Citation Nr: 1803023 Decision Date: 01/16/18 Archive Date: 01/29/18 DOCKET NO. 12-05 196 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE 1. Entitlement to an initial rating in excess of 30 percent for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating due to individual unemployability (TDIU) due to service-connected disabilities. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and the Veteran's spouse ATTORNEY FOR THE BOARD M. Thompson, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from December 1965 to December 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in April 2015. A transcript of that hearing has been associated with the claims file. This matter was remanded by the Board in July 2015 for further development and has since been returned to the Board for appellate review. The appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system and Legacy Content Manager (LCM) claims file. LCM contains documents that are either duplicative of the evidence in VBMS or not relevant to the issue on appeal. 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 For the entire period on appeal, the Veteran's PTSD has been characterized by occupational and social impairment with deficiencies in work, family relations, and mood, without an inability to establish and maintain effective relationships. CONCLUSION OF LAW Resolving all reasonable doubt in the Veteran's favor, for the entire period on appeal, the criteria for an initial evaluation of 70 percent, but no higher, for PTSD are met. 38 U.S.C.A. §§ 1155, 5103, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.130, Diagnostic Code (DC) 9411 (2016). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist The Veteran is challenging the evaluation assigned in connection with the grant of service connection for PTSD. Where an underlying claim has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated, and there is no need to provide additional § 5103 notice or prejudice from absent notice. Hartman v. Nicholson, 483 F.3d 1311, 1314-15 (Fed. Cir. 2007); VAOPGCPREC 8-2003 (Dec. 22, 2003). In addition, the duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records (STRs) as well as all identified and available post-service medical records are in the claims file. The Veteran has not identified any available, outstanding records that are relevant to the claims decided herein. The Veteran was afforded VA examination in October 2008, October 2010, and June 2012, and January 2017. The Board finds that the VA examination reports and opinions when taken together, are adequate to decide the case because they are predicated on a review of the claims file, as well as on an examination during which a history was solicited from the Veteran. In addition, these examinations, when taken together, fully address the rating criteria that are relevant to rating the disability in this case. Moreover, there is no objective evidence indicating that there has been a material change in the severity of the Veteran's service-connected disability since he was last examined. 38 C.F.R. § 3.327(a) (2017). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (noting that the passage of time alone, without an allegation of worsening, does not warrant a new examination); VAOPGCPREC 11-95 (April 7, 1995). Based on the foregoing, there is adequate medical evidence of record to make a determination in this case. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. For these reasons, the Board concludes that VA has fulfilled the duty to assist the Veteran in this case. The Veteran was also provided with an opportunity to set forth his contentions during the hearing before a Veterans Law Judge (VLJ). A Decision Review Officer or VLJ who chairs a hearing must fulfill two duties: (1) duty to fully explain the issues; and (2) the duty to suggest the submission of evidence that may have been overlooked. 38 C.F.R 3.103(c)(2) (2016); Byrant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). At the Board hearing, the VLJ outlined the issue on appeal and the hearing focused on the elements necessary to substantiate the claim. Additionally, additional subsequent development was conducted based on deficiencies in the record. As such, the Board finds that the VLJ complied with the duties set for in 38 C.F.R. 3.103(c)(2) (2016). There has been no allegation to the contrary. The Board will proceed to address the merits of the claim. The Board also finds compliance with the Board's prior remand directives. This case was remanded by the Board in July 2015. The July 2015 Board remand requested that the RO obtain VA treatment records form February 2012 onward, contact the Veteran and afford him the opportunity to identify private treatment providers, develop and adjudicate the Veteran's claim for TDIU, afford the Veteran a VA examination to determine the current severity of the Veteran's PTSD, and to readjudicate the claim for increased rating of PTSD. VA treatment records were received in December 2015 and February 2017. Correspondence regarding development of the TDIU claim was mailed to the Veteran in November 2015. The Veteran sent an application for increased compensation based on unemployability in February 2016. The claim for increased rating for PTSD was readjudicated in January 2017. The RO received new evidence and again readjudicated the claim in February 2017. The claim for TDIU was adjudicated in February 2016, January 2017 and February 2017 (after the receipt of new evidence). Accordingly, additional remand is not warranted. Stegall v. West, 11 Vet. App. 268 (1998). The Board will proceed to address the merits of the claim. II. Increased Evaluation for PTSD The Veteran seeks an initial evaluation higher than 30 percent for service connected PTSD. Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing the Veteran's symptomatology with the criteria set for the in the Schedule for Rating Disabilities. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). Separate diagnostic codes identify various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.1 (2017). After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). For an appeal of an initial disability evaluation, the Veteran's entire medical history is to be considered. Fenderson v. West, 12 Vet. App. 119 (1999). When a claimant disagrees with an initially assigned disability evaluation, the Board is required to consider whether the Veteran is entitled to separate evaluations for distinct periods based on the facts found during the appeal period, a practice known as "staged ratings." Fenderson, 12 Vet. App. at 126-27; Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's service-connected PTSD is rated under 38 C.F.R. § 4.130, DC 9411 (20167. That DC uses the General Rating Formula for Mental Disorders, which provides for a 30 percent rating 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/or mild memory loss (such as forgetting names, directions, or recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing 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); and inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for a mental disorder 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; and memory loss for names of close relatives, own occupation or own name. Id. Global Assessment of Functioning (GAF) scale scores are based on a scale indicating the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Carpenter v. Brown, 8 Vet. App. 240 (1995); Richard v. Brown, 9 Vet. App. 266 (1996); American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, 4th Ed. (1994) (DSM-IV). The GAF score is based on all of the Veteran's psychiatric impairments. A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or a major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). A GAF score of 41 to 50 indicates 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 51 to 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 coworkers). A GAF score of 61 to 70 represents 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, and has some meaningful interpersonal relationships. While particular GAF scores are not contained in the VA schedule of ratings for mental disorders, they are a useful tool in assessing a veteran's disability and assigning ratings. 38 C.F.R. § 4.130 (2017). However, they are just one of many factors considered when determining a rating. The specified factors for each rating for mental disorders are examples, rather than requirements, for that particular rating. The Board will not limit its analysis solely to whether a veteran exhibited the symptoms listed in the rating criteria. The Board will instead focus on the level of occupation and social impairment caused by the symptoms. Mauerhan v. Principi, 16 Vet. App. 436 (2002). However, "[w]ithout those examples, differentiating a 30% evaluation from a 50% evaluation would be extremely ambiguous." Mauerhan, 16 Vet. App. at 44. The list of examples "provides guidance as to the severity of symptoms contemplated for each rating." Mauerhan, 16 Vet. App. at 442. Each particular rating "requires sufficient symptoms of the kind listed in the requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms; the length of remissions; and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a) (2017). In addition, the evaluation must be 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. Id. Further, when evaluation the level of disability from a mental disorder, the extent of social impairment in considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2017). In May 2008 VA treatment record the Veteran stated that he works as a truck mechanic in a small shop, so that he doesn't have to deal with others. The Veteran enjoys the solitude, it reduces his chances of becoming angry about something. The Veteran admits to problems with mild insomnia, hypervigilance, avoidance of issues related to his combat experiences, anger, inappropriate rage, and depression. The medical provider observed that the Veteran's mood was anxious with congruent affect; thought process was linear; appropriately dressed and groomed; no delusions or hallucinations; and no suicidal or homicidal ideations. The medical provider noted that the Veteran had good short and long-term memory; an organized and logical thought process; and problems with depression, PTSD, sleep stage disturbances, and rage. The medical provider assigned a GAF of 50, which indicates 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). In the October 2008 VA examination report, the Veteran reported that he has worked for the gentleman that he now works for 40 years as a mechanic. The Veteran stated that he never misses work and that work keeps him occupied. The Veteran stated that he likes working alone, which he does. The Veteran reported hypervigilance, exaggerated startle response, and nightmares related to service in Vietnam. The nightmares vary sometimes from not having during the week to two to three times in a week. The Veteran stated that his nightmares are typically triggered by things such as seeing a movie or news about the war or hearing somebody discuss the war. The Veteran reported that he has had very poor sleep for years. The Veteran stated that he will sleep continuously for two to three hours, then wake up frequently after that. The Veteran reported feeling nervous and edgy. The Veteran stated that he has problems being close to people outside of his wife of almost 40 years, has no friends, and does not tolerate crowds. He reported a good relationship with his wife. The Veteran stated that he has problems with irritability. The Veteran reported that these symptoms have existed since his return from Vietnam. The examiner found that the Veteran reflected difficulties with anxious arousal, depression, and anger and irritability and that the Veteran describes mild symptoms of PTSD. The examiner reasoned that the Veteran has not missed any work due to symptomatology and has been at the same job for 50 years. The Veteran denies missing work and says work seems to help his symptomatology by keeping him busy. The examiner found the Veteran fully oriented, with normal psychomotor activity, appropriate speech, and an appropriate affect. His memory functions were grossly intact and thought processes were goal directed. Thought content was within normal limits. There were no suicidal or homicidal ideations. He was neatly dressed and groomed and no abnormal behavior. The Veteran's judgment appears to be intact. And the Veteran's cognitive function is intact. The examiner assigned a GAF of 61, which represents 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, and has some meaningful interpersonal relationships. In a November 2008 lay statement, the Veteran's wife stated that she and the Veteran have been married for 38 years. The Veteran works all of the time because the Veteran said it takes his mind off of Vietnam and all of the things he went through. The Veteran's wife further stated that the Veteran has been blessed because the man the Veteran works for is like family and understands how the Veteran is. The Veteran works by himself and does not have to deal with customers. She further stated that the Veteran cannot be in a crowd of people he gets nervous and he looks like a scared wild animal in a cage. If the Veteran and the Veteran's wife go to a restaurant they have to go early so there won't be a crowd and the Veteran has to sit by the wall so he can see everybody. The Veteran also gets in moods where he doesn't want to talk and just wants everybody to leave him alone. The Veteran's depression will last about a week. The Veteran's wife further stated that the Veteran also has a problem with loud and sudden noise and people coming up behind him. The Veteran doesn't want to have friends because he is afraid something will happen to them. The Veteran's wife believes this is why the Veteran does not have a close relationship with their two children. The Veteran's wife also stated that he Veteran has bad dreams when he sleeps, which is not much. In a November 2008 lay statement the Veteran's friend C.H. stated that the Veteran has faced problems with his anxiety issues. C.H. stated that she has witnessed the Veteran not being able to stay in a room with too many people, including friends and family. C.H. knew that the Veteran worked incessantly, even through illness as a way of coping. C.H. further stated that those who know and love the Veteran accept that he may only visit a few minutes or not be able to attend a family function. The Veteran has made a small circle around his life and is never comfortable to step out. In a February 2009 letter from the Veteran's employer E.M.P., the employer stated that the Veteran began working for E.M.P. as an apprentice mechanic. The Veteran left only to serve in Vietnam. Upon returning, the Veteran became a full-time employee. The Veteran made a couple of attempts as a young man at other fields of work. The Veteran was unable to cope with the people and demands. E.M.P. stated that the Veteran is an excellent worker, but has severe social anxiety problems. E.M.P. has always allowed the Veteran to work independently. The Veteran has his own space with easy access to the outside. E.M.P. did not require the Veteran to deal with the public directly. The Veteran always worked long hours. In E.M.P.'s opinion, working was the Veteran's therapy. Due to the Veteran's outstanding work ethic and the Veteran's longtime friendship, E.M.P has made many concessions necessary for the Veteran to continue to work for him. In February 2009 VA treatment record the Veteran's chief complaint is of mild insomnia due in part to trauma-related nightmares. The Veteran describes some anxiety and irritability which lead him to stay to himself but the medication remains helpful. The February 2009 VA medical provider noted that the Veteran's mood was anxious with congruent affect; thought process was linear; appropriately dressed and groomed; no delusions or hallucinations; no suicidal or homicidal ideation; and assigned a GAF of 53-55, which 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 coworkers). In June 2009 VA treatment records the Veteran described some irritability and occasional trauma-related nightmares but overall mood is stable. The Veteran is confident that medication is beneficial. The examiner observed that the Veteran's mood was slightly anxious with congruent affect; thought process was linear; appropriately dressed and groomed; no delusions or hallucinations; no suicidal or homicidal ideations; and assigned a GAF of 55, which 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 coworkers). In an October 2009 VA treatment record the Veteran reported that he is allowed to work by himself so it's the perfect job, but this will soon end due to the business closing and due to the severity of his symptoms of PTSD he will not be able to hold on to any type of employment. The presenting problem noted by the medical provider was that the Veteran was not comfortable being around people and was very jumpy. The Veteran's medication takes the edge off. The Veteran's wife puts up with a lot off of him. The Veteran stated that his boss was protective. The Veteran does not sleep, goes to bed between eight to nine pm and up by 12 am and he tosses and turns to 4 am. The Veteran stated that he has frequent combat nightmares. The Veteran stated that he has frequent anxiety attacks but it is better with his prescribed medication. The medical provider noted that the Veteran was pleasant and cooperative. The Veteran's grooming was adequate, dressed in casual street clothes. The Veteran's speech was within normal limits in rate, rhythm, volume, tone, and goal-directed, however very anxious. The Veteran's memory was grossly intact. Attention and concentration were unremarkable. The Veteran denied current suicidal or homicidal ideations, not considered a danger to himself or others. The medical provider found that insight, judgement, and reliability were adequate. The medical provider found that the Veteran was experiencing clinically significant levels of impairment in emotional, social, and occupational functioning as a result of PTSD. The medical provider assigned a GAF of 43, which indicates 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). In November 2009 VA treatment record the Veteran stated that he was doing basically the same as stated in previous appointments. The medical provider assigned a GAF of 43, which indicates 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). The December 2009 VA treatment record noted that the Veteran is very worried about losing his job and does not feel he cannot work at any other place because nobody else will put up with him. The Veteran stated that he stays with his wife mostly and will go to stores but it cannot be crowded. The Veteran stated that he continues to struggle with flashbacks, intrusive thoughts, nightmares and memory disturbances. The Veteran reported that he is hypervigilant to external stimuli and avoids crowded places. The Veteran stated that he is irritable and is angered easily. The December 2009 VA medical provider observed that the Veteran is adequately-groomed, casually and appropriately attired. The Veteran's behavior is cooperative, but nervous. Good eye contact. Mood is dysthymic with flat affect. Speech is of normal production and organized. No evidence of delusions, suicidal or homicidal ideations. Concentration and memory is poor. Good insight and judgment. The medical provider assigned a GAF of 45, which indicates 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). In February 2010 VA treatment record the Veteran reported that he continued to struggle with flashbacks, intrusive thoughts, nightmares and memory disturbances. The Veteran stated that he remained hypervigilant to external stimuli and avoided crowded places. Veteran stated that he kept to himself and is not interested in being around other people, the Veteran is irritable and angers easily. The Veteran stated that he avoids any type of social function. The medical provider assigned a GAF of 45, which indicates 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). In May 2010 VA treatment record the Veteran reported that he is not doing well, things are not going well at his job. The Veteran stated that he is becoming very angry at times and that he runs off everyone around him. The Veteran stated that the employer has put up with his behavior. The Veteran stated that he continues to struggle with intrusive thoughts, nightmares and memory disturbances. The Veteran stated that he is up and down all night. The Veteran wakes up mad at the world. The Veteran stated that he keeps to himself and is not interested in being around other people. The Veteran stated that he is irritable and angers easily. The Veteran avoids any type of social function. The Veteran stated that he goes home and he stays home. This has been the case for many years. The Veteran stated that he has only one good friend and the only person he really talks to. The examiner observed that the Veteran was adequately groomed, casually, appropriately attired. The Veteran thoughts are logical and goal-directed. The Veteran's behavior is cooperative, but nervous. The Veteran has good eye contact. The Veteran's mood is dysthymic with mostly flat affect. The Veteran's speech is or normal rate, tone and production and is organized. There is no evidence of delusions, suicidal ideations or homicidal ideations. The Veteran's concentration and memory is poor and the Veteran has fair insight and judgement. The medical provider assigned a GAF of 45, which indicates 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). In a July 2010 letter from J.B.S., a family friend, stated that he has known the Veteran for the last 18 years. J.B.S. recalled that his first meeting with the Veteran, the Veteran seemed distant from family functions within the home the first few months. The Veteran was always working or liked to be alone in his bedroom when at his home. The Veteran was a man of few words and always seemed up tight and nervous. J.B.S. was told by the Veteran's wife and daughter that he was to never ask the Veteran about his service. J.B.S. stated that the Veteran's wife and daughter found that the Veteran had a very had time in Vietnam and that was sore subject around their house. J.B.S. was also warned that if the daughter ever called and asked J.B.S. to not come over to please respect the request. The Veteran began to speak to J.B.S. about six months after their initial meeting. A few times the Veteran's daughter called J.B.S. to ask him not to come over because the Veteran was having a bad day. J.B.S. recalled an incident where the Veteran started screaming in his sleep and J.B.S. was asked to leave the residence. J.B.S. also observed the Veteran always looking out of the window through the blinds. J.B.S. stated that the Veteran acted as if someone was out to get him and his family. The Veteran always kept a rifle by his front door. J.B.S. stated that the Veteran does not sleep, is untrusting of people and paranoid, and has no hobbies or friends. The Veteran is always on edge and seems to stress out easily. J.B.S. has witnessed the Veteran's mood swings. In a July 2010 letter from D.D., D.D. stated that he has known the Veteran for 40 years. D.D., a veteran, stated that he and the Veteran talk about the problems they have. D.D. stated that the Veteran has a constant struggle every day because of flashbacks and nightmares. The Veteran has told D.D. that he would wake up in cold sweats, scared to death at night. In August 2010 a VA medical provider assigned a GAF of 43, which indicates 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). In an August 2010 letter, the Veteran's wife stated that she is an easy going person and it takes everything in her to deal with his moods. The Veteran's wife stated that he will be fine and then she can see the change in him. The Veteran gets angry and then says he feels like crap and the Veteran just zones out. The Veteran's wife stated that it's hard to see him struggle everyday with life. The Veteran does not sleep for the nightmares have gotten worse over the years. The Veteran and his wife have never been able to go places with crowds; he cannot cope with that at all. The Veteran often thinks of his buddies he lost in the battles they were in everyday of his life and he thinks that he doesn't deserve to be here. The Veteran's wife observed that every night the Veteran comes home from work and locks all the doors and lays his gun beside him. The Veteran and his wife have two children, but the Veteran has never been close to them. The Veteran's wife stated that the Veteran's job helps him a lot it keeps him from thinking as much about Vietnam. The Veteran works for a good man who lets him do what he wants and that is to stay away from people. In the October 2010 VA examination report, the Veteran reported ongoing nightmares which are occurring two to three nights a week. The Veteran reported he stayed away from everybody. The Veteran stated that he has pretty good days and weeks but for the most part, his symptoms have not improved since his last VA examination in 2008. The Veteran reported that he continued to work, but that he did not work as hard as he used to. The Veteran stated that he has worked for the same person for the past 40 years and denied any significant absenteeism from the job. The Veteran stated he worked mainly by himself because he does not want to be bothered with others. The Veteran stated that he worked with the owner who is like a father figure to him, the owner's relative, and his two brothers. The Veteran stated that the environment will trigger memories for him such as the smell of diesel. The Veteran also stated that when he hears helicopters, this will also trigger intrusive memories of Vietnam. The Veteran stated that he avoids people in general. The Veteran described getting irritable and angered and will yell and scream on a regular basis. The Veteran stated that this can happen daily. However, the Veteran is able to inhibit his anger at home with his wife. He reported getting along well with his family, although he had recently moved his son out of their home. He and his wife went out to dinner if the place is not too crowded. The Veteran stated that he is jumpy all the time and always needs to see what it going on. The Veteran reported having one good friend who is also a Vietnam Veteran, who is from his hometown. The VA examiner found that the Veteran has mild to moderate PTSD. The examiner observed that the Veteran was cooperative and was oriented to time, place, and person. The examiner found that there were no significant impairments in communications or thought processes. Memory was within normal limits. Concentration and attention appeared intact during the interview. The Veteran maintained his own activities of daily living independently. The Veteran's judgment and insight were grossly intact. There was normal speech, a fair to worse mood, a variable affect. He denied current suicidal ideations, although he had thought of it over time. He denied homicidal ideations, hallucinations, and delusions. The examiner assigned a GAF of 61, which represents 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, and has some meaningful interpersonal relationships. In November 2010 VA treatment record the Veteran reported that he continued to struggle with flashbacks, intrusive thoughts, nightmares, and memory disturbance. The Veteran keeps to himself and is not interested in being around other people, he is irritable and angers easily. The provider observed that the Veteran was adequately-groomed, casually, appropriately attired. Thoughts are logical and appropriate. Behavior is cooperative, but nervous. Good eye contact. Mood is dysthymic with mostly flat affect. Speech is of normal, rate, tone, and production and is organized. No evidence of delusions/illusions, no active suicidal ideation or homicidal ideation thoughts. Concentration is poor, not formally tested. The Veteran has good insight and judgement. The medical provider assigned a GAF of 48, which indicates 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). In a December 2010 letter, the Veteran clarified his October 2010 VA examiner's statements regarding the Veteran's employment, in that he is working part-time because he spends 10 to 12 hours a day at work because that is the only place he is half way comfortable. But just because he is there does not mean he is working. The Veteran stated that he picks what he wants to do and nothing else. The Veteran stated that he used to work on everything but now to him that his part-time. The Veteran stated that the owners of the mechanic shop are like family to him. The Veteran stated that he has worked there for 40 years because he could not work any place else. The Veteran stated that he had to work at dead end jobs because the Veteran cannot control his temper with people. The Veteran stated that he has been married for a long time. The Veteran stated that his wife is very special to put up with him. The Veteran tries harder to keep from yelling at his wife at home, but most of the time it comes out anyway. In March 2011 VA treatment record the Veteran reported that he continued to struggle with flashbacks, intrusive thoughts, nightmares, and memory disturbance. The Veteran keeps to himself and is not interested in being around other people, he is irritable and angers easily. The Veteran avoids any type of social function. The March 2011 VA treatment medical provider observed that the Veteran was adequately-groomed, casually, appropriately attired. Thoughts are logical and appropriate. Behavior is cooperative, but nervous. Good eye contact. Mood is dysthymic with mostly flat affect. Speech is of normal, rate, tone, and production and is organized. No evidence of delusions/illusions, no active suicidal ideation or homicidal ideation thoughts. Concentration is poor, not formally tested. The Veteran has good insight and judgement. The medical provider assigned a GAF of 45, which indicates 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). In a June 2011 VA treatment record that Veteran reported that he continues to struggle with flashbacks, intrusive thoughts, nightmares, and memory disturbances. The Veteran keeps to himself and is not interested in being around other people, he is irritable and angers easily. The Veteran avoids any type of social function. The provider observed that the Veteran was adequately-groomed, causally, appropriately attired. Thoughts are logical and appropriate. Behavior is cooperative, but nervous. The Veteran makes good eye contact. The Veteran's mood is dysthymic with mostly flat affect. Speech is of normal, rate, tone and production and is organized. No evidence of delusions/illusions, no active suicidal ideations or homicidal ideation thoughts. Concentration and memory is poor, not formally tested. The Veteran has good insight and judgment. The medical provider assigned a GAF of 45, which indicates 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). In a February 2012 VA treatment record the Veteran continued to report the same symptoms from May 2010 VA treatment records. The medical provider made the same observations from May 2010 VA treatment records and also assigned a GAF of 45, which indicates 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). On the Veteran's February 2012 substantive appeal the Veteran stated that he has nightmares, he stays from people, night sweats, jumpy to the point the Veteran' hits the ground. The Veteran has flashbacks. The Veteran further stated that he gets mad easy. The Veteran stated that he does not work 12 hours a day. The Veteran stated that he only works 16 hours a week at most. The Veteran stated that when he is at work he works at the back of the shop where there are no people around. The Veteran stated that he can't even go to church due to the people. In the June 2012 VA examination report, the Veteran indicated that he quit working in March 2012. The Veteran stated that he worked at a mechanic shop since 1969. The Veteran stated that he was able to work and maintain this job because the business owner was like a father to him and allowed him to work by himself and as much or as little as he needed. The Veteran stated that he began to work there part-time when he started collecting social security at age 62. The Veteran stated that he decided this past March that it was time to retire. The Veteran feels that he would be better off dead. The Veteran stated that even when he starts out in a pretty good mood it can easily become crappy and doesn't know why sometimes. The Veteran reported that he gets frequent intrusive thoughts about Vietnam which affects his mood. The Veteran stated that he has problems with sleep, issues with being in crowds, and jumpiness. The Veteran stated that he avoids being around other people, he gets jumpy to the point that he would hit someone if they came up behind him quietly, he has flashbacks and nightmares all of time, he has to sit facing doors when he goes anywhere, and the Veteran feels that is life is still like it was when he was in Vietnam. The Veteran stated that he has problems with extreme nervousness especially around crowds and loud noises and gets very uncomfortable but denies problems with anxiety or panic attacks. The Veteran stated that he has intermittent thoughts of suicide because he is unsure if his life is really worth living, but denied any thoughts of suicide with intent. The Veteran also stated that he has extreme problems with his temper. The Veteran stated that he is easily irritable and can become angry very quickly. The Veteran also stated that he has problems with his memory and concentration. The Veteran stated that he doesn't get along with others except his wife and he feels a good deal of guilt about the way he treats her at times. The examiner found that the Veteran completed the Trauma Symptoms Inventory as a part of this evaluation and endorsed chronic symptoms of anxious arousal, anger and irritability, depression, defensive avoidance, intrusive experiences, dissociation, tension reduction behaviors and impaired self-reference. The scale score for trauma indicated mild distress as a result of traumatic experiences. The examiner assigned a GAF of 65 based on symptoms of anxiety, depression, irritability, problems with sleep, few friends and conflicts with peers and/or co-workers. That GAF score reflects 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, and has some meaningful interpersonal relationships. The examiner found that the Veteran's level of occupational and social impairment was that of 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 that the Veteran experiences intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. The examiner found that that Veteran's PTSD symptoms cause clinically significant distress of impairment in social, occupational, or other important areas of functioning. The examiner noted that the Veteran experiences depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation. The examiner found that the Veteran did not demonstrate an inability to establish and maintain effective relationships, obsessional rituals which interfere with routine activities, impaired impulse control, spatial disorientation, near continuous panic or depression affective the ability to functional independently, among other symptoms. The examiner remarked that the Veteran symptoms of PTSD are persistent and without any significant periods of remission since his military service. His symptoms of anxiety, depression and problems with sleep are a part of his PTSD and do not warrant a separate diagnosis. At the August 2012 Decision Review Officer (DRO) Hearing, the Veteran stated that he does not sleep a whole lot. He has a lot of nightmares at night. Probably about three or four times a week most times. The Veteran stated that he is prescribed medication to help him sleep. The Veteran stated that the nightmares include night sweats. The Veteran stated that when he is having nightmares he wakes up a lot of times swinging and fighting. He stated that a lot of times he won't even remember it. The Veteran also stated that he experiences panic attacks. The Veteran stated that these panic attacks might last two or three days or it might go away in a day. The Veteran also experiences a lot of episodes of depression. The Veteran stated that he was not working. The Veteran stated that he retired in March. The Veteran stated that he has had thoughts of suicide. The Veteran stated that he never attempted suicide. The Veteran stated that he has had homicidal thought. The Veteran stated that a lot of people make him really angry and he is trying to be nice. The Veteran stated that he can't do large crowds. The Veteran stated that he has only one friend, L.Y. (witness at the DRO hearing). The Veteran stated he does not have relationship with his son. The Veteran stated that he has no relationship really with any one of his kids. The witness at the August 2012 DRO hearing, L.Y., stated that the Veteran knocked a hole in the wall one night when he got up from a nightmare. L.Y. stated that before the Veteran went to Vietnam he was always kind of carefree. Since the Veteran came back from Vietnam he never looked as he would live to see tomorrow. The Veteran and L.Y. sit down and keep each other from going crazy and killing somebody. Afterwards, L.Y. stated that he knows that the Veteran has sleep problem and likes to fight. L.Y. is the one helping the Veteran fix the holes in the walls. In a March 2015 VA treatment record, the Veteran reported that he has a lot of survivor's guilt and will ruminate about how his life seems to lack purpose and meaning . The Veteran also reported that he suffers from nightmares several nights per week and is also bothered by flashbacks several times a week. The Veteran stated that he will often emotionally and physical isolate himself from others. The Veteran stated that since his retirement he has struggled with finding a sense of belongingness and purpose. The medical provider noted that the Veteran was appropriately dressed and groomed, no psychomotor problems, moderately depressed, affect was congruent with mood, speech was of normal rate, speech had normal rhythm and volume, the Veteran's thought process was appropriate and relevant and logical, alert and oriented, had fair concentration, and fair attention. The Veteran was assigned a GAF score of 47. At another March 2015 appointment, the Veteran was assigned a GAF of 45, which indicates 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). At the April 2015 Travel Board Hearing, the Veteran stated that up until this point he hadn't really been very truthful, but he just haven't been telling them exactly how he feels because the Veteran didn't feel like he should be that way. The Veteran stated that it was embarrassing to say that he can't deal with something when he knows that a lot of people got killed that would glad to be here under any circumstances. It's just hard to admit it. The Veteran stated that he didn't tell the prior VA examiner very much of anything. The Veteran stated that he totally quit work about six or seven months prior to the Travel Board Hearing because he boss was getting on his nerves. The Veteran worked for his prior employer since he was 16. The Veteran stated that his prior employment was like a family organization. It wasn't a big thing where you had to deal with a lot of people. The Veteran stated that he didn't have to deal with nobody because the employer knew how the Veteran was and made it a point to keep the Veteran to himself. And the Veteran very seldom had to deal with anybody. The Veteran stated that he doesn't have any relationships with his family. The Veteran has a friend that served in Vietnam with the Veteran. In regards to his prior employment, the Veteran sated that his employer was willing to work with the Veteran even though the Veteran threw tubes through the wall. The Veteran stated that he has problems with short and long-term memory. The Veteran stated that he can't remember anything short term. At the April 2015 Travel Board Hearing, the Veteran's wife stated that the Veteran has a lot of problems with anger and irritability. She stated that the Veteran could get up in the morning and be okay. And then the next minute she's around him it's like a totally different person. It just goes like that. The Veteran's wife also stated that the Veteran has panic attacks. He might be fine one minute and the next ho looks like a wild person over there. The wife also stated that the Veteran has knocked down bedroom doors. On July 2015 VA treatment records the Veteran reported that his anxiety was worse at this time and he was still having down days but not as bad as before. From August 2015 to October 2015, January 2016 to November 2016, and February 2017 VA treatment records the Veteran was assigned a GAF score of 45. In November 2015 VA treatment records the Veteran was assigned a GAF score of 45. In November 2016 and December 2016 VA treatment record the Veteran was assigned a GAF score of 44. January 2017 VA treatment record the Veteran was assigned a GAF of 43. These scores indicate 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). In the January 2017 VA PTSD examination report, the Veteran reported current symptoms of anger, anxiety, depression, feeling lost and worthless, suicidal ideations, and social isolation, chronic sleep impairment. The examiner found a flattened affect, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner also found suicidal ideations without attempt or expressed intent and a history of vague homicidal ideations. The examiner opined that the Veteran has occupation 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 observed that the Veteran is loud, irritable, and vague but cooperative and mentally intact. The examiner found that the Veteran's claimed intense anger is not reflected by objective testing in the Minnesota multiphasic Personality Inventory (MMPI). In a February 2017 letter, the Veteran's VA treating psychologist stated that he has been working with the Veteran since March 2015. The VA psychologist stated that the Veteran's symptoms profile seems much more debilitating that the percentage rating indicates. The VA psychologist noted the Veteran's reported symptoms as re-experiencing (intrusive thoughts, nightmares, intense psychological reactivity and psychological stress when exposed to triggers), avoidance, and increased arousal. The VA psychologist found that the Veteran's symptoms combined with his documented depressive symptoms have severely impaired the Veteran's functioning across multiple life domains. The Veteran will require consistent outpatient follow-up to address his symptoms. The Veteran should be encouraged to live an active lifestyle, but additional undue stress would likely only exacerbate his already significant symptoms. The VA psychologist noted that employment would probably not be in the Veteran's best interests or the interests of those his limited functioning may negatively impact. In a February 2017 letter, the Veteran VA treating nurse practitioner stated that she has been treating the Veteran since 2009. The treating nurse practitioner noted that the Veteran stated he was allowed to work by himself but this business (mechanic shop) has since closed and he no longer works. The Veteran stated that he is not comfortable being around people and he is very jumpy. The Veteran reported that the prescribed medication seems to take the edge off. The Veteran reported that his sleep is fragmented and he has frequent combat nightmares. The Veteran stated that he does not feel he is able to work. The Veteran is enrolled in intensive psychotherapy that the Veteran stated has helped but he remains very symptomatic. The foregoing evidence demonstrates that for the entire period on appeal, and resolving all doubt in favor of the Veteran, his PTSD has warranted a 70 percent evaluation. The Veteran has demonstrated deficiencies in mood, family relations, and work. Although he maintained job until 2012, this was mainly due to his longstanding relationship with his employer. Likewise, he has remained married, but this is due in large part to his wife merely putting up with his anger and other symptoms. Furthermore, he has expressed suicidal ideations and impaired impulse control. Although the 2008, 2010, 2012, and 2017 VA examinations were adequate based on the symptoms as reported by the Veteran at those times, the Board affords greater weight to the lay statements from the Veteran, the Veteran's wife, D.D., C.H, J.B.S, E.M.P, L.Y., the VA treatment records, and letter from the Veteran's VA treating psychologist. This is because as the Veteran noted at t the Board hearing, he tended to underreport his symptoms to VA examiners with whom he was unfamiliar. VA treatment records note that the Veteran's GAF score was between 40 and 50, indicative of serious symptoms; or serious impairment in social, occupation, or school functioning, from October 2009 through the period on appeal. Also the Veteran's VA treating psychologist believed the Veteran's symptoms indicated a higher rating than assigned. And the VA treatment records and the letter by the VA treating psychologist were supported by all of the lay statements. The evidence does not show that entitlement to an evaluation higher than 70 percent is warranted. A 100 percent evaluation, however, is not for assignment. First, there is not total social impairment as the Veteran retains at least one friend and has remained married. The Veteran was consistently able to perform the activities of daily living and maintained good hygiene at all times. The Veteran was fully oriented and had no gross impairment in thought processes or speech. The Veteran denied hallucinations and delusions and did not have memory loss for names of close relatives or his own name. The VA treatment records, VA examinations, the Veteran, and the Veteran's wife do state that the Veteran does have anger, but that anger does not amount to persistent danger of hurting others. Moreover, at no point did the Veteran's symptoms approach the severity and frequency necessary to cause total social and occupational impairment. Thus, the criteria for an evaluation higher than 70 percent for PTSD are not met. For these reasons, and resolving all reasonable doubt in the Veteran's favor, the Board concludes that the Veteran's PTSD has more nearly approximated the 70 percent criteria for the entire appeal period, which begins on October 3, 2008. 38 C.F.R. §§ 4.3, 4.130, DC 9411 (2016); see Mauerhan, 16 Vet. App. 436. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. Ap. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER A 70 percent, but no higher, evaluation for PTSD for the entire period on appeal is granted. REMAND The Veteran asserts that his service-connected PTSD renders him unemployable. A TDIU may be assigned when a Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that: if the veteran has only one such disability, the disability must be rated at 60 percent or more, or, if the veteran has two or more disabilities, at least one disability is rated at 40 percent or more and additional disabilities bring the veteran's combined disability rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2017). In this case, the Veteran meets the schedular criteria. Beginning October 3, 2008, there are two service-connected disabilities. The Veteran's prostate cancer was rated 100 percent and reduced to 40 percent on December 1, 2009. The Veteran's PTSD is now evaluated at 70 percent from October 3, 2008. Effective March 21, 2009, the Veteran was service connected at noncompensable for erectile dysfunction. Effective April 6, 2009, service connection was granted for bilateral testicular atrophy, which was assigned a 20 percent evaluation, and then reduced to noncompensable in December 2009. Effective May 3, 2012, service connection was granted for tinnitus at 10 percent and hearing loss at noncompensable. From October 3, 2008 the Veteran's combined evaluation is at least 70 percent. Thus, the Veteran meets schedular requirements for a TDIU, and the only remaining issue is whether the Veteran is able to secure or follow a substantially gainful occupation as a result of service-connected disabilities. The Veteran reported that he has an eighth or ninth grade education. The Veteran worked as a mechanic. The Veteran stated that upon his discharge from service he worked a few jobs but was fired for unknown reasons. The Veteran stated that he began working as a mechanic with a family friend and had worked there for 40 years. The Veteran stated that his employer allowed him to work in isolation. In March 2012 the Veteran stated that he had to leave employment due to him being angry and throwing tubes through the wall. The Veteran's employer stated in a letter that the Veteran was unable to maintain employment upon his discharge from service. Because the Veteran was a family friend, the employer hired him and made accommodations for the Veteran's social anxiety. The employer stated that but for his accommodations, the Veteran would not be able to maintain employment. In a February 2017 letter, the Veteran's VA treating psychologist stated that the Veteran should be encouraged to live an active lifestyle, but additional undue stress would likely only exacerbate his already significant symptoms. The VA psychologist noted that employment would probably not be in the Veteran's best interests or the interests of those his limited functioning may negatively impact. The Board notes that these opinions are not significantly probative and thus adequate upon which to base a grant of TDIU. The Veteran's employer opinion is not competent as he is not qualified to make such determinations. Additionally, the Veteran's treating psychologist merely noted that employment would exacerbate his PTSD, not that he was unable to work. Thus, on remand, additional information regarding the Veteran's service-connected disabilities is warranted. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran a VA social and industrial survey by a VA social worker or other appropriate personnel. The examiner should elicit and set forth pertinent facts regarding the Veteran's medical history, education and employment history, day-to-day functioning, and social and industrial capacity. The ultimate purpose of the VA social and industrial survey is to ascertain the impact of the Veteran's service-connected disabilities (his PTSD, prostate cancer residuals, erectile dysfunction, bilateral testicular atrophy, tinnitus, and hearing loss) on his ability to work. The examiner should not consider the Veteran's age and any nonservice-connected disorders. The examiner is not limited to the foregoing instructions, and may seek initial or additional development in any survey area that would shed more light on the Veteran's ability to secure or follow a substantially gainful occupation. 2. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that 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 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. 3. Ensure compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 4. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. If the claim remains denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. 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. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs