Citation Nr: 1752972 Decision Date: 11/17/17 Archive Date: 11/22/17 DOCKET NO. 12-11 766 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an increased evaluation for service-connected posttraumatic stress disorder (PTSD), in excess of 70 percent disabling prior to March 7, 2012. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Veteran represented by: Vietnam Veterans of America WITNESSES AT HEARING ON APPEAL The Veteran, and his spouse ATTORNEY FOR THE BOARD M. R. Woodarek, Associate Counsel INTRODUCTION The Veteran had active service with the Army from November 1968 to November 1970, with service in the Republic of Vietnam from May 1969 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision from the Department of Veterans Affairs (VA) Regional Office in Cleveland, Ohio (RO), which implemented an October 2010 Board grant of service connection for PTSD, and assigned a 30 percent disability rating effective August 3, 2007, the date of the Veteran's claim. In an April 2012 statement of the case, the RO granted an increased evaluation for service-connected PTSD to 50 percent disabling prior to March 7, 2012, and an increased 100 percent disabling thereafter. AB v. Brown, 6 Vet. App. 35, 38 (1993) (a grant of a higher rating during the course of an appeal, but less than the maximum benefits allowable, does not abrogate the appeal). The appeal was previously before the Board in December 2014, and was remanded for record development and a VA addendum opinion to determine the severity of the Veteran's service-connected PTSD prior to March 7, 2012, which substantially complied with remand directives. See 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 (Fed. Cir. 2002). On remand, in a May 2015 rating decision and supplemental statement of the case, the RO granted an increased 70 percent disability rating for service-connected PTSD prior to March 7, 2012. AB, 6 Vet. App. at 38. The Veteran's claims file has been returned to the Board for further appellate proceedings. The Board finds that the claim for a TDIU has been raised in the context of the claim for an increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009), (holding that a TDIU claim is part of an increased rating claim when such claim is raised by the record). Accordingly, the issue of entitlement to a TDIU has been added to the present appeal. 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). FINDING OF FACT For the rating period prior to March 7, 2012, the Veteran's symptoms and impairment due to service-connected PTSD, and the severity of such, more nearly approximate a rating based on occupational and social impairment, with deficiencies in most areas, such as work, family relations, judgment, thinking, or mood, as due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; mild memory loss; impairment of short- and long-term memory; and chronic sleep disturbance, to include nightmares. CONCLUSION OF LAW Prior to March 7, 2012, the criteria for an initial evaluation in excess of 70 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2016). Here, the RO issued preadjudicatory notice to the Veteran in September 2007 which met the VCAA notice requirements with respect to entitlement to service connection for PTSD. Id. Because the appeal for a higher rating for service-connected PTSD stems from the initial grant of service connection, additional notice was not required in this case. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (in which the VA General Counsel interpreted that separate notification is not required for "downstream" issues following a service connection grant, such as initial rating and effective date claims); 38 C.F.R. § 3.159(b)(3)(i) (2016). VA has also made reasonable efforts to obtain relevant records and evidence needed to substantiate the claim. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c) (2016). The information and evidence that has been associated with the claims file includes Social Security Administration (SSA) medical records, hearing testimony, VA treatment records, VA examinations and addendum opinions. VA examinations and addendum opinions were provided in March 2012, February 2014, April 2015, and May 2015 in connection to the Veteran's claim for an increased evaluation for service-connected PTSD for the rating period prior to March 7, 2012. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations to address the Veteran's claimed disability has been met. 38 C.F.R. § 3.159(c)(4) (2016). Neither the Veteran nor his representative have raised any other issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board. . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.326(a) (2016). Disability Rating Laws and Regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. 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 military service and the residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321(a), 4.1 (2016). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2016). The Board notes that the Court has distinguished a new claim for an increased rating of a service-connected disability from a case where the veteran expresses dissatisfaction with an initial rating of a disability that has just been service-connected. See Fenderson v. West, 12 Vet. App 119 (1999). In the latter case, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as "staged rating." See Id. The Board finds that symptoms related to the Veteran's service-connected PTSD have not changed in severity over the course of the rating period on appeal to warrant a staged rating. Prior to March 7, 2012, the Veteran was assigned a 70 percent disability rating for service-connected PTSD under Diagnostic Code 9411. A 70 percent disability rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech that is 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 inability to establish and maintain effective relationships. 38 C.F.R. § 4.130 (2016). A 100 percent disability rating is assigned 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; and memory loss for names of close relatives, or for the veteran's own occupation or name. 38 C.F.R. § 4.130 (2016). In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (4th ed. 1994) (hereinafter DSM- IV). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. Id. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has generally embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. See Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). In rating psychiatric disabilities under 38 C.F.R. § 4.130, the Federal Circuit has held that a claimant's eligibility for a percent rating requires not only the presence of certain symptoms or others of similar severity, frequency, and duration, but also that those symptoms have caused occupational and social impairment. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Within the DSM-IV, Global Assessment Functioning (GAF) scale scores ranging from 1 to 100, reflect "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). GAF scores from 71 to 80 reflect transient symptoms, if present, and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family arguments); resulting in no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind school work). GAF scores from 61 to 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsession rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, inability to keep a job). GAF scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech which is at times illogical, obscure, or irrelevant) or major impairment in several areas such as work or school, family relations, judgment, thinking, or mood (e.g., a depressed patient who avoids friends, neglects family, and is unable to do work). DSM-IV at 46-47. Effective August 4, 2014, VA regulations were amended to remove references to the DSM-IV, and replace them with references to the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (5th ed. 2013) (hereinafter DSM-5). 79 Fed. Reg. 45,093-02, 45,094 (August 4, 2014). However, the amended provisions do not to apply to claims that were pending before the Board on or before August 4, 2014, even if such claims are subsequently remanded to the AOJ. The instant appeal was initially certified to the Board in September 2013. Therefore, the new version of the Schedule for Rating Disabilities is not for application in the instant appeal. In rendering a decision on appeal, the Board must analyze the credibility and probative value of all medical and lay evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. 38 U.S.C.A. § 1154(a) (West 2014); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of evidence for and against the claim. See 38 C.F.R. § 3.102, 4.3 (2016). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert, 1 Vet. App. 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Disability Rating Analysis After a review of all the evidence, lay and medical, the Board finds that for the period prior to January 29, 2015, the severity of the Veteran's psychiatric symptoms more nearly approximate a rating based on occupational and social impairment with deficiencies in most areas, due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; mild memory loss; impairment of short- and long-term memory; and chronic sleep disturbance, to include nightmares, as described for a continued 70 percent rating under Diagnostic Code 9411. See 38 C.F.R. § 4.130 (2016). In a September 2007 letter, the Veteran's spouse at the time had indicated that they had been married for 35 years and that the Veteran had not been able to sleep more than three to four hours at a time, as he always had nightmares and restless sleep. She stated that as time had gone on, his anger seemed to get worse, and that he was very irritable and avoided crowds. She also indicated that he had trouble concentrating and forgets where he is sometimes. In a September 2007 letter, the Veteran's VA clinical psychologist reported that she had met with the Veteran that month to evaluate him for his symptoms of PTSD. She indicated that the Veteran had reported persistent re-experiencing through distressing recollections every couple of months, distressing dreams of the events about once per month, and psychological and physiological reactivity to internal or external cues. The Veteran indicated persistent avoidance of stimuli that reminded him of the events, and general numbing of responsiveness, as demonstrated through effort to avoid activities, places, and people that arouse recollections, and occasional feelings of estrangement from others. He also reported increased arousal, shown by sleep difficulty, irritability, decreased concentration, hypervigilance, and exaggerated startle response. Additionally, the Veteran had indicated that these symptoms had interfered with his ability to maintain positive relationships at home and in the workplace, which had made it difficult for him to fully participate in social activities. In a November 2007 VA treatment record, the Veteran had undergone a mental health consultation after a positive screen for PTSD and depression. The Veteran reported poor sleep with nightmares, avoidance behavior, and irritability with a temper that leads to arguments, yelling, and willingness to fight. He indicated intrusive memories a few times a week, physiological reactions a few times a week, emotional reactions to triggers on a daily basis, and flashbacks about twice a month. The Veteran denied memory problems and suicidal ideations. During the evaluation, the Veteran's affect and mood was depressed and he was often tearful discussing combat memories during the evaluation. The Veteran was assigned a GAF score of 55. VA treatment records from January 2008 to February 2008, and June 2008 to August 2008 show the Veteran attended multiple psychiatric and psychotherapy appointments. He was sleeping better and had reduced nightmares with medication and had an improved mood with medication, which he also associated with having retired from work. He reported that he hears his name called sometimes and has intrusive thoughts, with flashbacks lasting a couple of minutes due to triggers from loud noises. The Veteran had trouble being around people, trouble enjoying things, trouble concentrating and was irritable, but reported that he joined the local Vietnam Veterans of America chapter and feels good about that, and about making some new friends there. The Veteran denied suicidal ideations and reported that he had panic attacks about twice a month, which did not stop him from doing anything he needed to do. The VA psychiatrist assigned a GAF score of 50. In July 2008, the Veteran had undergone a VA neuropsychological evaluation, in which he reported having poor short term memory, as he couldn't remember what happened yesterday or the day before. In day-to-day functioning, the Veteran reported he remained independent and that his wife would remind him of appointments as needed. Upon diagnostic testing, the VA neurologist opined that the results showed mild executive dysfunction, and diagnosed the Veteran with mild cognitive impairment, but that his PTSD symptoms and depression also needed to be considered in their contribution. In a September 2008 letter, the Veteran's Vet Center counseling therapist reported that the Veteran had been attending Vet Center group counseling since February 2008, in which the Veteran displaced marked psychological reactivity to external and internal cues that represent threat. The therapist believed that these issues had infused into his life on social, occupational and relationship levels. The Veteran took efforts to avoid thoughts, feelings or conversations; had markedly diminished interest or participation in significant activities; and had feelings of detachment or estrangement from others. The Veteran also had difficulty sleeping or staying asleep; irritability or outburst of anger; difficulty concentrating; hypervigilance; and exaggerated startle response. Within a September 2008 letter, the Veteran's Cincinnati VA Medical Center clinical social worker opined that the Veteran's PTSD was chronic, severe and disabling. Symptoms presented to the VA clinical social worker included flashbacks about combat experiences; nightmares about combat experiences; feeling that traumatic events are recurring; fear, depression and anxiety, including suicidal ideation; efforts to avoid anything associated with traumatic events; major loss of interest in significant life activities; tendency to self-isolate; difficulty expressing a normal range of feelings; inability to maintain normal social relationships; no real sense of a normal future life; sleep problems; irritability and outburst of anger; trouble concentrating; hypervigilance; and easily startled. The VA social worker indicated that the Veteran struggles with all of these symptoms every day. He opined that the Veteran was 100 percent disabled by PTSD and that the Veteran could not work in any sort of regular, normal employment, and would not be able to do so in the foreseeable future. VA treatment records show the Veteran attended over 13 psychotherapy and psychiatry appointments from January 2009 to November 2009, during which his appearance was appropriate, with appropriate speech, anxious mood and rational, linear thought patterns. Upon his initial appointment with the VA psychologist, the Veteran reported taking medication for his depression and that he had some suicidal ideations last summer, but denied recent and current problems. The Veteran was alert and oriented, was well-groomed, and had a depressed mood. From February 2009 to March 2009, the Veteran reported that he still hears people yell his name a couple times a week. He indicated he had intrusive thoughts, nightmares twice a month, flashbacks resulting from triggers, such as loud noises. The Veteran reported being irritable, with symptoms of depression, and had panic attacks about once or twice a week. By May 2009, the Veteran indicated that he had some fleeting thoughts of suicidal ideations but denied any plans or intentions to ever act on those thoughts. In June 2009, a VA psychiatrist noted that the Veteran's depression was better on medication and that his PTSD symptoms were improving, with panic attacks a little better. A July 2009 note by the VA psychologist shows the Veteran still experienced sleep problems but that he had less daytime flashbacks. He indicated that he was spending time with grandchildren, had attended a Veterans' Day Talks at a local school, which he found gratifying, and was looking forward to a combat reunion the following month. In October 2009, the Veteran still reported issues with sleep disruption, as he was waking up several times a night with nightmares, and indicated that the voices he hears are of his wife and brother calling his name, which he realized weren't real. VA treatment records from January 2010 to April 2010 show the Veteran attended 15 individual psychotherapy and psychiatry appointments, during which he had an appropriate appearance, with fair judgment, appropriate speech and linear, future-oriented thought patterns. The Veteran reported that he still had intrusive memories and could still hear people yelling his name. His sleep was still disturbed but was taking medication. He had a vague feeling that something bad was going to happen and had anxiety attacks a couple times a month, for which he was taking medication. The Veteran's appearance was appropriate and his thought patterns were future-oriented, and he denied suicidal and homicidal ideations. In a February 2010 psychotherapy appointment, the Veteran reported that he had been working on in vivo desensitization by going to the mailbox or driving without scanning the area, and reported some reduction in anxiety. He also indicated that he thought of suicide, but reported that he could not go through with it because it would devastate his family. SSA records dated May 2010, associated with the Veteran's claims file in February 2014, show that an SSA physician opined that the Veteran would not be capable of completing an 8/40 hour week or managing stress of full time work at this time based on his medical examination as a whole. The SSA physician indicated the veteran had PTSD, along with major depressive disorder, panic disorder, a brain tumor with mild dementia. In a Disability Determination and Transmittal document, the Veteran was determined to have been disabled beginning in February 2008, with a primary diagnosis of anxiety disorders, and a secondary diagnosis of disorders of the back. In a letter received in November 2010, the Veteran's spouse indicated that the Veteran retired in March 2008 because he couldn't get along with his co-workers and that he didn't want to hurt anyone. She reported that she takes the Veteran to most of his doctors appointments, therapy sessions, hospital appointments and Vietnam Veterans of America meetings, and that he doesn't live independently. She also stated that the Veteran sometimes sees objects in the road that aren't always there, like convoys of Army trucks, and will ask her if she'd seen them. She indicated that the Veteran wants to wear dirty clothes, forgets to complete tasks, and doesn't handle finances. She also stated that he forgot who her brother was, and forgot his name. In a November 2010 letter, a VA social worker stated that the Veteran had been receiving services at the Vet Center since September 2007, and presented persistent re-experiencing through distressing recollections, distressing dreams, both psychological and physiological reactivity to internal and external cues. The Veteran had described a history of avoidance of stimuli, sleep difficulties, irritability, decreased concentration, hypervigilance, and exaggerated startled response. The VA social worker opined that these symptoms occurred at various levels of frequency, duration, and intensity and resulted in impacting his daily function in areas of social relationships, judgment and mood. In a November 2011 letter from the Cincinnati VA Medical Treatment Center, a VA therapist indicated that the Veteran had been seen since February 2007 for PTSD treatment. The Veteran reported severe panic attacks once a week where he feels that he's outside his body looking in. He has nightmares at least three times a week, has feelings of guilt and cannot stay asleep. The Veteran had reported that he quit work because he felt that if he didn't, he would kill someone, as he would get into shoving matches with co-workers. He found it hard to be around others socially and was taking medication for his PTSD symptoms. VA treatment records from July 2011 to September 2011 VA treatment note shows the Veteran attended a psychiatry and psychotherapy appointments where he reported that his nightmares were about the same and that he was still hearing voices. The Veteran indicated that he was no longer seeing things in the field and that his flashbacks were occurring two to three times a week and continued to have intrusive memories. His panic attacks were occurring a little less often and he still could not stand to be in crowds. While the Veteran reported having a suicidal ideation a year prior in July 2011, by September 2011, the Veteran denied suicidal and homicidal ideations. The VA psychiatrist indicated that the Veteran was having memory and concentration problems, which would make most jobs difficult if they involved any complex tasks, but she was uncertain as to how much other causes, such as the Veteran's brain tumor or cognitive disorder, related to this. In a March 2012 VA examination, the VA psychologist confirmed the Veteran's diagnoses of PTSD and major depressive disorder. Upon reviewing the Veteran's medical history and examination, the VA examiner opined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking and or mood. The Veteran reported that he retired from Cincinnati Milacron after working there for almost 30 years, and stopped working because they offered him an early retirement, and denied missing work for mental health reasons but would get in shoving matches at work. He indicated that he subsequently worked for about two years in a warehouse after Cincinnati Milacron but had to quit because he "was going to kill someone." Clinical findings showed that the Veteran had GAF scores ranging from 30 to 45 within VA treatment records over the past year, his most recent GAF score being 40 in February 2012. The VA examiner listed the Veterans symptoms as suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; flattened affect; difficulty in understanding complex commands; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including a work-like setting; impaired impulse control, such as unprovoked irritability with periods of violence; and persistent delusions or hallucinations. The VA psychologist opined that the Veteran was most likely unable to sustain gainful employment and assigned a GAF score of 45. In a September 2013 statement, the Veteran contended that his PTSD condition had been consistent from 2007 to current, warranting him a 100 percent rating for the entire period on appeal. In a February 2014 VA authorized examination, the VA authorized psychologist, upon review of the Veteran's medical history and examination, opined that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran was experiencing symptoms of anxiety; suspiciousness; panic attacks that occurred weekly or less often; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; and an inability to establish and maintain effective relationships. In a June 2014 Travel Board hearing, the Veteran testified, through his representative, that his PTSD symptoms had been consistent from August 2007 until present, and that there was no event that suddenly caused his symptoms to worsen after five years to warrant an increased 100 percent disability rating in March 2012. Therefore, he contended that his PTSD symptoms during the rating period on appeal also warranted a 100 percent disability rating. The Veteran testified that he stopped working in February 2008 because of the stress and fear of killing somebody, and indicated that he started receiving SSA disability benefits with an effective date of March 2008, with a primary diagnosis of PTSD. The Veteran indicated that he continued to have homicidal ideations if someone messed with him, and preferred to stay on his own. In an April 2015 VA medical opinion, upon thorough review of the Veteran's claims file, to include VA treatment records, including six neuropsychological examinations conducted between 2007 and 2014, and hearing testimony, the VA psychologist opined that there was significant overlap of symptomology between diagnosed PTSD, major depressive disorder, and an unspecified neurocognitive disorder that cannot be fully separated in terms of impact on the Veteran's social and occupational function. Based on the current evidence of record, the VA psychologist opined that in regards to the combination of all three disabilities, the Veteran's occupational and social impairment during the time period from 2007 to 2012 most closely approximates occupational and social impairment with reduced reliability and productivity due to symptoms documented during that time frame, such as depressed mood; anxiety; suspiciousness; panic attacks more than once a week; impairment of short- and long-term memory; disturbances in motivation and mood; and difficulty in adapting to stressful circumstances. She indicated that the Veteran worked in a warehouse from 2008 to 2010 and was not terminated due to frequent conflicts on the job. The VA psychologist indicated that the record was silent for any documentation of a gross impairment in thought processes or communication; persistent delusions or hallucinations; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The examiner noted that while the Veteran heard his name called, there was no diagnoses of a psychotic disorder or that the Veteran responses to internal stimuli. She also reported that the record does not include evidence of suicidal ideation, disorientation to time or place, severe memory loss, or grossly inappropriate behavior at any time. The Board has reviewed all the evidence of record, lay and medical, and finds that for the entire rating period prior to March 7, 2012, the Veteran has not met or more nearly approximated the criteria for an increased 100 percent disability rating for service-connected PTSD. The Board finds that the weight of the evidence does not support a finding of total occupational and social impairment, due to symptoms of such a severity as described for a 100 percent evaluation for service-connected PTSD. While a March 2012 VA examiner opined that the Veteran was most likely unable to sustain gainful employment, and VA social worker, within a September 2008 letter, opined that the Veteran was 100 percent disabled by PTSD, and that he could not work in any sort of regular, normal employment, and would not be able to do so in the foreseeable future, the Board notes that the Veteran reported that he worked for two more years in a warehouse job after he retired from his Cincinnati Milacron position in February 2008. See March 2012 VA examination report. The Board also acknowledges that SSA documents show that the Veteran was considered disabled as of February 2008, however, SSA medical records show that he is unable to work due to the stress of full-time work, a criteria associated with a 70 percent rating, as caused by his mental conditions, to include his PTSD and non-service connected major depressive disorder and dementia. Additionally, the Board finds that the Veteran is not shown to have total social impairment as the record shows that the Veteran is married and had been living with his wife of over 30 years, was fostering a relationship with his grandchildren, and becoming involved at the local Vietnam Veterans of America chapter. Thus, while VA treating social workers and psychiatrists indicate that the Veteran was unable to work due to his PTSD, they do not indicate both total social and occupational impairment. VA examiners and treating psychiatrists identify GAF scores ranging from 30 to 55 throughout the rating period on appeal, consistent with moderate to major social and occupational impairment, however, the Board finds probative the medical and lay evidence of record which do not show total occupational and social impairment due to reported PTSD symptoms. The Board notes that the assigned GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. Richard v. Brown, 9 Vet. App. 266 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned, like an examiner's assessment of the severity of a condition, is not dispositive of the rating issue. Rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. 38 C.F.R. § 4.126(a) (2016). The descriptions of the Veteran's symptomatology are the most accurate guide to identifying the severity of the psychiatric condition, and the narrative description is more persuasive than an examiner's one-time snapshot at the moment of an examination through the GAF score. 38 C.F.R. § 4.126(a) (2016). The Board finds that the Veteran did not exhibit symptomology of such severity as indicated for a 100 rating, such as gross impairment in thought processes or communication; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; and memory loss for names of close relatives, or for the veteran's own occupation or name. While the Veteran's spouse reported that the Veteran would wear dirty clothing, forgot her brother's name, needed assistance in daily activities, and would see army convoys while out driving, the Veteran never reported such hallucinations or memory-loss of the same severity to VA medical professionals for treatment, and VA psychologists and examiners of record denoted the Veteran's appropriate appearance and speech, and rational, linear thought processes during dozens of scheduled appointments throughout the appellate period. Accordingly, the Board finds that the weight of the evidence shows that the Veteran did not have gross impairment in thought processes or communication; persistent delusions or hallucinations; disorientation to time or place; or memory loss of close relatives, and finds that the Veteran's spouse's report as to the severity of such symptoms is inconsistent with the record and not credible. Rather, during the period on appeal, VA examinations and VA treatment records show the Veteran's service-connected PTSD presented with symptoms as described for a 30 percent rating, 50 percent rating and 70 percent rating, to include depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; mild memory loss; impairment of short- and long-term memory; and chronic sleep disturbance, to include nightmares. The Board notes that the VA treatment records show the Veteran reported hearing voices call his name, however, the April 2015 VA examiner discussed that there were no diagnoses of a psychotic disorder or evidence that the Veteran responded to such internal stimuli. Also, while the Veteran indicated he often thought of suicide throughout 2010, and testified to feeling as though he would kill someone if they crossed him, the Veteran consistently denied having current suicidal or homicidal ideations in VA treatment records from September 2011 to present. Additionally, the Board finds probative the VA medical opinions of record, which were based on thorough review of the Veteran's claims file and the Veteran's reports of medical history, which do not show symptoms, and the severity of such, that more nearly approximate a 100 percent rating under Diagnostic Code 9411. A March 2012 VA examiner opined that the Veteran had occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking and or mood due to such symptoms as suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; flattened affect; difficulty in understanding complex commands; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including a work-like setting; impaired impulse control, such as unprovoked irritability with periods of violence; and persistent delusions or hallucinations. The April 2015 VA examiner indicated that there was significant overlap in terms of symptomology of diagnosed PTSD, major depressive disorder and an unspecified neurocognitive disorder, but opined that in regards to the combination of all three diagnoses during the time period on appeal, they manifested as occupational and social impairment with reduced reliability and productivity due to such symptoms as depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks; disturbances of motivation and mood; and difficulty in adapting to stressful circumstances, including work or a work-like setting. Moreover, VA treatment records, VA examinations and lay statements of record demonstrate that medication was generally effective in managing the Veteran's PTSD symptoms. See e.g. 2008 VA treatment records. In Jones v. Shinseki, 26 Vet. App. 56, 63 (2012), the Court held that the Board may not deny entitlement to a higher evaluation on the basis of relief provided by medication when the effects of medication are not specifically contemplated by the rating schedule. However, Diagnostic Code 9411 for PTSD expressly authorizes VA to take into account the ameliorative effects of medication when evaluating PTSD. 38 C.F.R. § 4.130, DC 9411 (2016) (providing a noncompensable PTSD evaluation when, inter alia, "symptoms are not severe enough. . . to require continuous medication" and a 10% PTSD evaluation when, inter alia, "symptoms [are] controlled by continuous medication"). For these reasons, the weight of the evidence is against the claim for an initial evaluation in excess of 70 percent for a service-connected PTSD prior to March 7, 2012. Because a preponderance of evidence is against the claim, the benefit of the doubt doctrine is not for application. ORDER Entitlement to an increased rating in excess of 70 percent for service-connected PTSD prior to March 7, 2012 is denied. REMAND A claim for a total rating based on individual unemployability due to service-connected disability (TDIU) is part of an increased rating issue when such claim is raised by the record. Rice, 22 Vet. App. at 447. The Board finds that the Veteran has reasonably raised a claim for a TDIU in conjunction with his increased rating claim for service-connected PTSD. The Board finds, however, that a remand is required prior to adjudication of the claim. During a June 2014 Travel Board hearing, the Veteran and his spouse testified that he retired in February 2008 from his warehouse job, and that he did not work thereafter. However, the Veteran reported during a March 2012 VA examination that he worked for two more years in a warehouse job after he retired from his Cincinnati Milacron position in February 2008. The Board notes that the SSA documents of record show that the Veteran was considered disabled as of February 2008 for anxiety disorders and a back disability. Prior to adjudication of the Veteran's claim for entitlement to a TDIU, the Board finds that remand is required for record development to determine when the Veteran last worked full-time. The matter of entitlement to TDIU is moot from August 7, 2013, as the Veteran is, effective as of that date, in receipt of a 100 percent schedular rating and special monthly compensation (SMC) at the housebound rate. See Bradley v. Peake, 22 Vet. App. 280, 294 (2009). However, as the 100 percent rating and grant of SMC were not effective prior to August 2013, entitlement to TDIU is only moot as of August 2013. Accordingly, the case is REMANDED for the following action: 1. The AOJ should provide the Veteran with appropriate notice under the VCAA to substantiate a claim for entitlement to a TDIU. 2. The AOJ should request that the Veteran identify the warehouse in which he worked after February 2008, and obtain employment records from that facility. The AOJ should also request and obtain employment records from the Cincinnati Milacron, where the Veteran retired from in February 2008. If the search for such records has negative results, the AOJ should notify the Veteran and place a statement to that effect in the record. 3. After all available evidence has been associated with the record, the AOJ should review the evidence and determine if further development is warranted. The AOJ should take any additional development as deemed necessary. 4. Thereafter, the AOJ should readjudicate the claim on appeal. If the benefit sought remains denied, the Veteran and his representative should be furnished a supplemental statement of the case, and be given an opportunity to submit a written argument in response before the claims file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter or matters 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). ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs