Citation Nr: 1304898 Decision Date: 02/11/13 Archive Date: 02/21/13 DOCKET NO. 10-37 929 ) DATE ) ) Received from the Department of Veterans Affairs Regional Office in Louisville, Kentucky THE ISSUE 1. Entitlement to an higher initial disability rating for posttraumatic stress disorder (PTSD) with depression, rated as 30 percent disabling. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Jan Dils, Attorney at Law WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD L. Crohe, Counsel INTRODUCTION The Veteran served on active duty from January 1970 to September 1971. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma that granted service connection for PTSD with depression and assigned a 30 percent disability rating, effective December 30, 2008. A September 2011 rating decision continued to rate PTSD as 30 percent disabling and denied entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). Although the Veteran did not file a notice of disagreement (NOD) with that decision denying entitlement to a TDIU claim, this TDIU issue has been raised by the record. The United States Court of Appeals for Veterans Claims (Court) has held that a request for a TDIU, whether expressly raised by a claimant or reasonably raised by the record, is an attempt to obtain an appropriate rating for disability or disabilities, and is part and parcel of a claim for higher compensation. But there must be cogent evidence of unemployability in the record. See Rice v. Shinseki, 22 Vet. App. 447 (2009), citing Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009). The Board has jurisdiction to consider entitlement to a TDIU in an appealed claim for a higher rating when the issue is raised by assertion or reasonably indicated by the evidence, regardless of whether the RO expressly addressed the issue. See VAOPGCPREC 6-96 (Aug. 16, 1996). See also Caffrey v. Brown, 6 Vet. App. 377, 382 (1994); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). However, the question of TDIU entitlement may be considered a component of an appealed rating claim only if the TDIU claim is based solely upon the disability or disabilities that are the subject of the increased rating claim. VAOPGCPREC 6-96. Therefore, the Board is additionally addressing this claim. In January 2011, the Veteran testified before a Decision Review Officer (DRO) and in March 2012, he testified before the undersigned at a Board hearing; transcripts of both hearings are associated with the claims file. FINDINGS OF FACT 1. Throughout the claim period, the Veteran's service-connected PTSD and depression have been productive of occupational and social impairment that approximates disability manifested by deficiencies in the areas of work, family relations, thinking, and mood. 2. Since March 19, 2010, the Veteran's service-connected PTSD with depression precludes substantially gainful employment for which his educational and occupational experience would otherwise have qualified him. CONCLUSIONS OF LAW 1. The criteria for an initial 70 percent schedular rating, but no higher, for PTSD with depression have been met. 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 (2012). 2. Since March 19, 2010, the criteria for a TDIU due to PTSD with depression have been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify & 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. 2012) redefined VA's duty to assist the 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, and 3.326(a) (2012). The appeal for a higher initial rating for PTSD with depression arises from the Veteran's disagreement with the rating assigned pursuant to 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 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 has obtained records of treatment reported by the Veteran, including private medical records and VA treatment records. Recent treatment records from the Huntington VA Medical Center (VAMC) were associated with the Veteran's Virtual (paperless) file and considered in a December 2011 supplemental statement of the case. Additionally, the Veteran was provided VA examinations in August 2009 and February 2011 pertaining to the severity of his service-connected PTSD and depression. Barr v. Nicholson, 21 Vet. App. 303 (2007). There is no indication that his service-connected PTSD with depression has worsened since the date of the most recent examinations, and hence an additional examination is not required. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995); cf. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). 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. II. Background Treatment records from the Huntington VA Medical Center (VAMC) reflect ongoing treatment for PTSD. In February 2009, an assessment noted that the Veteran was not doing well. He was not sleeping well and felt anxious and nervous. He was assigned a Global Assessment of Functioning (GAF) score of 45. In August 2009, he was assigned a GAF score of 55. On August 2009 VA PTSD examination, the Veteran had complaints of depression, elevated anxiety, sleep disturbance, and difficulty concentrating. He reported that he experienced persistent daily depressed mood; loss of interest in previously enjoyed activities, such as camping, fishing, and playing basketball; poor appetite, insomnia; difficulty making decisions; difficulty concentrating on a daily basis; forgetfulness; occupational impairment as a result of difficulty concentrating; feelings of worthlessness and hopelessness; and passive suicidal ideations once every couple of months with no plan or intent. He indicated that the symptoms caused clinically significant distress and impairment in functioning. He reported that he had a close relationship with his wife. He had two children who lived close by and whom he saw every day. His father lived close by and he saw him every day. He also enjoyed visiting his siblings and his cousins. He had friends at work, but did not spend time with them outside of work. He experienced mild detachment from others and did not make many friends. He did not get close to people and felt like he could not relate to others. He occasionally took his daughter fishing (once per month) and enjoyed watching television and spending time with family members. He attended church once a month. There was no history of suicide attempts or violence/assault. On examination, the Veteran was clean, neatly groomed, and appropriately dressed. His affect was appropriate and his mood was good. He was oriented to person, time, and place. His thought process and content were unremarkable. He did not experience delusions or hallucinations. He understood the outcome of his behavior. He had good impulse control and no episodes of violence. There were no problems with activities of daily living and he was able to maintain minimum personal hygiene. His recent and immediate memory was moderately impaired. He had difficulty with remembering names, telephone numbers, and tasks that he had been asked to complete at home, as well as recent events. He persistently re-experienced the traumatic event (his brother was killed in Vietnam while the Veteran was in service) and had nightmares. The examiner described the Veteran's re-experiencing symptoms as moderate. He avoided stimuli associated with the trauma and had a markedly diminished interest or participation in significant activities. He felt detached and estranged from others and had difficulty establishing and maintaining friendships outside of the family. His avoidance symptoms were described by the examiner as mild. He had difficulty with staying asleep, outbursts of anger, persistent irritability, and difficulty concentrating. The examiner described the Veteran's hyperarousal symptoms as moderate. The examiner stated that the disturbance caused clinically significant distress or impairment in social, occupational, or other areas of functioning. There were no significant periods of remission since the onset of symptoms. The Veteran was self-employed full time as a truck driver. He did not lose any time from work in the past 12 months. He was assigned a GAF score of 60, based on the severity of symptoms of PTSD and dysthymic disorder. The examiner acknowledged that the Veteran's dysthymic disorder was a condition independent of PTSD however, the symptoms of dysthymic disorder, like PTSD symptoms, were found to result from the Veteran's experience of his brother's death while in service. The examiner found that there was an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to PTSD, but with generally satisfactory functioning (routine behavior, self-care, and normal conversation). There was no evidence of total occupational impairment, and it was not believed that the Veteran was unemployable based solely on the symptoms of PTSD. In a January 2010 private psychological report from J.A. (M.A.), it was noted that the Veteran reported a history of interpersonal problems on the job. A July 2010 VA treatment record noted the Veteran's reports that he "went out of business" and that he had to sell his truck. He indicated that he could no longer drive it. He was assigned a GAF score of 50. In October 2010, he was assigned a GAF score of 60. In statements received in January 2011, C.S. reported that the Veteran was not able to be around crowds of people without becoming anxious and that he was unable to drive himself more than a few miles. P.B. reported that they only knew of the Veteran driving himself to the post office to check his mail, which was three miles from his house. He had a hard time understanding things and would get his words confused or backwards. During his January 2011 DRO hearing, the Veteran reported that he and his wife had been married for 26 years. He stated that he was no longer able to work. He reported that he used to be able to drive his gravel truck over any little road or bridge with no problem. While driving, he started to feel fear come over him and he would sweat. He was afraid of what he might be doing wrong. Even on four lane highways, he could not concentrate well enough to keep his truck under control and off of the shoulder or stop it from crossing the line. He indicated that he quit his job on March 18, 2010, the same day that he went across the line and ran a black pick-up truck into the median. He sold his truck the same day to a man who had wanted to buy it from him. He reported that he experienced the same feelings when he drives his car. He worked for a trucking company for 15-16 years and when they went out of business he bought his own truck. He completed high school with no additional training. He indicated that he mostly stayed at home and at times did not even go to church. He reported that he did not take showers or bathe. He no longer watched his daughter play volleyball and basketball, because he hollers and gets too loud. He also could not be in an environment where there were too many people. He reported that he thought about hurting himself around two to three times a month. He used to think about hurting others until he started to take Diazepam. At a February 2011 VA PTSD examination, the Veteran reported that he had a good relationship with his wife, which had improved since he left work as a truck driver and since he has been able to take his medication regularly. He feels that it was not safe to drive long distances on medication as it caused drowsiness. He could drive short distances around town. He reported that he had a good relationship with his children. He did not have "real close friends" other than family. He has retained some contact with a couple of former co-workers. He does not like to go out to eat, is uncomfortable in crowds, and attends church on a weekly basis, unless he needs to provide care to his ailing father. He attends church functions, such as picnics in the summer. Mental status examination findings were similar to findings on August 2009 VA examination. However, currently, the examiner found that the Veteran experienced inappropriate behavior in that he had irritability with verbal acting out, particularly at times of significant stress. He had panic attacks that were well controlled with medication. He had fair impulse control. The examiner noted that the Veteran retired in 2010 due to psychiatric problems and proprioception/balance problems. The Veteran was assigned a GAF score of 65. The examiner commented that there were mild symptoms and functional impairment, apparently slightly improved with current medication regimen. The Veteran remained employable from a mental health perspective. He would likely suffer no more than mild impairment in most employment settings. The examiner noted that the Veteran appeared to be experiencing mild social impairment. The Veteran reported some improvement in symptoms and functionality as a result of regular compliance with medication. The Veteran reported that his physical health also influenced his depressed mood. The examiner noted that the Veteran's GAF score was from all impairment as it was not possible to separate all of these factors without resorting to speculation. The examiner found that there were PTSD signs and symptoms that were transient and mild and decreased work efficiency and ability to perform occupational tasks only during period of significant distress. In a May 2011 addendum, the examiner restated the findings in the February 2011 VA examination. The examiner added that there could have been no reliable change in the Veteran's condition or in that opinion in the time period that has elapsed since that examination (i.e., it would take considerable longer to establish a new baseline). Treatment records from the Huntington VAMC dated from May to December 2011 and associated with the Veteran's Virtual (paperless) file reflect ongoing treatment for PTSD and a GAF score of 50. Social Security Administration (SSA) records received in July 2011 reveal that the Veteran was awarded disability benefits due to PTSD and chronic psychiatric difficulties. The Veteran has not engaged in substantial gainful activity since March 19, 2010. The January 2011 determination found that the Veteran's has the following residual functional capacity: a poor ability to deal with work stresses, relate predictably in social situations, and demonstrate reliability. In addition to VA treatment records, other records considered in conjunction with the January 2011 SSA determination include a June 2010 consultative examination from the Department for Disability Determination, in which the Veteran reported that he occasionally experienced auditory and visual hallucinations. His coping skills appeared to be somewhat overwhelmed. He presented with some skill deficits in the areas of activities of daily living and physical abilities. He was diagnosed with generalized anxiety disorder and assigned a GAF score of 57-59. The examiner commented that the Veteran's ability to tolerate stress and the pressure of day-to-day employment was affected by the impairment with moderate limitations. His capacity to respond appropriately to supervision, co-workers, and work pressures in a work setting was affected by the impairment with moderate limitations. A November 2010 evaluation from East Kentucky Psychological Services included a mental status examination and the Veteran was assigned a GAF score of 60. Clinical Progress Notes from R.S.P. from January 2009 to June 2010 included mental status assessments and GAF scores from 45 to 50. A June 2009 record noted his thought process as obsessive. A November 2009 record indicated that the Veteran was delusional, suicidal, homicidal, and had hallucinations. During his March 2012 Board hearing, the Veteran restated previously mentioned symptoms. III. Analysis Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 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. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the disability. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). 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). 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; 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. A rating of 30 percent is warranted for PTSD if there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. 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 United States 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 Board has considered the GAF scores assigned during the appeal period. 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). GAF scores ranging from 41 to 50 reflect 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). 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). Id. A GAF score of 61-70 indicates "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. 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). 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)). In the instant decision, the Board finds that, with resolution of reasonable doubt in the Veteran's favor, a 70 percent evaluation may be granted for the entirety of the rating period on appeal, as discussed below. On review of the record the Veteran has been diagnosed as having dysthymic disorder, generalized anxiety disorder, mood disorder, depressive disorder, PTSD, insomnia. While the August 2009 VA examiner acknowledged that the Veteran's dysthymic disorder was a condition independent of PTSD; the examiner found that the symptoms of dysthymic disorder, like PTSD symptoms, were the result of Veteran's experience of his brother's death while in service and did not separate the symptoms. Additionally, on February 2011 VA examination, the examiner acknowledged that the Veteran reported that his physical health also influenced his depressed mood. However, the examiner noted that the Veteran's GAF score was from all impairment as it was not possible to separate all of these factors without resorting to speculation. As there is no evidence to clearly distinguish the symptoms of the Veteran's PTSD with depression from his other currently diagnosed psychiatric disabilities, the Board will also attribute all of his psychiatric symptoms to PTSD with depression for the purposes of assessing the rating. See Mittleider, supra. The Board finds that the evidence demonstrates occupational and social impairment with deficiencies in most areas. For example, on August 2009 VA examination, the Veteran reported that he was in a persistent daily depressed mood and had passive suicidal ideations once every couple of months with no plan or intent. The examiner noted that the Veteran had sleep impairment, outbursts of anger, persistent irritability, and difficulty concentrating. On examination, his recent and remote memory was impaired. The examiner reported that the Veteran's disturbance caused clinically significant distress or impairment in social, occupational, or other areas of functioning. A June 2009 Clinical Progress Note, from R.S.P., reported the Veteran's thought process as obsessive. During his January 2011 DRO hearing, he reported that he did not take showers or bathe. He also indicated that he could no longer watch his daughter play volleyball and basketball, because he would holler and get too loud. He reported that he thought about hurting himself around two to three times a month. On February 2011 VA PTSD, the examiner found that the Veteran experienced inappropriate behavior in that he had irritability by verbally acting out, particularly at times of significant stress. His impulse control was fair. He had panic attacks that are well controlled with medication. Regarding social impairment, a review of the record reflects that the Veteran reported that he had a good relationship with his wife and children and that he would visit his father every day. See August 2009 and February 2011 VA examination reports. On August 2009 VA examination, the Veteran reported that he enjoyed visiting his siblings and cousins and had friends at work. He occasionally took his daughter fishing (once per month) and enjoyed watching television and spending time with family members. He attended church regularly. On February 2011 VA PTSD examination, he reported that he retained some contact with former co-workers. However, the examiner noted that the Veteran felt detached and estranged from others and had difficulty establishing and maintaining friendships outside of the family. A January 2010 private psychological report from J.A. noted the Veteran's history of having interpersonal problems on the job. During his January 2011 DRO hearing, he indicated that he mostly stayed at home. The January 2011 SSA determination acknowledged the Veteran's inability to relate predictably in social settings. On February 2011 VA PTSD examination, he reported that he did not have "real close friends" other than family. He did not like to go out to eat, and was uncomfortable in crowds. He also had loss of interest in previously enjoyed activities, feelings of worthlessness and hopelessness, and nightmares. See August 2009 VA examination report. Throughout the appeal period, the Veteran's GAF scores ranged from 45 to 65. Occupationally, the Veteran worked for a trucking company for 15-16 years and when the company went out of business he bought his own truck. He completed high school with no additional training. See January 2011 DRO hearing transcript. Prior to March 19, 2010, the Veteran was self-employed full time. At the August 2009 VA examination, the Veteran reported that he did not miss any time from work during the previous 12 months. The examiner found that there was no evidence of total occupational impairment. A July 2010 VA treatment record noted the Veteran's reports that he "went out of business" and that he had to sell his truck. He indicated that he could no longer drive it. During his January 2011 DRO hearing, the Veteran reported that he used to be able to drive his gravel truck over any little road or bridge with no problem; however, he began to experience fear in these situations and would become sweaty. He was afraid of what he might be doing wrong. Even on four lane highways, he could no longer concentrate well enough to keep his truck under control and off the shoulder or from crossing the line. He reported that on the last day he drove his truck, he went across the line and ran a pick-up truck into the median. He sold his truck the same day. He quit his job on March 18, 2010. The February 2011 VA examiner acknowledged the Veteran's decreased ability to perform occupational tasks during periods of stress. SSA records awarded disability benefits based on the Veteran's PTSD and other chronic psychiatric difficulties that showed that the Veteran had a poor ability to deal with work stresses, relate predictably in social situations, and demonstrate reliability. A June 2010 consultative examination from the Department for Disability Determination, reported that his coping skills appeared to be somewhat overwhelmed. The examiner commented that the Veteran's ability to tolerate stress and pressure of day-to-day employment was affected. His capacity to respond appropriately to supervision, co-workers, and work pressures in a work setting was affected. Lay statements submitted in January 2011 further support the Veteran's inability to drive long distances. C.S. reported that the Veteran was unable to drive himself more than a few miles. P.B. reported that she only knew of the Veteran driving himself to the post office to check his mail, which was three miles from his house. These letters further indicate the Veteran's inability to drive long distances. Despite the GAF scores reflecting only moderate impairment, the evidence described above portrays difficulties experienced by the Veteran to the point that it may be said that he has deficiencies in most areas, especially in an occupational setting where he would be required to focus, perform tasks, and interact appropriately with others. While a 70 percent rating is warranted, the record does not support assignment of a 100 percent schedular evaluation. While he has had some of the symptoms listed as examples for the 100 percent rating, and was reported to be delusional, homicidal, suicidal, and had hallucinations, such symptoms occurred only occasionally and were not persistent. See November 2009 Clinical Progress Note from R.S.P., June 2010 consultative examination, and January 2011 DRO hearing transcript. Additionally, while on August 2009 VA examination, he had difficulty with remembering names, telephone numbers, and tasks that he was asked to complete at home, none of the medical findings indicated a gross memory deficit such as memory loss for names of close relatives, own occupation, or own name. There was also no grossly inappropriate behavior-rather, his outbursts and irritability appeared to more closely approximate impaired impulse control, a problem contemplated by the 70 percent evaluation. There was also no showing of an inability to perform the activities of daily living and there was no showing of disorientation to time or place. Regardless, the question turns on not specifically the symptoms listed on the 100 percent rating criteria, but rather on whether or not the Veteran's PTSD with depression symptoms result in total occupational and social impairment. The record does indicate an inability to work. The record further demonstrates that the PTSD with depression in question is a significant factor in the Veteran's unemployability. However, total impairment as contemplated by the schedule has not been demonstrated. Although the Veteran had difficulty establishing and maintaining relationships, he has remained married to his current wife for over 26 years, he describe his relationship with her, his two children, and his siblings or other family members as close and/or good. The Board acknowledges that the Veteran clearly engages in isolating and avoiding behaviors. Nevertheless, while there is significant impairment with his social activities, a 70 percent rating contemplates deficiencies in most areas, including family relations and the inability to establish and maintain effective relationships. The evidence of record does not suggest that he is totally socially impaired due to PTSD with depression. Given the above, and in light of the absence of findings consistent with symptoms commensurate with a 100 percent rating under Diagnostic Code 9411, to include evidence of total social impairment, the Board finds that the requirements for a schedular rating in excess of 70 percent have not been met. In sum, throughout the rating period on appeal, a 70 percent schedular rating, but no higher, for PTSD with depression is warranted. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). 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). The Board must specifically consider 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 the Court, 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 symptoms of this Veteran's disability include impaired recent and immediate memory, impaired sleep depression, anxiety, difficulty concentrating, loss of interest feelings of worthlessness and hopelessness, suicidal and homicidal thoughts, feelings of detachment, avoidance, difficulty in establishing and maintaining relationships, outbursts of anger, persistent irritability, difficulty with being in crowds, impaired impulse control, depressed mood, irritability, withdrawal, panic attacks, loss of interest, delusions, and hallucinations. These symptoms are all contemplated by the rating criteria. Thus, referral for consideration of an extraschedular evaluation is not warranted. 38 C.F.R. § 3.321(b)(1). A claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been considered. Given the evidence of current service-connected disability, the Veteran's claim for the highest rating possible, and the evidence of unemployability, the record raises a claim for a TDIU under Roberson and Rice. VA will grant a TDIU when the evidence shows that the Veteran is precluded, by reason of his service connected disabilities, from securing and following "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 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). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012). A total disability rating for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more. If there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a) (2012). 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). In this decision, the Board increased the schedular rating assigned for PTSD with depression to 70 percent. Therefore, the Veteran meets the criterion for consideration of a TDIU rating. 38 C.F.R. § 4.16(a). However, the record reflects that the Veteran engaged in full-time employment prior to March 19, 2010 and the Veteran has repeatedly reported that he quit his job on March 18, 2010. It has neither been alleged nor shown, that the Veteran's service-connected PTSD with depression resulted in unemployability prior to March 19, 2010. Accordingly, consideration of TDIU pursuant to Rice prior to March 19, 2010 is not warranted. As the evidence reflects that the Veteran has not been gainfully employed since March 19, 2010, the Board will focus on this period of the appeal. Accordingly, the Veteran now meets the schedular criteria for a TDIU, and the Board's consideration thus turns to whether the Veteran's service-connected disability precludes gainful employment for which his education and occupational experience would otherwise qualify him since March 19, 2010. The Veteran worked for a trucking company for 15-16 years and when the company went out of business he bought his own truck. He completed high school with no additional training. See January 2011 DRO hearing transcript. During his January 2011 DRO hearing, the Veteran reported that he used to be able to drive his truck over any little road or bridge with no problem; however, he began to experience fear in these situations and would become sweaty. He was afraid of what he might be doing wrong. Even on four lane highways, he could no longer concentrate well enough to keep his truck under control and off of the shoulder or from crossing the line. He reported that on the last day he drove his truck, he went across the line and ran a pick-up truck into the median. He sold his truck the same day. He quit his job on March 18, 2010. The February 2011 VA examiner acknowledged the Veteran's decreased ability to perform occupational tasks during periods of stress. SSA records awarded disability benefits based on the Veteran's PTSD and other chronic psychiatric difficulties that showed that the Veteran had a poor ability to deal with work stresses, relate predictably in social situations, and demonstrate reliability. The January 2011 determination also found that the Veteran was unable to perform any past relevant work, and considering the Veteran's education, work experience, and residual functional capacity, there were no other jobs that existed in significant numbers that he could perform. A June 2010 consultative examination from the Department for Disability Determination, reported that his coping skills appeared to be somewhat overwhelmed. The examiner commented that the Veteran's ability to tolerate stress and pressure of day-to-day employment was affected. His capacity to respond appropriately to supervision, co-workers, and work pressures in a work setting was affected. Lay statements submitted in January 2011 further support the Veteran's inability to drive long distances. C.S. reported that the Veteran was unable to drive himself more than a few miles. P.B. reported that she only knew of the Veteran driving himself to the post office to check his mail, which was three miles from his house. These letters further indicate the Veteran's inability to drive long distances. Overall, the available evidence suggests that the Veteran's PTSD with depression symptoms prevent him from securing and following substantially gainful employment consistent with his education and occupational experience. Entitlement to a TDIU is, therefore, granted from March 19, 2010. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. § 4.16(a). ORDER An initial 70 percent schedular rating for PTSD with depression is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a TDIU rating based on PTSD with depression is granted from March 19, 2010, subject to the laws and regulations governing the award of monetary benefits. _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs