Citation Nr: 1614775 Decision Date: 04/12/16 Archive Date: 04/26/16 DOCKET NO. 11-24 357 ) ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) for the period from January 26, 2011, to November 5, 2013. 2. Entitlement to a disability rating in excess of 70 percent for PTSD for the period from November 6, 2013. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Sarah Campbell, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1979 to January 1982. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision of the Department of Veterans Affairs Regional Office (RO) in Muskogee, Oklahoma, in which the RO granted in part the Veteran's claim for an increased rating for his service-connected PTSD, assigning a 50 percent rating. The Board remanded the case to the RO in August 2013 for further development and adjudicative action. The case has been returned to the Board for further appellate review. As will be discussed further herein, the agency of original jurisdiction (AOJ) substantially complied with the remand orders and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97 (2008); Dyment v. West, 13 Vet. App. 141 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). FINDINGS OF FACTS 1. For the period from January 26, 2011, to November 5, 2013, the Veteran's PTSD was manifested by symptoms such as disturbances of motivation and mood, and difficulty in establishing and maintaining effective relationships that approximated occupational and social impairment with reduced reliability and productivity. 2. Resolving all doubt in the Veteran's favor, for the period from November 6, 2013, symptoms from PTSD nearly approximate total occupational and social impairment. CONCLUSIONS OF LAW 1. For the period from January 26, 2011, to November 5, 2013, the criteria for a rating in excess of 50 percent for PTSD were not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.22, 4.130, Diagnostic Code 9411 (2015). 2. For the period from November 6, 2013, the criteria for a 100 percent rating for PTSD are met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.22, 4.130, Diagnostic Code 9411 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Generally, VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). In a claim for increase, the VCAA requires only generic notice as to the type of evidence needed to substantiate the claim, namely, evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on employment, as well as general notice regarding how disability ratings and effective dates are assigned. Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (2009). In February 2011, the RO issued a letter notifying the Veteran about what information and evidence is needed to substantiate his increased rating claims, what information and evidence must be submitted by the claimant, what information and evidence will be obtained by VA, and what evidence is necessary to support a disability rating and effective date. The duty to notify has been met. Next, VA has a duty to assist the Veteran in the development of the claims. This duty includes assisting him in the procurement of service treatment records, pertinent treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service VA treatment records and adequate VA examination reports. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Moreover, his statements in support of the claim are of record. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. As noted above, the Board remanded the case in August 2013 for further evidentiary development and adjudication. Per the Board's instructions, the AOJ obtained the identified records of VA treatment and attempted to obtain records of an application of benefits from the Social Security Administration, which did not exist as of June 2014. The AOJ scheduled the Veteran for an additional VA examination, which was conducted in November 2013. The Veteran was then provided a rating decision and supplemental statement of the case (SSOC) in January 2014, in which the AOJ awarded the Veteran an increased rating of 70 percent, effective as of November 6, 2013. Thus, there has been substantial compliance with the Board's remand instructions. See Stegall, 11 Vet. App. 268. For the above reasons, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Analysis Disability evaluations are determined by comparing a Veteran's symptoms with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's PTSD is rated under Diagnostic Code 9411. 38 C.F.R. § 4.130. A 50 percent rating requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability evaluation 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 work like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability evaluation is warranted where the evidence shows 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; 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. Although the Rating Formula lists specific symptoms that are indicative of total impairment, the United States Court of Appeals for Veterans Claims has held that the symptoms listed in the Rating Formula are only examples, and that evidence of those specific symptoms is not required to show that the veteran is totally disabled. In rating a mental disability VA is required to consider all symptoms that affect his social and occupational functioning, and not limit consideration to those symptoms listed in the Rating Formula. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). In other words, the primary consideration is whether the manifestations of the service-connected psychiatric disorder result in total social and occupational impairment, regardless of whether the veteran demonstrates those symptoms listed in the Rating Formula. 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. One factor for consideration 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 (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 social 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). While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores. See 38 C.F.R. § 4.130. The Veteran's entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern, and VA must address the evidence concerning the state of the disability from the time period one year before the claim for an increase was filed until VA makes a final decision on the claim. See Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The RO received the Veteran's claim for an increased rating for his service-connected PTSD in January 2011. The Veteran contends that his PTSD is more disabling than reflected by the 50 percent disability rating assigned for the period from January 26, 2011 to November 5, 2013, and the 70 percent rating assigned thereafter. Records of VA treatment reflect that the Veteran has received ongoing care for his PTSD, including consistent reports of anxiety, depression, problems with sleep, including nightmares, and maintaining effective work and social relationships. A June 2010 VA treatment records reflect that the Veteran reported symptoms of anxious mood and depression occurring five to six times a month. He reported having dreams related to the war and plane crashes that he witnessed while in service about once or twice a week. He denied having the following: flashbacks, suicidal ideations, homicidal ideations, feeling worthless or hopeless. He reported having fair energy and motivation. He stated he was able to sleep for five to six hours a night. The Veteran described a prior history of drug and substance abuse, but that he was "clean" since 2008. The Veteran reported that he was employed. A June 2010 mental status examination conducted by a physician indicated that the Veteran was well-groomed, well-related, cooperative, easily engageable, had normal speech rate, volume, tone, and rhythm. The Veteran's mood was anxious. His thought process was coherent and goal-directed and recent and remote memory was intact. In addition, the Veteran had fair judgment. Although the Veteran stated that he had several suicide attempts in the past, he denied having suicidal and homicidal ideation, as well as perceptual disturbances. The physician provided an assessment of chronic PTSD. On the same day, the Veteran was also seen by a treating social worker who diagnosed the Veteran with recurrent moderate major depression and opioid and polysubstance, which was determined to be in full remission. A mental status examination conducted by the social worker indicated the same results, and added that the Veteran had an intact concentration, grossly intact sensorium and cognition, and he was oriented to date, place, and person. The Veteran had a GAF score of 45. In September 2010 VA treatment records, the Veteran reported similar dreams related to war and plane crashes. He stated that he felt on-guard and alert. He denied having flashbacks, suicidal or homicidal ideations, perceptual disturbances, and feelings of worthless/hopelessness. He also reported having fair energy and motivation, and indicated that he gets about five to six hours of sleep a night. A mental status examination indicated that the Veteran was well-groomed, well-related, cooperative, and easily engageable. The Veteran showed normal speech, rate volume, tone, and rhythm. He had an anxious mood that was congruent with full range. The Veteran showed a normal thought process and an intact memory. In a January 2011 VA treatment record, the Veteran reported similar symptoms and described his mood as "fine." He denied having flashbacks and denied use of drugs or alcohol. He denied suicidal and homicidal ideations, perceptual disturbances, and feeling worthless/hopeless. He reported having fair energy and motivation and a normal sleep pattern of seven to eight hours each night. Mental status examination showed he was well-groomed, a little guarded but cooperative, and easily engageable. The physician indicated that he showed normal speech rate, volume, tone, and rhythm. His mood was anxious and congruent with full range. His thought process was coherent and goal-directed. The physician also noted that the Veteran had an intact memory, limited insight, and fair judgment. The Veteran was afforded an examination for VA purposes by a psychiatrist in February 2011. At that time, he complained that he experienced flashbacks, intrusive thoughts, difficulty sleeping with nightmares occurring twice a week, problems concentrating, difficulty with his memory, being easily startled, avoiding activities, irritability, anger, inability to remember important aspects, intense physical reaction, sense of limited future, guilt, and difficulty trusting people. The Veteran reported that the severity of the symptoms was moderate and that his symptoms were constant, continuous or ongoing. The Veteran indicated that the symptoms affected total daily functioning, which resulted in difficulty controlling his anger, getting along with people, and irritability. The Veteran stated that he was not receiving any treatment for his condition at the time, but that he received psychotherapy as often as three times over the past year, which he indicated helped his mental condition. He indicated that he was divorced and that his relationship with his children was not good. The Veteran reported that he had few friends and he preferred to keep to himself. He reported that he was self-employed and denied a history of violent behavior. Mental status examination showed the Veteran to display a flat affect, although no abnormalities of thought or memory were noted. He denied suicidal and homicidal ideation as well as hallucinations and delusions. The examiner noted that the Veteran had high levels of anxiety and worry that affected his work and social relationships, and his mood was depressed and discouraged. The diagnoses included major depressive disorder and PTSD with a GAF score of 56. The examiner explained that the symptoms of major depressive disorder included mood disorder, marked with depressed mood, generalized loss of interest, no libido, no appetite, insomnia, low energy, having no social life, and found that his symptoms caused moderate stress and impairment in social and occupational functioning. The examiner noted that the Veteran's substance and alcohol abuse was in remission, and was related to his PTSD. The February 2011 examiner further found that the Veteran's PTSD symptoms indicated an anxiety disorder, described as having flashbacks, intrusive thoughts, difficulty sleeping with nightmares, problems trusting people, difficulty with his memory, being easily startled, avoiding activities, inability to remember important aspects, intense physical reaction, sense of limited future, guilt, and difficulty trusting people. The examiner determined that the Veteran was capable of managing his own finances, had no difficulty with recreation or leisurely pursuits, and was a reliable historian. The examiner specifically found that the Veteran's PTSD caused occupational and social impairment with reduced reliability and productivity. In his March 2011 statement, the Veteran reported having difficulty in maintaining employment and friendships. He stated that he had difficulty trusting people. He also expressed feeling depressed and having memories of the plane crashes. A March 2011 VA treatment record indicated that the Veteran was doing well, in a good mood, stable, calm, and collected. He reported that he continued to have PTSD symptoms from the traumatic event he witnessed. The physician conducted a mental status examination and described the Veteran as pleasant, truthful, with coherent speech, and a logical thought process. The Veteran's mood was described as good and affect was a bit guarded. The physician noted the Veteran exhibited good insight and judgment. The Veteran denied suicidal or homicidal ideations, as well as delusions or hallucinations. In August 2011 VA treatment records, the Veteran reported feeling "not up to par" and tired, lazy, and slow over the past nine months since the passing of his mother in November 2010. Mental status examination showed that the Veteran was neatly dressed, pleasant, and polite. He was somewhat guarded. He showed logical speech and thought, good insight and judgment. The Veteran denied any present suicidal or homicidal thoughts. The Veteran's September 2011 substantive appeal indicated that Veteran had an interview for a job. The Veteran stated that "no one wants a felon." He expressed difficulties in his relationships with his children and his third marriage. He denied having thoughts of hurting others. In September 2011 VA treatment records, the Veteran indicated that he was married and reported having anhedonia and depressed mood. He stated that despite his ability to joke around, he feels down and tired due to his weight. He also stated that he continued to experience PTSD symptoms. Mental status examination showed that the Veteran's speech was coherent and goal directed. He was in a sad mood and affect was congruent. He denied suicidal or homicidal ideations, as well as delusions and hallucinations. His insight and judgment were considered normal. In December 2011 VA treatment records, the Veteran reported that he was upset due to marital discord, but that his mood was otherwise okay. He denied having suicidal and homicidal ideations, delusions, and hallucinations. Mental status examination showed the Veteran's speech was coherent and goal-directed. He joked during treatment and his mood was noted as "ok." He showed good insight and judgment. In a subsequent December 2011 VA treatment record, the Veteran reported continued difficulties in coping with the passing of his mother. He also described difficulty in his relationship with his step-daughter due to her mental disability. Mental status examination showed the Veteran was pleasant and engaging with normal speech, thought processes, insight, judgment, and speech and motor skills. The Veteran denied having suicidal or homicidal ideations, as well as hallucinations. In his April 2011 notice of disagreement, the Veteran stated that he was unable to hold a job for over two years at any place. He stated that he worked at a lumber yard for several years and had difficulty maintaining a good relationship with his employer and coworkers. He also stated that he had his own business, but that he had trouble retaining employees. Finally, he expressed difficulty in maintaining relationships and friendships and that his longest marriage lasted two years. January 2012 VA treatment records indicated that the Veteran started PTSD focused treatment. The Veteran displayed a dysthymic mood with congruent affect. The Veteran was not in crisis state, and he did not report or demonstrate any evidence of suicidal or homicidal ideation. The Veteran was administered a PCL-S (PTSD checklist) in which the Veteran had a score of 64, which was considered moderate PTSD. The Veteran had a GAF score of 55. In a March 2012 statement, the Veteran indicated that he was separated from his third wife after seven months of marriage and that his relationship with his children remained unchanged. In addition, he stated that he did not want to work because he did not want to be around people. From May 2012 to August 2012, the Veteran was enrolled in a VA Mental Health Residential Rehabilitation program. In May and June 2012 VA treatment records from the program, the Veteran denied having feelings of harming himself. He also rated his depression as a two out of ten and indicated he was sleeping well. In the May 2010 VA treatment record, the Veteran was described as alert, oriented, cooperative with a pleasant affect, and a great sense of humor. He was casually dressed and groomed. He appeared motivated. The Veteran indicated that he had a strong spiritual belief. He also indicated that he previously owned a building/construction company, and he was unsure of whether he wanted to work. In the June 2010 VA treatment record, the Veteran indicated that he experienced symptoms of depression such as worthlessness, low energy, low mood, anhedonia, over-sleeping and weight gain. In a June 2012 psychiatric evaluation, the Veteran reported having vivid dreams and occasional nightmares, trouble with energy, motivation, and concentration. He indicated an improvement in his depressed mood. He also stated his sleep was okay at times. No psychosis or mania was noted. A mental status examination indicated normal results. The veteran denied any suicidal or homicidal ideas, plan, or intent. The physician stated that the Veteran met the PTSD criteria, but also had some complicated bereavement issues. The Veteran had a GAF score of 55. A July 2012 VA treatment record indicated that the Veteran rated the severity of his depression a two to three out of ten. He reported having improved motivation and that medication has improved his dreams. He also stated that he had quite a bit of avoidance regarding the traumatic incidents he observed. Upon conducting a mental status examination, the physician indicated his mood was depressed and saw an improved motivation. The Veteran showed some isolation. No abnormalities were noted. An August 2012 discharge note summarized that the Veteran was pleasant and cooperative throughout the program from May 2012 to August 2012. The report also indicated that the Veteran successfully completed the program. It was noted that the Veteran had a good support network and had a normal mental status examination. January and April 2013 VA treatment records indicated that the Veteran was not experiencing depression or suicidal ideations and he appeared calm and clean. He denied having thoughts of harming himself or others in the April 2013 VA treatment record. Severe depression was indicated based on the Veteran's self-report in a depression screen. He indicated experiencing difficulty in finding a job because of his prior felony convictions. No abnormalities were noted in his mental status examination. May 2013 and June 2013 VA treatment records noted no abnormalities in the Veteran's mental status examinations. In the June 2013 VA treatment record, he indicated that he was unemployed except for occasional part-time work. He stated that finding employment was difficult due to his prior felony convictions. In a July 2013 VA treatment record, the Veteran indicated that his third marriage ended due to intimacy and commitment issues. The Veteran reported that he had issues with anger, intimacy, and concerns about his weight. The Veteran appeared disheveled and grooming was unkempt. A mental status examination showed no abnormalities. In a September 2013 statement, the Veteran stated that he had good and bad days, and that he was unable to hold a job. He indicated that he had difficulty focusing, short patience, and experienced depression. The Veteran underwent mental status examinations with no abnormalities noted in September and October 2013 VA treatment records. Those records noted a moderate level of depression. In an October 2013 VA treatment record, the Veteran complained of periods of depression lasting about four to five days. He stated difficulty in obtaining employment and expressed that "no one wants to hire a felon." Mental status examination showed that the Veteran was casually dressed and appeared clean with no abnormalities noted. The Veteran underwent an additional VA examination on November 6, 2013. The Veteran reported that he was married three times and that his current marriage was probably over. He stated that he does not do well in marriages. He also reported not having a lot of friends and disliked crowds, but that he typically went shopping for needed items and attended his daughter's softball games. He stated that he attended AA meetings several days a week and attended church weekly. He stated that he enjoyed playing the guitar and was learning how to play the piano. He expressed enjoyment in helping others in AA and that he wanted to help others at the Salvation Army. The Veteran indicated that he was self-employed as a home builder until 2003 at which time he lost his business as a result of drug and alcohol use and prison time. Since leaving prison in 2007, the Veteran indicated that he had not worked regularly, and that he did some carpentry work or projects for friends for short periods of time. The Veteran indicated that he attempted suicide after his business failed in 2003, but he was not hospitalized for the incident. The examiner noted symptoms of depressed mood, anxiety, suspiciousness, panic attacks, problems with sleep, mild memory loss, flattened effect, disturbances of motivation and mood, and difficulty maintaining effective work and social relationships, as well as difficulty adapting to stressful circumstances. The VA examiner noted that the Veteran's previous diagnosis of major depressive disorder was strongly connected to his trauma response and PTSD diagnosis, and that PTSD more accurately described his entire symptom picture. The examiner indicated that the Veteran's PTSD symptoms caused clinically significant distress or impairment in social, occupation, or other important areas of functioning. The examiner diagnosed the Veteran with chronic PTSD and assigned a GAF score of 51, which the examiner noted was due to low social tolerance, restricted activities, and few friendships. In particular, the examiner found the Veteran's PTSD symptoms to cause occupational and social impairment with deficiencies in most areas, including work, school, family, relationships, judgment, thinking and/or mood. The examiner concluded that the effect of his PTSD has worsened since 2011, as he was unemployable due to the effect of his PTSD on his concentration, thought, organization, social comfort, frustration tolerance, and anger control. The examiner opined that it is more likely than not that the Veteran would not be able to attend work regularly and reliably because of his PTSD. Initially, the Board observes that the record on appeal demonstrates that, in addition to the Veteran's service-connected PTSD, he has also been diagnosed with having major depressive disorder and alcohol and substance abuse, in remission, secondary to PTSD. Although the February 2011 VA examiner determined that symptoms associated with the PTSD and depressive disorder can be delineated from one another, the November 2013 VA examiner conducted a more recent and thorough psychiatric examination of the Veteran, and did not distinguish between symptoms arising from his depression versus the symptoms arising from his PTSD. The November 2013 VA examiner attributed the Veteran's major depressive disorder to his military service rather than any post-service cause. In addition, the February 2011VA examiner did not differentiate between symptomatology associated with the Veteran's PTSD and the nonservice-connected substance and alcohol abuse, in remission, and concluded that it was secondary to PTSD. The Board notes that, when it is not possible to separate the effects of the service-connected disability from a nonservice-connected disability, such signs and symptoms shall be attributed to the service-connected disability. See 38 C.F.R. § 3.102 (2014); Mittleider v. West, 11 Vet. App. 181 (1998) citing Mitchem v. Brown, 9 Vet. App. 136 (1996) (the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence which does so). Accordingly, the Board will consider the more recent psychiatric symptoms as depicted by the evidence as a whole in rating the service-connected PTSD unless clearly attributed to the other nonservice connected disorders. a. Period from January 26, 2011 to November 5, 2013 Upon review of the relevant medical evidence, the Board finds initially that the Veteran's PTSD has been consistent with the criteria for a 50 percent rating for the period between January 26, 2011 and November 5, 2013, and that a higher rating is thus not warranted for that period. In that connection, the Board notes that the Veteran was treated on multiple occasions during this period, for complaints of depressed mood, anxiety, disturbances in motivation, difficulty with maintaining effective work and social relationships, problems with sleeping, as well as nightmares, intrusive thoughts, and problems concentrating. He was specifically noted at his February 2011 VA examination to display occupational and social impairment with reduced reliability and productivity. The Veteran was described as having a great sense of humor in May 2010 VA treatment records and engaged in joke-telling as shown in September 2011 VA treatment records. He was consistently described as an engaging and cooperative individual. In addition, the Veteran reported his symptoms as being of a moderate severity when he rated his symptoms of depression as a two out of ten as shown in May, June, and July 2012 VA treatment records. In June and July 2012 VA treatment records, the Veteran reported an improved motivation. The physician also noted the improvement in the Veteran's motivation in the July 2012 VA treatment record. The August 2012 VA treatment record also indicated that the Veteran was pleasant and cooperative throughout the VA Mental Health Residential Rehabilitation program. The Veteran consistently had normal mental status examinations throughout this period, and he denied having suicidal or homicidal ideations, including hallucinations or delusions. Despite the Veteran's PTSD symptoms, the treatment records reflect a cooperative and engaged individual with fair judgment and an intact memory. In addition, in June 2013 VA treatment records, the Veteran reported that he was working part-time at different intervals, and attributed his inability to secure employment mainly due to his previous felony convictions. In October 2013 VA treatment records, the Veteran reiterated that "no one wants to hire a felon." Thus, the Board finds that, for the period between January 26, 2011 and November 5, 2013, the Veteran's PTSD more nearly approximated the assigned 50 percent rating for occupational and social impairment with reduced reliability and productivity, as manifested by the Veteran's anxiety, disturbances of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. See Mauerhan v. Principi, 16 Vet. App. 436 (2002) (holding that symptoms recited in the rating schedule for mental disorders are to serve as examples of the type and degree of the symptoms and not an exhaustive list). In so concluding, the Board finds compelling the February 2011 VA opinion that concluded the Veteran's symptoms were best described as occupational and social impairment with reduced reliability and productivity. In addition, the Veteran's ongoing anxiety and difficulty in maintaining social or intimate relationships, disturbances of motivation, as well as multiple assessments of depression, nightmares, and ongoing sleeping problems more closely approximates the 50 percent disability rating. In its analysis, the Board has considered the GAF scores assigned to the Veteran in June 2010, February 2011, and January 2012 of 45, 56, and 55, respectively, which is indicative of moderate and serious symptoms. The GAF score of 45 by a social worker is an outlier and was not accompanied by symptom manifestations of severe disability. The Veteran has consistently denied having suicidal ideations during the period in question, and there is no evidence that the Veteran experienced severe obsessional rituals, or frequent shoplifting. The GAF score of 55 and 56 are consistent with the overall findings in the VA treatment records and VA examination reports. Further, there is no evidence that the Veteran displayed 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). To the contrary, the Veteran has consistently exhibited normal speech, good personal appearance and hygiene, good judgment, and normal thought processes. Furthermore, the Veteran has been shown to function independently, appropriately and effectively. Specifically, the February 2011 VA examiner determined that the Veteran was capable of managing his own finances, had no difficulty with recreation or leisurely pursuits, and was a reliable historian. The Veteran also stated that he had a job interview in his September 2011 substantive appeal, which further indicates his ability to function independently and effectively. Although the Veteran appeared disheveled and his grooming was described as unkempt in July 2013 VA treatment records, this description does not rise to the level of neglect of personal appearance and hygiene as required for a total disability rating. Further, a mental status examination showed no abnormalities at that time. The Board additionally notes that the Veteran's mother passed away in November 2010, and the Veteran has expressed symptoms related to his difficulty in coping with her death on numerous occasions including in August and December 2011 VA treatment records. A June 2012 psychiatric evaluation also noted these symptoms and concluded that the Veteran had complicated bereavement issues. In sum, the overall evidence reflects that he did not experience deficiencies in most areas prior to November 6, 2013, as is required for a 70 percent rating. Rather, his difficulties are akin to the problems identified by the criteria for a 50 percent rating, with reduced reliability and productivity as a result. In particular, the Board notes that during the period in question, the Veteran was not found to have deficiencies in most areas-work, school, family relations, judgment, thinking, and mood. Although the Veteran indicated he had marital discord and relationship issues with his children, the February 2011 VA examiner considered his statements and specifically found him to display symptoms productive of social and occupational impairment with reduced reliability and productivity to warrant a 50 percent rating. The Board notes, as discussed above, that it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. 38 C.F.R. § 4.21 (2013). Nonetheless, upon review of the relevant medical evidence discussed above, the Board finds that, for the period between January 26, 2011 and November 5, 2013, the Veteran's PTSD was manifested by symptoms resulting in occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective relationships. See 38 U.S.C.A. § 5017(b) ; 38 C.F.R. §§ 3.102 , 4.3, 4.130 (Diagnostic Code 9411). Therefore, a rating higher than the 50 percent disability rating assigned from January 26, 2011 to November 5, 2013, is not warranted. b. Period from November 6, 2013 Findings from the November 2013 VA examination are internally inconsistent. The November 2013 VA examiner found the Veteran's PTSD symptoms to cause occupational and social impairment with deficiencies in most areas, but did not find his symptomatology productive of total social and occupational impairment. Furthermore, the GAF score assigned of 51 signifies moderate impairment. However, the examiner indicated that the Veteran was unemployable because of his inability to attend work regularly and reliably due to PTSD symptoms. In view of the inconsistency and resolving all doubt in the Veteran's favor, the Board finds that an evaluation of 100 percent is warranted for the period beginning November 6, 2013. However, prior to November 6, 2013, the evidence does not show 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 oneself or others; inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. In this regard, although he has reported a suicide attempt in 2003 after the failure of his business, no intent or plan was noted after 2003. Further, the Board notes that, on every occasion on which he was asked, the Veteran has denied experiencing suicidal or homicidal ideations, as well as hallucinations or delusions. c. Additional considerations Consideration has been given regarding whether the schedular rating is inadequate for this disability, requiring that the RO refer a claim to the Chief Benefits Director or the Director of the Compensation and Pension Service for consideration of extraschedular rating under 38 C.F.R. § 3.321(b)(1). Here, the rating criteria specifically address the Veteran's PTSD. As indicated above, VA examination reports and treatment records noted the Veteran's sleep impairment, anxiety, depression, disturbances of motivation and mood, difficulty in maintaining employment and social relationships, impaired concentration and memory, and irritability; however, these signs and symptoms, and their resulting impairment, are contemplated by the rating schedule. Thus, the Board finds that the Veteran's disability picture is contemplated by the rating schedule. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). Accordingly, a referral for extraschedular consideration is not warranted because his PTSD, is contemplated by the rating schedule. Under Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 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 conditions fails to capture all the service-connected disabilities experienced. However, there are no symptoms caused by a service-connected disability that have not been attributed to and accounted for by a specific service-connected disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed to the combined effect of multiple conditions. Additionally, if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for a higher rating is whether a total disability rating based on individual unemployability (TDIU) as a result of that disability is warranted. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The record shows that the Veteran is in receipt of TDIU, effective November 6, 2013, which was granted in a July 2014 rating decision. Prior to November 6, 2013, the Veteran indicated that was employed part-time at different intervals. The Veteran has indicated that he was unable to obtain employment due to his felony convictions. Additionally, as reflected in the February 2011 VA examination and VA treatment records prior to November 6, 2013, there was no indication that the Veteran was unemployable due to his PTSD. Thus, the Board finds that prior to November 6, 2013, the Veteran's service-connected disability alone did not preclude gainful employment. Therefore, the Board finds no basis for awarding entitlement to TDIU, prior to this date. See Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). ORDER Entitlement to a disability rating in excess of 50 percent for PTSD for the period from January 26, 2011, to November 5, 2013, is denied. Entitlement to a disability rating of 100 percent for PTSD for the period from November 6, 2013, is allowed, subject to the regulations pertinent to the disbursement of monetary funds. ______________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs