Citation Nr: 1723904 Decision Date: 06/23/17 Archive Date: 06/29/17 DOCKET NO. 05-34 665 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Anchorage, Alaska THE ISSUES 1. Entitlement to a rating in excess of 70 percent disabling for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. Unger, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1993 to February 1996. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2003 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah. Jurisdiction of the claims file rests with the RO in Anchorage, Alaska. The Veteran testified at a hearing before the undersigned in July 2006. A transcript of that hearing is associated with the claims file. The Board remanded the instant matters in February 2016. The Board finds that the Agency of Original Jurisdiction (AOJ) has substantially complied with the remand orders and no further action is necessary in this regard for the claim decided herein. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (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). This appeal was processed using the Veterans Benefits Management System and Virtual VA paperless claims processing system. The issue of entitlement to a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the period prior to July 14, 2005, the Veteran's PTSD is manifested by occupational and social impairment with reduced reliability and productivity as a result of psychiatric symptomatology, to include occasional suicidal ideation, depression, anxiety, hypervigilance, nightmares and difficulty sleeping, flashbacks, irritability, panic attacks, anger, and a need to clean herself and her surroundings, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. 2. For the period after July 14, 2005, the Veteran's PTSD is manifested by occupational and social impairment with deficiencies in most areas as a result of psychiatric symptomatology, to include suicidal ideation including a suicide attempt, panic attacks, anxiety, suspiciousness, chronic insomnia, severe marital discord, limited judgment and insight, an angry and dysphoric mood, nightmares, obsessional rituals, episodic hallucinations, depression, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work and work like setting, impaired impulse control, and mild memory loss such as forgetting names, directions or recent events, without more severe manifestations that more nearly approximate total occupational and social impairment CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for PTSD prior to July 14, 2005 are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.21, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2016). 2. The criteria for a rating in excess of 70 percent for PTSD from July 14, 2005 are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.21, 4.125, 4.126, 4.130, Diagnostic Code 9411 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS With respect to the Veteran's claim herein decided, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). The Board has reviewed all of the evidence in the Veteran's claims file, including her VA treatment records, VA examination reports, hearing testimony, and statements submitted in support of her claim. In this regard, the Board notes that, although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, all of the extensive evidence of record. Indeed, it has been held that while the Board must review the entire record, it need not discuss each piece of evidence in rendering a decision. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007); Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board's analysis will focus specifically on the evidence that is needed to substantiate the Veteran's claim for an increased rating for PTSD. I. Increased Rating Claim The Veteran is currently in receipt of a 50 percent rating effective May 12, 1998 and a 70 percent rating effective July 14, 2005 for her PTSD. She contends that such disability is more severe than the currently assigned ratings, and as such, an increased rating is warranted. As the Veteran's claim was received in April 2003, the appeal period extends to April 2002. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). While the Veteran's entire history is reviewed when making a disability determination, where service connection has already been established and an increase in the disability rating is at issue, it is a present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). The Court has held that, in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. The Veteran's service-connected PTSD is evaluated under the criteria of Diagnostic Code 9411, which provides evaluations pursuant to VA's General Rating Formula for Mental Disorders. Under the formula, a 30 percent rating is warranted where occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events); a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty 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; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating 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; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; 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. A 100 percent rating is warranted when 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. As the United States Court of Appeals for the Federal Circuit recently explained, evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation ... requires an ultimate factual conclusion as to the Veteran's level of impairment in 'most areas.'" Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126 (a). In addition to evidence regarding the Veteran's symptomatology and its impact on his social and occupational functioning, a Global Assessment of Functioning (GAF) score is another component considered to determine the entire disability picture for the Veteran. The GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness" from 0 to 100, with 100 representing superior functioning in a wide range of activities and no psychiatric symptoms. Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (quoting DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 32 (4th ed. 1994)). A GAF score of 61 to 70 reflects some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. A GAF score of 41 to 50 signifies serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 31 to 40 signifies some impairment in reality testing or communication, or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., where a depressed man avoids friends, neglects family, and is not able to work). DSM-IV; 38 C.F.R. §§ 4.125, 4.130. See Carpenter, 8 Vet. App. at 242. The Board notes that VA recently updated references in its regulations to the Fifth Edition of the DSM (DSM-5). However, the changes do not apply to claims that were certified for appeal to the Board on or before August 4, 2014. See 80 Fed. Reg. 14,308 (March 19, 2015) (Applicability Date). Inasmuch as the Veteran's appeal was certified to the Board in June 2006, the amendments are not applicable. The Board notes that a GAF score need not be accepted as probative if it is determined that the score does not reflect the overall psychiatric disability picture at the time of the examination. Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995) (it is the responsibility of the Board to weigh the evidence, including the medical evidence, and determine where to give credit and where to withhold the same and, in so doing, the Board may accept one medical opinion and reject others). However, the probative value of the GAF scores will be considered in light of the other evidence of record. During an April 2002 treatment session, the Veteran reported that she thought that she was pregnant and her husband was "pushing the divorce through." She also reported continued distress at work due to an alcoholic co-worker. She denied any suicidal or homicidal ideation but stated that she had "meltdowns during which she is very emotional." Mental status examination of the Veteran showed that she was emotionally labile at times with coherent thought processes, frequent eye contact, and rapid, hyper-verbal speech. Following VA outpatient mental health treatment on May 1, 2002, the VA psychologist stated that the veteran was in a distressed mood and that her emotional stability "is not good." On VA mental health assessment on May 15, 2002, the Veteran complained of periods of intense anxiety and difficulties with sleep onset and maintenance. She was estranged from her husband of 8 years. She reported holding 20 jobs since service separation in 1996 and being fired "from all of them." She also complained that she cried often, felt that others did not value her, and was very critical of herself. Mental status examination of the Veteran showed that her behavior, speech, and thought processes were all within normal limits with an appropriate affect, an anxious, agitated, and depressed mood, no suicidal or homicidal ideation, impaired insight, and somewhat impaired judgment. The Veteran also was hypervigilant, anxious, experienced flashbacks and had a general fear of men. The Veteran's GAF score was 55, indicating moderate symptoms or moderate difficulty in social, occupational, or school functioning. The diagnosis was PTSD. During an October 2002 treatment session, the VA examiner stated that the Veteran was dysthymic but not suicidal. In December 2002, the Veteran reported increased nightmares, waking screaming from sleep, and a lack of energy. In April 2003, the Veteran was emotionally labile, irritable, tearful, angry, and focused on her low self-worth. She agreed to go to a crisis respite center rather than hurting herself. In an April 2003 statement, the Veteran contended that she experienced "continuous nightmares and my marriage is starting to crumble" due to her service-connected PTSD. The Veteran's spouse also submitted a statement in April 2003 in which he contended that the veteran "battles constant depression...[and] is often angry." He stated that the Veteran experienced severe "emotional and mental turmoil" and was "overwhelmed by depression, mood swings, anger, excessive need to clean herself and the house, defensiveness, panic attacks, fear, and insomnia." On VA outpatient treatment in September 2003, the Veteran complained of not wanting to start treatment with a new therapist because of anxiety about her mental health issues and military sexual trauma. She reported that her marriage was deteriorating because of her problems with sexual intimacy as a result of an in-service rape. She stated that, if her prior therapist did not return, "she will regress back to being suicidal" although she denied any current suicidal ideation. She reported continuing nightmares once a week or more and screaming in her sleep. Mental status examination of the Veteran showed normal speech, a labile mood, depressive and angry thoughts, coherent thought processes, fair judgment, and good insight. The Veteran also was anxious and guarded. In statements on her November 2003 notice of disagreement, the Veteran contended that she experienced "constant extreme panic & nightmares about my rape and feelings of worthlessness." She also complained that her service-connected PTSD was "ruining my marriage." She reported further, "I have extreme trouble establishing or maintaining both work and personal relationships." Her nightmares had increased, her sleep had decreased, and she had been unemployed for 16 months. She also stated, "I feel extreme panic and failure when confronted by men." On VA PTSD examination in July 2005, the Veteran complained of problems with sleep, terrifying nightmares 5 times a week, night sweats, daily intrusive thoughts, flashbacks that occurred "a lot" and interfered with her relationship with her husband, "tons" of suicidal ideation "lately" but no plan, a weight gain of 30 pounds in the last 2 years, an exaggerated startle response, and hypervigilant behavior at night. The VA examiner reviewed the Veteran's claims file and medical records. The Veteran reported that she could not be in a room alone with a man whom she did not know and was unable to get on an elevator if there was a strange man on it. She also reported anger and irritability at her husband and at co-workers. She had been married to her husband for 7 years but had been separated from him for 2 of those years. She reported a significant level of stress in her marriage and was currently living alone. She stated that her husband did not understand her and there was a significant amount of conflict in her marriage. She had been employed for the past 6 months but stated that most of her jobs had ended when she had been fired by male bosses. Her hypervigilant behavior at work had impaired her work performance because she refused to shake hands or touch male co-workers. She managed her own activities of daily living. Mental status examination of the Veteran showed somewhat rapid speech with normal volume, two periods of tearfulness during the examination, spontaneous and abundant thought processes, some rambling thought content but no suicidal or homicidal ideation, no delusions, ideas of reference, or feelings of unreality, intact concentration, a dysphoric mood, a restricted affect, intact judgment, and fair insight. The Veteran's GAF score was 45, indicating serious symptoms or serious impairment in social, occupational, or school functioning. The diagnosis was chronic PTSD. In a September 2005 statement, the Veteran contended that her nightmares had increased and prevented her from working. She also reported hallucinations, increased panic attacks, problems relating with others, including her husband and her family, increased social impairment, frequent suicidal ideation, obsessional rituals, flashbacks to her in-service rape, and increased anger, frustration, and depression. The Veteran was hospitalized at a private hospital in December 2005 after attempting suicide. On admission to the emergency room (ER), she was inconsistent and guarded with the interviewer and was considered an unreliable historian. Information was obtained from the Veteran's mother and husband, who reported that, on the day of her ER admission, the Veteran had called both of them and reported that she wanted to kill herself and was saying goodbye. The Veteran was found at home by her husband trying to locate a pistol in the bedroom closet. The pistol was not loaded and there was no ammunition in the house. Police brought with the Veteran to the ER a "goodbye note" that she had written to her children. Initially, the Veteran denied making a suicidal threat, was quite hostile, and was very angry with her husband. She reported that she would be better off dead but denied thoughts of taking her own life. She had an ongoing conflict with her husband and was considering a divorce. Her history included recent depressive symptoms such as concentration and memory difficulties, daily sadness, anhedonia, and appetite and weight increase. She reported chronic insomnia with frequent awakening. She reported an in-service rape but was unwilling to discuss the incident. She denied a history of psychiatric symptoms. Mental status examination of the Veteran showed that she was curled up in a fetal position on the floor in the examination room covered by a fur coat with a pained expression on her face, hostility, anger, poor eye contact, an angry and dysphoric mood, a restricted affect, goal-directed and reality-based thoughts focused on anger at her husband, no evidence of delusional content or hallucinations, and limited judgment and insight. The Veteran was at elevated imminent risk for harm to herself. The diagnoses included depressive disorder with suicidal ideation. She was admitted to the psychiatric unit for observation. On the day after her admission, the Veteran denied being actively suicidal or homicidal. Her medical history included depression and PTSD. Neuropsychiatric examination showed that she was animated and appropriate with no signs of agitation or tremulousness, full orientation, and no auditory or visual hallucinations. The diagnoses included PTSD and depression with acute suicidal ideation. During a January 5, 2006 treatment session, the Veteran complained of increased anger, depression, and suicidal ideation. She reported a recent hospitalization for suicidal ideation. Mental status examination of the Veteran showed that she was agitated and irritable with normal speech, a labile affect, an angry and depressed mood, normal thought processes, a mild to moderate suicide risk, and no homicidal ideation. On January 11, 2006, the Veteran complained of insomnia due to multiple stressors. She described her insomnia as difficulty falling asleep and early morning awakening with occasional nightmares. She also complained of an exacerbation of depression and increased anxiety and fearfulness. Mental status examination of the Veteran was essentially within normal limits. The Veteran's GAF score was 63, indicating some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well with some meaningful interpersonal relationships. The impressions included PTSD. During an April 2006 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood was angry and dysphoric and her affect was congruent. The Veteran reported irritability, which was explosive at times. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was unusual and consisted of obsessions regarding dirt. She stated "I cannot sleep if my floor is dirty." She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner assigned a GAF score of 65. During a May 2006 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was pressured/pushed, but her language was intact. Her mood was anxious and her affect was congruent with her mood and was blunted/restricted/constricted. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner found that the Veteran was irritable and assigned a GAF score of 60. During a July 2006 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood was anxious and her affect was congruent. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner assigned a GAF score of 55. During the July 2006 Board hearing, the Veteran testified that she had recently attempted suicide and continued to experience insomnia and memory problems due to her service-connected PTSD. She also testified about obsessional rituals that involved cleaning herself and her house and were triggered by daily intrusive thoughts and flashbacks to her in-service rape. During a November 2006 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood and affect were congruent. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She stated "I cannot sleep if my floor is dirty." She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner found the Veteran to be tearful when she spoke about her husband leaving and assigned a GAF score of 60. During a September 2007 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and her appearance was casual and her hygiene fair. The Veteran's speech was normal but rapid. Her attention/concentration was distracted. Her mood was sad, depressed, angry, and anxious and her affect was appropriate. Her thought process was goal directed and her thought content was of obsessions. She reported no suicidal or homicidal ideation and her insight and judgment were fair. The Veteran reported no perceptional abnormalities or disassociations. During an October 2007 treatment session, the Veteran was reported to be casually dressed and cooperative. Her affect was normal and her mood dysphoric. The Veteran's speech was normal and her thought process obsessive. The Veteran's thought content consisted of negative self-talk but she denied any suicidal or homicidal ideations. During a November 2007 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood was euthymic and her affect was congruent. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner assigned a GAF score of 60. During a December 2007 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood was anxious and her affect was congruent. The Veteran reported irritability, which was explosive at times. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner assigned a GAF score of 60. During a January 2008 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood and affect were congruent. The Veteran reported irritability, which was explosive at times. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner assigned a GAF score of 60. During a February 2008 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood was euthymic and her affect was congruent. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner assigned a GAF score of 60. During a March 2008 treatment session, the examiner noted that the Veteran was casually dressed and cooperative. Her affect was normal and her mood dysphoric. The Veteran's speech was normal and coherent. Her thought process was obsessive and her content had negative self-talk. She reported no suicidal or homicidal ideation. During an April 2008 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood was euthymic and dysphoric and her affect was congruent. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. She continued to report marital difficulties and communication issues with her husband. During a May 2008 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood was anxious and her affect was congruent. The Veteran reported irritability, which was explosive at times. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner assigned a GAF score of 57 and a GAF score of 60. During a September 2008 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood and affect were congruent. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner assigned a GAF score of 57. During an October 2008 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran appeared very agitated. The Veteran's speech was pressured and pushed, and her language was intact. Her mood was angry and anxious and her affect was labile. The Veteran reported irritability, which was explosive at times. The Veteran reported no hallucinations or delusions and her thought process was disorganized, obsessive and tangential. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight was limited and her judgment impulsive. The Veteran's memory was intact. The examiner assigned a GAF score of 55. During a December 2008 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood and affect were congruent. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner assigned a GAF score of 60. During a January 2009 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was pressured and pushed, and her language was intact. Her mood was anxious and her affect was labile. The Veteran reported no hallucinations or delusions and her thought process was obsessive regarding cleanliness with a negative view of her children and feelings of being blamed by everyone. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight was limited and her judgment impulsive. The Veteran's memory was intact. The examiner assigned a GAF score of 52. During a February 2009 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood was anxious and her affect was congruent. The Veteran reported irritability, which was explosive at times. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. The examiner assigned a GAF score of 55. During a March 2009 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood was dysphoric and her affect was blunted/restricted/constricted. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact. The examiner assigned a GAF score of 55. During a May 2009 treatment session, the examiner noted that the Veteran was alert and attentive, and that she was cooperative and reasonable. The Veteran's speech was normal in rate and rhythm, and her language was intact. Her mood and affect were congruent. The Veteran reported no hallucinations or delusions and her thought process was normal and coherent. Her thought content was normal. She reported no suicidal or homicidal ideation and her insight and judgment were good. The Veteran's memory was intact and her fund of knowledge was average. In November and December 2009, the Veteran was found to be casually dressed and cooperative, her affect and mood were normal. Her speech was normal and coherent. The Veteran's thought process was obsessive but her thought content was normal. She reported no suicidal or homicidal ideations. In January and September 2010, the Veteran was found to be casually dressed and cooperative, her affect was normal but her mood was dysphoric. Her speech was normal and coherent. The Veteran's thought process was obsessive but her thought content was normal. She reported no suicidal or homicidal ideations. In January, May, June, July, October, and November 2011, the Veteran was found to be well groomed and cooperative. Her affect and mood were normal. Her speech was normal and coherent. The Veteran's thought process was logical and her thought content was normal. She reported no suicidal or homicidal ideations. During a February 2014 VA disability benefits questionnaire (DBQ), the examiner confirmed the Veteran's PTSD diagnosis. The examiner opined that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The Veteran reported that she lived with her four children and had been married since 1998. She indicated that there was significant conflict and lifestyle stressors. Furthermore, the Veteran reported that she was unemployed but that she did 35-40 hours of volunteer work a week at various social service agencies. She also indicated that she was taking full time college courses, but that she was unable to keep a job due to her PTSD. The examiner noted that the Veteran's PTSD caused her to suffer from a depressed mood, anxiety, suspiciousness, impaired judgment, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, and impaired impulse control, such as unprovoked irritability with periods of violence. The examiner observed that the Veteran's behavior was hostile, angry, impatient and critical. Furthermore, he indicated that she had poor boundaries and low frustration tolerance. As the Board previously found the February 2014 VA examination inadequate, the Veteran underwent an additional examination in August 2016. The August 2016 VA examiner confirmed the Veteran's chronic PTSD diagnosis. The examiner opined that the Veteran's PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported that she lived with her two youngest children and her ailing husband. She noted that she spent her time doing household chores, dealt with bills, and took care of her husband. She reported that she had two adult daughters who did not live with her and with whom she had little contact. She reported that for the previous year, she had been working as a full-time contractor and worked as an administrator, but that she had to invoke FMLA to help keep up with bills. The examiner noted that the Veteran exhibited symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions or recent events, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work like setting, and suicidal ideation. The examiner described the Veteran as cooperative, but noted that she obsessed over the cleanliness of her home, had intrusive thoughts, nightmares, dissociative episodes/flashbacks, avoidance of being alone in a room with males, avoidance of thoughts/feelings related to her stressor, difficulty remembering important aspects of her stressor, pervasive/distorted beliefs about self/others/world, regrets about her actions from the stressor, pervasive anger, loss of enjoyment of previously enjoyable activities, emotional distancing and numbing, irritability and verbal outbursts, hypervigilance, exaggerated startle response, and recurrent suicidal ideation. Period prior to July 14, 2005 Following a review of the relevant evidence of record, which includes VA treatment records dated through June 2014, the Veteran's own statements and testimony, and the VA examination report dated in July 2005, the Board concludes that the Veteran is not entitled to a rating in excess of 50 percent for her PTSD prior to July 14, 2005. In this regard, the Board finds that such disability is manifested by occupational and social impairment with reduced reliability and productivity as a result of psychiatric symptomatology, to include occasional suicidal ideation, depression, anxiety, hypervigilance, nightmares and difficulty sleeping, flashbacks, irritability, panic attacks, anger, and a need to clean herself and her surroundings, without more severe manifestations that more nearly approximate occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. In this regard, the Board finds that such symptomatology, to specifically include the Veteran's occasional suicidal ideation, depression, anxiety, hypervigilance, nightmares and difficulty sleeping, flashbacks, irritability, panic attacks, anger, and a need to clean herself and her surroundings, as well as the frequency, severity, and duration of her psychiatric symptoms are contemplated in her current 50 percent rating. As indicated previously, a 70 percent rating 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; 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. Based on the evidence of record, the Board finds that the Veteran's PTSD does not result in occupational and social impairment with deficiencies in most areas prior to July 14, 2005. With respect to the symptoms noted to be indicative of a 70 percent rating, the Board notes that while the Veteran has reported some suicidal ideation in the past, she has also vehemently denied such as well as denied any intent or plan. Furthermore, there is no evidence that the Veteran has obsessional rituals which interfere with routine activities. Specifically, while the Veteran reported a need to clean herself and her surroundings, these do not appear to interfere with her routine activities. Pertaining to the Veteran's speech, it has never been described as illogical, obscure, or irrelevant. Specifically, her speech has routinely been described as normal in rate and tone. Likewise, the Veteran's thought process was noted to be linear and that the Veteran responded to questions without difficulty. There is also no evidence of near-continuous panic or depression affecting the Veteran's ability to function independently, appropriately, and effectively. In this regard, the Veteran reported anxiety on occasion, and depression. However, the Veteran reported that she lived with her children and her husband and she took care of the home as well as her family while all the while working and attending classes. Therefore, the Board finds that she was able to function independently, appropriately and effectively. Furthermore, while the Veteran indicated that she suffered from panic attacks, and in November 2003, she reported "constant extreme panic," the remainder of the record fails to show near-continuous panic. As such, these symptoms have not been shown to affect her ability to function independently, appropriately, and effectively. Additionally, there is no evidence that the Veteran suffers from impaired impulse control. In this regard, no problems with impulse control were noted during her VA treatment sessions. Furthermore, the Veteran has never been noted to have spatial disorientation. In this regard, the Veteran has been found to be consistently alert and oriented during the course of the appeal. The Board further finds that the evidence fails to demonstrate that the Veteran neglects her personal appearance and hygiene. In this regard, VA treatment records and the VA examination report dated during the appeal period consistently show that she has been clean and casually dressed and neatly groomed. Pertaining to whether the Veteran has difficulty in adapting to stressful circumstances, the Board finds that, while the Veteran reported working on and off during the course of her appeal, she continued to work as well as take college courses. Furthermore, the examiner who conducted the VA mental health assessment in May 2002, indicated that the Veteran's PTSD resulted in moderate symptoms or moderate difficulty in social, occupational or school functioning. The Board finds the Veteran is able to adapt to stressful circumstances. Regarding the Veteran's ability to establish and maintain effective relationships, the Board notes that the Veteran maintained her relationships with her children and while her marriage had difficulties throughout her appeal, she maintained the relationship. Therefore, the Board finds that the Veteran is able to maintain effective relationships. The Board further notes that the evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the rating criteria, to include hypervigilance, nightmares, difficulty sleeping, and flashbacks. See Mauerhan, supra; Vazquez-Claudio, supra. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 50 percent under the General Rating Formula as they are not of such a severity or frequency to result in occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. The Board has also considered the Veteran's GAF scores assigned during the course of the appeal prior to July 14, 2005. In this regard, the May 2002 examiner who conducted the VA mental health assessment, assigned a score of 55, indicating moderate symptoms. A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). As the Veteran has been assigned a GAF score reflecting primarily moderate symptoms and the evidence of record, as detailed previously, supports such a score, the Board finds that the Veteran is not entitled to a rating in excess of 50 percent for PTSD prior to July 14, 2005. The Board also notes that the mental status examinations conducted during this period indicate only mild to moderate symptoms indicative of no more than a 50 percent rating. Therefore, as the Veteran's PTSD symptoms, as detailed previously, are contemplated by her 50 percent rating and, absent more severe symptoms, a higher rating is not warranted. Moreover, the Board finds that the criteria for a 100 percent rating under the General Rating Formula are not met. In this regard, the evidence does not show that the Veteran has 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. In this regard, there was no evidence of delusions, or significant cognitive impairment found on mental status examination. All of the medical evidence throughout the appeal, found the Veteran's thought process and content to be unremarkable, or without impairment or delusions. VA treatment records showed no perceptual disturbance such as delusions, hallucinations, mania or psychosis. Furthermore, as indicated previously, the evidence reflects that the Veteran has generally maintained employment. Additionally, the evidence reflects that she maintained relationships with her children. Furthermore, there is no evidence of gross impairment in thought processes or communication, grossly inappropriate behavior, persistent danger to herself or others, an inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, occupation, or own name. Therefore, the Veteran is not entitled to a 100 percent rating under the General Rating Formula. Period after July 14, 2005 Following a review of the relevant evidence of record, which includes VA treatment records dated through June 2014, the Veteran's own statements and testimony, and the VA examination reports dated in July 2005, February 2014, and August 2016, the Board concludes that the Veteran is not entitled to a rating in excess of 70 percent for her PTSD after July 14, 2005. In this regard, the Board finds that, for the period after July 14, 2005, such disability is manifested by 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 including a suicide attempt, panic attacks, anxiety, suspiciousness, chronic insomnia, severe marital discord, limited judgment and insight, an angry and dysphoric mood, nightmares, obsessional rituals, episodic hallucinations, depression, difficulty in establishing and maintain effective work and social relationships, difficulty in adapting to stressful circumstances including work and work like setting, impaired impulse control, and mild memory loss such as forgetting names, directions or recent events, without more severe manifestations that more nearly approximate total occupational and social impairment. In this regard, the Board finds that such symptomatology, to specifically include the Veteran's suicidal ideation including a suicide attempt, panic attacks, anxiety, suspiciousness, chronic insomnia, severe marital discord, limited judgment and insight, an angry and dysphoric mood, nightmares, obsessional rituals, episodic hallucinations, depression, difficulty in establishing and maintain effective work and social relationships, difficulty in adapting to stressful circumstances including work and work like setting, impaired impulse control, and mild memory loss such as forgetting names, directions or recent events, as well as the frequency, severity, and duration of his psychiatric symptoms are contemplated in her 70 percent rating. As indicated previously, a 100 percent rating is warranted when 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. Based on the evidence of record, the Board finds that the Veteran's PTSD does not result in total occupational and social impairment. In this regard, the evidence does not show that the Veteran has 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. In this regard, there was no evidence of delusions, or significant cognitive impairment found on mental status examinations. The VA examinations conducted in July 2005, February 2014 and August 2016 and the mental status examinations conducted throughout the appeal found the Veteran's thought process and content to generally be logical and coherent, and without impairment or delusions. VA treatment records showed no perceptual disturbance such as delusions, mania or psychosis. While the Veteran did report hallucinations in a September 2005 statement, there are no other reports of hallucinations throughout the record. Therefore, the Board finds such report to be episodic and not persistent. Furthermore, the Veteran has not displayed grossly inappropriate behavior or persistent danger of hurting herself or others. While the Veteran has expressed some suicidal ideation, it has not resulted in a persistent danger of hurting herself. And finally, the record reflects that the Veteran has always been noted to be alert and oriented, clean and well-groomed and no indication of memory loss for names of close relatives, own occupation, or own name. The Board further notes that the evidence of record reflects that the Veteran has additional symptomatology that is not enumerated in the rating criteria, to include suspiciousness, nightmares, severe marital discord, and flashbacks. See Mauerhan, supra; Vazquez-Claudio, supra. However, the Board finds that such symptoms do not more nearly approximate a rating in excess of 70 percent under the General Rating Formula as they are not of such a severity or frequency to result in occupational and social impairment with deficiencies in most areas, or total occupational and social impairment. The Board has also considered the Veteran's GAF scores assigned during the course of the appeal. In this regard, the July 2005 VA examiner assigned a score of 45, indicating serious symptoms. In January and April 2006, during mental status examinations, the examiners assigned scores of 63 and 65, indicating mild symptoms. In May, July, and November 2006, the Veteran was assigned scores of 60, 55, and 60, respectively, indicating moderate symptoms. In November and December 2007, the Veteran was assigned scores of 60, also indicating moderate symptoms. In January, February, May, September, October and December 2008, the Veteran was assigned scores of 60, 60, 60, 57, 55, and 60 respectively. Again indicating moderate symptoms. In January, February, and March 2009 the Veteran was assigned scores of 52, 55, and 55, respectively indicating moderate symptoms. A GAF score is highly probative as it relates directly to the Veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey, 7 Vet. App. at 207. While the Veteran was assigned a GAF score of 45 in July 2005, such appears to be an outlier as the remainder of the Veteran's scores were consistent with symptoms in the moderate range and therefore indicative of a 70 percent rating. As the Veteran has been assigned GAF scores reflecting primarily moderate symptoms and the evidence of record, as detailed previously, supports such a score, the Board finds that the Veteran is not entitled to a rating in excess of 70 percent for PTSD after July 14, 2005. The Board also notes that the mental status examinations conducted during this period indicate only moderate symptoms indicative of no more than a 70 percent rating. Therefore, as the Veteran's PTSD symptoms, as detailed previously, are contemplated by her 70 percent rating and, absent more severe symptoms, a higher rating is not warranted. The Board has considered whether further staged ratings under Fenderson, supra, are appropriate for the Veteran's service-connected PTSD; however, the Board finds that her symptomatology has been stable for each stage throughout the appeal. Therefore, assigning further staged ratings for such disability is not warranted. In making its determinations in this case, the Board has carefully considered the Veteran's contentions with respect to the nature of her service-connected disability at issue and notes that her lay testimony is competent to describe certain symptoms associated with such disability. The Veteran's history and symptom reports have been considered, including as presented in the medical evidence discussed above, and have been contemplated by the disability ratings for which the Veteran has been found to be entitled to by the Board. Moreover, the competent medical evidence offering detailed specific findings pertinent to the rating criteria is the most probative evidence with regard to evaluating the pertinent symptoms of the service-connected disability at issue. As such, while the Board accepts the Veteran's testimony with regard to the matters she is competent to address, the Board relies upon the competent medical evidence with regard to the specialized evaluation of functional impairment, symptom severity, and details of clinical features of the service-connected condition at issue. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to a rating in excess of 50 percent for PTSD prior to July 14, 2005 and in excess of 70 percent thereafter. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER A rating in excess of 50 percent for PTSD prior to July 14, 2005 is denied. A rating in excess of 70 percent for PTSD from July 14, 2005 is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that she is afforded every possible consideration. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015). In addition, where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall, 11 Vet. App. at 271. The Board in its prior remand in February 2016, found that an examination was needed in order to determine the impact of the Veteran's service-connected disabilities upon her employability. While such an examination was conducted it was only conducted for the period prior to November 9, 2007. In April 2016, the RO granted an increase in one of the Veteran's other service-connected conditions which resulted in her receiving a 100 percent combined schedular rating. It was determined that as she was in receipt of a 100 percent combined rating as of November 9, 2007, that a TDIU claim was moot as of that date. The Board finds that this is an incorrect assumption, and therefore an examination which contemplates the impact of the Veteran's service-connected disabilities upon her employability for the entire appeal period is needed. Accordingly, the case is REMANDED for the following action: 1. The Veteran should be scheduled for a VA general medical examination to determine whether the Veteran's service-connected disabilities, considered in combination, render her unemployable, for the entire appeal period. The examiner must elicit from the Veteran and record for clinical purposes her full work and educational history. Based on a review of the evidence of record, and with consideration of the Veteran's statements, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's service-connected disabilities, considered in combination, render her unable to obtain or retain substantially gainful employment consistent with her education and occupational experience, and irrespective of age and any nonservice-connected disorders. The opinion provided must include a complete rationale. If the examiner cannot provide the requested opinion(s) without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. 2. Notify the Veteran that it is her responsibility to report for the scheduled VA examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2016). In the event that the Veteran does not report for a scheduled examination, documentation must be obtained which shows that notice was sent to the Veteran's most recent address of record. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ L. M. BARNARD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs