Citation Nr: 1216005 Decision Date: 05/03/12 Archive Date: 05/10/12 DOCKET NO. 09-23 960 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to an increased rating in excess of 50 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating based on individual unemployability (TDIU). 3. Entitlement to a compensable rating for migraines. REPRESENTATION Veteran represented by: Robert Chisholm, Esq. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Shana Z. Siesser, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1966 to June 1968. This matter comes before the Board of Veterans' Appeals (Board) from a June 2007 rating decision of the Department of Veteran's Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The Veteran appeared before the undersigned Veterans Law Judge at a March 2010 Travel Board hearing at the RO. A transcript is of record. This case was previously before the Board in September 2010 when the Board denied the Veteran's claim for an increased rating for PTSD. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court). In June 2011, the Court issued an order granting the parties' Joint Motion for Remand (Joint Motion) to vacate the Board's decision and remand the case back to the Board for compliance with the Joint Motion. The issue of entitlement to a compensable rating for migraines is addressed in the REMAND portion of the decision below and is REMANDED to the RO. FINDINGS OF FACT 1. The Veteran's PTSD manifested symptomatology that included: suicidal ideations; isolation; sleep impairment, including nightmares; depression and anxiety; irritability and anger; and an inability to establish and maintain effective relationships. 2. The Veteran's PTSD symptomatology did not manifest as: gross impairment of thought process and communication; persistent delusions or hallucinations; grossly inappropriate behavior; being a persistent danger to himself or others; intermittent inability to perform activities of daily living; disorientation to time and place; or, significant memory loss, such as forgetting his name, occupation or names of close relatives. 3. With resolution of the doubt in favor of the Veteran, he is unable to obtain and maintain gainful employment due to his PTSD symptoms. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating of 70 percent for PTSD are approximated. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.159, 3.321(b), 4.1, 4.7, 4.130, Diagnostic Code 9411 (2011). 2. The criteria for entitlement to TDIU are approximated. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the Court of Appeals for the Federal Circuit (as noted by citations to "Fed. Cir.) and the Court of Appeals for Veterans Claims (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d); see also 38 C.F.R. § 19.7 (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). In ascertaining the competency of lay evidence, the Courts have generally held that a layperson is not capable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183 (1997). In certain instances, however, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See, e.g., Barr, supra (concerning varicose veins); see also Jandreau, supra (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). Laypersons have also been found to not be competent to provide evidence in more complex medical situations. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (concerning rheumatic fever). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-512 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Brown, 125 F.3d 1447 (Fed Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). Duty to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2011). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) VA must ask the claimant to provide any evidence in her or his possession that pertains to the claim in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ), as was done in this case. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In compliance with the duty to notify the Veteran of what information would substantiate his claim, the Veteran was advised that VA used a Schedule for Rating Disabilities (Schedule) that determined the rating assigned and that evidence considered in determining the disability rating included the nature and symptoms of the condition, the severity and duration of the symptoms, and the impact of the condition and symptoms on employment. Here, the VCAA duty to notify was satisfied by way of letters sent to the Veteran dated in September 2006, January 2008, and April 2010 that fully addressed all notice elements. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. 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). The RO has obtained the service treatment records, VA outpatient treatment records and private medical records. Additionally, the Veteran was afforded VA examinations in April 2007 and April 2009. 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 claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran 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). Merits of the Claim The Veteran contends that the 50 percent rating assigned for his PTSD does not adequately reflect the severity of his symptoms and he is therefore, entitled to a higher rating. With resolution of the doubt in favor of the Veteran, the Board finds that the evidence supports the criteria for a higher rating of 70 percent. Therefore, the Veteran's claim is granted. Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities (Schedule). 38 C.F.R. Part 4 (2011). The percentage ratings contained in the 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 the residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.321(a), 4.1 (2011). Separate diagnostic codes identify the various disabilities. In considering the severity of a disability it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2011). Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, where the question for consideration is the propriety of the initial disability rating assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. See Fenderson v. West, 12 Vet. App. 119, 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. 38 C.F.R. § 4.7 (2011). 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 an evaluation 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) (2011). When evaluating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2011). PTSD is rated under 38 C.F.R. § 4.130 , Diagnostic Code 9411, which in turn incorporates criteria contained in the General Rating Formula for Mental Disorders. Under the General Rating Formula, a noncompensable disability rating is warranted when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational or social functioning or to require continuous medication. A 50 percent rating is assigned 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 understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is warranted for PTSD if the Veteran exhibits: 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 actives; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id. A 100 percent evaluation is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. The schedular criteria incorporate the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). 38 C.F.R. §§ 4.125, 4.130. The Global Assessment of Functioning (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). A GAF score of 41-50 is assigned 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 GAF score of 51-60 rating indicates 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 GAF score of 61-70 reflects some mild symptoms, such as depressed mood and mild insomnia, or some difficulty in social, occupational, or school functioning, such as occasional truancy, or theft within the household, but generally functioning pretty well, and has some meaningful interpersonal relationships. Id. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (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 Court of Appeals for 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 Veteran filed his claim of service connection for PTSD in September 2006. In April 2007, the Veteran underwent a VA examination. The Veteran reported social isolation and limited interaction with people other than his wife. The examiner noted the Veteran was appropriately dressed with good hygiene and grooming. His orientation was good, he was alert and responsive but tense overall. He was cooperative and attentive but guarded and detached through much of the interview. Eye contact was good with speech soft in volume and tone, normal in rhythm and rate. His mood was somewhat depressed and anxious with a generally restricted affect, until talking about his stressors, at which point he broke down and cried. The Veteran reported sleep impairment with occasional dreams and nightmares. The Veteran stated that he had punched his wife several times to the point that she no longer sleeps with him through the night. He denied active thoughts of suicide, but stated "it would be okay if I just didn't wake up." He denied homicidal ideation. Thought processes were generally logical with no hallucinations or delusions. There was no evidence or observation of ritual or obsessive behaviors. The Veteran reported drinking heavily and being withdrawn. He stated his only social activity was the group sessions that he attended at the Vet Center. Insight and judgment appeared to be fair. The examiner diagnosed the Veteran with PTSD, chronic, mild to moderate, and alcohol abuse, assigning a GAF of 65. The examiner noted that despite his symptomatology, the Veteran had a relatively successful history of employment and reported neither lost time from work or any history of impulsive, erratic, or dangerous behavior. He reported being married for 39 years, and his relationship with his wife appeared stable. The examiner noted that after his retirement, the Veteran appeared to have had difficulty with part-time work, and had quit on several occasions due to conflict. The examiner noted the Veteran was currently on no medication for treatment of PTSD and remained employable. A June 2007 rating decision granted the Veteran's claim of service connection for PTSD and assigned a 50 percent rating. The Veteran disagreed with this rating, stating that his symptoms were more severe than the rating reflected. In a July 2007 letter, the Veteran's wife reported that his PTSD was "more pronounced" than the medical records indicated and that the Veteran continued to have outbursts of anger not only in stressful situations but everyday as well. The Veteran's wife stated that she was "walking on eggshells." She stated the Veteran was negative and complained frequently. She also reported that he was displaying less interest in his hobbies and experiencing difficulties at work. In a July 2007 letter, JB, an administrative assistant at the Veteran's church, commented that the Veteran was very talented and knowledgeable, however, she stated his mood could change as quickly as "you can blink an eye." She stated he was quick tempered and on occasion was rude to parishioners and relatives visiting graves. She stated that since the Veteran retired from the Port Authority, he had gone on several extended trips with his wife and family. JB stated the Veteran changed after returning from a Marine Reunion in 2006, noting he was a "different person." In April 2009, the Veteran was afforded a VA examination. The Veteran reported that he lived with his wife of 41 years in their own home. The Veteran reported that he worked with the Port Authority for 25 years until January 2002 his retirement in January 2002 when he was offered a buyout package. The Veteran stated that he wished he had never retired, that he liked working, 12-16 hour days, with good pay and benefits. The Veteran began working part-time at his church in 2001 performing maintenance duties. The Veteran reported being "let go" from his job at the church for not following directions or overt defiance, rather than for specific symptoms of PTSD. The Veteran reported that he had applied for several jobs, but was not called back for any position. He stated that since 2006 he spent more time in a basement room by himself. He and his wife argued more frequently, and some of the arguing centered around his alcohol use. The Veteran reported a good relationship with one of his daughters, and a fair to poor relationship with another daughter. He stated that he stopped contact with friends who he thought were using him and also with friends from military reunions. The Veteran noted that he was pushing his family away from him. The Veteran stated that he was having daily unwanted thoughts about Vietnam but only dreaming about Vietnam 5-7 times per year. The Veteran did not report any particular avoidance symptoms, but would try to push away the sadness that he experienced occasionally when he thought about Vietnam. The Veteran denied any inability to recall details of his traumatic stressors; however, he occasionally would have some difficulty concentrating. The examiner noted the Veteran was neatly dressed with good hygiene and fair eye contact. He was alert and oriented in all spheres and able to maintain focus and attention throughout the interview, except for one occasion when he lost his train of thought. His thought process was clear, coherent, and goal directed without evidence of a formal thought disorder or psychosis. His mood was euthymic, affect was blunted with some appropriate brightening, and memory and intellect were grossly intact. The Veteran reported that he last thought about harming himself in January 2009 when his family canceled their trip to Florida. The Veteran said he rarely had thoughts of harming himself and he had never attempted to harm himself in the past. There was no homicidal ideation and the Veteran denied a history of violent acts. The Veteran denied panic attacks, obsessions, or compulsive rituals that interfered with behavior or functioning. There were no symptoms consistent with depression, mania, panic, obsessive compulsive disorder, generalized anxiety, eating disorders, or psychosis. The examiner diagnosed the Veteran with PTSD, mild to moderate, and assigned a GAF of 65. The examiner opined that the Veteran had not had an appreciable increase in symptoms since his last examination. The examiner stated the Veteran had never had symptoms severe enough to cause him to seek out psychiatric medications or additional psychological treatment. Further, there was no evidence to suggest that the Veteran was unemployable. In June 2009, D.M., M.D., a psychologist and team leader at the Pittsburgh Vet Center, noted the Veteran had weekly individual and group therapy sessions. During this period, he had stopped working at several jobs since he was having difficulty sleeping and experiencing panic attacks. He had a strained relationship with his family and few friends except those from his unit in Vietnam with whom he maintained contact through e-mail. Dr. M diagnosed the Veteran with PTSD, delayed onset, chronic, and assigned a GAF of 58. The Veteran testified at a Board hearing in March 2010 that he attended individual weekly therapy sessions for his PTSD in addition to weekly group therapy. He stated he did not leave the house other than 3 times per week, twice for VA appointments and once for church. He testified that he prefers to remain isolated has difficulty concentrating and impaired memory, has nightmares, is hypervigilent, and is extremely irritable with a tendency to lash out in anger. In a September 2010 Board decision, the Board denied the Veteran's claim for an increased rating finding that his symptoms did not approximate the criteria for a evaluation in excess of 50 percent. The Veteran appealed this decision and in June 2011, the Court issued an Order granting the parties joint motion for remand. The joint motion stipulated that the Board did not provide adequate reasons and bases for denying the Veteran's claim for an increased rating. The Court vacated the September 2010 decision and remanded the case to the Board for further development. In February 2012, the Veteran underwent a psychiatric evaluation with S.S., Ph.D. for the purpose of obtaining information to support his claim. Dr. S. specified that he examined the Veteran on three different occasions, each interview lasting 1 to 2 hours. Dr. S. also interviewed the Veteran's spouse and reviewed the entirety of the claims file. The Veteran reported the following symptoms: significantly reduced social contact, irritability, argumentativeness, and general isolation. The Veteran's spouse described him as explosive, aggressive, and agitated when interacting with others. She also stated that the Veteran experienced vivid nightmares. A mental status examination revealed that the Veteran was well-groomed, cooperative, and fully oriented. His motor activity was calm, speech was normal, mood was depressed, and his affect was restricted. Additionally, the Veteran's thought processes were organized and his attention and concentration was good; however, Dr. S. stated that "[the Veteran's] internal state differed from his external presentation." The Veteran reported severe levels of fatigue, sleep disturbance, social withdrawal, worthlessness, hopelessness, depression, oppositional and defiant behaviors, aggression and rage, grief, anxiety, compulsions, appetite loss, and low self-esteem. Dr. S. performed a series of testing on the Veteran. He showed a moderate to severe level of anxiety symptoms and a severe level of depression symptoms. The Veteran also demonstrated negative self-concept, pessimism, guilt, loss of interest, difficulty concentrating, and suicidal ideation. Dr. S. stated that his scores suggested high levels of anxiety and depression that are likely to cause significant impairment of functioning. The report concluded that the Veteran's internal experience and symptoms were greater than his external expression of that effect, specifically that he experiences his symptoms more intensely and at a greater severity than his testing profiles predict. Dr. S. opined that the Veteran meets the criteria for a 70 percent rating as the Veteran reported suicidal ideation, has near continuous levels of anxiety, re-experiences his stressors, has heightened arousal, and avoidance. Based on the above evidence, the Board finds that the Veteran has occupational and social impairment with deficiencies in most areas, and an inability to establishing and maintaining effective relationships. With resolution of the doubt in favor of the Veteran, these findings are sufficient to support a 70 percent evaluation. 38 C.F.R. § 4.130. The Veteran was noted as having poor impulse control, as evidenced by his unprovoked irritability and lack of patience. Additionally, Dr. S. noted that the Veteran experienced suicidal ideation and near-continuous depression. The Veteran also demonstrated difficulty in interacting in stressful circumstances, such as in a work-like setting, as noted by his inability to follow directions during his employment at the church. The Veteran was also shown throughout the appeal period to be socially isolative, including only interacting on a limited basis with his wife and children, shunning all other relationships. This isolation-type behavior and lack of social interaction is demonstrative of an inability to establish and maintain effective relationships. At no time during the increased rating period has the Veteran's PTSD symptomatology more nearly approximated total occupational and social impairment, as required for a higher disability rating of 100 percent under Diagnostic Code 9411. While there does appear to be some variation in the Veteran's symptomatology during the course of the appeal, the Board finds that the evidence reflects that the disability level during the entire course of the appeal has consistently more closely approximated the criteria for a 70 percent evaluation than that for a 100 percent evaluation. See 38 C.F.R. § 4.7. It is for this reason that the Board has also determined that staged ratings, pursuant to Hart, are not warranted in this case. Hart, supra. Although the claims file indicates that the Veteran experiences relative social isolation and has no friends outside of his immediate family, the evidence shows that the Veteran has been married for over forty years and has maintained relationships with his children. Therefore, it does not appear that the Veteran has been totally socially impaired for any period. Furthermore, although he is irritable and has angry outbursrs, the Veteran has not been a persistent danger of hurting himself or others. The Veteran has denied homicidal thoughts and while the Veteran has reported suicidal ideation, it has been without intent. Finally, the evidence does not show that the Veteran has gross impairment in thought processes or communication, grossly inappropriate behavior, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives, his own occupation, or his own name. The record indicates occupational and social impairment with deficiencies in most areas. Despite this, there have been no specific examination findings or other evidence of record demonstrating total social or occupational impairment. The Veteran's retirement from his employment was unrelated to his PTSD symptoms, and although he had difficulty relating to his aggressiveness in his subsequent employment at the church, there is no evidence that his PTSD symptoms constitute total social and occupational impairment. The criteria under Diagnostic Code 9411 specify that total occupational and social impairment must be shown for a 100 percent evaluation. Absent such a showing, the evidence does not support a 100 percent evaluation under these criteria for any period of increased rating claim. The Board has also considered the Veteran's lay statements and sworn testimony regarding the severity of his disability. The Board finds the Veteran competent to testify as to his symptoms and the Board finds his statements credible; however, the medical findings, which directly address the criteria under which his PTSD is evaluated are more probative than his assessment of the severity of his PTSD. See Jandreau, supra; Buchanan, supra. Therefore, a 70 percent rating, but not higher, is warranted for the Veteran's service-connected PTSD. TDIU Entitlement to a total rating for compensation based on individual unemployability (TDIU) is an element of all appeals of an increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). With resolution of the doubt in favor of the Veteran, a total rating based on individual unemployability is warranted because of the occupational impairment imposed by his PTSD. Therefore, the Veteran's claim of TDIU is granted. In order to establish entitlement to TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, 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). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The regulatory scheme for TDIU provides both objective and subjective criteria. Hatlestad, supra; VAOPGCPREC 75-91 (Dec. 27, 1991), 57 Fed. Reg. 2317 (1992). The objective criteria provide for a total rating when there is a single disability or a combination of disabilities that result in a 100 percent schedular evaluation. Subjective criteria provide for a TDIU when, due to service-connected disability, a Veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability rated 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the Veteran does not meet the percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). As the Veteran is rated at 70 percent disabling, as per the Board's decision above, the statutory criteria have been met. Additionally, the Veteran was reportedly not working throughout the appeal and the evidence shows that he had previously stopped his part-time work at the church in January 2008 due to his PTSD symptomatology. The April 2009 VA examiner opined that there is no evidence to suggest that the Veteran is unemployable. The examiner noted that the Veteran had successfully functioned at work for 25 years until he chose to retire early. The Veteran then worked at the church from 2001 through 2008, except for some minor disagreements. The examiner acknowledged that the Veteran may work best in situations that limit social interacting, but found that there was no evidence to suggest the Veteran was not capable of gainful employment. A June 2009 Vet Center report indicates that the Veteran stopped working at several jobs due to difficulty sleeping and panic attacks. In a June 2009 statement, the Veteran claimed that while employed at the church from 2002 through 2007, there were ongoing complaints regarding his agitated mood and aggressive behavior. He often found himself in a rage and exploded in anger at his wife when he came home. At the Board hearing in March 2010, the Veteran testified that he was let go from his position at the church five different times over the five year period that he was employed there. He stated that he had difficulty interacting with others and had problems controlling his temper. In his February 2012 report, Dr. S. stated that although the Veteran was able to tolerate the interaction required for his employment until 2002, since his retirement, his symptoms have increased. He therefore expressed concern about the Veteran's employability "unless there was a reduction in his symptoms and unless a workplace could be identified that ensured low conflict and isolation as part of the job description." Dr. S. also suggested that the Veteran coped in his previous employment due to his ability to isolate himself. He stated that the Veteran's ability to reengage in work was compromised by the disruption of his isolation strategy. Dr. S. concluded that the Veteran should be entitled to a total rating due to his inability and inadvisability of the Veteran obtaining and maintaining substantially gainful employment. It is not clear whether the Veteran may be employable in a more isolated work environment. Nevertheless, as there is evidence both for and against the Veteran's ability to engage in substantially gainful employment, the Board will resolve all doubt in favor of the Veteran and grant a total disability based on individual unemployability. ORDER Entitlement to a rating of 70 percent, but no higher, for PTSD is granted. Entitlement to TDIU is granted. REMAND In an October 2010 rating decision, the RO granted the Veteran's claim of service connection for headaches and assigned a noncompensable rating. In December 2010, the Veteran expressed disagreement with this decision. However, a Statement of the Case has not been issued. Under these circumstances, an SOC should be provided to the Veteran so that he can further address his disagreement with the rating assigned for the service-connected headaches. See Manlicon v. West, 12 Vet. App. 238 (1999). Accordingly, the case is REMANDED for the following action: The RO/AMC must issue the Veteran and his representative a Statement of the Case (SOC) on the issue of entitlement to a higher (compensable) initial disability rating for headaches. The Veteran should also be advised that, for the Board to have jurisdiction in the matter he must file a timely substantive appeal responding to the SOC. Should the Veteran or his representative submit a timely substantive appeal, the matter should be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON THE NEXT PAGE) This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). ______________________________________________ Cheryl L. Mason Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs