Citation Nr: 1642120 Decision Date: 11/01/16 Archive Date: 11/18/16 DOCKET NO. 11-02 749A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD) under the schedular criteria. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) due to PTSD. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Jessica O'Connell, Associate Counsel INTRODUCTION The Veteran served on active duty from April 1965 to October 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The record before the Board consists of the Veteran's electronic records located within the Veterans Benefits Management System (VBMS) and Virtual VA. When the case was before the Board in January 2016, it was remanded for further development and adjudicative action. As will be discussed more fully below, the Board finds the Appeals Management Center (AMC) substantially complied with all of the January 2016 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The issue of entitlement to a TDIU due to PTSD is addressed in the REMAND that follows the ORDER section of this decision. FINDING OF FACT Throughout the period of the claim, the Veteran's PTSD has resulted in occupational and social impairment that has more nearly approximated deficiencies in most areas than total. CONCLUSION OF LAW Throughout the period of the claim, the schedular criteria for a disability rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411 (2016). REASONS AND BASES FOR FINDING AND CONCLUSION Duty to Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2014), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2016), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The Veteran's service treatment records, Social Security Administration records, and VA treatment records have been obtained. Moreover, the Veteran has been afforded VA examinations, which in combination are adequate. Specifically, the May 2010, June 2010, July 2014, and March 2016 VA examiners performed mental status examinations of the Veteran, took into account the Veteran's statements and treatment records, and collectively provided all information required for rating purposes. In his February 2011 Substantive Appeal, the Veteran declined the opportunity to testify at a hearing before the Board. Neither the Veteran nor his representative has identified any additional, existing evidence that could be obtained to substantiate his claim. The Board is also unaware of any such evidence. Accordingly, the Board finds that VA has satisfied its duty to assist the Veteran. Burden of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2016); see also Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2016). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during active service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2016). Where there is a question as to which of two ratings shall be applied, the higher rating 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. PTSD is rated under the General Rating Formula for Rating Mental Disorders (General Rating Formula). 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran's service-connected PTSD is currently rated as 70 percent disabling. He contends that manifestations of his PTSD are more severe than the 70 percent rating reflects. Under the General Rating Formula, a 70 percent rating is assigned 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; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. The next highest and maximum 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as 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 and place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. Symptoms listed in the General Rating Formula 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, 442 (2002). The record contains Global Assessment of Functioning (GAF) scores assigned by mental health professionals who have evaluated the Veteran during the period of the claim. The GAF score is based on a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. See DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed.) (DSM-IV). Effective August 4, 2014, VA amended the regulations regarding the evaluation of mental disorders by replacing references to DSM-IV with the fifth edition of the DSM (DSM-5). See 38 C.F.R. § 4.125, amended by 79 Fed. Reg. 45099 (effective Aug. 4, 2014). Although the DSM-5 no longer uses the GAF scale to assess functioning, the DSM-IV was in effect at the time the GAF scores of record were assigned. Therefore, the Board will consider the various GAF scores of record in evaluating the Veteran's occupational and social functioning. However, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is not determinative of the VA disability rating to be assigned. See VAOPGCREC 10-95, 60 Fed. Reg. 43186 (1995). As such, in evaluating the severity of mental disorders, the disability rating is to be based on all of the evidence that bears on occupational and social impairment, rather than solely on an examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126 (2016) (emphasis added). A GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. See DSM-IV. A GAF score of 51-60 indicates moderate symptoms or moderate difficulty in social, occupational or school functioning. Id. A GAF score of 41-50 is assigned where 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). Id. A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or a 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). Id. A GAF score of 21-30 indicates behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g. sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends.). Id. A GAF score of 11-20 reflects some danger of hurting self or others (e.g., suicidal attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). Id. Factual Background and Analysis In accordance with 38 C.F.R. §§ 4.1, 4.2 (2016) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the Veteran's PTSD. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to this disability. By way of history, the Veteran filed a claim for entitlement to service connection for PTSD in December 2009 and in an August 2010 rating decision, the RO granted his claim and assigned a 70 percent disability rating. The Veteran appealed the decision assigning a 70 percent disability rating to the Board. In January 2016, the Board remanded the Veteran's claim to obtain outstanding VA treatment records dated from October 2008 to the present, to provide the Veteran with a more recent VA examination to assess the current severity of his PTSD, and to readjudicate his claim in a Supplemental Statement of the Case. On remand, the AMC obtained VA treatment records dated from January 2008 to February 2016 and associated them with the electronic record, the Veteran was afforded an adequate March 2016 VA PTSD examination, and the AMC readjudicated the Veteran's claim in a March 2016 Supplemental Statement of the Case. Based on the foregoing, the Board finds the AMC has substantially complied with the Board's January 2016 remand directives. Stegall, 11 Vet. App. at 271. The Board notes that the Veteran's only service-connected psychiatric disorder is PTSD and that the record contains evidence of mental health diagnoses of PTSD, a cognitive disorder, not otherwise specified, and a neurocognitive disorder. In reaching the below determination, the Board has afforded the Veteran the benefit of the doubt and attributed all psychiatric symptoms present to his service-connected PTSD. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). In support of the Veteran's claim for service connection for PTSD, he submitted a June 2009 private psychiatric examination report by H. B., M.D. The report indicates that the Veteran's chief complaints were that he was unable to sleep well and that he wanted to be alone all the time. He reported experiencing flashbacks and nightmares with sleep disturbance since returning from Vietnam. He indicated he lived alone, had very little contact with other people, and had a dog whom he was very close to. The examiner found the Veteran's grooming was "not good" and described him as unkempt in appearance. The Veteran had difficulty maintaining eye contact and volunteered information spontaneously, yet sparsely. He found himself thinking of his military service regularly, which caused problems with concentration. Memory was intact for recent events but impaired for events that occurred during his military service. Affect was distant, judgment was impaired, and orientation was intact. Mood was blunted and bland, and there was considerable depression present; the Veteran described depression symptomatology of depressed mood, lack of energy, anhedonia, constriction of interests, isolation and sleep disturbance. He denied hallucinations, and there was no evidence of delusions or a thought disorder. Dr. H. B. assigned a GAF score of 30. At a March 2010 VA PTSD examination, the Veteran stated he had trouble sleeping; he awakened after about two or three hours of sleep and was only able to fall back asleep sometimes. He was easily awakened by noises and when he awoke in the middle of the night, he would check inside and outside his house. He did not feel safe at home and was concerned that he would not be able to protect himself if someone attacked him. The Veteran acknowledged feeling like he always needed to be on guard. He experienced nightmares approximately two to three times a week about being in danger or being unsafe, which caused him to wake up feeling anxious. He denied flashbacks but acknowledged attending to noises other people ignored and having intrusive thoughts several times a week. The Veteran indicated he stayed to himself at home and did not have any friends. He reported difficulty with anger control, dysphoria, and feeling discouraged. He stated he last worked as a handyman but was now unable to do so due to orthopedic problems. The examiner found the Veteran was logical and goal directed, although mildly irritable. There was no evidence of disorder of thought process or content and speech was not pressured, grandiose, or restless. The Veteran reported passive thoughts of death but denied suicidal or homicidal ideation or plan. The examiner assigned a GAF score of 45. At a June 2010 VA PTSD examination, the examiner determined the Veteran's PTSD was "severe" and assigned a GAF score of 45. The Veteran reported typically sleeping three to four hours a night, with problems initiating and maintaining sleep. He experienced nightmares almost nightly. He acknowledged problems with anger and irritability, which caused him to isolate himself, and he reported that he and his current wife had been separated for 10 years because of his problems with anger, irritability, temper, and arguing. The Veteran reported having one close friend outside of family and conceded he had difficulty trusting others. While he felt hopeless at times, he denied suicidal or homicidal thoughts. He acknowledged decreased motivation and forgetting to complete his personal hygiene routine one to two times a week. He indicated he had had problems with long-term memory for years, which were becoming worse. The Veteran stated he worked for the past seven years as a handyman doing maintenance and yard work at a ranch and that he stopped working the previous week because he "couldn't handle it." He reported confusion and memory loss and stated he was "messing up" on the job. The Veteran indicated he received counseling and group therapy and acknowledged mild remission of symptoms due to treatment. On examination, the Veteran was alert and oriented, thought process was linear, affect was mildly anxious, and insight was fair. Speech was fluent, attention was intact, memory was mildly impaired, and he did not report any overt symptoms of psychosis. The examiner concluded the Veteran's PTSD symptoms caused severe impairment of social and occupational functioning. Social Security Administration (SSA) records include the record of an August 2010 mental residual functional capacity assessment. The examiner who performed the assessment concluded that the Veteran was not significantly limited in understanding, memory, and adaptation, but was moderately limited in social interaction. While generally not significantly limited in sustained concentration and persistence, he was moderately limited in his ability to work in coordination with or proximity to others without being distracted. An August 2010 psychiatric review examination revealed the Veteran was mildly restricted in his activities of daily living; exhibited mild difficulty maintaining concentration, persistence, or pace; and was moderately limited by difficulty maintaining social functioning. At a September 2010 South Carolina Disability Division examination, the Veteran informed the examiner he had PTSD, angered easily, and found it difficult to become associated with a crowd. He was unable to sleep during the night due to, in part, flashbacks. On examination, the Veteran appeared slightly anxious. He was able to name the current President, spell the word "world" forwards and backwards, and complete simple mathematical equations. At a December 2010 VA general medical examination, the Veteran indicated he last worked at a ranch in June 2010 and that his PTSD prevented him from seeking or holding gainful employment. Based on a review of the Veteran's claims file, the examiner determined the Veteran's PTSD rendered him unable to secure and maintain substantially gainful employment and that his other service-connected disabilities, in and of themselves, would cause minimal interference with both physical and sedentary employment. At a July 2014 VA PTSD examination, the examiner summarized the Veteran's level of occupational and social functioning as characterized by reduced reliability and productivity. The Veteran reported problems with sleep, nightmares, and night sweats; he never slept more than four hours a night. He acknowledged intrusive thoughts, avoidance behaviors, hypervigilance, exaggerated startle response, feeling detached, and experiencing difficulty relating to others. The Veteran stated he had one or two close friends outside of family and that he enjoyed fishing. Although he experienced increased anxiety at times, he denied panic attacks. He acknowledged problems with anger and irritability and periods of depressed mood with decreased energy and motivation. The Veteran also acknowledged problems with concentration and memory for years, with a decline in memory ability. The examiner reported the Veteran's PTSD symptoms included depressed mood, anxiety, chronic sleep impairment, mild memory loss (such as forgetting names, directions, or recent events), disturbances of mood and motivation, difficulty establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work or a work-like setting. The examiner observed that the Veteran was generally alert and oriented and was cooperative with the examination; his mood was mildly depressed, affect was mildly constricted, and speech was fluent. At a March 2016 VA PTSD review examination, the examiner diagnosed PTSD and determined it was manifested by occupational and social impairment with reduced reliability and productivity. The Veteran indicated he lived alone and had two children and four grandchildren; he described his relationship with his daughter as good and with his son and grandchildren as poor. He was close with a cousin whom he saw several times a week. While he denied having any close friends, he acknowledged having four casual friends he saw once a week at his PTSD support group. He reported that in his spare time he cooked, cleaned, did yard work, watched a lot of television, spent time on the internet, played games on the computer, fished, and walked around his land. The Veteran stated he stopped working because he was old enough to draw Social Security and was having problems with his memory. He denied missing time from work in his last year of employment due to mental health issues but indicated that he only worked three days a week and had a lot of control over his schedule. He acknowledged problems with concentration, which slowed him down and caused him to make mistakes. While he was irritable on the job, he found that working alone helped him manage his irritability. The Veteran felt group counseling was helpful because it made him feel supported and helped him to understand and cope with his condition. The examiner documented the Veteran's PTSD symptoms as anxiety, suspiciousness, chronic sleep impairment, difficulty establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances, including work and a work-like setting. The examiner observed that the Veteran's mood was dysphoric, his affect and mood were congruent, and his thought process was logical and coherent. While speech was slow, there was no evidence of psychomotor agitation or retardation. The Veteran was casually dressed with adequate attention to grooming and was cooperative and pleasant with the examiner. There was no evidence of auditory or visual hallucinations and the Veteran denied current suicidal or homicidal ideations. The examiner opined that the Veteran's PTSD resulted in "considerable impairment" but did not render him unable to secure and maintain substantially gainful employment. The examiner further opined that given the Veteran's problems with sleep, irritability, and concentration, he would perform best on a job where he worked alone or with one or two other people and had few competing job demands and few interruptions of job tasks. VA outpatient treatment records reflect that the Veteran has been receiving consistent mental health treatment since August 2007 and continues to be seen for medication management, group therapy, and individual cognitive behavioral therapy. At group therapy, while the Veteran's mood was consistently depressed, he was very receptive to treatment. The Veteran regularly attended VA mental health appointments appearing casually dressed with fair hygiene and grooming. He exhibited fair to little eye contact, was calm and cooperative, and mood was congruent and appropriate, although at times he was mildly withdrawn and anxious. Psychomotor activity was consistently normal and appetite and energy were consistently fair. Affect was restricted in range and speech was normal in volume and rate and restricted in range of tone. Thought process was regularly organized and logical while insight and judgment were fair. The Veteran did not report and there is no evidence of any delusions. Although he felt hopeless at times, he consistently denied suicidal or homicidal ideations. In September 2013, while the Veteran reported hearing vague noises at night, he denied hearing voices and he consistently denied auditory and visual hallucinations throughout the period of the claim. The Veteran typically reported an overall fair or variable mood and consistently indicated that he felt he was maintaining overall functioning. At a November 2012 appointment, the Veteran reported feeling more depressed over the past few weeks due to the death of multiple family members. He was unable to attend any of the funerals due to worries about his PTSD symptoms increasing in severity. Despite not attending the funerals, he nonetheless experienced increased nightmares and intrusive thoughts since his family members passed. At another November 2012 appointment, he stated he took things "day by day" and that he had good and bad days. In July 2014, the Veteran reported feeling more dysthymic, tense, and hypervigilant since one of his dogs disappeared two months prior. He also reported a friend in his group therapy passed and that he had been grieving. In September 2013, he reported feeling predominantly anxious lately. The Veteran regularly denied crying spells and anhedonia. He found his symptoms worsened when he did not stay busy and when he was restricted to the indoors during the winter. He enjoyed warmer weather and felt that fishing and gardening served as good outlets. He consistently reported experiencing intrusive thoughts, distressing memories, and night sweats and indicated that hearing gunshots from hunters nearby his property triggered thoughts of Vietnam. Treatment records consistently document a GAF score of 50. VA treatment records reflect that the Veteran's most severe symptoms of his PTSD are his chronic sleep impairment and isolative behavior. Several records document that the Veteran was more anxious at night and felt safer during the day, which caused him to sleep little at night and more during the day. He was on guard and hypervigilant at night and regularly slept sitting up in a chair facing the door. Little noises easily awakened him, and upon awakening, the Veteran performed "safety checks" around his house and yard. He experienced nightmares almost nightly and his sleep pattern was erratic and fragmented. He was only able to sleep one to four hours at a time and was only sometimes able to fall back asleep. The Veteran has acknowledged he preferred to be alone and isolate himself, and throughout the period of the claim, he denied socializing on a regular basis. He endorsed a general distrust for other people and only trusted his dogs as they were good companions. In September 2010, the Veteran indicated his only support system was his VA group therapy and in February 2012 the Veteran reported making friends in the group. At a December 2012 appointment, the Veteran stated he avoided going out because he did not want people to see the person he was now. In September 2015, the Veteran explained that he kept to himself because it made him feel calmer and he was less irritable alone. Although still married, the Veteran and his wife have lived separately since approximately 2000. At a September 2011 appointment the Veteran stated he was unable to live with his wife "because of the way [he] act[ed]." He mostly lived alone during the period of the claim, although around November 2012, he allowed his wife to move in with him while she was on dialysis and at the time of a March 2013 appointment, she was still living with him. At a January 2014 appointment, the Veteran stated he was living alone and that he was unable to get along with his wife or anyone else. In September 2010, the Veteran acknowledged that he had one friend whom he occasionally went fishing with; he did not socialize on a regular basis and indicated his VA group therapy was his only support. In September 2011, the Veteran said he occasionally spoke to his siblings on the phone. In June 2012, the Veteran stated that his sister lived close by but that he could "only tolerate her for very short visits," and that the same was true of his wife. In November 2012, the Veteran also indicated his mother was living with him while his sister was in the hospital. He found himself raising his voice to his mother and felt he needed space when he became angry with her because he was used to being by himself. In March 2013, the Veteran reported seeing his mother and sister on a weekly basis. At a January 2014 appointment, the Veteran acknowledged talking to his mother and sister occasionally and to his two grown children very rarely. In July 2014, the Veteran reported talking to his mother, sister, and niece on the phone regularly; while his daughter called him, he was seldom in contact with his son. In November 2014, he noted that although he did not "socialize much," he saw his mother and sister periodically, and in March 2015, he reported keeping in contact with his mother, sister, and niece and that they were supportive. The Veteran's short term memory has been poor throughout the period of the claim, and a January 2014 treatment note reflects it was becoming "progressively worse." He found his memory impairment made it difficult to concentrate and complete projects and he indicated he was not a good listener. He frequently misplaced items and regularly forgot things like important dates, turning off the oven, and refilling his prescription medication. At a September 2013 appointment the Veteran first reported that he had an aid who came to his home a few times a week to clean, prepare meals, do laundry, and organize his medication because the numbness in his fingers and hands restricted him in those activities and his short term memory was becoming progressively worse. In November 2014, the Veteran acknowledged difficulty remembering to take his medication on a daily basis and that he was unsure when he last ran out. However, he remained mostly independent with activities of daily living. The Veteran was able to drive, attend group therapy, and go to the store by himself and he was also able to take care of his finances independently. Following a thorough review of the evidence, the Board finds that a disability rating in excess of 70 percent for PTSD is not warranted under the schedular criteria. While the Board recognizes that the Veteran's PTSD symptoms cause deficiencies in most areas, the social and occupational impairment does not more nearly approximate the total impairment required for a 100 percent rating. The Veteran's thought processes have been consistently logical and there is no evidence of any thought disorder; moreover, his judgment has predominantly been characterized as fair. The June 2009 report from Dr. H. B. describes the Veteran's judgment as "impaired," but does not discuss the level of impairment. Although the Veteran acknowledged once at his March 2010 VA PTSD examination that he has had passive thoughts of dying, throughout the period of the claim he has otherwise denied suicidal or homicidal ideations. While the Veteran acknowledged that he heard noises at night and reacted to noises that others did not react to, he denied ever hearing voices and consistently denied audio and visual hallucinations. He did not report or exhibit any delusional or psychotic thoughts at any time during the period of the claim. Despite the Veteran's PTSD symptoms, he has been able to perform activities of daily living and, by his own admission, he felt he was maintaining overall functioning. The evidence reflects he has been mostly independent with his activities of daily living. While the Veteran experienced mild memory loss and would do things such as forget to turn the stove off or forget to take his medication daily, his memory loss was not so severe that he forgot people's names or important details about himself. Additionally, even though he acknowledged that once or twice a week he was unable to maintain personal hygiene, VA treatment records during the period of the claim reflect the Veteran's hygiene was consistently described as "fair." Although on one occasion in June 2009, the Veteran was described as looking "unkempt" and his grooming was "not good," he was still able to maintain minimal personal hygiene standards throughout the claim. With regard to social impairment, at one point the Veteran indicated he had no friends and on other occasions he reported having one or two close friends and four casual friends. He was able to maintain a relationship with several family members, even though at times those relationships appeared strained and his level of contact with family members varied. Although he and his wife did not live together, which he attributed to his PTSD symptoms, he allowed her to move into his home temporarily while she was undergoing dialysis, continued to support her, and kept in touch with her by telephone. Significantly, while the Veteran certainly experienced difficulty with relationships with his wife and family, and while the level of the relationship and interaction with those people may have varied, there is no showing that he is completely unable to establish and maintain effective relationships. With regard to occupational impairment, the Veteran has reported that his memory impairment makes it difficult to concentrate and that when he was working he made several mistakes on the job, prompting his decision to retire. The March 2010 VA examiner found the Veteran's PTSD resulted in a moderate-to-severe degree of impairment in occupational functioning, with an overall severe PTSD disability level, and the June 2010 VA examiner described the Veteran's occupational functioning as "severe." At a December 2010 VA general medical examination, which was afforded to the Veteran for the purpose of obtaining a medical opinion regarding whether he was entitled to a total disability rating based on individual unemployability (TDIU), the examiner determined the Veteran's PTSD rendered him unable to secure and maintain substantially gainful employment. The July 2014 and March 2016 VA examiners both determined the Veteran's PTSD caused occupational impairment with reduced reliability and productivity, as opposed to deficiencies in most areas or total impairment. The Veteran denied missing any time from work in his last year of employment due to his mental health issues, but indicated he only worked three days a week and had significant control over his schedule. Notably, in April 2011, the RO granted entitlement to TDIU effective June 1, 2010. The RO relied on the December 2010 VA general examination report where an examiner found it was "at least as likely as not that th[e] Veteran's PTSD render[ed] him unable to secure and maintain substantially gainful employment." In rendering the instant decision, the Board notes that the RO's finding that TDIU is warranted is not inconsistent with the Board's current finding that the Veteran's PTSD does not warrant a 100 percent disability rating under the schedular criteria. To the extent that the December 2010 opinion appears to support the Veteran's claim for a disability rating in excess of 70 percent, the Board finds it significant that the core purpose of the December 2010 examination and opinion was to address the Veteran's TDIU claim. See 38 C.F.R. § 4.16(a). The examiner did not opine that the disability was productive of total social and occupational impairment or impairment that more nearly approximates total impairment than deficiencies in most areas. Therefore, the medical opinion when considered with the other evidence of record does not demonstrate the degree of impairment necessary for a 100 percent schedular rating. As discussed previously, a GAF score of 30 was assigned at the June 2009 examination by Dr. H. B. and a GAF score of 50 was consistently assigned throughout the Veteran's VA treatment records. While these GAF scores reflect serious symptoms, and while a GAF score of 30 may represent the inability to function in almost all areas, see DSM-IV, the fact remains that the overall evidentiary picture does not demonstrate the degree of social and occupational impairment required for a 100 percent rating. The Board has considered the Veteran's statements and finds that his statements regarding the symptoms he experiences are competent evidence because this requires only personal knowledge. See 38 C.F.R. § 3.159(a); see also Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Board also finds the Veteran to be credible and an accurate reporter of his symptoms. Never the less his statements do not demonstrate the degree of social and occupational impairment required for a 100 percent rating. The Board has contemplated whether assigning staged ratings would be appropriate but for the reasons discussed above has determined that the criteria for a rating in excess of 70 percent have not been met for any portion of the period of the claim. See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The Board has also considered whether the Veteran's claim should be referred to the Director of Compensation Service for extra-schedular consideration. In determining whether a case should be referred for extra-schedular consideration, the Board must compare the level of severity and the symptomatology of the Veteran's disabilities with the established criteria provided in the rating schedule for each disability. See 38 C.F.R. § 3.321(b). If the criteria reasonably describe the Veteran's disability level and symptomatology, then the disability picture is contemplated by the rating schedule, the assigned evaluation is therefore adequate, and no referral for extra-schedular consideration is required. Thun v. Peake, 22 Vet. App. 111, 115 (2008). In this case, the manifestations of the Veteran's service-connected PTSD are contemplated by the schedular criteria. There is no indication in the record that the average industrial impairment from the disability would be in excess of that contemplated by the assigned rating. The Board has therefore determined that referral of this case for extra-schedular consideration under 38 C.F.R. § 3.321(b) is not in order. The Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. ORDER Entitlement to a disability rating in excess of 70 percent for PTSD under the schedular criteria is denied. REMAND With respect to the issue of entitlement to a TDIU based on PTSD, the record reflects that the Veteran has contended that he is unemployable due to PTSD. The Board has jurisdiction over the TDIU claim because the claim is based on the disability at issue in this appeal. See VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). In the narrative part of an April 2011 rating decision, the RO cited evidence showing that the Veteran was unemployable due to PTSD and appears to have based its grant of entitlement to a TDIU on the Veteran's PTSD. However, the code sheet portion of the rating decision reflects that the RO continued the assigned schedular rating of 70 percent for PTSD and granted a TDIU based on all of the Veteran's service-connected disabilities. That being the case, the Board has determined that the originating agency should undertake any indicated development and then formally adjudicate the issue of entitlement to a TDIU based on PTSD and, if appropriate, provide the Veteran and his representative with a supplemental statement of the case on the issue. Accordingly, this case is REMANDED to the RO or the Appeals Management Center (AMC) in Washington, D.C. for the following actions: 1. The RO or the AMC should undertake any indicated development. 2. Then, the RO or the AMC should adjudicate the issue of entitlement to a TDIU based on PTSD. If the benefit sought on appeal is not granted to the Veteran's satisfaction, he and his representative should be provided a supplemental statement of the case and the requisite opportunity to respond before the case is returned to the Board for further appellate action. The Veteran need take no action unless he is otherwise notified, but he may furnish additional evidence and/or argument during the appropriate time frame. See Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) This REMAND must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or 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). ____________________________________________ Shane A. Durkin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs