Citation Nr: 1124414 Decision Date: 06/28/11 Archive Date: 07/06/11 DOCKET NO. 09-39 097 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for posttraumatic stress disorder (PTSD), from December 1, 2008. 2. Entitlement to a total disability rating due to individual unemployability (TDIU). WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD F. Yankey, Counsel INTRODUCTION The Veteran served on active duty from May 1964 to April 1976. This case comes before the Board of Veterans' Appeals (Board) on appeal of a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia, that, in pertinent part, granted service connection and assigned an initial 50 percent rating for PTSD, effective August 4, 2008. In that rating decision, the RO also granted entitlement to a nonservice-connected pension, finding that the Veteran was unable to secure and follow a substantially gainful occupation due to disability. Subsequently, in an April 2009 rating decision, the RO granted a temporary total rating (TTR) from August 4, 2008 under the provisions of 38 C.F.R. § 4.29, and assigned an initial 50 percent rating, effective December 1, 2008. Because the Veteran asserts that his PTSD warrants a 100 percent rating, or alternatively a TDIU, the claims for an initial rating in excess a 50 percent for PTSD, including a TDIU rating, remain viable issues on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, the Board construes the issues on appeal as listed on the title page. In January 2010, the Veteran testified at a Decision Review Officer (DRO) hearing; a copy of the hearing transcript is in the record. In February 2011, the Veteran withdrew his request for a Board hearing. See C.F.R. §20.702(e) (2010). FINDINGS OF FACT 1. Since December 1, 2008, the Veteran's PTSD has been manifested by deficiencies in most of the areas of work, school, family relations, judgment, thinking and mood; it has not been manifested by total social and occupational impairment, gross impairment in thought process or communication, delusions, hallucinations, suicidal or homicidal ideation, grossly inappropriate behavior, disorientation to person or place, or memory loss for names of close relatives, own occupation or own name. 2. Resolving all reasonable doubt in the Veteran's favor, the evidence shows that the Veteran is unable to secure or follow a substantially gainful occupation, as a result of his service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent rating for PTSD have been met, from December 1, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.126, 4.130, Diagnostic Code 9411 (2010). 2. The criteria for TDIU due to service-connected disability have been met. 38 C.F.R. §§ 3.102, 3.321, 3.340, 3.341, 4.3, 4.15, 4.16 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010)) defined VA's duty to assist a Veteran in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2010). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. See 73 Fed. Reg. 23,353-356 (Apr. 30, 2008). VA's notice requirements also apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In rating/TDIU cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. The United States Court of Appeals for Veterans Claims (Court) held that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before an initial decision on a claim for VA benefits. See Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004). However, VA's notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. Initially, in light of the Board's favorable decision granting the Veteran a TDIU, the Board finds that all notification and development action needed to fairly adjudicate that claim has been accomplished. In September 2008 and March 2009 pre-rating notice letters, the RO described the evidence necessary to substantiate claims for service connection and for a TTR, and met all of the requirements noted above, including informing the Veteran that it was ultimately his responsibility to see to it that any records pertinent to his claims are received by VA. The March 2009 letter provided information pertaining to assignment of disability ratings and effective dates consistent with Dingess. This notification would also apply to the "downstream" issues of entitlement to a higher initial rating/TDIU. The courts have held that once service connection is granted the claim is substantiated, additional VCAA 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). The United States Court of Appeals for Veterans Claims (Court) has elaborated that filing a notice of disagreement (NOD) begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as a higher initial rating/TDIU or an earlier effective date) are appropriately addressed under the notice provisions of 38 U.S.C.A. §§ 5104 and 7105. Goodwin v. Peake, 22 Vet. App. 128 (2008). Where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to the downstream elements. Id. There has been no allegation or evidence of prejudice. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103S; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claims, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). VA has obtained records of treatment reported by the Veteran, including service treatment records, and VA treatment records. Additionally, the RO assisted the Veteran in substantiating his claims by affording him VA examinations in October 2008 and February 2010, and there is no evidence or contention that there has been a change in the Veteran's symptoms since the last examination in February 2010. In addition, a copy of the DRO hearing transcript and various statements submitted by the Veteran have been associated with the record. For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The appeal is thus ready to be considered on the merits. Legal Criteria Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4 (2010). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each disability must be considered from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson, 12 Vet. App. at 126; see also Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD is currently rated as 50 percent disabling under Diagnostic Code 9411. The Board notes that psychiatric disabilities other than eating disorders are rated pursuant to the criteria for General Rating Formula. See 38 C.F.R. § 4.130. Under the formula, a 50 percent rating is warranted for PTSD if it is productive of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech 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 worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (adopted by VA at 38 C.F.R. §§ 4.125 and 4.126 (2010)), a GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). Scores ranging from 31 to 40 reflect "Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school)." DSM-IV at 32. A score of 41 to 50 is indicated where there are "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. A score of 51-60 is appropriate where there are, "Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning, (e.g., few friends, conflicts with peers or co-workers)." Id. A score of 61-70 is indicated when there are, "Some mild symptoms (e.g., depressed mood and mild insomnia OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships." Id. In accordance with 38 C.F.R. §§ 4.1 and 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed all evidence of record pertaining to the history of the service-connected disability at issue. The Board has found nothing in the historical record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Moreover, the Board is of the opinion that this case presents no evidentiary considerations which would warrant an exposition of remote clinical histories and findings pertaining to this disability. Background The Veteran underwent an initial PTSD examination in October 2008. The examiner noted that the Veteran had PTSD symptoms such as persistent re-experiencing of the traumatic event that led to his disorder through recurrent and intrusive recollections and dreams, and intense psychological distress at exposure to cues that symbolize or resemble an aspect of the traumatic event, and physiological reactivity on exposure to cues that symbolize or resemble an aspect of the traumatic event. He also showed signs of persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness. This included efforts to avoid thoughts, feelings, conversations, activities, people and places associated with the trauma or that brought forth recollections of the trauma; markedly diminished interest or participation in significant activities, and feelings of detachment and estrangement from others. The Veteran also reported intermittent sleep issues, noting that when he becomes fatigued and requires rest throughout the day when he does not get much sleep. He demonstrated symptoms of increased arousal, such as irritability and outbursts of anger, difficulty concentrating, hypervigilance and exaggerated startle response. The examiner also noted that the Veteran's disorder caused clinically significant distress or impairment in social and occupational functioning. With regard to marital, family and social relationships, the Veteran reported that he was married once in 1972 for six months. He also indicated that he had three children with whom he had good relationships and regular contact with. Otherwise, he stated that he preferred isolation and that he did not establish or maintain relationships well. He also reported that he did not pursue any leisure activities. The examiner noted that the Veteran did not have a history of physical violence, but that he did have a history of being verbally aggressive. The Veteran explained further that, although he did not become violent, he became quite angry and wanted to become violent. Psychosocially, the Veteran reported that he maintained distance from most people and that he became angered easily and had lost a significant amount of jobs due to his anger. At the time of the examination, he was unemployed and he reported that his unemployment was due to his difficulty with managing his anger and being easily provoked. On mental status examination, the Veteran was clean and cooperative; his speech and psychomotor activity were unremarkable; and his affect was full. His mood was labile and his attention was intact. He was oriented in all spheres, and there were no abnormalities noted with regard to thought process or content. Judgment was normal and intelligence was noted to be average. The Veteran partially understood that he had a problem. He denied delusions, hallucinations, panic attacks, obsessive/ritualistic behavior and homicidal or suicidal thoughts. No inappropriate behavior was noted. The Veteran, however, was not able to interpret proverbs appropriately. Impulse control was fair and as noted above, the Veteran denied any episodes of violence. Remote and recent memory was moderately and mildly impaired, respectively, but immediate memory was normal. The examiner diagnosed PTSD and assigned a GAF score of 55. The examiner added that the Veteran had extreme difficulty establishing and maintaining long-term relationships. The Veteran had challenges with trust and sharing intimate details regarding his life. He had eliminated all recreation and leisure activities due to multiple triggers. In addition, the examiner also noted that the Veteran's anger was also a significant issue, especially in regards to his job functioning, in that he felt easily provoked and had difficulty keeping himself calm. In a December 2008 rating decision, the Veteran was granted service connection and a 50 percent evaluation for PTSD, effective August 4, 2008. He perfected an appeal with regard to the initial disability rating assigned. In his January 2009 NOD, the Veteran asserted that he was 100 percent disabled due to his PTSD, and that he had successfully participated in the combat PTSD Residential Rehabilitation Program (PRRP) at the Martinsburg, West Virginia VA Medical Center (VAMC) from June 2008 to November 2008. And the evidence of record confirms that from June 2008 to November 2008, the Veteran participated in the PRRP at the Martinsburg VAMC. In an April 2009 rating decision, the RO granted a TTR (100 percent rating) for PTSD from August 4, 2008 for hospitalization in excess of 21 days, under the provisions of 38 C.F.R. § 4.29; the initial 50 percent rating was resumed, effective December 1, 2008. During VA outpatient treatment in July 2009, the Veteran was noted to be in a euthymic mood and clinically stable, and to have very minimal PTSD symptoms. He was living in Martinsburg West, Virginia, attending PTSD groups and socializing with a large group of veterans on a daily basis. The Veteran reported that he had been able to control his anger using coping skills obtained in the PRRP program. The Veteran was assigned a GAF of 70 at that time. In October 2009, the Veteran submitted a claim for a TDIU, again claiming that he was 100 percent disabled and unable to work due to his service-connected PTSD. In a subsequent October 2009 statement, the Veteran claimed that he was unable to work due to difficulty with controlling his anger as a result of his PTSD. He also claimed that he was unable to follow simple tasks or respect authority, and that he was constantly angry and fighting with his co-workers and managers. The Veteran also claimed that he lost his marriage and destroyed other family relationships, due to his anger and violence, including physical violence towards his wife. He also claimed that he struggled with homicidal thoughts and made plans to harm others who had wronged him or made him angry. The Veteran also stated that he had experienced severe depression and anxiety, sometimes causing him to stay in the house for days, and that he had isolated himself from others and neglected his appearance and hygiene. Finally, he claimed that he also had short-term memory loss, which required him to keep a written log of his appointments so that he would not miss them. The Veteran indicated that he had had these symptoms since Vietnam. The Veteran was afforded another VA PTSD examination in February 2010. At that time, the Veteran's social functioning appeared to have improved. The Veteran reported that he and his long-term girlfriend of 25 years had decided to live apart because he could not deal with conflicts; however, she visited him on the weekends. He also reported that he stayed in contact with his elderly mother, one brother and three sisters, as well as his daughter. He was friends with several (8-12) other veterans, whom he socialized with on a daily basis and had formed a special bond with. The Veteran also reported that he went to church three days per week, and loved his church and pastor, whom he fished with. In addition, the Veteran reported that he was active, and was going to the gym a few days per week. He also indicated that the people in West Virginia had been kind to him and that he was glad he was living there. The Veteran also denied suicide attempts, violence or assaultiveness, but the examiner noted that he still endorsed symptoms of hyperarousal, which included irritability and outbursts of anger. The examiner also noted that medications had helped to moderate the Veteran's anger and agitation, which had caused significant impairment in social and occupational functioning, including causing detriment to his relationships with his girlfriend and his daughter. With regard to occupational impairment, the examiner indicated that the Veteran retired in 2008, due to a history of two strokes. However, the Board notes that the Veteran has consistently reported that he stopped working because he could not control his anger on the job. The Veteran reported that since he stopped working, he had fewer problems with anger, as there were fewer opportunities for anger. He also reported that he did not think he would be able to go back to work because he would have difficulty controlling his anger when provoked. The Veteran denied any current stressors, indicating that he tried not to worry about anything. On mental status examination, the Veteran was neatly groomed, cooperative, friendly and attentive. His speech and psychomotor activity were unremarkable. His affect was normal and his mood was good. Attention was intact, and he was oriented in all spheres. Thought process and thought content were unremarkable; judgment was not impaired; intelligence was average; and insight was good. The Veteran denied hallucinations and delusions. The Veteran did report sleep impairment and nightmares, but reported that they were controlled with medication. The examiner noted that the Veteran did not display inappropriate behavior and he interpreted proverbs appropriately. The Veteran also denied obsessive/ritualistic behavior, panic attacks and homicidal or suicidal thoughts. He also reported fair impulse control and denied any episodes of violence. Specifically, the Veteran reported that he controlled his anger by choosing carefully who he was around and by staying to himself. The Veteran also reported that he was able to maintain minimum personal hygiene and that he did not have problems with activities of daily living. Remote, recent and immediate memory was all normal. The examiner diagnosed PTSD again, and assigned a GAF score of 55. The examiner opined that the Veteran's PTSD symptoms caused moderate and severe impairment in social functioning, and when he was employed, serious impairment in occupational functioning, with both physical and sedentary employment, and that if he were to work again, the same impairment would be present. The examiner stated further that one reason the Veteran's symptoms had stabilized was that he did not have to deal with the demands of the workplace, including interpersonal conflicts. The examiner also concluded that the Veteran's PTSD symptoms were moderately severe with medication management and that his psychiatric condition was stable and would likely remain so as long as he continued to comply with his medications. During the January 2011 DRO hearing, the Veteran testified that he was pretty violent with his wife after his return from Vietnam; that he could not keep a job; that he was depressed and unable to sleep at night; and that, when he did go to sleep, he had terrible dreams/nightmares. At few times, he felt like he had no reason to live and had homicidal thoughts because he could not keep a job. Then, when he got older he had no reason to live or to continue to look for a job. He indicated that he had a problem with memory loss and that he forgets appointments and has to write them down. He reported that he gets together with a group of veterans and plays cards and that he has had a lady friend for 25 years, who visits him once every two months. The Veteran added that his lady friend has put up with him calling her names and him doing all kinds of immoral things to her. He joined a church and got baptized in late November 2010. Except for his lady friend, his veterans' group and the church, he does not have a social life. Analysis The evidence of record shows that the Veteran has deficiencies in work, school and family relations. As discussed above, The Veteran reported that he has lost a significant amount of jobs due to his inability to control his anger on the job, with co-workers and managers, and his inability to respect authority figures. The October 2008 VA examiner noted that the Veteran's anger was a significant issue, especially in regards to his job functioning, in that the Veteran felt easily instigated and had difficulty keeping himself calm. The February 2010 VA examiner opined that when he was working, the Veteran's PTSD symptoms caused serious impairment with employment, both physical and sedentary. Given his occupational difficulties, and difficulty respecting authority, it is likely that he would experience similar difficulties if he returned to school. The Veteran also reported difficulty concentrating and memory problems, which suggests that there would be a deficiency in the area of school. The Veteran maintained a very long-term relationship of 25 years with his former girlfriend. However, he reported that the relationship only worked if they did not actually live together. Therefore, they lived separately for a while, with her only visiting him on weekends. The Veteran maintains contact with his children and some siblings, and has friends from church and other veterans that he has formed a bond with. However, as noted above, on VA examination in October 2008, the Veteran reported that he preferred isolation, did not establish or maintain relationships well, and did not pursue any leisure activities. He also he reported in October 2009 that he lost his marriage and had destroyed other family relationships as a result of his anger and violence, including physical violence towards his wife, and that he had isolated himself from others. Furthermore, on VA examination in February 2010, he reported that he stayed to himself and chose carefully who he allowed himself to be around in order to control his anger. During VA outpatient treatment in May 2010, he reported that he had ended his relationship with his long-term girlfriend. The October 2008 examiner concluded that the Veteran had extreme difficulty establishing and maintaining long-term relationships, and challenges with trust, and the February 2010 examiner opined that currently, the Veteran's PTSD symptoms caused moderate impairment in social functioning, and that they had caused serious impairment in social and occupational functioning in the past. VA outpatient treatment records show that the Veteran has been prescribed medication for mood and diagnosed with an adjustment disorder with depressed mood. Furthermore, in his October 2009 statement, the Veteran reported that he had experienced severe depression and anxiety, sometimes causing him to stay in the house for days, isolate himself from others, and neglected his appearance and hygiene. The Board also notes that symptoms of the Veteran's PTSD, including his unprovoked irritability and anger outbursts with periods of violence, have affected his ability to function independently, appropriately and effectively, and made it difficult for him to adapt to stressful circumstances such as work. He has also shown an inability to establish and maintain effective relationships. In this regard, on VA examination in October 2008 and February 2010, and in his October 2009 statement, the Veteran reported that his problems with anger outbursts and irritability made it impossible for him to work, and have made it difficult for him to be around others, except those few friends and church members that he interacts with on a regular basis, and to live with others, including those with whom he has had long-term relationships. The October 2008 examiner found that the Veteran had extreme difficulty establishing and maintaining long-term relationships, and the February 2010 examiner found that during the appeal period, the Veteran's PTSD symptoms had caused moderate and serious impairment in social functioning and serious impairment in occupational functioning. Given the reported deficiencies and the findings with regard to occupational functioning, the Board finds that the Veteran's October 2009 statement credible that his PTSD symptoms have been consistent over time and make it difficult for him to follow simple instructions and respect authority and to get along with co-workers and managers on the job, because he is easily provoked to anger. The Board also finds credible his claim that he has struggled with homicidal thoughts and made plans to harm others who had wronged him or made him angry. Resolving all doubt in the Veteran's favor, the Board concludes that these symptoms, along with depression, anxiety, irritability, and tendency to isolate and occasionally neglect his appearance, have more nearly approximated deficiencies in most of the areas described in the criteria for a 70 percent rating, during the entire period on appeal. However, the evidence does not show that the Veteran had total occupational and social impairment. In this regard, symptoms of gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to person or place; memory loss for names of close relatives, own occupation, or own name were not generally demonstrated, so as to warrant a 100 percent schedular rating. Thus, the preponderance of the evidence does not show that the Veteran's symptoms warrant a rating in excess of 70 percent for the time period in issue. TDIU A TDIU 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, 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 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the Veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to secure or follow a substantially gainful occupation. 38 C.F.R. § 4.16(a). In the instant case the Veteran meets the schedular criteria for a TDIU pursuant to 38 C.F.R. § 4.16 due to his service-connected PTSD, rated as 70 percent disabling, since December 1, 2008. He is also service connected for diabetes mellitus, rated as 20 percent disabling, for a combined rating of 80 percent. Thus, the Veteran meets the schedular criteria outlined in 38 C.F.R. § 4.16(a). The Court has held that TDIU is an element of all claims for a higher initial rating, when unemployability is asserted by the claimant. Rice, 22 Vet. App. at 454; see also Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). The central inquiry is, "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Throughout the pendency of the appeal, the Veteran has consistently reported that symptoms from his PTSD, specifically unprovoked irritability and uncontrollable anger outbursts, as well as problems with authority, have made it impossible for him to maintain employment. During his initial PTSD evaluation in October 2008, the Veteran reported that he had been unemployed for one to two years. He reported that the reason for his unemployment was difficulty managing anger and being easily instigated. In his VA Form 21-4192, Request for Employment Information in Connection with Claim for Disability Benefits, the Veteran reported that he had last worked on April 23, 2007. On VA examination in February 2010, the Veteran reported that he was unemployed and had retired in 2008, due to a history of two strokes. However, as noted above, during the examination, he also reported that he was unemployed and unemployable due to his PTSD. The October 2008 examiner opined that the Veteran's anger was a significant issue, especially in regards to his job functioning. The February 2010 examiner opined that as the Veteran was not working, his PTSD symptoms caused moderate impairment in social and occupational functioning, but also opined that if he were working, the Veteran's PTSD would cause serious impairment in occupational functioning, both physical and sedentary. Furthermore, the Veteran has reported in several statements that he was not working and was totally disabled and unemployable due to his PTSD. Outpatient treatment records from the Martinsburg VAMC show that during treatment in the GOALS PTSD program in May 2008, the Veteran reported that he was a truck driver for twelve years with a good work history, and that he also worked as a yard jockey for a company in Manassas, Virginia for five years and was fired for getting into an argument with a co-worker. In a February 2010 response, the Veteran's former employer indicated that "policy prohibits release of [ ] information" as to why the Veteran was terminated from employment, tends to confirm the Veteran's assertions. Social Security Administration (SSA) records show that the Veteran became disabled in January 2008, due to a history of cerebral vascular accident and carpal tunnel syndrome, not due to his service-connected psychiatric disability. On VA examination in October 2008, he reported that he had been unemployed for one to two years (since 2006 or 2007), due to his PTSD. On VA examination in February 2010, he reported that he retired in 2008, due to a history of strokes. The earliest evidence of the Veteran actually being unemployed and unemployable due to his service-connected PTSD is the October 2008 VA examination report. If the Veteran was employed prior to that time, it does not appear that his employment was consistent or more than marginal. Thus, resolving all doubt in the Veteran's favor, the Board concludes that the Veteran's PTSD symptoms alone render him unemployable due to his inability to follow simple tasks or respect authority and get along with co-workers and managers and the fact that he is easily provoked to anger. Given that the Veteran meets the criteria outlined in 38 C.F.R. § 4.16(a), and resolving all doubt in his favor, the Board concludes that a TDIU is warranted. Other Considerations Also considered by the Board is whether the Veteran's PTSD warrants referral for extraschedular consideration. Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards." 38 C.F.R. § 3.321(b)(1). The question of an extraschedular rating is a component of a claim for an increased rating. See 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). If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration 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. Therefore, initially, 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. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, 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. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine 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"). The above determinations are based on application of pertinent provisions of the VA's Schedule for Rating Disabilities. There is no showing that the Veteran's PTSD reflects so exceptional or unusual a disability picture as to warrant the assignment of an evaluation higher than the 70 percent rating and the TDIU already assigned. See 38 C.F.R. § 3.321(b)(1). The effects of his PTSD on employment are already considered in the assignment of a TDIU. Moreover, when the Veteran was hospitalized because of his PTSD, he was granted a TTR. Accordingly, referral for extraschedular consideration is not warranted at this time. Thun v. Peake, 22 Vet. App. 111, 115 (2008). ORDER Entitlement to an initial rating of 70 percent for PTSD is granted from August 4, 2008. Entitlement to a TDIU is granted. ______________________________________________ M. R. VAVRINA Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs