Citation Nr: 1120460 Decision Date: 05/25/11 Archive Date: 06/06/11 DOCKET NO. 08-00 070 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUE 1. Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD K. Gielow, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1943 to January 1946. This matter comes before the Board of Veterans' Appeals (Board) from a September 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts, which granted service connection for PTSD and assigned a 30 percent evaluation, effective October 25, 2005. During the pendency of the Veteran's appeal, in a January 2007 rating decision, the RO assigned a higher 50 percent evaluation for PTSD, effective October 25, 2005. The U.S. Court of Appeals for Veterans Claims (Court) has held that on a claim for an original or increased rating, the appellant will generally be presumed to be seeking the maximum benefit allowed by law or regulation, and it follows that such a claim remains in controversy where less than the maximum benefit is allowed. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Court further held that, where a claimant has filed a notice of disagreement as to a RO decision assigning a particular rating, a subsequent RO decision awarded a higher rating, but less than the maximum available benefit, does not abrogate the appeal. Id. In this case, the Veteran's representative, in an October 2006 statement, indicated that the Veteran was seeking a 50 percent rating for PTSD. However, the Veteran in subsequent communications, including a February 2007 statement, expressly declared that he was entitled to an initial rating in excess of 50 percent. Accordingly, notwithstanding the assignment of a higher 50 percent rating during the course of the appeal, his claim for a higher disability evaluation remained in controversy. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total rating based on individual unemployability (TDIU) is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. The Court further held that when evidence of unemployability is submitted at the same time that a veteran is appealing the initial rating assigned for a disability, the claim for TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Id. Because a February 2006 VA treatment report reflects that the Veteran was unable to work and was disabled secondary to PTSD, the Board finds that the issue of TDIU has been reasonably raised by the record and is, thus, properly before the Board by virtue of his increased-rating claim pursuant to Rice. Accordingly, the issues have been recharacterized as shown on the first page of this decision. The appellant and his spouse testified before the undersigned Veterans Law Judge in October 2009. A transcript of the hearing is of record. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. The Veteran's PTSD has been reflective of occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood; it does not more nearly approximate total occupational and social impairment. 2. The Veteran's service-connected PTSD prevents him from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an initial rating of 70 percent, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1 through 4.14, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for entitlement to TDIU are met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.16 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duty to Notify and Assist VA has specified duties to notify a claimant as to the information and evidence necessary to substantiate a claim for VA benefits. The Board has considered whether further development and notice under the Veterans Claims Assistance Act of 2000 (VCAA) or other law should be undertaken. Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. With regard to the claim for TDIU, the Board is granting in full the benefit sought on appeal. Accordingly, assuming that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and need not be further considered. With regard to the Veteran's claim for a disability rating in excess of 50 percent for PTSD, the Veteran's claim arises from his disagreement with the initial evaluation following the grant of service connection for PTSD. The Federal Circuit and the U.S. Court of Appeals for Veterans Claims have held that, once service connection is granted, the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Therefore, no further notice is needed under VCAA with regard to this issue. As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). As an initial matter, service treatment records and VA outpatient treatment records have been obtained and associated with the claims file, and the Veteran has submitted written statements, including a statement from his wife, on his behalf. Additionally, in October 2009, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Veterans Law Judge. The Court has recently held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the October hearing, the undersigned Veterans Law Judge identified the issue on appeal. Hearing Transcript (T.) at p. 2. Also, information was solicited regarding the severity of the Veteran's PTSD, to include an inquiry for the reasons of the Veteran's retirement from work (see T. at p. 9-11) and the nature of his family relationships (see T. at p. 9, 13). Therefore, not only was the issue explained in terms of the scope of the claim for benefits, but the outstanding issues material to substantiating the claim were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the October 2009 hearing discussion did not reveal any evidence that might be available that had not been submitted. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the appellant's claim for a higher rating for PTSD. In fact, to the extent that the testimony indicated that the Veteran's condition may have worsened since his last VA examination, the Board remanded the claim in February 2010 for a new VA examination in order to ascertain the current level of severity of his PTSD. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that the Board may proceed to adjudicate the claim based on the current record. Next, the Veteran was provided with VA examinations in June 2006 and May 2010. Upon a review of these examinations, the Board determines that the examination reports are adequate for rating purposes. Specifically, the examiners reviewed the claims file, interviewed the Veteran, and conducted a psychological examination; there is no indication that the Veteran's past history or any relevant fact was misstated. Importantly, the VA examination reports discussed the effect of the Veteran's PTSD in terms of social and occupational functional limitation, so as to facilitate an informed assessment of his disability under the criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). Thus, the Board finds that a remand for another VA examination is not required. The Board is also satisfied there was substantial compliance with the February 2010 remand directives, which requested that the RO obtain VA treatment records and conduct a new VA examination with regard to the Veteran's PTSD. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand by the Court or the Board confers on the veteran or other claimant, as a matter of law, the right to compliance with the remand orders); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (the appellant has the right to substantial, but not strict, compliance with a remand order). In this regard, VA outpatient treatment records through March 2011 have been associated with the claims file, and Veteran was provided with a VA examination in May 2010 that evaluated the severity of his PTSD and was based upon a review of the claims file. Following this development, the RO issued a supplemental statement of the case and provided the Veteran and his representative with an opportunity to respond in compliance with the Board's February 2010 remand instructions. Of significance, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Therefore, the Board finds that the available records and evidence have been obtained in order to make adequate determination as to this claim. Accordingly, the Board finds that no useful purpose would be served in remanding the matter for yet more development and that such a remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit flowing to the Veteran. The Court has held that such remands are to be avoided. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). For these reasons, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Initial Rating Claim Disability evaluations are determined by the application of a schedule of ratings based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1 (2010). Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2010). However, the Board has been directed to consider only those factors contained wholly in the rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); but see Mauerhan v. Principi, 16 Vet. App. 436 (2002) (finding it appropriate to consider factors outside the specific rating criteria in determining level of occupational and social impairment). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2010). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2010). In this case, the Veteran contends that his PTSD is of such severity so as to warrant a disability rating in excess of 50 percent. At the outset, the Board notes that the Veteran is appealing the initial disability rating assigned for his PTSD. As such, the claims require consideration of the entire time period involved and contemplation of staged ratings where warranted. See Fenderson v. West, 12 Vet. App. 119 (1999). Under the applicable rating criteria for PTSD, a 50 percent is indicative of occupational and social impairment, but with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, 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 task); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2010). A 70 percent rating is warranted for even greater occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting 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. The maximum rating of 100 percent requires 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. The specified factors for each incremental psychiatric rating are not requirements for a particular rating but are examples providing guidance as to the type and degree of severity, or their effects on social and work situations. Thus, any analysis should not be limited solely to whether the symptoms listed in the rating scheme are exhibited; rather, consideration must be given to factors outside the specific rating criteria in determining the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In Mauerhan, the Court rejected the argument "that the DSM-IV criteria should be the exclusive basis in the schedule governing ratings for PTSD." Id. at 443. Rather, distinctive PTSD symptoms in the DSM-IV are used to diagnosis PTSD rather than evaluate the degree of disability resulting from the condition. Although certain symptoms must be present in order to establish the diagnosis of PTSD, as with other conditions, it is not the symptoms but their effects that determine the level of impairment. Id. After a thorough review of all of the evidence of record, the Board finds that the Veteran's symptoms more nearly approximate the rating criteria for a 70 percent evaluation for PTSD. In this regard, there is evidence demonstrating that he had occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood. While VA therapy notes routinely indicated a diagnosis of "mild" PTSD from September 2005 to July 2008, the Board finds this characterization of the severity of his disability to be less probative than the individualized assessment provided in VA examination reports and VA psychological evaluations, which demonstrate more severe effects of PTSD-related symptoms. For instance, in an October 2005 letter, the Veteran's VA mental health care providers noted recurrent nightmares, intrusive thought patterns, and flashbacks that often interfered with memory, as well as the ability to communicate affectively and to perform tasks of daily living. The Veteran demonstrated low tolerance for stresses and significant periods of disorientation, memory loss, and concentration problems. Irritability and impulsive behavior were shown, with unprovoked outbursts of anger, as well as isolation, anxiety, and depression. As a result of this assessment, the VA examiners diagnosed him with PTSD "chronic and severe" and opined that he had "significant limits in his ability to function both socially and occupationally." The June 2006 VA examination identified PTSD symptoms of recurrent and intrusive recollections of the stressful event and "[i]ntense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event." Further, the Veteran demonstrated persistent avoidance of thoughts, feelings, or conversations associated with the trauma. This appeared to affect the Veteran socially as he made efforts to avoid activities, places, or people that arouse recollections of the trauma, and he had "[m]arkedly diminished interest in participation of significant activities" and restricted range of affect. It was also noted that he had persistent symptoms of irritability or outbursts of anger and difficulty concentrating. Importantly, with response to overall occupational and social impairment, the VA examiner's response was "Yes" to the question of whether there was clinically significant distress or impairment in social, occupational, or other important areas of functioning. The most recent May 2010 VA examination report noted additional cognitive impairment and explained that the Veteran experienced intrusive memories, distractibility, forgetfulness, difficulty sleeping, nightmares, flailing in his sleep, hypervigilance, anxiety, and depression. The examiner further noted that "social impairment" was demonstrated and that the Veteran was retired and no longer capable of competitive employment. Importantly, although an October 2010 VA neuropsychological evaluation indicated that the Veteran's cognitive declines were consistent with a dementing process, it was also noted that a "mixed process" could not be ruled out. Significantly, the May 2010 VA examiner suggested that the "decline[ ]in mood and cognitive decline can be associated with PTSD" and that his depression, distractibility, and forgetfulness are associated with PTSD and may be contributory factors to the Veteran's cognitive problems. Accordingly, without competent evidence differentiating the cognitive impairments from PTSD, the Board will consider the cognitive impairments as symptoms of his service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996) (indicating that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability in the absence of medical evidence that does so, although the Board may not ignore such distinctions where they appear in the medical record). The above evidence supports a correlation between the Veteran's PTSD symptoms and significant functional occupational and social impairment. Notwithstanding the fact that many of symptoms listed in the criteria for a 70 percent rating under Diagnostic Code 9411 have not been demonstrated (such as suicidal ideation, obsessive rituals, neglect of personal appearance or hygiene, and intermittently illogical, obscure, or irrelevant speech), the Court has emphasizes in Mauerhan that "[t]he use of the term 'such as' 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, 442 (2002) (emphasis added). Further, the Federal Register accompanying the 1996 amendment to Diagnostic Code 9411 explains, "Although certain symptoms must be present in order to establish the diagnosis of PTSD, as with other conditions it is not the symptoms, but their effects, that determine the level of impairment." 61 Fed. Reg. 52,695, 52,697 (Oct. 8 1996) (emphasis added). Accordingly, the Board finds that, given the noted occupational and social impairment of record, his disability picture is more nearly approximate to the symptomatology represented by a 70 percent rating for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, judgment, thinking or mood. In order to be entitled to the next-higher 100 percent rating, however, the evidence must show 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. 38 C.F.R. § 4.130. Here, however, the Board finds that a 100 percent rating is not warranted because the Veteran's symptoms do not more nearly approximate total occupational and social impairment. The Board recognizes that the evidence establishes some social impairment, as explained more fully above, as well as occupational impairment. However, according to VA therapy notes, the Veteran had been married to his wife for over 60 years and "[h]is social support network is quite adequate and sufficient to meet his needs at this stage in his life." See, e.g., VA treatment reports dated October 2005 and February 2007. In addition, the Veteran testified at the October 2009 hearing that he gets along with family "fairly good." T. at p. 9. The Board acknowledges that the Veteran has recently reported additional decreases in memory, to include trouble remembering his grandchildren's names as noted in the May 2010 VA examination and forgetting how to get to familiar places in his neighborhood in the October 2010 neuropsychological evaluation. However the October 2010 neuropsychological evaluation report also indicated that he remained independent in all activities of daily living (he denied problems with driving, managed appointment with a calendar, and denied problems with cooking) and that he reported playing board games with this wife. This is evidence of at least some ability to function socially. Furthermore, although the Board recognizes that the symptoms listed in the rating criteria are not dispositive of the issue of overall impairment, the evidence does not demonstrate gross impairment of thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, or that the Veteran is a persistent danger of hurting himself or others throughout the appeal period. Rather, of the symptoms listed in the criteria for a 100 percent rating, the evidence shows at most only an intermittent inability to perform activities of daily living, occasional disorientation as to time and place, and memory loss of names of close relatives. Importantly, even with the presence of some of the symptoms listed for a 100 percent rating, the evidence does not establish that the Veteran's overall impairment, at least with respect to his ability to function socially, has been totally impaired. Moreover, throughout the time period on appeal the Veteran was assigned a Global Assessment of Functioning (GAF) score ranging between 42 and 55. The GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health illness." See the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) (DSM-IV); see also Carpenter v. Brown, 8 Vet. App. 240 (1995). According to DSM-IV, a GAF score from 51 to 60 indicates represents "[m]oderate 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 Scale score of 41 to 50, however, 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). Id. Thus, to the extent that the Veteran's GAF scores were rated as above 50, this is indicative of more moderate symptomatology, and even considering the lowest GAF score of 42, which was reported in a January 2009 VA treatment report, the scores of 42, 45, and 50 are indicative of "serious" occupational and social impairment. The Veteran has not received GAF scores lower than 42 that would indicate even more limited occupational and social impairment, such as a GAF score of 31 to 40, which indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant), or an 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) or a GAF Scale score of 21 to 30, which indicates behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation), or inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). Thus, inasmuch as the Veterans GAF scores indicate serious social and occupational impairment, the GAF scores are not found to be indicative of total occupational and social impairment. Because the weight of evidence establishes that the Veteran's social impairment is not total or complete, the Board finds that the Veteran's symptoms do not demonstrate a disability picture more nearly approximating a 100 percent under Diagnostic Code 9411 for total occupational and social impairment. Instead, the overall disability picture is more suggestive of a 70 percent rating, and no higher, for occupational and social impairment with deficiencies in most areas. In considering whether the Veteran is entitled to a higher disability rating, the Board has also carefully considered his contentions, as well as the statements of his wife, asserting that his disability is more severe than currently characterized. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). In this case, the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, and his wife is capable of reporting events that she witnessed. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Moreover, the Board acknowledges their beliefs that his symptoms are of such severity as to warrant a higher rating; however, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity. Therefore, the Board finds that the overall evidence and reported symptoms, which correspond to the criteria under which the service-connected disability, to be the most probative assessment of the severity of his PTSD. Significantly, although the Veteran and his wife have submitted lay statements in favor of a higher rating, neither has specifically alleged that his PTSD symptoms have rendered him totally occupationally and socially impaired. As the weight of the evidence does not demonstrate total social and occupational impairment, the criteria for a 100 percent rating have not been met, irrespective of any lay assertions of entitlement to a 100 percent rating. In consideration of the above, the Board finds that Veteran's symptoms more nearly approximate the rating criteria for a 70 percent rating, but no higher, for PTSD. The Board has further considered his symptoms throughout the pertinent period on appeal and finds that the assignment of different ratings for different periods of time is not warranted, as total social and occupational impairment has not been demonstrated for any length of time throughout the appeal period. See Fenderson v. West, 12 Vet. App. 119 (1999). As such, a rating of 70 percent, but no higher, is granted for PTSD. His appeal is granted to this extent. Extraschedular Consideration The Board has also considered whether the Veteran is entitled to a referral for an extraschedular rating, which is a component of a claim for an increased rating under Bagwell v. Brown, 9 Vet. App. 337, 339 (1996). Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record. Barringer v. Peake, 22 Vet. App. 242 (2008). The determination of whether a claimant is entitled to an extraschedular rating under § 3.321(b) is a three-step inquiry, the responsibility for which may be shared among the RO, the Board, and the Under Secretary for Benefits or the Director, Compensation and Pension Service (Director). Thun v. Peake, 22 Vet. App. 111, 115 (2008). The threshold factor is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Id. "[I]nitially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability." Id. The Court provided that "if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required." Id. In the second step of the inquiry, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, it must be determined whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). Id. at 115-16. When an analysis of the first two steps reveals that the rating schedule is inadequate and that the disability picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Turning to the threshold inquiry, the Board notes that the criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411, expressly contemplate varying degrees of occupational and social impairment due to a wide variety of symptoms, to include, e.g., thought process deficiencies, inability to maintain personal or work relationships, and an inability to adapt to stressful circumstances. In this case, even considering the nature of the psychological impairment demonstrated by the record, the rating criteria for psychiatric disorders such as PTSD reasonably describe the Veteran's disability level and symptomatology. Additionally, the rating criteria provide for higher ratings for additional or more severe symptoms than currently shown by the evidence, i.e. when there is shown to be total occupational and social impairment. Therefore, the Board finds that the evidence does not establish an exceptional disability picture such that the available schedular evaluations for the Veteran's PTSD have been rendered inadequate; the Veteran's disability picture is sufficiently contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. Consequently, the Board finds that referral to the Under Secretary for Benefits or the Director, Compensation and Pension Service for consideration of an extraschedular evaluation for his disability under 38 C.F.R. § 3.321 is not warranted. TDIU Claim It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. See 38 C.F.R. § 4.16 (2010). A finding of total disability is appropriate "when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation." See 38 C.F.R. §§ 3.340(a)(1), 4.15 (2010). A TDIU rating may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more, and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2010). Rating boards should refer to the Director of the Compensation and Pension Service for extra-schedular consideration all cases of veterans who are unemployable by reason of service connected disabilities but who fail to meet the percentage requirements set forth in 38 C.F.R. § 4.16(a). In Faust v. West, 13 Vet. App. 342 (2000), the U.S. Court of Appeals for Veterans Claims (Court) defined "substantially gainful employment" as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a veteran actually works and without regard to a veteran's earned annual income. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to TDIU is whether his or her service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-32 (1991). Further, in determining whether the Veteran is entitled to a TDIU rating, neither non-service-connected disabilities nor advancing age may be considered. 38 C.F.R. § 4.19 (2010). In the present case, and as further explained in the discussion above, the Veteran is service-connected for PTSD, now rated as 70 percent disabling. Based on this 70 percent rating, the Veteran meets the threshold minimum percentage criteria in 38 C.F.R. § 4.16(a) for consideration of TDIU. Further, the Board finds that the weight of the evidence demonstrates that the Veteran is prevented from securing or following substantially gainful employment due to his service-connected PTSD. Despite the Veteran's previous employment history (it was noted in VA treatment reports that the Veteran "had quite a productive and high-functioning life"), it appears that his PTSD symptoms have increased in severity so as to preclude employment. As referenced above, according to an October 2005 opinion, two VA examiners assessed that the Veteran's PTSD significantly limited his ability to function occupationally. In a February 2006 VA psychological evaluation, it was expressly noted that the Veteran was "not able to work at present, disabled secondary to PTSD." This finding is further supported by a June 2006 VA examination, wherein the VA examiner's response was "Yes" to the question of whether there was clinically significant distress or impairment in social, occupational, or other important areas of functioning. Moreover, the most recent May 2010 VA examination report explained that the Veteran's recent cognitive decline can be associated with PTSD and indicated that the Veteran, who was retired, was no longer capable of competitive employment. To the extent that the VA examiner remarked that the Veteran was retired, VA regulations make clear that advancing age may not be considered when assessing the level of occupational impairment caused by a service-connected disability for purposes of establishing entitlement to TDIU. In this case, despite the Veteran's retirement, there is competent and credible evidence demonstrating that his PTSD alone is of such severity so as to preclude the Veteran from securing or following substantially gainful employment. After carefully reviewing all the evidence on file, the Board finds no adequate basis to reject the evidence and medical opinions of record that are favorable to the Veteran, based on a rational lack of credibility or probative value. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). While the competent evidence is not unequivocal, it has nevertheless placed the pertinent record in relative equipoise. Given the occupational impairment that has been shown with respect to the Veteran's PTSD, the Board finds that the evidence sufficiently demonstrates that he is unable to secure or follow a substantially gainful occupation solely as a result of his service-connected disability. Accordingly, the Board resolves doubt in the Veteran's favor and finds that the evidence supports assignment of TDIU. As such, this claim is granted. ORDER A rating of 70 percent, but no higher, is granted for PTSD, subject to governing criteria applicable to the payment of monetary benefits. TDIU is granted, subject to governing criteria applicable to the payment of monetary benefits. ____________________________________________ STEVEN L. KELLER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs