Citation Nr: 1753829 Decision Date: 11/24/17 Archive Date: 12/01/17 DOCKET NO. 10-05 654 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to an initial rating in excess of 30 percent 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: Mississippi State Veterans Affairs Board ATTORNEY FOR THE BOARD M. J. In, Counsel INTRODUCTION The Veteran served on active duty from February 1968 to February 1970 and from October 1990 to June 1991. This case comes before the Board of Veterans' Appeals (Board) on appeal from February 2009 and February 2012 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In the February 2009 rating decision, the RO denied the Veteran's claim of entitlement to TDIU. The February 2012 rating decision granted service connection for PTSD and assigned an initial rating of 30 percent from June 29, 2011. The Veteran disagreed with the initial rating assigned for his service-connected PTSD and the present appeal ensued. The case was previously remanded by the Board in December 2013 for further evidentiary development. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT The Veteran's PTSD has been manifested by symptoms productive of functional impairment comparable to occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for an initial rating of 50 percent, but not greater, for PTSD are met. 38 U.S.C. § 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 4.126, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Pursuant to the Veterans Claims Assistance Act of 2000 (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Neither the Veteran nor his representative has raised any 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 a duty to assist argument). Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4 (2017). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2017). Evaluation of a service-connected disability requires a review of a veteran's medical history with regard to that disorder. However, the primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where a veteran appeals the initial rating assigned for a disability, evidence contemporaneous with the claim and the initial rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." See Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Id. As noted previously, service connection for PTSD was established with an initial rating of 30 percent from June 29, 2011. As such, the rating period on appeal for the initial rating for PTSD is from June 29, 2011. 38 C.F.R. § 3.400(o) (2017). However, in accordance with 38 C.F.R. §§ 4.1 and 4.2 (2017) and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the history of a disability is for consideration in rating a disability. Under the General Rating Formula for Mental Disorders, 38 C.F.R. § 4.130, Diagnostic Code 9411. Ratings are assigned according to the degree of occupational and social impairment resulting from manifestations of the disability at issue. However, the use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Under the provisions for rating psychiatric disorders, a 30 percent rating is assigned for 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, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). A 50 percent rating requires evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted when 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.). Id. 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. Id. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating 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. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126. The evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, the VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan, 16 Vet. App. 436. Within the DSM-IV, Global Assessment Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). While not determinative, 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). Effective August 4, 2014, VA amended the portion of the Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and replaced them with references to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). See 79 Fed. Reg. 149, 45094 (August 4, 2014). The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the Agency of Original Jurisdiction (AOJ) on or after August 4, 2014. The provisions of this interim final rule apply to claims that had been certified for appeal to the Board prior to August 4, 2014. VA adopted as final, without change, the interim final rule, effective March 19, 2015. 80 Fed. Reg. 53, 14308 (March 19, 2015). This appeal was certified to the Board in September 2013. As such, the provisions of DSM-V are not for application. According to DSM-IV, a GAF score ranging from 31-40 reflects some impairment in reality testing or communication (e.g., speech is at times illogical, obscure or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A GAF score of 41-50 reflects serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g. no friends, unable to keep a job). GAF score of 51-60 represents 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). A GAF score of 61-70 denotes 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, has some meaningful interpersonal relationships. A GAF score of 71-80 indicates that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). In a September 2011 VA mental health note, the Veteran expressed his thoughts without evidence of looseness of associations, ideas of reference or flight of ideas. He reported forgetfulness with things he needs to do or where he placed items but no major memory deficits. He also reported decreased focus with difficulty staying on task and having several unfinished projects. His judgment and insight were adequate. He stated "I've been doing fairly well." On mental status examination, his speech, mood, affect, and orientation were normal. There were no delusions or hallucinations. The Veteran denied suicidal or homicidal ideation. The impression was mood disorder, not otherwise specified (NOS), and a GAF score of 55 was assigned. In November 2011, the Veteran's wife and his daughter submitted written statements in support of this case. They described his memory impairment, anger problems, and hyper-startle response. A November 2011 VA examination report noted a diagnosis of PTSD and assigned a GAF score of 55. The examiner found that the Veteran's level of occupational and social impairment with regard to his mental diagnosis was best summarized as 'occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication.' The Veteran reported he was currently married for 34 years with two grown children; he described his relationship to his children as positive. Generally, he reported lack of interest in previously enjoyed hobbies, including hunting and playing pool. He reported only talking to his wife and children about personal topics. He also stated he has two sisters and two brothers and talked to them as well. He currently reported spending most of his time doing odds and ends at his and his neighbors' homes. As to occupational history, the Veteran reported working as a truck driver and manager about 9 years; he retired in June 2003 following an automobile accident for which he received approximately 2 years of chiropractic care. The examiner noted the Veteran's current symptoms included depressed mood and suspiciousness and that he was capable of managing his financial affairs. The examiner noted although the Veteran reported symptoms consistent with PTSD there did not seem to be historically a disruption in his typical work pattern (i.e. multiple odd jobs or positions of short duration) following military service; the Veteran's longest period of consistent employment was after his second tour in Saudi Arabia. It was also noted that current medications had been helpful in managing physiological arousal that formerly accompanied reminders of the war. VA inpatient treatment records dated January 2013 show that the Veteran was hospitalized to a psychiatric unit secondary to his expression of suicidal ideation. He had mild psychomotor retardation and a flat affect. There was increased latency of speech and it was suspected that there was thought blocking. He was unable to describe his emotions. His urine drug screen was positive for Benzodiazepines, and his family expressed concern that the Veteran had been possibly delirious. It appeared that the Veteran had had an unclear perspective of his circumstances prior to admission as he had reported that he had a gun and tried to fire it at himself but his family said this was not accurate and he had never had possession of a gun prior to admission. Prior to discharge the Veteran showed significant mood improvement and no longer endorsed suicidal ideation. He demonstrated improved insight and importantly, he acknowledged that his family loved him and had his best interests in mind. He was alert and fully oriented. The diagnoses were major depressive disorder, recurrent, severe without psychotic features, and PTSD, and a GAF score of 50 was assigned. A February 2013 VA mental health note reflects that the Veteran stated he had been feeling okay. He denied suicidal or homicidal ideation, any recent depression, anxiety, hallucinations, and nightmares or night sweats lately. He stated he had been basically sitting around watching television but also been busy cleaning up around the house. On mental status examination, the Veteran was casually dressed and fairly groomed, alert, and fully oriented. His mood was appropriate/ and his affect was congruent to his mood. His speech was normal and his thought process was coherent without any flight of ideas or loose associations. His thought content reflected no suicidal or homicidal ideations or delusions, and his perception showed no auditory or visual hallucinations. The diagnosis was PTSD and depression. A March 2013 VA mental health note reflects that the Veteran admitted to feeling depressed and complained of low energy. He reported he mostly lay around doing nothing. He denied suicidal ideation, hallucinations and delusions. On mental status examination, the Veteran was casually dressed and fairly groomed, and fully oriented. His mood was appropriate/subdued, and his affect was congruent to his mood. His speech was normal, and his thought process was coherent without any flight of ideas or loose associations. His thought content reflected no suicidal or homicidal ideations, delusions, or auditory or visual hallucinations. The diagnosis was PTSD and depression. An April 2013 VA mental health note reflects that the Veteran stated his mood had been pretty good and denied suicidal or homicidal ideation and auditory or visual hallucinations. He had slight depression which was managed with medications. He stated he had been doing a little small engine repairing and lawn mowing. He denied any problems with his anger and denied feelings of paranoia. He endorsed hyper startle response. On mental status examination, the Veteran was casually dressed and fairly groomed, and fully oriented. His mood was appropriate, and his affect was congruent to his mood. His speech was normal, and his thought process was coherent without any flight of ideas or loose associations. There were no auditory or visual hallucinations. The diagnosis was PTSD and a GAF score of 60 was noted. A July 2013 VA mental health note reflects that the Veteran stated he had been feeling pretty good, and his medications were working well in treating his depression. He stated with current medications he had not had any recent nightmares, but had night sweats sometimes. He denied suicidal or homicidal ideations, or auditory or visual hallucinations. He stated he was managing his anxiety well. He denied feelings of paranoia and feelings of hypervigilance. He stated he had not completely isolating himself, but did isolate himself to some degree. He also stated current medications were managing his PTSD symptoms appropriately. On mental status examination, the Veteran was casually dressed and fairly groomed, alert, and fully oriented. His mood was appropriate, and his affect was congruent to his mood. His speech was normal, and his thought process was coherent without any flight of ideas or loose associations. There were no auditory or visual hallucinations. The diagnosis was PTSD and a GAF score of 60 was noted. A February 2014 VA examination report notes the Veteran was severely depressed with psychomotor slowing and his assessments at the VA psychiatric treatment also reflected severe PTSD. The examiner further noted it is as likely as not that the Veteran is unable to pursue gainful employment due to severe PTSD. The examiner characterized the Veteran's level of occupational and social impairment with regard to his mental diagnosis as total occupational and social impairment. The Veteran reported he had been married to his second wife for 36 years. He appeared fearful, depressed, and shy but was very well dressed and groomed. He stated his marriage was good. It was noted the Veteran had been in aggressive mental health treatment at the VA clinic for 12 years with Abilify, Prozac and Trazodone with some symptom relief. The Veteran last worked full time in 2003 as a courier and has not worked since 2003 after a motor vehicle accident (MVA) causing orthopedic impairment. He was irritable and depressed and reported vague auditory hallucinations. The examiner found the Veteran's symptoms included depressed mood, anxiety, flattened mood, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation. The Veteran was capable of managing his financial affairs. The examiner noted the Veteran's intellect was within the average range. He did not complete the MMPI test because he was very slow and he had to stop the test to catch the VA transportation; however, his incomplete MMPI reflected very high depression. A July 2014 VA mental health note shows that the Veteran stated he was doing alright and his mood had been flexible. He denied suicidal or homicidal ideations, auditory or visual hallucinations, nightmares, and anxiety. He stated he continued to have intrusive memories but denied any flashbacks or feeling of paranoia. He remained hypervigilant. On mental status examination, the Veteran was casually dressed and fairly groomed, alert, and fully oriented. His mood was appropriate and his affect was congruent to his mood. His speech was normal and his thought process was coherent without any flight of ideas or loose associations. There were no auditory or visual hallucinations. The diagnosis was PTSD and a GAF score of 58 was noted. An October 2014 VA mental health note shows that the Veteran stated he was doing pretty well and his medications were working fine. He denied feeling depressed or anxious and had no suicidal or homicidal thoughts. He still had nightmares related to his experiences in Vietnam and had difficulty controlling his temper but did alright most of the time. He tended to isolate at times and could not be too much around crowds. He used to hear voices and feel paranoid but none lately. He spent most of his time meditating, doing things around the house, cooking, cleaning, and watching television. On mental status examination, the Veteran was casually dressed and fairly groomed, alert, and fully oriented. His mood was appropriate and his affect was congruent to his mood. His speech was normal and his thought process was coherent without any flight of ideas or loose associations. His thought content was without suicidal or homicidal ideations. There were no auditory or visual hallucinations, delusions, or paranoia. His concentration and attention were intact. The diagnoses were PTSD and psychotic disorder. A January 2015 VA mental health note shows that the Veteran stated he was doing pretty well. He denied any recent nightmares, suicidal or homicidal thoughts, and hallucinations. He stated he was managing his anger well. He denied isolating himself lately and stated he had been keeping busy with raking leaves. He denied paranoia, hypervigilance, or flashbacks. On mental status examination, the Veteran was casually dressed and fairly groomed, alert, and fully oriented. His mood was appropriate and his affect was congruent to his mood. His speech was normal and his thought process was coherent without any flight of ideas or loose associations. His thought content was without suicidal or homicidal ideations or delusions. There were no auditory or visual hallucinations. The diagnoses were PTSD and psychotic disorder, and a GAF score of 58 was noted. VA mental health notes dated August and September 2015 show that the Veteran stated he was doing fairly well. He denied feeling down, depressed or hopeless. He stated he occasionally had night sweats and intrusive thoughts. He stated his anxiety was up and down and he had gotten sluggish with going around other people. He reported to spending time with his children on Saturday and enjoying it. He had been taking care of things around the house. He denied paranoia, but was hypervigilant sometimes. On mental status examination, the Veteran was casually dressed and fairly groomed, alert, and fully oriented. His mood was appropriate and his affect was congruent to his mood. His speech was normal and his thought process was coherent without any flight of ideas or loose associations. His thought content was without suicidal or homicidal ideations or delusions. There were no auditory or visual hallucinations. The diagnoses were PTSD, depression /psychosis and a GAF score of 57 was noted. A February 2016 VA examination report noted diagnoses of PTSD and unspecified depressive disorder. The examiner noted the Veteran's symptoms of PTSD and unspecified depressive disorder intertwined such that clear differentiation could not be made. The examiner found that the Veteran's level of occupational and social impairment with regards to his mental diagnosis was best summarized as 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 examiner noted the Veteran's current symptoms included depressed mood, anxiety, suspiciousness, chronic sleep impairment, flattened affect, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a work-like setting. On behavioral observation, he had restricted affect. He was capable of managing his financial affairs. The Veteran reported that he was able to drive his vehicle around his locale without difficulty, paid his own bills, and made purchases, and in general denied significant impairment of his usual daily activities, although he experienced occasional impairment of occupational and social functioning because of symptoms of PTSD and unspecified depressive disorder, which were responding to treatment. After reviewing the Veteran's outpatient records, the examiner noted although in January 2014, the Veteran reported anxiety, he denied significant depression, hallucinations, hypervigilance or flashbacks; in July 2014, he reported a few intrusive memories of trauma and some hypervigilance, otherwise he was asymptomatic; in September 2015, he reported intrusive memories and dreams of trauma, some paranoia and isolation. Based on these records, combined with the clinical evaluation, the examiner concluded that the Veteran's presentation in February 2014 was not actually reflective of his general functioning at that time, but more consistent with occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks. By applying the Veteran's psychiatric symptomatology to the rating criteria described above, the Board finds that his total disability picture most closely approximates the criteria for a 50 percent rating during the entire rating period on appeal. Initially, the Board notes that it is precluded from differentiating between the symptomatology attributable to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so. Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). In this case, multiple psychiatric diagnoses were shown, namely PTSD, depressive disorder, NOS, and psychotic disorder. The Board has considered all of the Veteran's psychiatric symptoms and their severity in reaching its conclusion. In this regard, the Board determines that the Veteran's psychiatric disability has been productive of symptomatology resulting in functional impairment comparable to occupational and social impairment with reduced reliability and productivity, without more severe manifestations that more nearly approximate functional impairment comparable to occupational and social impairment with deficiencies in most areas or total occupational and social impairment. The Veteran's total disability picture does not rise to the severity required for a 70 percent or higher rating. In this regard, the Board finds that occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, has not been shown. Notably, the November 2011 and February 2016 VA examiners opined that the Veteran's level of occupational and social impairment with regard to his mental diagnosis was best summarized as 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 examiner further indicated that the Veteran's PTSD signs and symptoms did not result in deficiencies in areas of judgement, thinking, family relations, work, mood and school, or total occupational and social impairment. In this regard, the Board recognizes that a disability rating is based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's characterization of symptoms. Also, the Board observes that the February 2014 VA examiner characterized the Veteran's level of occupational and social impairment with regards to his mental diagnosis as total occupational and social impairment. However, the clinical findings made by the Veteran's VA mental health providers who have treated him throughout the rating period do not support the February 2014 VA examiner's conclusion. The February 2014 VA examiner found that the Veteran's severe depression prevented him from pursuing gainful employment. However, the reports of VA outpatient treatment and VA examinations conducted prior to and subsequent to this VA examination do not reflect severe depression. Indeed, in numerous VA mental health notes dated from September 2011 to September 2015, the Veteran has consistently reported that he was feeling fairly good and his medications were working well in treating his depression. He denied significant depression. Indeed, the February 2014 VA examination indicated that although the MMPI administered during that examination reflected very high depression, this result was incomplete as he actually did not complete the MMPI test because he was slow and then he had to stop the test to catch the VA transportation. Therefore, due to the incompleteness of this test and based on the conflicting evidence throughout the rating period, the Board attaches little probative value to the February 2014 VA examiner's finding that the degree of the Veteran's depression was severe and that he had total occupational and social impairment due to severe depression. Significantly, the February 2016 examiner, who reviewed the Veteran's prior records, determined that the Veteran's presentation in February 2014 was not actually reflective of his general functioning at that time, but more consistent with occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks. The Board thus finds that this one report, from February 2014, does not suffice to present a basis for an increase, staged or otherwise. The Board recognizes that the Veteran's PTSD has impacted his social functioning due to limited social interaction. Lay statements from the Veteran and his family, as well the medical evidence, reflect that he has hard time controlling his anger and has difficulty to be around other people. The Board finds the lay statements to be competent and credible evidence as to symptoms relating to his mental condition. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a lay person is competent to report on that of which he or she has personal knowledge); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). However, the evidence also shows that the Veteran has interaction with his spouse, children and siblings and described these relationships as positive. In the November 2011 VA examination report, he reported he talked to his family about personal topics. He did not report any ongoing discord with his family members. While the clinical findings of record describe experiences, thoughts, and emotions due to PTSD that had significant impact on the Veteran's social relationships, the evidence, overall shows that he was able to function fairly well in his daily activities. In other words, the Veteran's tendency for social isolation suggests difficulty in establishing and maintaining effective work and social relationships with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, as is required for the next higher rating of 70 percent. See Bowling v. Principi, 15 Vet. App. 1, 11 (2001). Regarding the Veteran's occupational functioning, the record reflects that the Veteran has not worked full time since 2003 after a MVA causing orthopedic impairment. However, total occupational impairment due to PTSD has not been shown. As to occupational history, the Veteran reported working as a truck driver and manager about nine years; he retired in June 2003 following an automobile accident for which he received approximately two years of chiropractic care. The November 2011 VA examiner noted although the Veteran reported symptoms consistent with PTSD there did not seem to be historically a disruption in his typical work pattern (i.e., multiple odd jobs or positions of short duration) following military service as the Veteran's longest period of consistent employment was after his second tour in Saudi Arabia. Further, the VA examinations of record indicate that the Veteran has been capable of managing his financial affairs. The February 2016 VA examiner noted the Veteran was able to drive his vehicle around his locale without difficulty, paid his own bills, and made purchases, and in general denied significant impairment of his usual daily activities, although he experienced occasional impairment because of symptoms of PTSD, which were responding to treatment. After reviewing the Veteran's outpatient records, the examiner concluded based on these records, combined with the clinical evaluation, the Veteran's presentation in February 2014 was not actually reflective of his general functioning at that time, but more consistent with occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks. The Board also finds it significant that no abnormalities were found with regard to the Veteran's thought processes, speech and communication. He was capable of managing his financial affairs. The record consistently shows that his speech was normal, that his thought process was coherent without any flight of ideas or loose associations, and his judgment and insight were normal. He was fully oriented and there were no delusions or hallucinations. Mental status examination indicated that there was no obvious gross impairment in orientation, attention, and memory. Thus, deficiencies in the areas of judgment or thinking are not shown. Other symptoms demonstrative of the level of functional impairment required for a higher 70 percent rating were neither complained of nor observed by medical health care providers, including suicidal ideation, obsessional rituals, illogical, obscure, or irrelevant speech, impaired impulse control, or periods of violence. The Veteran had not been shown to have symptoms equivalent in, nature or severity to the criteria required for a higher rating. The record shows the Veteran's disability was found to be consistently manifested by the symptoms of depressed mood, anxiety attacks, nightmares, chronic sleep impairment, intrusive thoughts, irritability, exaggerated startle response, hypervigilance, hyperarousal, avoidance behaviors, suspiciousness, flattened affect, disturbances of motivation and mood, and difficulty in adapting to stressful circumstances, including work or a work-like setting. The evidence does not otherwise show speech suggestive of disorders of thought or perception, difficulty understanding commands, or impairment of memory, judgment, or abstract thinking. In his March 2016 VA Form 646, the Veteran indicated that he suffers from hallucinations and suicidal ideation. However, his outpatient treatment records show that he has repeatedly denied suicidal ideation and hallucination. The Board notes that had the Veteran been experiencing ongoing suicidal ideation, it would have been in his best interest to report that to his treating physicians. See Rucker v. Brown, 10 Vet. App. 67 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). It is further noted that the Veteran was hospitalized for his expression of suicidal ideation in January 2013. However, the records show that his drug screen was positive for Benzodiazepines on this occasion, and his family indicated that the Veteran had been possibly delirious. It was noted the Veteran had had an unclear perspective of his circumstances prior to the admission as he had reported that he had a gun and tried to fire it at himself but his family said this was not accurate. Despite this single incident which appears to have been caused by reaction to a drug, there is no evidence of psychotic symptoms or cognitive deficits. In general, the Veteran had no problem maintaining minimal personal hygiene or with activities of daily living. The Board has also taken into account that the VA physicians who examined the Veteran for treatment purposes or evaluated him to assess the nature, extent and severity of his mental diagnosis, estimated a GAF score between 50 and 60 which, according to the DSM-IV, denote moderate symptoms (e.g., flat effect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or co-workers). Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). This GAF score is consistent with the symptomatology noted and does not provide a basis for an initial rating for the Veteran's PTSD in excess of 50 percent. Accordingly, the Board finds that the Veteran's impairment due to PTSD for the period was more consistent with a 50 percent rating and that the level of disability contemplated in Diagnostic Code 9411 to support the assignment of a 70 percent rating or higher was absent. This determination constitutes a partial grant of the claim on appeal. If an exceptional case arises where a rating based on the disability rating schedule is found to be inadequate, consideration of an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities will be made. 38 C.F.R. § 3.321(b)(1). However, an extraschedular analysis is not required in every case. When extraschedular consideration is not "specifically sought by the claimant nor reasonably raised by the facts found by the Board, the Board is not required to discuss whether referral is warranted." Yancy v. McDonald, 27 Vet. App. 484, 494 (2016); see also Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances to raise the extraschedular issue). Here, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. As the preponderance of the evidence is against the claim for an increased rating, there is no doubt to be resolved, and an initial rating greater than 50 percent for the Veteran's PTSD are not warranted. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to an initial rating of 50 percent, but not greater, for PTSD is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND Unfortunately, the Veteran's TDIU claim must once again be remanded to ensure compliance with the Board's prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998) (holding the Board is obligated by law to ensure that the RO complies with its directives; 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). In December 2013, the Board remanded the case to obtain a new VA examination to assess the current severity of the Veteran's PTSD, as well as his employability as a result of his service-connected disabilities, including PTSD. On remand, the Veteran underwent a VA mental disorders examination in February 2016, but the examiner's opinion only addressed the impact of the Veteran's PTSD on his occupational functioning. This opinion fails to comply with the Board's remand directive. Consequently, in order to satisfy VA's duty to assist, the Board finds that a VA medical opinion should be obtained addressing the impact of all of the Veteran's service-connected disabilities on his employability. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file any updated records from the VA Medical Center (VAMC) in Jackson, Mississippi, dated from October 2015 to the present. All records and/or responses received should be associated with the claims file. 2. Thereafter, schedule the Veteran for a VA medical examination to determine whether his service-connected disabilities result in unemployability. Based on a review of the claims file, the examiner must provide an opinion on the impairment in occupational functioning (the ability to secure and follow a substantially gainful occupation) caused solely by the Veteran's service-connected disabilities, irrespective of age and any nonservice-connected disabilities. In this regard, the examiner must elicit from the Veteran, and record for clinical purposes, a full work and educational history. The opinion must be based on the review of the claims file, and a complete rationale must be provided for any opinions expressed. 3. After completing the above, adjudicate the remaining issue of entitlement to TDIU. If the benefit sought on appeal remains denied, provide an additional supplemental statement of the case to the Veteran, and return the appeal to the Board for appellate review, after the Veteran and his representative have had an adequate opportunity to respond. The Veteran has the right to submit additional evidence and argument on this matter. 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. §§ 5109B, 7112 (2012). ______________________________________________ A. C. MACKENZIE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs