Citation Nr: 1140887 Decision Date: 11/03/11 Archive Date: 11/16/11 DOCKET NO. 08-36 740 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to a higher initial rating for post traumatic stress disorder (PTSD), currently rated as 50 percent disabling. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran served on active duty from January 1967 to January 1969. He received the Army Commendation, Vietnam Service, National Defense Service, and Vietnam Campaign Medals. These matters come before the Board of Veterans' Appeals (Board) from a July 2007 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO) in Cleveland Ohio that denied entitlement to TDIU and granted service connection for post traumatic stress disorder (PTSD) and assigned a 30 percent disability rating, effective March 4, 2003. (The Board notes that the original claim of service connection for PTSD was previously under the jurisdiction of the Washington, DC RO. The file had been brokered to the Cleveland RO to render the January 2007 rating decision and afterwards was transferred to the Roanoke, Virginia RO as the agency of original jurisdiction.) In a November 2008 rating decision, the Roanoke RO assigned an initial 50 percent disability rating for PTSD, effective March 4, 2003. A veteran is generally presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). Therefore, the claim for a higher initial rating for PTSD remains before the Board. The Veteran failed to appear for a hearing scheduled at the Board in September 2011. His hearing request is deemed to have been withdrawn. See 38 C.F.R. § 20.704(d). FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's service connected PTSD has been productive of occupational and social impairment which more nearly approximates deficiencies in the areas of work, family relations and mood, but is not productive of total social and occupational impairment. 2. Since March 17, 2005, the Veteran's service connected PTSD has precluded gainful employment for which his education and occupational experience would otherwise qualify him. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating for PTSD have been met since the effective date of service connection. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.7, 4.10, 4.21, 4.125, 4.126, 4.130, Diagnostic Code (DC) 9411 (2011). 2. The criteria for a TDIU due to a service connected disability have been met since March 17, 2005. 38 U.S.C.A. § 1155, 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify & Assist The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2011). As the Board is granting the claim for a TDIU, the claim is substantiated, for the period beginning March 17, 2005, and there are no further VCAA duties as to that issue. Wensch v. Principi, 15 Vet App 362, 367-68 (2001); see also 38 U.S.C.A. § 5103A(a)(2) (Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); VAOPGCPREC 5-2004; 69 Fed. Reg. 59989 (2004) (the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance). In April 2007, the RO sent the Veteran a letter that told him what evidence was needed to substantiate a claim for TDIU, what evidence VA would obtain and what evidence he was responsible for providing. In December 2008, the RO provided VCAA notice required by a decision of the United States Court of Appeals for Veterans Claims (Court) in increased rating claims. Vazques-Flores v. Peake, 22 Vet. App. 37 (2008); vacated in part Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The generic first, third, and fourth elements (contained in the veteran's court's decision) were not disturbed by the Federal Circuit's decision. This notice was provided after the initial adjudication of the claim, but the timing deficiency was cured by readjudication in a supplemental statement of the case issued in March 2011. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). The appeal for a higher initial rating for PTSD arises from the Veteran's disagreement with the initial rating assigned after the grant of service connection. The courts have held, and VA's General Counsel has agreed, that where an underlying claim for service connection has been granted and there is disagreement as to "downstream" questions, the claim has been substantiated and there is no need to provide additional VCAA notice or address prejudice from absent VCAA notice. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); VAOPGCPREC 8-2003 (2003). The Court has elaborated that filing a notice of disagreement begins the appellate process, and any remaining concerns regarding evidence necessary to establish a more favorable decision with respect to downstream elements (such as initial rating) 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 of such error in this case. 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. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, 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 obtained all available post-service VA treatment records and private medical records. In addition, the Veteran was afforded VA examinations for PTSD and opinions were provided as to the Veteran's employability. The Veteran has consistently reported that he was employed prior to March 17, 2005, and this employment appears to have been gainful. Hence a specific opinion is not required as to his employability prior to that date. II. Factual Background Treatment records from Kaiser Permanente dated from 2001 to 2003 show that the Veteran was hospitalized multiple times in 2001 and at least once in 2002 and 2003 due to alcohol related problems. The records reported a past history of depression and anxiety. Treatment records from Washington VA Medical Center (VAMC) dated from 2005 to 2011 showed that the Veteran was assigned a Global Assessment of Functioning (GAF) scores that ranged between 48 and 60. A March 10, 2005, treatment records reveals that the Veteran had a depressed effect. He drank alcohol as a means to self-medicate his anxiety and he had been hospitalized a number of times related to alcohol abuse. He described frequent nightmares, trouble sleeping, persistent intrusive recollections of combat, isolative behavior, and depressed mood. He reported that his job was "okay," but that he missed a lot of work. In June 2005, he was given a dual diagnosis of prolonged PTSD and alcohol dependence. He reported that he thought he might lose his job due to how much time he missed from work related to drinking. He had last been hospitalized in March 2005. A history of psychiatric hospitalization in 1993 with depression and suicidal ideations and drinking was also noted. An April 2005 note shows that the Veteran had begun drinking heavily again on March 17, 2005, and had been briefly hospitalized at the end of that month. On May 3, 2005, it was reported that he was unemployed. On May 12, 2005 a GAF of 48 was reported. It was noted that he was experiencing stress related to his attempt to resume his employment in a mail room. In June 2005, he was scheduled for an interview regarding possible re-employment. In November 2005, he experienced serious depression, serious anxiety or tension, and hallucinations for 4 out of the past 30 days. In January 2007, his mood was described as "pain" and his affect was restricted. In July 2007, he reported that he had on occasion experienced visual hallucinations while drinking. He took quetiapine, which was an anti-psychotic. He reported that he was unemployed and that he was previously employed for 36 years as of March 31, 2005. In a February 2007 statement, the Veteran reported that he was forced to leave his job because he missed so much work due to PTSD. On July 2007 VA examination, the examiner noted that the Veteran was hospitalized for depression in 1994 and had recurrent admissions for problems related to excessive alcohol use (4/07, 1/07, 12/06, 9/06, 1/06, 10/05, 8/05, and 3/05). The Veteran was prescribed multiple medications for his PTSD/depressive symptoms, but he took ativan when he got "nervous" and it helped him avoid drinking. He described himself as "pretty much a loner." The Veteran reported that he was unemployed or missed considerable time away from work due to the effects of his mental illness. The Veteran also associated his unemployment with his alcohol use/binge drinking. He previously worked for 30 years in a mailroom, but has been unemployed for the last two years. By the time he left that position he was "third in command" and supervised a staff of nine. He reported that he came to work drunk and would be sent away. He had been married for 36 years and had a son and a step-son. He described his relationship with his wife and children as good. He had no social relationships. He did not socialize with friends or his family (in Georgia). His only consistent social interaction occurred while he assisted in cooking breakfast at church a couple of times per month. He reported that if someone disrespected his wife, he became violent. His activities of daily living and family responsibilities were fine except when he was binge drinking. The Veteran experienced intrusive thoughts, nightmares, and flashbacks on a weekly basis. He avoided crowds and would not go to the movies. He had a high level of distrust of others. He had symptoms of hypervigilance. The disturbance and symptomatology caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The Veteran's PTSD symptoms had a mild affect on employment, activities of daily living, and family role. There was a moderate affect on physical health, quality of life, and relationships. There was a severe affect of leisure activities. The examiner noted that the when the effects of the Veteran's substance abuse were considered, the ratings were more severe. The Veteran reported occasional visual hallucinations when he was inebriated. The examiner further noted that when the Veteran was on a binge, he apparently lost his capacity for basic activities of daily living and his wife would intervene to get him basic care. He experienced memory impairment during binges. He reported a frequent depressed mood and anxiety. He took ativan to "take the edge off his nervousness: and when that didn't work he drank. He had impaired impulse control. He reported that his primary impulse control problem pertained to him drinking. He noted that he experienced other issues impaired impulse control when he drank, but was not specific. He had occasional night sweats. His psychiatric symptoms included depressed mood, anxiety, sleep impairments, flashbacks, hypervigilance, avoidance, and binge drinking. The examiner opined that the Veteran was not unemployable; however, the Veteran's chronic pattern of binge drinking was his greatest impediment to holding a job. He was assigned a GAF score of 54. The examiner commented that PTSD, depression, and substance abuse frequently coexisted and attempting to attribute a portion of the functional problems to depression, another to substance use, and another to PTSD as if they were independent of each other is beyond the intended purpose and capabilities of the GAF scale. The examiner added that there was a slight linkage between the Veteran's employment problems and PTSD symptoms. The Veteran's employment problems were directly related to his binge drinking. The linkage between the Veteran's PTSD symptoms and employment problems were indirect in that the Veteran's alcohol dependency was at least as likely as not linked to his PTSD symptoms. The examiner found that the Veteran's alcohol dependency contributed to his current psychosocial and quality of life impairment and it was not possible to determine to what degree alcohol dependence was independently responsible for his impairments. His prognosis for improvement of psychiatric condition and impairments in functional status as well as for sustained recovery and improvement was very poor. On VA outpatient treatment in October 2008, the Veteran stated that he was depressed with sad mood, loss of pleasure, and felt worthless. He also reported intrusive thoughts, nightmares, and having physical reactions when reminded of his stressful military experiences. He avoided thinking or talking about his military experiences and felt distant from others. He stated that he had incidents in the past where he threatened people when he thought that they disrespected his wife. The treating physician noted depressed mood, constricted affect, and intrusive thoughts. The physician also noted that the Veteran's current psychosocial stressors included problems related to his social environment, occupational problems, and other psychosocial problems, including exposure to war. The Veteran had a longstanding history of PTSD and alcohol abuse that stemmed from his military experience and that he had been hospitalized "over 50 times" for his alcohol problems. In November 2010, the Veteran was admitted for detox from alcohol. A mental status examination upon admittance for detox revealed that his mood was irritable with a restricted affect. His speech was angry in tone. In March 2011, he was admitted for continuous episodes of anxiety that required ativan. He reported that he was going to do "crazy" things, but denied suicidal or homicidal ideations. On April 2011 VA examination, the examiner noted that the Veteran had at least 16 alcohol related admissions in 2010 at the Washington VAMC. The Veteran described his family relationships as "okay" and he mostly stayed at home with his family. For social activities and leisure pursuits, he watched TV, did some gardening, and was active in his church. He indicated that he was unemployed or had missed considerable time away from work due to the effects of a mental disorder. He had last worked in a mail room, 3-4 years ago, and retired after 33 years. He indicated that he was pressured to retire. He wanted to work part-time, but had trouble holding down a job due to alcohol abuse. He isolated himself. He reported that three to four different times, he experienced delusions and hallucinations when he wasn't drinking, in which he would binge drink afterwards. He reported that he had suicidal thoughts and ideations about three to four months ago. He needed reminders from his wife at times to maintain personal hygiene and to perform basic activities of daily living. He was oriented to person, place, and time. He did not engage in obsessive or ritualistic behaviors, his speech was normal. He reported that his memory sometimes came and went. He was constantly anxious and had a pattern of drinking to quiet his nerves. He was depressed and lost his appetite. He reported that he lost 40 pounds. He had impaired impulse control that was related to drinking. He had nightmares and woke him up in a panic soaking wet. The severity of his symptoms was described as moderate and chronic and continuous. The Veteran persistently re-experienced the service related stressors and had persistent symptoms of increased arousal (poor sleep, irritability, startle response, and hypervigilance). The disturbance and symptomatology caused clinically significant distress or impairment in social, occupations, or other important areas of functioning. The examiner noted that the Veteran's substance abuse/dependence contributed to his impairment and was more likely than not largely responsible for his impaired occupational functioning. However, the Veteran reported that his social isolation, sleep difficulties, and nightmares persisted even when he was not drinking. The degree to which his substance abuse/dependence was independently responsible for his impairments was not possible to determine given the high co-morbidity of PTSD and substance dependence. The examiner found that the Veteran was unemployable. The Veteran's ability to work was found to be significantly impacted by binge drinking. However, given continued sobriety, it was possible that he might be able to work in a setting that didn't involve significant amounts of interpersonal interaction. He was assigned a GAF of 55. The examiner stated that it was not possible to determine to what degree the Veteran's alcohol dependency was independently responsible for his psychosocial and quality of life impairment's. His prognosis for improvement of psychiatric condition and impairments in functional status as well as for sustained recovery and improvement was very poor. III. PTSD Initial Rating Criteria & Analysis Disability evaluations are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155. Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). 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. See 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign a rating based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, VA will also consider the extent of social impairment, but shall not assign a rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The schedular criteria for rating psychiatric disabilities incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). See 38 C.F.R. §§ 4.125, 4.130. PTSD is rated under 38 C.F.R. § 4.130, DC 9411, according to the General Rating Formula for Mental Disorders. Under the General Rating Formula, a 50 percent disability rating is warranted when there is 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 and maintaining effective work and social relationships. A 70 percent disability 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 worklike setting); and inability to establish and maintain effective relationships. A 100 percent disability rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Id. at 443. The Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). The GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). The evidence reflects that the Veteran has been assigned GAF scores ranging from 48 to 60. GAF scores ranging from 51-60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores between 41 and 50 reflect serious symptoms (e.g. suicidal ideation, sever obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g. no friends, unable to keep a job). This decision grants a 70 percent rating in recognition of the Veteran's serious symptomatology and grants TDIU during the period when GAFs below 51 were provided. On July 2007 VA examination, the Veteran was assigned a GAF score of 54. The examiner commented that PTSD, depression, and substance abuse frequently coexist and attempting to attribute a portion of the functional problems to depression, another to substance use, and another to PTSD as if they were independent of each other is beyond the intended purpose and capabilities of the GAF scale. On April 2011 VA examination, he was assigned a GAF score of 55. The examiner stated that it was not possible to determine to what degree the Veteran's alcohol dependency was independently responsible for his psychosocial and quality of life impairment. A veteran can receive compensation for an alcohol or drug abuse disability acquired as secondary to, or as a symptom of, a service-connected disability. Allen v. Principi, 237 F.3d 1368 (2001). Where an examiner is unable to distinguish the symptoms of a service connected disability from non-service connected manifestations, all the manifestations will be considered part of the service connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996)). The evidence shows that the Veteran's PTSD has caused deficiencies in most of the areas needed for a 70 percent rating. The record contains ample examples of his deficiencies in area of work. While he has not attempted schooling during the current appeal period, the GAF scores contemplate serious deficiency in the area of school. He has provided evidence showing deficiency in the area of family relations. Deficiencies in mood have also been well documented. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). The Veteran does not, however, have total occupational and social impairment, as would be needed for a 100 percent rating. Prior to March 17, 2005 that Veteran maintained responsible employment that involved supervising others, albeit with significant difficulties. He worked for the same company for over 30 years and was a mailroom supervisor at the time of retirement. Since leaving his employment, the Veteran has been able to maintain satisfactory relationships with his wife and children. At times he has been reported as active in his church. These reports weigh the evidence against a finding that he has a disability that has approximated total social impairment. Overall, the evidence reveals that the Veteran has experienced impairment in most of the areas of work, family relations, judgment, thinking, and mood since March 4, 2003, as evidenced by the GAF scores and assessments of his level of disability. Accordingly, the Board finds that an initial rating of 70 percent for PTSD is warranted since the effective date of service connection. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 4.7, 4.130, DC 9411. Extraschedular Pursuant to 38 C.F.R. § 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, 244 (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 a 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), aff'd sub nom, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). 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 evidence reveals that the Veteran has reported that his PTSD interfered with his ability to maintain employment. For example, during the pendency of the appeal he indicated that although he worked for 30 plus years for the same company, he was forced to retire. Prior to retirement, he missed a lot of time from work due to his PTSD and/or alcohol abuse and after retirement, he was unable to hold down a part-time due to alcohol related problems that he attributed to his PTSD. The statements by the Veteran and his family raise the question of entitlement to an extraschedular rating. The symptoms of his disability are recurrent recollections of a traumatic event, intrusive thoughts, flashbacks, trouble sleeping, isolative behavior and feelings, depressed and constricted mood, loss of pleasure, violent behavior towards people when they disrespected his wife, impaired impulse control, persistent symptoms of increased arousal, hypervigilance, occasional delusions or hallucinations, neglect of personal appearance and hygiene, suicidal thoughts and ideations, difficulty in establishing and maintaining effective work and social relationships; resulting in social and occupational impairment. These symptoms are contemplated by the rating criteria. Thus, referral for consideration of an extraschedular evaluation is not warranted. 38 C.F.R. § 3.321(b)(1). Total Rating for Compensation Based on Individual Unemployability VA will grant a TDIU when the evidence shows that the Veteran is precluded, by reason of his service connected disabilities, from obtaining or maintaining "substantially gainful employment" consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992). The regulations provide that if there is only one such disability, it must be rated at 60 percent or more; and if there are two or more disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Disabilities resulting from common etiology or a single accident or disabilities affecting a single body system will be considered as one disability for the above purposes of one 60 percent disability or one 40 percent disability. 38 C.F.R. § 4.16(a). 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). The Board must evaluate whether there are circumstances in the Veteran's case, apart from any non service connected condition and advancing age, which would justify a total rating based on individual unemployability due solely to the service connected conditions. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993); see also Blackburn v. Brown, 5 Vet. App. 375 (1993). Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). The Veteran has been granted service connection for PTSD, rated 70 percent disabling. Therefore, he meets the schedular requirements for a TDIU. 38 C.F.R. § 4.16(a). The remaining question is whether the Veteran's service connected disability precludes gainful employment for which his education and occupational experience would otherwise qualify him. As previously noted the Veteran was able to maintain employment through approximately March 17, 2005. He had reportedly been promoted and been given supervisory responsibilities and it was apparently sufficient to support his family. It cannot be found that this employment was marginal. Hence, the evidence is against a finding that the Veteran's service connected disability rendered him unemployable prior to March 17, 2005. The record reflects; however, that the Veteran did not work after March 17, 2005, when he began a period of heavy drinking. The evidence supports a finding that the drinking was secondary to the service connected PTSD. Hence the effects of his alcohol abuse are evaluated as part of the PTSD. Allen. The April 2011 VA examiner opined that the Veteran could be employable under certain specific conditions, namely that he did not indulge in binge drinking and he had employment that did not involve significant contact with others. The examiner also found; however, that the Veteran's prognosis for improvement of psychiatric condition and impairments in functional status as well as for sustained recovery and improvement was very poor. It would therefore, seem doubtful that the Veteran would be able to avoid binge drinking were he employed. Moreover, all of his significant employment experience has been in a mail room, in a job that required significant contact with others. It thus does not appear likely that the Veteran would be able to obtain or retain employment under the conditions specified by the examiner. The evidence establishes that the Veteran has been unable to obtain or maintain substantially gainful employment since March 17, 2005 due to his service connected PTSD and associated alcohol abuse. Therefore, entitlement to a TDIU is granted, effective from that date. ORDER Entitlement to an initial 70 percent rating for PTSD is granted, for the entire period since the effective date of service connection. Entitlement to a TDIU is granted, effective March 17, 2005. ______________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs