Citation Nr: 1604023 Decision Date: 02/04/16 Archive Date: 02/11/16 DOCKET NO. 13-13 740 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Evaluation of posttraumatic stress disorder, currently rated as 50 percent disabling. 2. Entitlement to a total rating based upon individual unemployability. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs ATTORNEY FOR THE BOARD A. Rocktashel, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1965 to August 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. The Veteran submitted additional evidence since he filed his substantive appeal in May 2013, and additional records were associated with the claims file prior to the last AOJ adjudication in April 2013. However, these records are either not pertinent to the issue on appeal, or they are duplicative of evidence previously associated with the file. Therefore, RO consideration of the evidence in the first instance is not necessary and the Board can proceed with adjudication of the case on the merits FINDING OF FACT Posttraumatic stress disorder (PTSD) was productive of occupational and social impairment with deficiencies in most areas. CONCLUSION OF LAW The criteria for an evaluation of 70 percent for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). 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, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The rating decision on appeal arises from the Veteran's disagreement with the initial rating assigned for his PTSD. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112, 116-17 (2007); VAOPGCPREC 8-2003 (2003). In this case, notice of the requirements for disability evaluations was satisfied by letters sent to the Veteran in March 2009, May 2009, and September 2011. The claim was last adjudicated in April 2013. Next, VA has a duty to assist the Veteran in the development of the claim. To that end, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate the claim for the benefit sought, unless no reasonable possibility exists that such assistance would aid in substantiating the claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2015); see Golz v. Shinseki, 590 F.3d 1317, 1320 (2010). Furthermore, "[t]he duty to assist is not boundless in its scope" and "not all medical records . . . must be sought-only those that are relevant to the [V]eteran's claim." Golz at 1320, 21. In this case, service treatment records, private medical records, VA treatment records, Social Security Administration records and lay statements have been associated with the record. Additionally, in May 2009, VA afforded the Veteran an examination with respect to the severity of his PTSD. The Board finds this examination to be adequate. The VA examiner reviewed the evidence of record, considered the Veteran's history and statements, and rendered medical opinions based upon the facts of the case and his knowledge of medical principles. The examiner described the disability in sufficient detail so as to allow the Board to evaluate its current severity. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. There is no additional evidence which needs to be obtained. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. Ratings Principles Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2015). Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities may be assigned where the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1) (2015). 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). Although the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of a claimant's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The United States Court of Appeals for Veterans Claims has held that "staged" ratings are appropriate for any rating claim 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); Fenderson v. West, 12 Vet. App 119 (1999). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. However, separate evaluations for separate and distinct symptomatology may be assigned where none of the symptomatology justifying an evaluation under one diagnostic code is duplicative of or overlapping with the symptomatology justifying an evaluation under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259, 262 (1994). Additionally, if two evaluations are potentially applicable, the higher evaluation is assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable based upon the assertions and issues raised in the record and to explain the reasons and bases for its conclusion. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that a Veteran is competent to report on that of which he or she has personal knowledge). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). When all of the evidence is assembled, VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Analysis The Veteran's PTSD is evaluated under Diagnostic Code 9411. While this Diagnostic Code addresses PTSD, all psychiatric disabilities are evaluated under a general rating formula for mental disorders. Under the general rating formula, a 30 percent rating requires a showing of 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). A 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal 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 worklike setting); inability to establish and maintain effective relationships. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2014). One factor for consideration in the evaluation of mental disorders is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). A GAF score of 61 to 70 indicates some mild symptomatology (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, with some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect 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 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). Scores ranging from 31 to 40 reflect 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 man avoids friends, neglects family, and is unable to work, child frequently beats up younger children, is defiant at home, and is failing in school). 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. 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 (2015). In this case, the Veteran claims that as a result of PTSD, he experiences vivid and violent dreams filled with explosions and death at the hands of the enemy. He also endorses recurring symptoms of depression, short term memory loss, and avoidance of crowds and social situations. He has taken medication (Halcion and Ambien) for a sleep disorder since the early 1970's and has had repeated marital problems in both of his previous marriages which ended in divorce. At the time of his August 2008 claim, he expressed an inability to commit to a relationship with a long-time girlfriend, saying that he feared he would cause her harm, although at a later point in the appeal period, he notes that he was unsure why he could not commit. In February 2011, the Veteran ultimately married his girlfriend. The Veteran reported that he lives alone in a secluded rural area and has done so for most of the time since he left his first wife and two children. He noted that his depression worsened after a diagnosis of prostate cancer in December 2007. He also claims that he is extremely susceptible to any kind of stress as it brings about severe anxiety and panic attacks. VA treatment records show that an August 2008 depression screen was positive for moderate depression. The Veteran reported that he had little interest or pleasure in doing things for several days over the prior two weeks, and more than half the days he felt down, depressed, or hopeless. He had trouble falling or staying asleep nearly every day. He felt tired or had very little energy several of the days. He had a poor appetite or overate several of the days. He felt bad about himself or felt that he was a failure several of the days. He had trouble concentrating on things more than half the days. He denied moving or speaking so slowly that other people could have noticed and denied being fidgety or restless. He also denied having thoughts that he would be better off dead or hurting himself in some way. He reported that the foregoing problems have made it very difficult to do his work, take care of things at home, or get along with other people. An August 2008 VA mental health outpatient intake note revealed the following symptoms: anxiety; panic attacks (increased pulse, racing heart, sweating); excessive worry about things out of his control; periods of extreme depression; violent nightmares resulting in kicking the ceiling, thrashing around, and unconsciously holding down his ex-wife and girlfriend; night sweats; difficulty falling asleep; awakening startled; experiencing panic after nightmares; being easily confused; poor memory (worsening over the past 8 years); difficulty with change; isolation; avoidance of crowds, socialization and people altogether; hyper-vigilance; a heightened startle response; and multiple psycho-somatic symptoms such as nausea. The Veteran reported triggers as helicopters, thunder and lightning storms, earthquakes, crowds, and being approached by people. The Veteran experienced an earthquake resulting in damage to his home after which he was unable to feel comfortable in his home for over a year. The Veteran reported living in a remote location 1/2 mile off the road in the middle of the woods where he has placed "noise makers" strategically around his property in order to notify him of anyone's approach to his home. He reported enjoying working around his home The examiner's assessment and impressions were that the Veteran has been experiencing the aforementioned symptoms for over 30 years without treatment. His symptoms were compounded with a diagnosis of prostate cancer. The examiner concluded that the Veteran lived a reclusive life, had limited interaction with the outside world, and reported bouts of extreme depression and symptoms consistent with PTSD and panic attacks. A GAF score of 40 was assigned. The mental status examination showed a nervous mood, guarded affect, good eye contact, clear logical speech, and somewhat impaired judgment with paranoid thought content. The Veteran also appeared depressed when discussing his physical illness. The Veteran denied suicidal and homicidal ideation and perceptual disturbances. A September 2008 VA mental health treatment note reported images from the trauma experienced in Vietnam plagued his sleep from time to time. He described being excessively worried about nearly everything and being always pessimistic. He also reported extreme bouts of depression where he sometimes felt as though never waking from his sleep would be better. It was noted that the Veteran isolates from others and would like to be able to socialize with others for the benefit of his girlfriend. The mental status examination noted a tearful affect, depressed mood, soft speech, cooperativeness, and denial of suicidal and homicidal ideation. November 2008 and December 2008 VA treatment records note the complaints described above along with the objective evaluation of tearfulness, depressed mood, and slow soft speech. The Veteran denied suicidal and homicidal ideation and was assessed as a low suicide risk. In January 2009, it was noted that he continued to experience anxiety, heightened startle response, excessive sleep, and depression. Excessive sedation was thought to be caused by medications. In February 2009, the Veteran began attending a VA support group. Records note that he was hesitant to share at first, however, he was seen after the group discussing treatment and symptom management with other Vietnam veterans. Another record from February 2009 indicates that a lower medication dose improved his daytime sleepiness. It was also noted that his mood was down but he looked more stolid than depressed. Yet another February 2009 record notes that the Veteran saw a weight increase. A mental status examination revealed the Veteran was stable and cooperative, and he denied suicidal and homicidal ideation. A February 2009 VA mental health outpatient record noted that the Veteran's cancer diagnosis and prostatic resection were followed by impotence and depression. It also noted the Veteran awakened from a nightmare having a panic attack. It was again noted that his mood was down, but that it looked more stolid than depressed. Beginning March 2009, and almost once a month thereafter until April 2013, records of the VA PTSD combat support group generally indicate that the Veteran was an active participant in the therapy sessions. VA treatment records for April 2009 show the Veteran underwent Thought Field Therapy (TFT) for a nightmare that he had been suffering, which he entitled "Terror." He rated his subjective unit of distress as a 6/10 with tension felt in his chest. After treatment, the Veteran rated his subjective unit of distress as a 3/10 with the tension in his body reduced. He denied suicidal and homicidal ideation. In a May 2009 VA examination, the Veteran reported that he took voluntary retirement as he became increasingly afraid of crowds of people and he was becoming increasingly anxious being around people. The examiner reported that the Veteran rarely called his family members and had poor social relationships. The examiner reported that the Veteran did not go out to socialize with people, did not work and had no leisure activities. The psychological examination revealed casual dress, and unremarkable psychomotor activity and speech. The Veteran was cooperative toward the examiner. His affect was constricted. The examiner commented that the Veteran could not experience loving feelings and could not become close to people. The examiner found the Veteran's mood was anxious and fearful. His attention was intact. He was oriented to person, time, and place. His thought content and thought process were unremarkable. The examiner found there to be no delusions. The Veteran understood the outcome of behavior. His intelligence was average. He understood that he had a problem. He had impaired sleep, as he would wake up several times a night from sleep and would feel tired the following day. There were no hallucinations present. The examiner found no inappropriate behavior, no panic attacks, no homicidal thoughts, no suicidal thoughts, no episodes of violence, and no inability to perform the activities of daily living. The Veteran was able to interpret a proverb appropriately, he had good impulse control, and he was able to maintain minimum personal hygiene. The Veteran's memory was found to be normal. The examiner commented that the mental status examination was unremarkable. The examiner reported that there was persistent re-experiencing of the traumatic event by recurrent and intrusive distressing recollections of the event. There were recurrent, distressing dreams of the event. There was intense psychological distress at exposure to internal or external cues that symbolized or resembled an aspect of the traumatic event. The Veteran made efforts to avoid thoughts, feelings or conversations associated with the trauma. He had markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, a restricted range of affect (e.g. unable to have loving feelings), and a sense of a foreshortened future. Additionally, the examiner found that the Veteran had difficulty falling or staying asleep, had irritability or outbursts of anger, and had difficulty concentrating. The examiner opined that the disturbance caused clinically significant distress or impairment in social occupational or other important areas of functioning. The examiner noted that the Veteran experienced the symptoms daily except that the severity of the symptoms varied from day to day. A GAF score of 55 was assigned. The examiner concluded that there was total occupational and social impairment due to the mental disorder. The Board notes at this juncture that the Veteran disputed certain portions of the VA examination, and supplemented other portions. In particular, he notes that he dresses and cleans up when going out, but when he stays home, he does not shower or shave often and wears the same clothes for weeks. A May 2009 VA mental health outpatient note reported that the Veteran continues to experience symptoms of depression, anxiety, poor sleep, and various other symptoms associated with PTSD. The examination revealed the Veteran was somewhat depressed with quiet, soft, slow speech. Another record from that month noted complaints of anxiety, panic attacks, excessive worry, depression, nightmares, night sweats, sleep problems, awakening startled, experiencing panic after nightmares, being easily confused, poor memory, isolation hyper-vigilance, and a heightened startle response. It was noted that daytime sleepiness improved due to a change in medication dosage. It was also noted that he awakened from a nightmare having a panic attack. His mood reportedly was still down but he looked more stolid than depressed. A June 2009 VA group counseling note reported that the Veteran was recently in contact with a friend who was there the night their unit was mortared. He reported that many things he tried to forget came back to him as a result of the conversation. A July 2009 VA group counseling note reported the Veteran feeling his mood had improved somewhat as a result of the medication and that he found comfort with others in the group. A January 2011 GAF score assigned by the VA treating professional was 50. A July 2011 VA group therapy record notes the Veteran now being in control of his anger and wanting to spend time with his family, as he was learning to allow himself to become emotionally attached to others. An August 2011 VA mental health outpatient note showed complaints of increased depression, complaints of being frequently tearful, some occasional anger (road rage), social isolation and anxiety. The mental status examination showed the Veteran was fit, looked his stated age, and dressed appropriately for weather and conditions. He was cooperative with normal speech, good eye contact, and clear, logical thought processes. A September 2011 VA psychiatric progress note shows the Veteran reporting symptoms of startle reflex, disrupted sleep when he does not take medication, hypervigilance, panic attacks, recurrent flashbacks, high levels of social avoidance and emotional numbing as well as negativity about the future and much dependence in terms of his interpersonal interactions. He denied suicidal ideation. He admitted possessing several guns, but denied any thoughts to harm himself or others. There was no evidence of mania or psychosis, present or past. The Veteran reported some increased stress recently related to his daughter having some difficulties. The examiner noted that the prostate cancer treatment and ongoing significant incontinence as well as impotence seemed to be contributing to low self-esteem and depression. The Veteran reported trouble with concentration, motivation, energy and a tendency towards depressed mood and general passivity. The mental status examination performed at the time revealed a pleasant, cooperative gentleman. He had a depressed and anxious mood. His affect was blunted. There was noted an avoidance of social situations as much as possible. The Veteran experiences hypervigilance, startle reflex, and ongoing nightmares as well as disrupted sleep when he would not take medication. He denied any thoughts to harm himself or others. A GAF score of 60 was assigned. An October 2011 VA general medical examination report noted that the Veteran's PTSD caused significant occupational and psychosocial impairment in him to such an extent that he has been jobless and has not been able to work. The examiner opined that it is a known fact that PTSD chronic can render people unable to secure and maintain substantially gainful employment which is the case with this Veteran. The Board notes that the Veteran previously was a state trooper from which he retired, and then he worked at the U.S. Customs and Border Protection. A November 2011 mental health note shows the Veteran endorsing significant depression particularly following his cancer surgery which left him sexually impotent and with ongoing bladder issues. He reported that although he always was socially isolated, the surgery and resulting after affects have worsened this. He described several instances where he became increasingly uncomfortable and was forced to flee a social situation. He admitted he recently married a "wonderful woman because that was what she wanted." He also described a daughter moving into the "get away cabin I built for myself" and a brother relocating to the area and the resultant stress on him. On examination, the Veteran was frequently tearful although he denied thoughts of self-harm. He was cooperative and had good hygiene and appropriate eye contact. His speech was normal in rate and tone. His thought process was organized, goal directed, and logical. He reported there were no changes associated with recent responses to the Suicide Risk Assessment and the examiner continued his low risk assessment. In March 2012, the Veteran entered a residential program for the treatment of PTSD at the Batavia VA facility. Records from admission show the Veteran's anxiety and depression were moderate. He rated his anger level as none. He rated his risk for suicide as none. He denied unintentional weight loss and an inability to drink or eat. In a "spiritual assessment" chart, he rated problems such as worry, denial, withdrawal, dread, discouragement, guilt, anger, and grief with an "x" on a horizontal line on the "(-)" side of the chart, but close to the center. The Veteran responded "quite a bit" or "extremely" to many of the PTSD symptoms in a questionnaire. He responded "moderately" to the question about physical reactions. An admission evaluation note showed a GAF score of 55. The note reported that the Veteran was seeking help for his depression and overwhelming anxiety. It further noted that occasionally, he almost broke into tears trying to explain his symptoms of PTSD and how hard he wanted to get better. The Veteran endorsed having fleeting thoughts of harming himself within the past thirty days, but denied a plan or intent, and he reported that he would never take his life due to moral reasons. An examination at that time showed the Veteran to be alert and able to carry out routine tasks. He was neat, clean, and dressed appropriately for the season. There were no tics, tremors, or fasciculations noted. His attitude toward the interviewer was pleasant and cooperative. His speech was clear and coherent. His mood was appropriate to thought content. His affect was sad and depressed. There were no delusions or hallucinations noted. He was in good contact with reality. His concentration was fair. Recent and remote recall was intact but fair. A psychiatry note from the residential treatment program reported that the Veteran does not like being around people. It further reported that he had trust issues especially regarding cleanliness. He felt his mind was not clear and he had problems with concentration. He felt he was unable to control certain emotions and would get tearful during certain situations where he felt people were harmonious such as when singing or getting along well. He felt mostly that there were clouds surrounding him with a good day now and then. He denied feeling helpless or worthless but felt hopeless about his medical situation and the recurrence of his prostate cancer. He had a sense of a foreshortened future. He denied having any suicidal ideation or past suicide attempts. He would get angry at times when he was alone and something went wrong, but denied a history of assaultive behavior other than in necessary situations pertaining to his job as a police officer. He reported his appetite decreased since the previous October and he had lost approximately 21 pounds. He would still eat, but not as much. His energy was not "that great." He denied having hallucinations or a history suggestive of a manic/hypomanic episode. He reported experiencing panic attacks in the past while in groups of people where he would feel very anxious, closed in, and unable to escape. The examiner found the Veteran to be in no acute distress, and with good hygiene. The Veteran's mood was depressed and anxious, and his affect was mood congruent. He denied having suicidal or violent/homicidal thoughts. He denied having hallucinations, and there was no evidence of delusional thinking. The examiner found the Veteran's cognition was grossly intact. A GAF score of 45-50 was assigned. Another record from the treatment program reports the Veteran having a goal to learn more about PTSD, the impact that it has had on his life, and how to cope with it. The examiner characterized this as future-oriented and goal-directed. Another evaluation resulted in the assignment of a GAF score of 50. A mental status examination showed his mood and affect were anxious and noted recent anxiety and panic attacks. Further records from the treatment program indicated that the Veteran felt he was more relaxed and was benefiting from the program. He endorsed handwashing more frequently than most people, but did not feel it interfered with his life. He started to get a panic attack the day before when he met someone with similar military experiences, but was able to cope with the anxiety. He found it to be helpful to go to the woods and read a book. He found it to be much easier to be alone but was trying to engage in social interactions. The objective examination findings show that the Veteran's mood was less depressed and less anxious. A GAF score of 45-50 was assigned. Upon discharge, the Veteran reported that a lot of progress had been made. The objective finding was a euthymic mood and calm affect. Lay statements from the Veteran's girlfriend and ex-wife are of record, which support the Veteran's contentions. The August 2008 statement from the Veteran's current wife indicates the Veteran is social on his own terms and has a loving and strong relationship with his two children and their families. In her January 2011 statement, she describes the near panic state in which the Veteran continually lives. She also states that if the Veteran does not have to leave his property, he will appear unshaven, he will not shower and he will wear the same clothes for some time. Private treatment records from Dr. B.K. show that since the Veteran's transient ischemic attack in 2005, it was hard for him to remember passwords and names, which increased his stress. The records show reports of anxiety and insomnia during the appeal period. October 2010 records of a private consultation by Dr. J.A.-V. report that the Veteran had mood and anxiety issues, including flashbacks, nightmares in which he sometimes choked his girlfriend. He avoided going to events where there would be numerous people. The examiner described other symptoms such as exaggerated startle reflex, self-criticism over his symptoms, and an inability to go to events such as a wedding without feeling choked up and tearful, which he found embarrassing. He described being easily in touch with his anger, but he would take great pains to control outward signs of it. He endorsed low energy. His focus and concentration were very poor. Interest and motivation could be okay, but not at a normal level. He also admitted to passive suicidal ideas at times, but no active ideation. The October 2010 consultation record also reported the Veteran struggled with anxiety in the form of panic attacks which averaged about one a week. These occurred especially around people or around the anticipation of stressful events. He reportedly endorsed chronic worrying, although not specifically compulsive worries. He denied psychotic phenomenon but would become anxious to the point of almost feeling paranoid. The report further noted that the Veteran's daughter was living on his land and that his son was in Arizona. He seemed to have a close and supportive relationship with his girlfriend of 10 years. He reported being uncomfortable in the VA support group. The objective findings were that the Veteran looked somewhat younger than his stated age. He appeared somewhat uncomfortable and restless initially and was somewhat uncomfortable talking about his symptoms. He made good eye contact, and showed a reasonable range of affect, but most predominantly it was an anxious and constricted affect punctuated by occasional smiles. Thought process was mostly linear; occasionally obsessive. Thought content did not reveal any active suicidal or homicidal ideas or psychosis. A November 2006 statement from a private medical provider revealed that bouts of atrial fibrillation experienced by the Veteran were linked with stress. In Social Security Administration submissions, the Veteran described the inability to perform certain actions, a lack of motivation, a lack of grooming, a lack of "faculty," and lack of preparing meals. However, it appears that some of these symptoms are due to physical disabilities, such as a stroke, and back and "IT band" problems. Still others are due to the fact that his wife performs those chores. After a review of the evidence of record, the Board finds that, resolving reasonable doubt regarding the degree of disability in the Veteran's favor, an evaluation of 70 percent for PTSD is warranted. The evaluation of 70 percent is warranted due to the severity of the Veteran's symptoms of social isolation, the frequency and severity of the Veteran's panic attacks, and his daily anxiety and depressed mood. The severity of his desire for isolation is illustrated by the Veteran having left his first family to isolate himself in a cabin in the woods, where he has largely remained. The reports of "noise makers" around his property to warn of anyone approaching underscore his hyper-vigilance in this regard. The record also shows instances of frequent panic attacks that result in physical manifestations such as nausea and arrhythmias of the heart. The panic attacks occur in stressful situations such as dealing with people in his job and having to remember many passwords in the job context. The record also shows that the Veteran experienced a panic attack while in the VA residential treatment program. It also has been reported that the Veteran left social situations because he felt trapped. Moreover, the Veteran's depression has been persistent, and his sleep disturbances are frequent, his GAF scores have been reflective of serious symptoms. The Board is, thus, of the opinion that the disability picture more nearly approximates occupational and social impairment with deficiencies in most areas. Therefore, a 70 percent evaluation is warranted. A higher evaluation is not warranted because the Veteran is not totally occupationally and socially impaired. The Veteran was able to maintain a long term relationship with his girlfriend, who he ultimately married. The preponderance of the evidence indicates that he also has relationships with his children, and a friendly relationship with one of his ex-wives. Although he prefers to be alone, he is able to function in some social settings and maintain some relationships. For instance, he was an active participant in many group therapy sessions, and was cooperative and communicative with all examiners. There was no evidence of psychosis. He was not a harm to himself or others, even though he had fleeting thoughts in that regard on occasion. In any event, such fleeting thoughts have been contemplated in the now assigned 70 percent evaluation. The evidence also shows the Veteran's insight was good and his judgment was intact. Although he may disregard some hygiene while he is alone in his cabin, when he leaves his property, his hygiene is appropriate. Although he was assigned one GAF score of 40 reflecting some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood, the majority of the evidence shows GAF scores were 45 and above. Additionally, the Veteran does not have short-term memory loss to the degree of forgetting names of close relatives, his occupation, or his own name. The Board notes that the May 2009 VA examiner concluded that there was total occupational and social impairment. However, the Board finds that this conclusion is inconsistent with the balance of the examiner's report and the evidence of functioning by the Veteran throughout the balance of the appeal period as discussed above. Nonetheless, the Board finds that the disability picture, even when considering the May 2009 examiner's conclusion, more nearly approximates the 70 percent evaluation. To the extent that the Veteran asserts his symptoms warrant a 100 percent evaluation, the Board finds that the findings of trained medical professionals are significantly more probative in determining the extent of the disability and whether it meets the criteria for a higher rating than are the Veteran's lay statements. Consideration has also been given regarding whether the schedular evaluations are inadequate, thus requiring that the AOJ refer a claim to the Under Secretary for Benefits or the Director, Compensation Service, for consideration of an extra-schedular evaluation. 38 C.F.R. § 3.321(b)(1) (2015). An extra-schedular evaluation is for consideration where a service-connected disability presents an exceptional or unusual disability picture with marked interference with employment or frequent periods of hospitalization that render impractical the application of the regular schedular standards. Floyd v. Brown, 9 Vet. App. 88, 94 (1996). An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of the veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, then the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. In this regard, the schedular evaluations in this case are not inadequate. Regarding the first step of Thun, the Board finds that the rating criteria reasonably describe the Veteran's disability and symptomatology. Of note, the symptoms listed in the General Rating Formula for Mental Disorders are merely demonstrative and not exhaustive. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The evidence does not reflect any symptom or degree of severity not contemplated by the General Rating Formula, which focuses on occupational and social impairment caused by all symptoms of a mental disorder. Therefore, the threshold factor for extra-schedular consideration under step one of Thun has not been met, and the Board need not reach the second step of the Thun analysis. As the disability picture is contemplated by the Rating Schedule, the assigned schedular ratings are, therefore, adequate. Finally, the Board notes that, under Johnson v. McDonald, 762 F.3d 1362, 1365-66 (Fed. Cir. 2014), a veteran may be awarded an extra-schedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, the Veteran is already receiving a combined 100 percent evaluation and a total disability rating based on individual unemployability. Thus, an extra-schedular rating on this basis is moot. Consequently, referral for extra-schedular consideration is not required under 38 C.F.R. § 3.321(b)(1). ORDER An evaluation of 70 percent for PTSD is granted subject to the controlling regulations applicable to the payment of monetary benefits. REMAND The AOJ has coded the rating determination to include individual unemployability since 2011. However, one disability was recently reclassified as 100 percent disability. SMC was not awarded based upon TDIU and a separately rated 100 percent disability. In this case, the record raises a theory of entitlement to a total rating based upon unemployability solely due to PTSD. Since TDIU (based upon PTSD) has been raised by the record, the issue must be addr3essed ion the first instance by the AOJ. Accordingly, the case is Remand for the following: The AOJ should develop and address the issue of entitlement to TDIU based upon the impact of PTSD. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs