work setting. He concluded that the Veteran was capable of managing his own money, but that his functional capacity was limited at best, with medication. During a November 2004 VA examination, the Veteran reported that he has not worked since 1996 and that he had to quit working on account of his skin condition and his PTSD. The Veteran's representative has argued that the evidence of record establishes that the Veteran's "extremely severe PTSD symptomatology" has rendered him unemployable since well before the Veteran filed his claim in August 1999. In a July 2012 addendum opinion, a VA examiner concluded that the Veteran's mental problems make it difficult for him to complete and perform the task required by an employer. He also noted that the Veteran's social problems make him unable to adapt in most social atmospheres. The VA examiner concluded that the Veteran has moderate difficulty obtaining and/or maintaining employment. Despite the VA examiner's conclusion, the Board finds that a grant of a total rating based on individual unemployability is warranted. It appears that the Veteran is no longer employed and the Veteran's own statements and the statements of his own treating psychiatrist show that gainful employment is precluded due to PTSD symptomatology as well as other service-connected disabilities. ORDER Prior to March 21, 2012, entitlement to a rating in excess of 30 percent for PTSD is not warranted. From March 21, 2012, to June 7, 2013, entitlement to a rating in excess of 50 percent for PTSD is not warranted. From June 7, 2013, entitlement to a rating of 70 percent (but no higher) for PTSD is warranted, subject to the regulations governing payment of monetary awards. Entitlement to a total rating based on individual unemployability due to service-connected disability is warranted, subject to the regulations governing payment of monetary awards. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs