Citation Nr: 1604967 Decision Date: 02/09/16 Archive Date: 02/18/16 DOCKET NO. 10-07 334 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD), to include entitlement to an earlier effective date for service connection. REPRESENTATION Appellant represented by: Oregon Department of Veterans Affairs ATTORNEY FOR THE BOARD A. G. Alderman, Counsel INTRODUCTION The Veteran had active service from July 1968 to July 1970 and from March 1974 to August 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee which granted service connection for PTSD, and assigned a 10 percent evaluation, effective from March 11 2008, the date of receipt of his claim to reopen 38 C F R § 3 400(q)(2)(r). The Board remanded this matter in February 2013 for additional development, which was completed. See Stegall v. West, 11 Vet. App. 268 (1998). On remand, in June 2015 the RO granted an initial 50 percent evaluation for PTSD. The Veteran appealed, seeking a higher initial rating and an earlier effective date. The current record before the Board consists entirely of electronic files known as Virtual VA and the Veterans Benefits Management System (VBMS). FINDINGS OF FACT 1. While medical records indicate a diagnosis of PTSD in January 2008, because the informal claim was received after the diagnosis of PTSD, the date of claim is March 11, 2008 as it is the later of the two dates. 2. The Veteran's PTSD has caused total occupational and social impairment due to persistent delusions or hallucinations, inappropriate behavior, persistent danger of hurting others, intermittent inability to perform activities of daily living, occasional disorientation to place, obsessional rituals which interfere with routine activities, ear-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. CONCLUSIONS OF LAW The criteria for an initial evaluation of 100 percent, effective March 11, 2008, for PTSD have been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.400, 4.7, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2015). In this case, the Board is granting in full the benefit sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. II. Analysis The Veteran seeks an initial rating in excess of 50 percent and an earlier effective date for the date of service connection. First, the Board observes that service connection was granted, effective March 11, 2008, the date of receipt of the informal claim. Generally, the date of entitlement to an award of service connection is the day following separation from active service or the date entitlement arose, if the claim is received within one year after separation from service; otherwise, it is the date of receipt of claim, or date entitlement arose, whichever is later. 38 U.S.C.A. § 5110(b)(1) (West 2014); 38 C.F.R. § 3.400(b)(2) (2015). With regard to reopened claims, the date of an award of service connection based on a claim reopened after final disallowance will be the later of the date of receipt of the claim or the date entitlement arose. See 38 C.F.R. § 3.400(q). In this case, the RO denied reopening the Veteran's claim for service connection for PTSD in December 2006. Subsequent to the December 2006 denial, the Veteran did not submit a notice of disagreement and did not submit new and material evidence within one year of the denial of his claim. 38 C.F.R. § 3.156(b). Therefore, the December 2006 rating decision became final. The next correspondence received that could be considered a claim for service connection for PTSD was not received until March 11, 2008. Medical records indicate a diagnosis of PTSD in January 2008; however, because the informal claim was received after the diagnosis of PTSD was made, the appropriate effective date for service connection for PTSD is March 11, 2008 as it is the latter of the two dates. 38 C.F.R. § 3.400(q). Accordingly, an effective date prior to March 11, 2008 is not warranted. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part IV (2015). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Veteran's service-connected PTSD has been assigned a 50 percent rating pursuant to the criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411, which is included under the General Rating Formula for Rating Mental Disorders. According to the General Rating Formula for Mental Disorders, a 50 percent evaluation is warranted where 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; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent evaluation is warranted where 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; intermittently illogical obscure, or irrelevant speech; 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. Id. A 100 percent evaluation is warranted where 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. In evaluating psychiatric disorders, the VA has adopted and employs the nomenclature in the rating schedule based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-V). See 38 C.F.R. § 4.130. As such, the diagnosis of a mental disorder should conform to DSM-V. See 38 C.F.R. § 4.125(a). Diagnoses many times will include an Axis V diagnosis, or a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). Higher scores correspond to better functioning of the individual. GAF scores ranging between 61 and 70 are assigned when there are 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 when the individual is functioning pretty well and has some meaningful interpersonal relationships. GAF scores ranging between 51 and 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging between 41 and 50 are assigned when there are 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). GAF scores ranging between 31 and 40 are assigned when there is 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). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record to this time period and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered, but is not determinative of the percentage VA disability rating to be assigned. The percentage evaluation is to be based on all of the evidence that bears on occupational and social impairment. Id. ; see also 38 C.F.R. § 4.126 (2014); VAOPGCREC 10-95, 60 Fed. Reg. 43186 (1995). Symptoms listed in VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). In addition, in Mittleider v. West, 11 Vet. App. 181 (1998), the U.S. Court of Appeals for Veterans Claims (Court) held that VA regulations require that when the symptoms and/or degree of impairment due to a veteran's service-connected psychiatric disability cannot be distinguished from any other diagnosed psychiatric disorders, VA must consider all psychiatric symptoms in the adjudication of the claim. According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). In addition, the evaluation must be 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. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b). The Board observes that the words "slight," "moderate" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. Following a review of the evidence of record, the Board finds that an initial 100 percent rating is warranted throughout the appeal. The Veteran indicated that his treatment had primarily been at VA Vet Centers. During his intake appointment in January 2008, he reported having been married four times. He was living with a girlfriend but maintained a motor home as a home and residence. He had an older brother but did not talk to him often. He had a son but had trouble communicating with him. He also had a daughter from his first marriage. He had not spoken to his son in six years. The Veteran had a work history showing many jobs with short periods of employment. He was medically terminated from his last place of employment due to non-service-connected vertigo. The Veteran reported that his mental health symptoms had worsened over the last few years and that his symptoms were severe. The provider observed that his speech was appropriate and he was oriented to all three spheres. However, he had impaired memory and labile affect; was tense, agitated and restless; and had fair judgment. The Veteran had delusions and disorganized thinking and believed people were following him or out to get him. He forgot directions to places even though he had been to them several times. He could not subtract serial sevens and had problems putting things together and following directions. Hallucinations, including his report of seeing the faces of guys that died in the war and hearing their voices were noted. Symptoms of depression included excessive appetite with weight gain; sleep disturbance; lack of sex drive; low energy and motivation; and suicidal thoughts. Also contributing was a history of leukemia and vertigo. He reported that he was withdrawn and had difficulty talking to people and dealing with authority figures. He had had major problems maintaining steady employment since returning from the war. He would occasionally go out dancing and singing but he did not socialize. He did not participate in any organizations and avoided things that reminded him of war. The Veteran reported chronic anxiety, depression, panic attacks, and inability to deal with stress. He had a quick temper and would get irritated easily. In the past he would explode in anger and throw things. He reported frequent road rage. The provider observed restricted range of affect. After service, he quit attending church. The Veteran described his work history and the provider noted problems with anxiety, inability to communicate with others, irritability with anger, and an explosive temper. The Veteran admitted to frequent anger, including anger with managers and bosses. He also had problems communicating with coworkers. The diagnosis was PTSD. March 2008 Vet Center records indicate that the Veteran was anxious with a worsening depressed mood. Records show reports of worsening anxiety and depression. He also reported feeling discouraged. He was unemployed and not able to work due to his PTSD symptoms, vertigo, and diabetes. One provider said the Veteran's job history showed problems with anxiety, inability to communicate with people, irritability with anger, and an explosive temper. The Veteran was fired from at least five jobs due to PTSD symptoms. The Veteran said he had quit other jobs before being fired. He reported having frequent anger and road rage. The provider indicated that the Veteran was very anxious and depressed. The Veteran was treated at a VA medical center in March 2008. He was depressed and anxious and had low energy. He lived in a camper and had poor support. He had lost interest in activities he used to enjoy. He denied suicidal and homicidal ideation, denied hallucinations and delusions, and did not exhibit paranoia. His appearance was normal, his behavior and motor skills were appropriate, and his speech, language, and affect were normal. His mood was okay. His thought process and content were normal. He was oriented and had fair insight and judgment. A GAF score of 60 was assigned. In an April 2008 report from the Vet Center, completed by C.B., LCSW, C.B. noted that the Veteran had been married four times but lived with a girlfriend. He maintained a mini motor home as a home and residence. His work history showed many jobs with short periods of employment. The Veteran was medically terminated from his last place of employment due to non-service-connected vertigo. The Veteran reported having recurrent and intrusive distressing recollections of the war and said it affected him daily. He recently began having nightmares about being in the war zone every night. He reported having flashbacks while awake and said the flashbacks could last all night. He indicated that triggers reminding him of the war caused a physiological reaction in his body. His symptoms included tremors, anxiousness, nervousness, increased heart rate, and sleep disturbance. He did not watch television or read the newspaper because he wanted to avoid exposure to violence or news of the war in Iraq and Afghanistan. Instead, he went for walks in the woods to be alone. He no longer attended church and avoided crowds unless he was singing or performing. He avoided patriotic events. He no longer spent time with his friends and had no close friends. He isolated himself and bottled his feelings. He did not participate in or attend recreational activities, such as attending sporting events, or socialize with others. He felt like no one cared about him. C.B. observed a restricted range of affect and the Veteran said he was unable to have loving feelings. Also reported was irritability as well as anger outbursts. He said he had no patience with people, and would get mad and blow up but would be fine 10 minutes later. He had difficulty concentrating at work. He would daydream and had problems listening to others. He would do things his way instead of how he was told to do them. He reported hypervigilance, lack of trust, and hyperawareness of his safety. Sudden noises and movements startled him. C.B. found that the Veteran had occupational and social impairment with deficiencies in most areas. C.B. stated that the Veteran had frequent depressed moods affecting his ability to function independently and effectively. He also had considerable difficulty adjusting to stressful circumstances including work and social settings. He was unable to establish and maintain effective relationships. The Veteran was withdrawn and did not socialize. As a result of the severity of his PTSD symptoms, the Veteran had been unable to maintain a normal line of employment and follow a career. C.B. said the Veteran was withdrawn and had problems communicating with coworkers and the public. He was often irritable and had a bad temper. He also had problems with authority figures when he was able to work. C.B. stated that the Veteran was unable to work due to medical problems but that his PTSD symptoms were a major contributing factor in his inability to maintain steady gainful employment. VA treatment records show multiple visits for psychiatric follow-ups. A May 2008 VA treatment record notes anxious mood, fair insight, and fair judgment. All other findings were normal or appropriate. A GAF score of 65 was assigned. Similarly, in August 2008, the Veteran reported flashbacks and sleep disturbance, but the mental examination showed fair insight and judgment with "fine" mood. All other findings were normal or appropriate. A GAF score of 65 was assigned. In October 2008, the only change was that his mood was "up and down." In December 2008, he reported better sleep due to the C-PAP machine but still had dreams. His mood "could be better" but insight and judgment were good. A GAF of 65 was continued. The Veteran had a VA examination in October 2008. Reported symptoms included difficulty sleeping; nightmares; suicidal ideation; and feelings of guilt, worthlessness, failure and depressed mood. He said flashbacks of Vietnam had haunted him daily since returning from his first tour of duty in 1970. He discussed his four marriages and indicated that his first marriage ended because his wife was frustrated over his inability to maintain employment. He was unable to travel to attend his daughter's wedding, his brother's funeral, or his granddaughter's funeral due to finances. He had not seen his son since 2001. The examiner noted that the Veteran had a girlfriend, little to no relationship with his family, and did not have other social outlets. The Veteran said he enjoyed singing and working on cars but indicated that he liked to do things his way. The examiner found that the Veteran's psychosocial functioning was limited to poor. He had very few social supports and appeared to rely heavily on his social worker. He did not engage in pleasurable activities and was preoccupied by thoughts of his war service. He had an extensive work history and had worked over 30 jobs since service. He could not stand for people to tell him what to do. The examiner found his psychomotor activity was unremarkable but restless; his affect blunted; his mood anxious, hopeless, depressed, fearful, and angry; his thought content preoccupied; and his intelligence average. He reported sleep impairment and noted that he had been diagnosed with sleep apnea. He also had nightmares about service. The Veteran's remote and recent memory was mildly impaired. He was a poor historian. PTSD symptoms included persistent reexperiencing of the traumatic event, avoidance of stimuli associated with the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or estrangement from others; difficulty falling or staying asleep; irritability or outbursts of anger; hypervigilance; and flashbacks. When exposed to a reminder of his trauma, the Veteran's heart rate increased, his vertigo worsened, and he got headaches. The Veteran lived a lonely life, estranged from his family and without friends. He reported having only friend in which he could confide. The examiner found that the Veteran's failed marriages were due to difficulties with intimacy and maintaining a steady financial life. His inability to relate to others effectively caused him to lose many jobs over his lifetime, cause financial distress, and dramatically impacted his relationships with family. The examiner found that the Veteran's symptoms resulted in deficiencies in family relations, work, and mood. The examiner reiterated symptoms discussed above in support of his finding. The examiner assigned a GAF score of 50. Of record is a December 2009 letter from D.J.E., LPS/MHSP, NCC, of the Vet Center. He noted that the Veteran was being followed at the VAMC for medication management. The Veteran reported continued reexperiencing of his trauma from service, which included recurrent and intrusive distressing recollections and recurrent distressing dreams of events. He also reported having intense psychological distress and physiological reactivity at exposure to cues that symbolized or resembled an aspect of the traumatic events. The Veteran demonstrated persistent avoidance of stimuli associated with combat stressors and numbing of general responsiveness that was not present before the trauma as indicated with efforts to avoid thoughts, feelings or conversations associated with the traumas, efforts to avoid activities places or people that aroused recollections of the traumas, inability to recall an important aspect of the traumas, feelings of detachment from others, and having a restricted range of affect. The Veteran reported difficulty falling or staying asleep when not medicated, irritability and outbursts of anger, difficulty concentrating, hypervigilance, and an exaggerated startle response. The provider indicated that the Veteran's symptoms have caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The following symptoms severely troubled the Veteran: wanting to isolate or be alone; feeling angry or irritable; anhedonia; short and long term memory problems; feeling detached from others; upsetting and intrusive thoughts; troubled by certain smells, sights or sounds; feeling as if his life will be cut short; exaggerated startle response; feeling anxious; hypervigilance; guilt; trouble staying asleep; feeling numb inside or lack of emotion; difficulty concentrating; flashbacks; frequent nightmares; feeling helpless; feelings of sadness, depression, and fatigue; and crying spells. The following symptoms moderately troubled him: paranoia, low self-esteem, and trouble falling asleep. The following symptoms mildly troubled him: anxiety attacks and feelings of hopelessness. His symptoms of auditory hallucinations, too much energy and poor appetite did not trouble him at all. The Veteran stated that his experience in Vietnam affected his decision making. He noted that his relationships suffered and that he would leave rather than work through problems. He also noted his extensive employment history and said that when conflict arose, he would walk away. He had not worked in the last two to three years and indicated that he was anxious when driving. He reported having a daughter, whom he got along with, as well as a son whom he rarely spoke to. He lived with his girlfriend but was considering moving west. The Veteran noted that he had become more depressed since his therapist retired. VA treatment records show a GAF score of 58 in January 2010. He was sleeping about 8 hours per night and was happy about being a new grandfather. He described his mood as "some days okay and some days not so okay." All other observations were normal. In March 2010, the Veteran recognized that he needed to engage socially. He wanted to return to church and maybe participate at the Senior Citizens Center in Springfield. His mood was "alright" while all other objective observations were normal. A GAF score of 60 was assigned. In July 2010, his mood was noted as improved. In May 2011, the Veteran said he had his ups and downs but was generally reasonable with mood. He reported having bought a used camper but still lived with his girlfriend. His daughter was overseas. All mental status observations were normal or appropriate. A GAF score of 66 was assigned. In February 2013, the Veteran was examined by A.H.F., PhD. who completed a mental health examination report and disabilities and benefits questionnaire (DBQ). In the DBQ, A.H.F. indicated review of the claims file and that a mental status evaluation was conducted. The provider discussed the PTSD criteria and stated that the Veteran was exposed to trauma and had recurrent and distressing recollections and dreams of the event; and had intense psychological distress and physiological reactivity 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 as well as activities, people and places associated with the trauma; had markedly diminished interest or participation in significant activities; had feeling of detachment or estrangement from others; and had a sense of foreshortened future. Also noted was difficulty falling asleep, irritability or outbursts of anger, difficulty concentrating, hypervigilance, and exaggerated startle response. The provider found that the symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. Symptoms included: depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; flattened affect; difficulty understanding complex commands; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships; and neglect of personal appearance and hygiene. In a separate worksheet, A.H.F. found that the Veteran would miss 3 or more days of work per month and would have to leave work early 3 or more days per month due to his PTSD. He would also have 3 or more days per month where he would have trouble with concentration or focus and be unable to stay focused for at least 7 hours of an 8 hour workday. A.H.F. diagnosed PTSD, depressive disorder, and anxiety disorder. A GAF score of 45 was assigned. A.H.F. stated that the symptoms of each disability could not be differentiated and opined that the Veteran's mental health condition resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. In the remarks, A.H.F. discussed the October 2008 examiner's findings, and indicated that despite some uncertainty of the etiology of some symptoms, the Veteran's social and functional difficulties were more likely than not a function of PTSD, with a level of severity that was present at the time his claim for compensation was filed. The Veteran also submitted an opinion from S.B., PhD, addressing vocational opportunities. In this March 2013 report, S.B. indicated that she had reviewed the claims file, including the report from A.H.F. She noted that the Veteran did not complete high school, earned his GED post-military, and completed 2 years of college, earning an Associate's degree in auto body repair. He was trained in welding. Subsequent to service he worked at 30 short-term jobs in areas such as retail, construction, food service, and auto body repair. He last worked in 2008. S.B. noted that the 2008 VA examination showed impairment in social and occupational functioning. He was not able to sustain social contact due to anxiety and intrusive thoughts. He had issues with stress tolerance for the same reasons. She stated that while he was functional at times, his ability to sustain a functional status in a work setting was questionable. She noted that A.H.F. found symptoms of near constant anxiety, depressed mood, social issues, sleep issues, judgment issues, stress tolerance issues, and productivity issues. A.H.F. believed the Veteran would miss excessive days in the workplace, need to leave work early at an unacceptable level, experience distraction which would interfere with work tasks, and have stress tolerance and social issues in the workplace. A.H.F. rated the severity of the condition as serious with a GAF score of 45. She indicated that this rating would indicate a level consistent with being occupationally unemployable. She opined that the severity of the Veteran's emotional symptoms appeared to be significant enough to render him totally unable to work as he had issues with sustained public contact, social interaction, stress tolerance, concentration, and panic attacks. Over the years his symptoms have worsened and he is unable to tolerate even the simplest employment setting on a sustained basis. While the VA notes are not as detailed in their vocational opinion, the severity of symptoms reported in the narrative would render this Veteran disabled. She said the opinion is further supported by the opinion of A.H.F. which is a more recent evaluation of the severity of the condition. The Veteran is totally unemployable as a result of his service-connected PTSD. The Veteran had a VA examination in April 2013. Results of the self-report psychiatric work function impairment test showed marked impairment with attention and concentration when performing work requiring setting limits, tolerance and standards; with getting along with coworkers or peers; when performing activities with a schedule; with maintaining regular attendance and punctuality; when completing a normal work day and work at a constant pace; and when interacting with others. The Veteran had severe, i.e. unable to perform work function, when related to synthesizing, coordinating, or analyzing data; performing tasks requiring the precise attainment of set limits, tolerance and standards; performing work activities requiring negotiating, explaining, or persuading; responding appropriately to criticism; negotiating, instructing, and supervising; and responding appropriately to changes in work conditions. The Veteran lived in a camper located in his platonic, 80 year old girlfriend's driveway. He described his relationship with her as mutual caregivers. The Veteran said she threatened to end the relationship if he were to leave town to visit his daughter. He reported having telephone contact with his daughter and indicated that he would like to visit her. He did not trust and was suspicious of everyone. He had no friends and engaged in no recreational activities. He avoided contact with others and spent time in an abandoned factory building 3 to 4 times per week for the solitude and peace. He discussed his employment history and noted that angry outbursts resulted in termination as well as one physical altercation. The examiner noted that since the October 2008 VA examination, the Veteran was scheduled for 9 followup mental health appointments for PTSD and had an average GAF score of 59. His GAF score at the last visit in May 2011 was 66. Since January 2008, he has had individual psychotherapy 2 to 4 times a month at the Vet Center. The examiner said his prognosis was guarded or poor without psychiatric medication management. Further, while the Veteran reported benefit from individual psychotherapy, he distrusted mental health clinic providers and had not been seen in the mental health clinic since May 2011. Symptoms included depressed mood; anxiety; suspiciousness; panic attacks more than once per week; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; impairment of short and long term memory; flattened affect; difficulty understanding complex commands; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances including work or a worklike setting; obsessional rituals which interfere with routine activities; impaired impulse control such as unprovoked irritability with periods of violence; persistent delusions or hallucinations; and neglect of personal appearance and hygiene. He also reported visual, auditory and olfactory hallucinations. The examiner stated that since the last VA examination, the severity of the Veteran's PTSD had worsened. The examiner noted the criteria present for a finding of PTSD and noted that the raw score indicated severe or extreme PTSD. A GAF score of 49 was assigned. The examiner stated that the Veteran had more than one mental disorder diagnosed but that it was not possible to differentiate the symptoms attributable to each diagnosis. The examiner stated that while depressive symptoms were noteworthy, a separate diagnosis was not assigned because depressive symptoms are diagnostically viewed as an essential part of PTSD psychopathy. The examiner also stated that significant physical and medical problems, such as gout, tinnitus, Type II diabetes, acute myeloid leukemia, thrombophlebitis, osteoarthrosis, sleep apnea, and hypertension, impact Veteran's mood; however, while each co-morbidity further limits the Veteran's psychosocial functioning, gauging the exclusive and adverse impact of each co-morbidity on his functioning separate from that of another is not feasible. The examiner opined that the Veteran's PTSD caused total occupational and social impairment. A July 2013 mental health note shows he went to visit his children and grandchildren. He also contacted his ex-wife. He said he never got over her, and tried to reconcile the relationship by reaching out, sending letters, etc. but that she had no interest in getting back together with him. He reported feeling depressed by this. He described his mood as "I exist." He also noted that he was going through bankruptcy and was struggling to make ends meet financially. He reported low energy, sad mood, and poor sleep, with frequent wakening and nightmares. He also reported exacerbation of PTSD symptoms. He had intrusive thoughts and recollections of traumatic events that occur during the day and night. He described survivor's guilt, anxiety, avoidance of thoughts and memories, nightmares and flashbacks. He admitted having passive suicidal ideation however he denied having an active plan or intent to harm him. The mental status examination showed he was struggling with his mood. His affect was dysphoric and congruent with mood. No other abnormalities were noted. A GAF score of 55 was assigned. Similar symptoms and GAF score were noted in October 2013 and January 2014 In May 2014, the Veteran reported that he had been more emotional and that his mood had been down, which he attributed in part to wishing he was with his family and ex-wife. He also struggled with feeling that nobody really cared about him. He expected to see his son later that day. He felt very discouraged about relationships with family and friends over the past few months and had even contemplated his own death on a few occasions. He denied having any intent to harm himself, nor had he had any thoughts of suicide in the past few months. He denied any previous attempts. He reported that he frequently had thoughts of and still saw the face and heard the sounds of a good friend dying back in Vietnam. The provider said he carried a tremendous amount of guilt related to this death as he felt responsible for sending this friend out of their foxhole, which ended up in a friendly fire incident that killed the friend. He reported ongoing intrusive thoughts about this episode but denied any recent nightmares. Much of his time was spent at his home and tended to avoid going out. He reported depressed mood most days, problems sleeping without the help of medication, fatigue, feelings of guilt/failure, loss of interest and general psychomotor slowing. He indicated that he still lived with his female friend but said they were just good friends and supported each other financially. All observations in the mental status examination were noted as normal. However, the provider noted that the Veteran's thought content included rumination over his previous marriage and combat experiences. A GAF score of 60 was assigned. The Board has reviewed all of the evidence and finds that it supports the assignment of a total initial rating. As discussed above, the Veteran's PTSD has resulted in symptoms of the severity to cause total occupational and social impairment due to persistent delusions or hallucinations; inappropriate behavior; persistent danger of hurting others; intermittent inability to perform activities of daily living; occasional disorientation to place; obsessional rituals which interfere with routine activities; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control, including anger outbursts and road rage; difficulty in adapting to stressful circumstances (including work or a worklike setting); impaired short and long term memory, and an inability to establish and maintain effective relationships among other symptoms. Consequently, the Board finds that a total rating is warranted for the entire pendency of the claim. The appeal is granted. Finally, in Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) stated that a claim of entitlement to a total disability rating based upon individual unemployability (TDIU) is part and parcel of an increased rating claim when such claim is reasonably raised by the Veteran or the evidence of record. Here, the evidence suggests that the Veteran is unemployable due to his PTSD; therefore, a claim for TDIU was raised. As the Veteran is now in receipt of a total schedular rating for his PTSD, it follows that the issue of entitlement to a total disability rating based upon individual unemployability due to service-connected disability is moot. ORDER A 100 percent rating for PTSD is granted for the entire pendency of the claim. _________________________________________________ L. M. BARNARD Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2014). Department of Veterans Affairs