Citation Nr: 1524626 Decision Date: 06/09/15 Archive Date: 06/19/15 DOCKET NO. 04-38 018 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Buffalo, New York THE ISSUES 1. Entitlement to a rating greater than 30 percent for posttraumatic stress disorder (PTSD) for the period prior to September 5, 2008. 2. Entitlement to a rating greater than 50 percent for PTSD for the period from September 5, 2008 to August 8, 2012. 3. Entitlement to a rating greater than 70 percent for PTSD for the period from August 9, 2012. 4. Entitlement to special monthly compensation (SMC) at the housebound rate for the periods prior to February 22, 2005 and from April 1, 2005. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD M. Carsten, Counsel INTRODUCTION The Veteran served on active duty from December 1968 to June 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2003 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Buffalo, New York, which granted service connection for PTSD and assigned a 30 percent rating from July 24, 2003, the date of receipt of the Veteran's claim. In September 2007, the Board remanded the case for additional development. In December 2009, the Board denied entitlement to an initial rating in excess of 30 percent for PTSD. In a September 2011 Memorandum Decision, the United States Court of Appeals for Veterans Claims (Court) vacated the Board's December 2009 decision and remanded the case for action consistent with the Memorandum Decision. In June 2012, the Board again remanded the case. In December 2012, the Appeals Management Center (AMC) granted an increased rating for PTSD to 50 percent from September 5, 2008 and to 70 percent from August 9, 2012. In April 2013, the Board denied entitlement to an increased rating for PTSD initially evaluated as 30 percent disabling prior to September 5, 2008; 50 percent disabling from September 5, 2008 to August 8, 2012; and 70 percent disabling thereafter. The Veteran appealed the Board's decision. In an October 2014 Memorandum Decision, the Court vacated the Board's decision and remanded for further adjudication. In addition to the PTSD rating issue, the Court agreed that a remanded was warranted for the Board to determine whether SMC was warranted. Accordingly, the issue has been listed above. The Veterans Benefits Management System (VBMS) and Virtual VA folders have been reviewed. The issue of entitlement to SMC at the housebound rate for the periods prior to February 22, 2005 and from April 1, 2005 is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, for the period prior to September 5, 2008, his PTSD is manifested by no more than occupational and social impairment with reduced reliability and productivity. 2. Resolving reasonable doubt in the Veteran's favor, for the period from September 5, 2008 to August 8, 2012, his PTSD is manifested by no more than occupational and social impairment with deficiencies in most areas. 3. For the period beginning August 9, 2012, the Veteran's PTSD is not manifested by total occupational and social impairment. CONCLUSIONS OF LAW 1. For the period prior to September 5, 2008, the criteria for a 50 percent rating, and no more, for PTSD are met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2014). 2. For the period from September 5, 2008 to August 8, 2012, the criteria for a 70 percent rating, and no more, for PTSD are met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. 3. For the period beginning August 9, 2012, the criteria for a rating greater than 70 percent for PTSD are not met. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) In the case at hand, inasmuch as service connection, an initial rating, and an effective date have been assigned, the notice requirements of 38 U.S.C.A. § 5103(a) (West 2014) have been met. VA has fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claim, and, as warranted by law, affording VA examinations. Currently, there is no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, there is currently no error or issue which precludes the Board from addressing the merits of the Veteran's appeal. Analysis Evaluation for PTSD In July 2003, the Veteran filed a claim for service connection for PTSD. In a Vet Center Social Survey dated in mid July 2003, the Veteran was described as neat and clean in appearance, with good hygiene, and both friendly and cooperative. According to the examiner, the Veteran displayed no unusual mannerisms or movements, nor was there any evidence of psychotic symptomatology. When further questioned, the Veteran complained of occasional nightmares about Vietnam. Further noted were problems with sleep apnea. When questioned, the Veteran complained of "intrusive thoughts about the military." Moreover, he displayed "a lot of avoidance behaviors." According to the Veteran, he was often irritable, and found himself "getting angry at little things." The Veteran's affect was described as sad, and his mood depressed. According to the Veteran, he should never have retired. On mental status examination, the Veteran was oriented to place and person, but thought the date was the 19th when it was only the 16th. His memory appeared to be within normal limits, though he experienced some difficulty with serial 7's, suggestive of problems with focus and attention. At the time of evaluation, the Veteran was able to interpret proverbs. However, his insight into his problems appeared poor. According to the examiner, the Veteran clearly suffered from a number of traumatic incidents while in Vietnam, which resulted in "some significant" PTSD symptoms. At the time of a VA psychiatric examination in November 2003, the Veteran indicated that he had worked for the same company both before and after his military service. Reportedly, the Veteran had retired from that job the previous year after having worked for 35 years. Although the Veteran reported difficulties at work with his supervisors, his period of employment was continuous. When questioned, the Veteran complained of emotional problems, and indicated that his temper had become increasingly worse. He spoke in a reserved tone, but with a strained voice, and noted that he became "very jumpy" when disturbed by loud noises. By the Veteran's own admission, he tended to be hypervigilant. On mental status examination, the Veteran's attitude was described as one of resignation and mild despair. Rapport was adequately established, though at times, the Veteran appeared pressured in offering information. Significantly, at the time of evaluation, there were no abnormalities in gross motor function, though random fine motor activity was strongly suggestive of anxiety. The Veteran's mood was dysthymic, and his affect depressed, with an attitude characterized by mild despair and feelings of helplessness or futility. According to the examiner, the Veteran appeared to experience mild, though significant, anxiety. Depression was also noted, though there were no manifestations of guilt, grief, or mania. When questioned, the Veteran reported considerable, and at times intrusive, anxiety in social situations, in particular, when in large groups or in the presence of unexpected noises. Moreover, the Veteran was notably tense and anxious throughout the interview, though he appeared able to control it reasonably well. The Veteran's speech and language functions were fully intact and unimpaired. Thought processes were similarly unimpaired, and there was no evidence of any delusions, hallucinations, or aberrations of thinking. While the Veteran did appear to experience some ruminative thinking regarding his experiences in Vietnam, it was unclear whether these were specific to the evaluation, or more endemic to the Veteran's functioning. While the Veteran reported what might be considered paranoid delusions to others "by report," these were not present during the interview. At the time of evaluation, the Veteran was fully oriented to time, place, and person. Cognitive dexterity was described as somewhat limited, and executive cognitive functions appeared mildly impaired as related to the Veteran's speed of thought and information processing. According to the examiner, the Veteran's capacity for abstract thinking was intact, though not sophisticated. Simple analogies and proverbs were easily understood, though the Veteran experienced difficulty with more integrative, complex material. The Veteran's remote memory was intact, and he was able to recall both recent events and activities in his life. Short term memory was also intact, though immediate recall was somewhat limited by what appeared to be distractibility. Judgment appeared to be intact some of the time, though occasionally compromised by impulsivity, frustration, and general anxiety. According to the examiner, the Veteran's insight appeared to be developing, though it was not a well-established aspect of his thinking. At the time of examination, there was no evidence of either homicidal or suicidal ideation. The pertinent diagnosis noted was PTSD with a Global Assessment of Functioning (GAF) score of 55. In December 2003, the RO granted service connection for PTSD assigning a 30 percent rating from the date of claim. In a Vet Center treatment record dated in April 2004, the Veteran indicated that he had been managing his PTSD without significant exacerbation. Further noted was that the Veteran appeared to be applying what he had been learning, and was currently managing his symptoms. In a Vet Center treatment record dated October 15, 2004, the clinician noted that the Veteran attended PTSD group regularly and recently asked for an individual session because his wife threatened to leave him. The clinician noted that the Veteran felt guilty for getting a 30 percent rating even though his symptoms deserved a higher rating. His affect was agitated and sad and his mood was depressed. A record dated October 22, 2004 indicates the Veteran and his wife were doing a little better and he was doing what he could to salvage his family situation. A record dated October 28, 2004 documents a recent incident of road rage and describes the Veteran's PTSD as severe. He continued to struggle with anger and rage, as well as paranoia around other people, and his symptoms significantly interfered with his ability to hold gainful employment. A VA record of hospitalization covering the period from mid-February to mid-March 2005 reveals that the Veteran was hospitalized at that time for what was described as an exacerbation of PTSD symptomatology. At the time of admission, the Veteran reported experiencing increased anger, nightmares, startle response, hypervigilance, intrusive thoughts, and sleep disturbance since retiring three years earlier. During hospitalization, the Veteran participated in both individual and group psychotherapy, and received medication management and peer support. Reportedly, the Veteran dealt with his anger and anxiety issues, and began to understand the relationship of his symptoms to his problems. By the time of discharge, the Veteran appeared to have gained from his stay on the PTSD unit. He was cooperative, and fully participated in all functions and activities. While the Veteran initially demonstrated some difficulty in managing anger and interpersonal interactions, he successfully utilized supports and developed skills to address these concerns. The pertinent diagnosis noted was PTSD, with a GAF of 41 at both admission and discharge. The prognosis, however, was noted to be poor due to the duration, chronicity and severity of his symptoms. It was further noted that he was not employable. In May 2005, the RO awarded a temporary total evaluation of 100 percent effective February 22, 2005 based on hospitalization for PTSD of over 21 days. A 30 percent rating was assigned from April 1, 2005. On VA psychiatric examination in June 2005, it was noted that the Veteran was in a weekly group, but that he also attended day treatment one day a week. Further noted was that, while the Veteran had reportedly experienced difficulties at work, his period of employment had been continuous. According to the examiner, the Veteran was able to conduct all activities of daily living without difficulty, though his wife took care of most of the family finances. The Veteran reported that he takes out his anger towards his wife and children, and also has road rage. He subsequently reported a good relationship with immediate family members although as recently as October 2004 the relationship was troubled to the point that they contemplated separation. On mental status examination, the Veteran was somewhat tremulous, and he startled suddenly at the sound of an ambulance siren. His personal hygiene was good, while his attitude was unremarkable and generally cooperative. Rapport was described as adequately established for the intended purpose of the assessment. As was the case during the course of the Veteran's last evaluation, he was once again somewhat angry and embittered, as well as anxious. The Veteran's mood was described as dysphoric, and he appeared to feel entitled to, and deeply ensconced in, such mood and affect. The Veteran appeared to experience some grief regarding certain aspects of his combat experiences, and became intermittently emotionally labile, with an inappropriate affect at moments of heightened anger and embitterment. The Veteran's speech was unremarkable in all respects, and both expressive and receptive language were intact. Verbal productivity was described as average, and the Veteran's vocal tone and quality were within normal limits. Speech was relevant, coherent, and goal-directed. According to the examiner, the Veteran did not appear to suffer from visual or auditory hallucinations, or any other form of perceptual or cognitive distortion. There were no other disturbances of thought process or content, with the exception of some mild persecutory and grandiose ideation at times of emotional arousal. Noted at the time of examination was that the Veteran was oriented to place and person. While according to the Veteran, he did not know the date, the examiner felt this might very well not be true. The Veteran's capacity for abstract thinking was described as probably consistent with his intellect. While the Veteran's remote memory appeared to be somewhat impaired, his short-term memory appeared intact. According to the examiner, while the Veteran's immediate memory might be markedly impaired, malingering could not be ruled out. The Veteran's insight was described as lacking, and he appeared to have a very concretistic and overdetermined understanding of the role of trauma in his problems. At the time of examination, the Veteran's judgment appeared practical and intact. While suicidal ideation appeared to be periodically and recently experienced, the Veteran denied any plans upon which he had acted in the past. At the time of examination, the Veteran denied any problems with homicidal ideation. The pertinent diagnosis noted was once again PTSD, with a GAF score of 55. According to the examiner, the Veteran's clinical condition was substantially unchanged from when he was last seen in terms of social, interpersonal, and related problems. During the course of VA outpatient treatment in mid June 2005, it was noted that the Veteran remained in PTSD counseling at the local Vet Center, and that he had started to attend the VA day treatment center. When questioned, the Veteran voiced general satisfaction with his medication. According to the Veteran, with that medication, his mood was good, and he did not find himself irritable or engaging in rage episodes. On mental status examination, the Veteran's overall presentation was unremarkable. He related fairly well, and did not appear to be irritable, angry, distressed, or panicky. At the time of subsequent VA outpatient mental health treatment in August 2005, the Veteran reported some decrease in anger and irritability. On mental status examination, the Veteran's affect was described as mildly blunted, though not markedly so. Moreover, the Veteran did not appear distressed, agitated, helpless, hopeless, or morbidly depressed. During the course of VA outpatient treatment in September 2005, the Veteran indicated that he had volunteered at his church at least once per week during the period from August 17 to September 4, 2005. While the Veteran indicated that he had not volunteered for the past two weeks due to an exacerbation of his PTSD, he intended to "get back to it," given that it "really helps [him] and they need the help." In a VA outpatient note dated in November 2005, the Veteran indicated he was starting to wonder if the fluoxetine was no longer working because he tended to have an "edge" to him and liked to sit in the dark. He often found himself irritable. Objectively, he did not appear morbidly depressed. His medication was changed to citalopram. In a VA outpatient treatment note dated in late January 2006, it was noted that the Veteran attended and participated in day treatment activities. Further noted was that the Veteran enjoyed the socialization opportunity, as well as enhanced self-esteem, increased community resource awareness, and increased motivation. Significantly, the Veteran had developed constructive leisure skills, and was feeling better since his change in medication. During the course of VA outpatient treatment in February 2006, the Veteran indicated that he often found himself irritable and on edge. However, with his medication change, he was feeling less jumpy and on edge. On mental status examination, the Veteran's affect was described as less blunted than it was on a prior occasion. He related somewhat better, and did not appear to be irritable, anxious, panicky, or distressed. A VA outpatient note dated in August 2006 indicates that the Veteran felt he was still kind of irritable. Objectively, he related quite well and demonstrated a good sense of humor. He did not appear at all irritable, anxious, panicky, distressed or depressed at the time. The Veteran appeared quite well on his regimen but was wondering about a larger dose of citalopram. The clinician stated that his goal was to maintain the Veteran in his current state of psychiatric stability and that significant change was not anticipated. A VA outpatient note dated in November 2007 indicates that the Veteran wanted to remain on his medications because he found them helpful with his PTSD symptoms. During the course of VA outpatient treatment in mid May 2008, the Veteran denied any history of suicide attempts, and similarly denied any recent or current suicidal ideation. The assessment of danger to self or others was "nil to low". On September 5, 2008, an additional VA psychological examination was accomplished. At the time of examination, the employment history was unchanged from previous reports. According to the examiner, during the course of the evaluation, the Veteran was very anxious and garrulous, at times speaking at great length about matters of little or passing consequence. According to the examiner, the Veteran appeared to be over reporting symptoms, responding in a manner predicated upon fulfilling the symptoms about which he was being asked. When questioned, the Veteran indicated that he attended anger management training, though he had not recently been involved in any physical altercations. Activities of daily living skills were reportedly intact, though according to the Veteran, he was in need of occasional reminders to maintain his personal hygiene. According to the examiner, the Veteran's social and interpersonal functioning was mildly to moderately disturbed. However, given that he was retired, his occupational functioning could not be assessed, though it was not considered an issue at the present time. On mental status examination, the Veteran's personal hygiene was adequate, though he was somewhat nervous throughout the interview. According to the examiner, the Veteran's attitude was unremarkable and generally cooperative, and rapport was adequately established for the intended purpose of the assessment. Noted at the time of examination was that the Veteran continued to present as angry and dysphoric in mood, with an affect which was primarily depressed, as well as anxious and angry. The Veteran's speech was somewhat dysfluent, representing a change in the status of that function since the time he was last seen. Expressive and receptive language were intact, and verbal productivity was average, with a voice tone and quality which were within normal limits. At the time of evaluation, the Veteran's speech was coherent, though at times rambling, and lacking in relevance and goal direction. According to the examiner, the Veteran did not appear to suffer from visual or auditory hallucinations, or, for that matter, any other form of perceptual or cognitive distortion. With the exception of continued mild persecutory and grandiose ideation at times of emotional arousal, there was no evidence of any disturbance of thought process or content. At the time of examination, the Veteran was oriented to time, place, and person. His capacity for abstract thinking was described as probably consistent with his intellect, and while his remote memory appeared to be intact, both short term and immediate memory now appeared to be impaired, representing a change from when he was previously seen. The Veteran's insight continued to be lacking, and once again, he appeared to have a very concretistic and overdetermined understanding of the role of trauma in his problems. The Veteran's judgment was practical and intact, and while suicidal ideation appeared to be periodically and recently experienced, the Veteran had no specific plans or actions directed at self harm. In similar fashion, while homicidal ideation was reported, the Veteran acknowledged no intent or plan. The pertinent diagnosis noted was PTSD, with a GAF of 51. The examiner further noted that the Veteran's clinical condition was considered substantially unchanged from when he was last seen. During the course of VA outpatient treatment in early July 2009, the Veteran indicated that he was satisfied with his medications, and found them quite helpful with his mood, irritability, and sleep. On mental status examination, the Veteran was alert, calm, pleasant, and composed. According to the examiner, while when last seen in December 2008, he was described as slightly annoyed, this was not evident at the present time. Rather, the Veteran's overall presentation was unremarkable, with him appearing neither anxious nor depressed. The Veteran most recently underwent a VA psychological examination on August 9, 2012. At that time, the Veteran described many symptoms associated with PTSD, including a tendency to isolate and not make friends, or develop close relationships. According to the Veteran, he was at times hypervigilant, with a startle reflex, and a tendency to become angered and somewhat hostile when challenged. When questioned, the Veteran complained of recurrent distressing dreams of previous events. Also noted was some physiological reactivity on exposure to internal or external cues. The Veteran complained of difficulty falling asleep, as well as irritability or outbursts of anger, hypervigilance, and an exaggerated startle response. Regarding symptoms that apply to the PTSD diagnosis, there was evidence of suspiciousness, as well as chronic sleep impairment. Also noted was impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work like setting. There was also an inability to maintain effective relationships, as well as impaired impulse control, characterized by unprovoked irritability with periods of violence. Nonetheless, in the opinion of the examiner, the Veteran's level of occupational impairment was best summarized as consisting of occupational and social impairment, with occasional decrease in work efficiency and intermittent periods of an inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The pertinent diagnosis noted was PTSD, with a GAF of 65. In the opinion of the examiner, while the Veteran described many symptoms associated with a diagnosis of PTSD, and had carried that diagnosis by history, it was important to note that he described himself as an alcoholic who drank for many years of his life, never received treatment for his alcohol use, and only stopped in 1983 following a motor vehicle accident where, by his own account, he was drunk, fell asleep at the wheel, and his truck caught on fire. The Veteran additionally admitted to drug use both before going to Vietnam and after his return. In the opinion of the examiner, it was difficult to know how many of the Veteran's symptoms might also have been caused by his alcoholism and drug use. In that regard, by the Veteran's own admission, his alcoholism had led to many aggressive fighting incidents. According to the examiner, over and above the symptoms which the Veteran described, it was important to note that he was also quite functional on a daily basis. When asked about his hobbies, the Veteran indicated that he liked to hunt and fish, had recently joined the fire department as part of the fire police, and went out to restaurants with his wife. Further noted was that the Veteran traveled a fair bit, having gone on Alaskan and Caribbean cruises, and planned a flight to visit his son in the near future. When questioned, the Veteran indicated that he was encouraged to ask for an increase in his service connection by people who said he should get more because of his symptoms. However, according to the examiner, while the Veteran described many symptoms of PTSD throughout the years, there was no reason to suspect that an increase was necessarily in order given his financial status, and ability to function quite well on a day-to-day basis. In December 2012, the RO increased the rating for PTSD to 50 percent from September 5, 2008 and to 70 percent from August 9, 2012. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C.A. § 1155. Evaluation of a service-connected disorder requires a review of a Veteran's entire medical history regarding that disorder. 38 C.F.R. §§ 4.1, 4.2 (2014); Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2014). If there is a question as to which evaluation to apply to a Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2014). Where an increase in the disability rating is at issue, the present level of a claimant's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings, however, are appropriate when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). PTSD is evaluated pursuant to the General Rating Formula for Mental Disorders A 30 percent evaluation is assigned 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). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; 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); and the inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted if there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. As the United States Court of Appeals for the Federal Circuit (Federal Circuit) recently explained, evaluation under § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed under the referenced diagnostic code are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The GAF scale reflects the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). A score of 31 to 40 indicates that the examinee has some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed person avoid friends, neglects family, and is unable to work). A score of 41 to 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 score of 51-60 is appropriate where there are 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). Scores between 61 and 70 reflect 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, has some meaningful interpersonal relationships. See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM -IV) 47. Effective March 19, 2015, VA adopted as final an interim rule adopting the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The provisions of the final rule shall apply to all applications for benefits that are received by VA or that are pending before the AOJ on or after August 4, 2014. The Secretary does not intend for the provisions of this final rule to apply to claims that have been certified for appeal to the Board or are pending before the Board, the United States Court of Appeals for Veterans Claims, or the United States Court of Appeals for the Federal Circuit even if such claims are subsequently remanded to the AOJ. See 80 Fed. Reg. 14308-09 (March 19, 2015); 79 Fed. Reg. 45093-99 (August 4, 2014). This appeal was certified to the Board prior to August 4, 2014 and thus, the provisions of DSM-5 are not for application. The Veteran seeks an increased evaluation for service-connected PTSD. In pertinent part, he contends that manifestations of his disability are more severe than presently evaluated, and productive of a greater degree of impairment than is reflected by the respective 30, 50, and 70 percent ratings currently assigned. In the Appellant's Initial Brief, the attorney argued that the evidence supports a 70 percent rating since the initial date of claim. Or, at the very least, the evidence clearly established entitlement to a 50 percent rating prior to September 5, 2008, and a 70 percent rating thereafter. i. For the period prior to September 5, 2008 In the September 2011 Memorandum Decision, the Court indicated that the Board failed to discuss some evidence favorable to the Veteran's claim. This included: (1) his failure to hold a job since 2002, (2) his physical altercations with former coworkers, (3) his reasons for ending his brief volunteer work at church, (4) his marital problems, (5) his avoidance behavior, (6) his intrusive thoughts, (7) his depression, and (8) his various GAF scores. The October 2014 Memorandum Decision indicates that the Secretary conceded that the Board failed to comply with the Court's September 2011 remand in denying a rating in excess of 30 percent prior to September 5, 2008. Specifically, it was noted that the Board again failed to account for the favorable evidence and to address whether such symptoms warranted a rating greater than 30 percent prior to September 5, 2008. The Court further stated that it "now, for the second time, remands this matter and orders the Board to consider and address relevant evidence. The Court expects the Board to carefully and thoughtfully consider the evidence and to address the Court's concern or the Court will later be forced to conclude that evidence against a higher disability rating does not exist." In an effort to comply with the Memorandum Decision, the Board will address each piece of "favorable" evidence as identified in the initial Memorandum Decision. First, evidence of record shows that the Veteran retired in December 2001 following approximately 35 years of continuous employment. The July 2003 social survey noted the Veteran's statement that he shouldn't have retired and that he has been unable to find a job. On VA examination in November 2003, he reported that he hoped to work as a bus driver on a part-time basis but his driving record was interfering with that plan. Subsequent to that, he worked part-time cleaning a church. Pay stubs show employment as recent as August 2004. The evidence generally suggests that the Veteran wanted to work but that he had difficulty finding employment or working in environments where he was not alone. Second, the Veteran reported that he had gotten in to fights and had hit co-workers. See July 2003 social survey. He said the problems were especially strong the first few years after Vietnam. On review, the physical altercations with co-workers appear to have been in the Veteran's remote history. The Board observes that the appeal period follows the Veteran's long-term employment. Third, the Veteran reportedly ended his volunteer work at church because of an exacerbation in PTSD symptoms. The Board notes, however, that he indicated he would return to volunteering because it helped him out a lot and the church needed the help. Fourth, evidence of record shows the Veteran had a long-term marriage. Vet Center records note some ups and downs and even that separation was contemplated. Nonetheless, the Veteran was committed to his marriage and the relationship appeared generally stable. Fifth and sixth, there is evidence of intrusive thoughts and avoidance behaviors. The July 2003 social survey noted that when he was working his mind would go back to the military. He did not like fireworks, loud noises, or war movies. He did not like crowds or anybody sitting behind him. The November 2003 examiner indicated that hypervigilance and avoidance were noted and somewhat demonstrated during the interview. While he re-experiences the anxiety and trauma related to combat, he did not report having flashbacks related to those events. On examination in June 2005, the Veteran reported he continues to frequently re-experience the events through intrusive thoughts, recurrent dreams and infrequent flashbacks. He was generally avoidant of anything that would remind him of his experiences. Seventh, the Veteran exhibits some depression. The July 2003 social survey noted that the Veteran's mood was depressed. On VA examination in November 2003, the Veteran's mood was dysthymic and affect was depressed. There was no manifestation of guilt, grief or mania. On VA examination in June 2005, mood was dysphoric. Finally, the Board will consider the recorded GAF scores during this portion of the appeal period. On VA examinations in November 2003 and June 2005, the GAF was reported as 55, which indicates moderate symptoms. The GAF on admission and discharge in February and March 2005 was reported as 41, indicating serious symptoms. The Board observes that these scores concern the period where the Veteran was hospitalized for PTSD and was receiving a 100 percent temporary total evaluation. In January 2006, the GAF was reported as 45, also indicating serious symptoms. In considering the level of occupational and social impairment prior to September 5, 2008, exclusive of the period of hospitalization, the Veteran is shown to generally function satisfactorily. Notwithstanding, there is also evidence of symptoms which cause reduced reliability and productivity such as impaired judgment, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The November 2003 VA examination indicates that the Veteran's judgment was occasionally compromised by impulsivity, frustration, and general anxiety. He experienced depression and anxiety, and had some difficulty in working with others or being around new people or crowds. On examination in June 2005, insight appeared to be lacking although judgment was intact. The Veteran's PTSD symptoms were also characterized as "significant" in July 2003 and GAF scores indicate moderate to serious symptoms. Resolving reasonable doubt in the Veteran's favor, the Board finds that the disability picture prior to September 5, 2008, more nearly approximates the criteria for a 50 percent rating. The evidence during this period does not support a 70 percent rating. The Board acknowledges that the Veteran had some evidence of impulse control as demonstrated by his reports of "road rage" and the June 2005 examination noted some periodic and recent suicidal ideation. However, he was not shown to have obsessional rituals, or speech that is intermittently illogical, obscure, or irrelevant. While there was evidence of depression, it did not affect his ability to function independently. He was generally oriented and able to complete the activities of daily living. While he had some difficulty in adapting to stressful circumstances, it appears that he was able to work by himself on a part-time basis and even able to volunteer. The Veteran was able to maintain relationships with his wife and children and reported having a few friends. The overall evidence does not show an inability to establish and maintain effective relationships. Thus, for the period prior to September 5, 2008, the Board simply does not find the Veteran's PTSD productive of social and occupational impairment with deficiencies in most areas. ii. For the period from September 5, 2008 to August 8, 2012 The October 2014 Memorandum Decision indicates that in awarding a 50 percent rating as of September 5, 2008, the Board noted that the September 2008 examination showed an increase in severity of symptoms as manifested by dysfluent speech and impaired short-term memory. Although the Board discussed evidence of increase in disability, the Board again failed to address evidence favorable to the appellant, such as continued battles with road rage, impaired judgment, hypervigilance, interpersonal issues with his wife and family and intrusive thoughts and flashbacks. The Court noted that the Board did not address any of these symptoms or whether they would justify a rating greater than 50 percent. In discussing the aforementioned symptoms, the Board notes the September 2008 examiner's concern that the Veteran was "over-reporting" symptoms. Nonetheless, the Board agrees that on examination, the Veteran described a recent episode of road rage, which suggests impaired impulse control. He also reported periods of depression where he isolates himself in the house. His judgment was described as intact, but insight was lacking. He reported a strained relationship with his wife. He had little contact with others except the few friends that he played cards with or with whom he went fishing. The examiner described his social and interpersonal functioning as mildly to moderately disturbed. The Veteran's GAF at this time was 51, indicating moderate symptoms. Considering the September 2008 examiner's statement regarding a change in the status of functions from when last seen, as well as the evidence specifically delineated by the Court, and resolving reasonable doubt in the Veteran's favor, the Board finds that the disability picture for this period more nearly approximates the criteria for a 70 percent rating, and no more. Entitlement to a rating greater than 70 percent will be discussed in the section below. iii. For the period from August 9, 2012 The October 2014 Memorandum Decision notes that for this period, the Board relied upon the August 2012 VA examiner's conclusion that while the Veteran described many symptoms, there was no reason to suspect that an increase was necessarily in order given his current financial status and ability to function quite well on a daily basis. The Court stated that the Board failed to explain the relevance of the Veteran's current financial status and further noted that this appears to be a factor "'wholly outside the rating criteria' for PTSD and therefore, the Board's consideration of such evidence is 'error as a matter of law.'" Considering the Memorandum Decision, the Board will disregard the information as to financial status in determining whether a rating greater than 70 percent is warranted. Regardless, the overall evidence simply does not support a finding of total occupational and social impairment. In making this determination, the Board notes that despite the symptoms reported by the Veteran on the August 2012 VA examination, the examiner summarized the Veteran's disability level as "occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily with normal routine behavior, self-care and conversation." This approximates a 30 percent rating pursuant to the rating schedule. Further, the Board finds that there is no evidence of gross impairment in thought processes or communication or persistent delusions or hallucinations. The Veteran does not exhibit grossly inappropriate behavior, persistent danger of hurting self or others, or disorientation. He is clearly able to perform the activities of daily living and is able to hunt, fish and travel by himself. The Board also notes that he can go out to eat and again participates in volunteering, this time with the local fire department. Also weighing against a finding of total impairment are the GAF scores which were 51 (moderate symptoms) and 65 (mild symptoms) on VA examinations in September 2008 and August 2012 respectively. As set forth, staged ratings are assigned in this case. See Fenderson. Additional stages are not warranted. Finally, the Board has considered whether the Veteran may be entitled to an extraschedular rating pursuant to 38 C.F.R. § 3.321 (2014). On review, the referenced diagnostic code contemplates the Veteran's occupational and social impairment due to PTSD symptoms. As the rating criteria are considered adequate, referral for consideration of an extraschedular rating is not warranted. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual condition fails to capture all the service-connected disabilities experienced. In addition to PTSD, the Veteran is service-connected for diabetes, diabetic nephropathy, erectile dysfunction, and amebiasis. The only issue being considered at this time is the evaluation for service-connected PTSD. Accordingly, that is the only disability the Board has considered in the extraschedular analysis with respect to considering the collective impact of the disabilities. See id. ORDER For the period prior to September 5, 2008, a 50 percent rating for PTSD is granted, subject to the laws and regulations governing the award of monetary benefits. For the period from September 5, 2008 to August 8, 2012, a 70 percent rating for PTSD is granted, subject to the laws and regulations governing the award of monetary benefits. For the period from August 9, 2012, a rating greater than 70 percent for PTSD is denied. REMAND In Appellant's Initial Brief, the attorney argued that the Veteran was entitled to statutory housebound for the periods from October 28, 2004 to February 22, 2005 and from April 1, 2005 to the present. This issue was not previously addressed by the Board. Nonetheless, in the October 2014 Memorandum Decision, the Court agreed that remand was warranted for the Board to assess all the appellant's disabilities to determine whether SMC was warranted. The attorney argues that the benefit sought is warranted due to the Veteran's total disability rating based on individual unemployability (TDIU) on account of his PTSD, along with his service-connected diabetic nephropathy independently ratable at 60 percent. As is relevant to this case, SMC provided by 38 U.S.C.A. § 1114(s) (statutory housebound) is payable where the Veteran has a single service-connected disability rated as 100 percent and, (1) Has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 C.F.R. § 3.350(i). In Bradley v. Peake, 22 Vet. App. 280 (2009), the Court held that the provisions of section 1114(s) do not limit a "service-connected disability rated as total" to only a schedular 100 percent rating. This finding allows a TDIU rating to serve as the "total" service-connected disability, if the TDIU entitlement was solely predicated upon a single disability for the purpose of considering entitlement to SMC at the (s) rate. The Court was clear that the requirement for a single "service-connected disability rated as total" cannot be satisfied by a combination of disabilities. In December 2006, the RO granted entitlement to TDIU from October 28, 2004. It also granted entitlement to SMC at the housebound rate for the period from February 22, 2005 to April 1, 2005. The code sheet indicates that this was awarded on account of PTSD rated 100 percent and additional service-connected diabetic nephropathy rated as 60 percent. The Board observes that the 100 percent schedular rating for PTSD was temporary based on hospitalization in excess of 21 days. See 38 C.F.R. § 4.29 (2014). A June 2011 deferred rating indicates that there was a clear and unmistakable error (CUE) found in the December 2006 decision. Specifically, that the rating granted TDIU based on PTSD and thus, the Veteran was entitled to statutory housebound benefits under Bradley. An October 2011 deferral indicates that there was no CUE in the December 2006 rating because although the narrative was not completely clear, the TDIU award was based on all service-connected disabilities at the time and not just the PTSD. On review, the basis for the TDIU award is unclear and a remand is needed. The RO should implement the rating increases granted herein and adjudicate the issue of entitlement to SMC at the housebound rate for the periods in question in the first instance. Such adjudication must include consideration of whether the TDIU award was predicated on a single disability (PTSD) or was based on a combination of service-connected disabilities. Accordingly, the case is REMANDED for the following action: 1. Implement the rating increases granted herein. Specifically, a 50 percent rating for PTSD for the period prior to September 5, 2008; and a 70 percent rating for the period from September 5, 2008 to August 8, 2012. 2. Thereafter, adjudicate the issue of entitlement to SMC at the housebound rate for the periods prior to February 22, 2005 and from April 1, 2005. In making this determination, the RO must consider whether the award of TDIU was predicated on a single disability or a combination of disabilities. If the benefit sought on appeal is denied, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs