Citation Nr: 1307121 Decision Date: 03/01/13 Archive Date: 03/11/13 DOCKET NO. 07-26 146 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES Entitlement to an initial disability rating in excess of 30 percent for post traumatic stress disorder (PTSD) from November 17, 2005, to February 12, 2007, and in excess of 70 percent for PTSD from February 13, 2007. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran; Veteran's spouse ATTORNEY FOR THE BOARD Shana Z. Siesser, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1966 to October 1969, from December 1972 to October 1974 and from November 1974 to December 1976. This matter comes to the Board of Veterans' Appeals (Board) on appeal from July 2006 and January 2008 rating decisions of the Department of Veterans' Affairs (VA) Regional Office (RO) in Waco, Texas. In July 2006, the RO granted service connection for PTSD and assigned an initial disability rating of 30 percent, effective November 17, 2005. During the pendency of this appeal, a January 2008 rating decision assigned a 70 percent rating for PTSD from February 13, 2007. As that rating is less than the maximum available rating, the issue remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). The January 2008 rating decision also granted entitlement to a total disability rating based on individual unemployability (TDIU) effective February 13, 2007. The Veteran appeared before the undersigned Veterans Law Judge at a Travel Board hearing in May 2010. The record contains a transcript of that hearing. This case was previously before the Board in November 2009, July 2010, and April 2012 and was remanded for additional development. The RO has complied with the remand directives. A review of the Virtual VA paperless claims processing system shows relevant treatment records. FINDING OF FACT For the entire period on appeal, the Veteran's PTSD symptoms have been shown to manifest as total social and occupational impairment, due to such symptoms as: persistent delusions; grossly inappropriate behavior; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); continuous depression, and disorientation to time or place. CONCLUSION OF LAW The criteria for the assignment of a 100 percent rating for PTSD are met for the entire period on appeal. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130, including Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's 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); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). The Board has considered this legislation, but finds that, given the favorable action taken below; no discussion of the VCAA at this point is required. Increased Rating Claim The Veteran contends that he is entitled to a rating in excess of 30 percent for his PTSD prior to February 13, 2007, and a rating in excess of 70 percent from February 13, 2007, due to the severity of his symptoms. With resolution of the doubt in favor of the Veteran, the evidence shows that the Veteran's symptoms warrant a 100 percent rating for the entire period on appeal. 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 (2012). 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 (2012). 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 (2012). 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 (2012). The Veteran's service-connected PTSD has been rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411, which provides: A 30 percent disability rating is warranted when 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, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9411. A 50 percent disability rating is warranted if the Veteran experiences occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent disability rating is warranted when the Veteran experiences occupational and social impairment, with deficiencies in most area, 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 work like setting); inability to establish and maintain effective relationships. Id. A 100 percent disability rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of closest relatives, own occupation, or own name. Id. Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2012). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). A Veteran need not exhibit "all, most, or even some" of the symptoms enumerated in the General Rating Formula for Mental Disorders to warrant the assignment of a higher rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Rather, the criteria ("such symptoms as") provides guidance as to the severity of symptoms contemplated for each rating in addition to permitting consideration of other symptoms particular to the Veteran. Id. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV), a global assessment of function (GAF) score reflects the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM IV, American Psychiatric Association (1994), pp.46-47; 38 C.F.R. §§ 4.125(a), 4.130. A GAF score of 41-50 indicates serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Id. A GAF score of 51-60 represents 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. The GAF score is only one factor to be considered in ascertaining the degree of impairment caused by the Veteran's psychiatric illness. The GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In a March 2006 mental health record, the Veteran reported a recent exacerbation of PTSD symptoms, including irritability, anger, intrusive memories, and flashbacks. He also reported being tearful and isolative, both physically and socially. He stated that he had difficulty sleeping, poor attention and concentration, and exhaustion. The Veteran denied thoughts of self harm or harm to others, confusion, or disorientation. He stated that he was married and enjoyed playing with his grandchildren and visiting with friends. A mental status examination revealed that the Veteran was fully alert and oriented. He was cooperative with good self care and hygiene and had no psychomotor abnormalities. His mood was upset, anxious, depressed, and tearful and his affect was appropriate and congruent with restricted range and reactivity while talking about Vietnam. His attention and concentration was fair to impaired, cognition was grossly intact, and his insight and judgment were fair. The Veteran's thought process was goal directed with tight associations. However, his thought content was anxious and depressive, cognitive of moderate severity with prominent themes of helplessness, hopelessness, and worries about the future. The Veteran also had combat-related emotional trauma, nightmares, flashbacks, and intrusive memories with recent exacerbation after contact with his Vietnam buddies. The Veteran was diagnosed with PTSD and assigned a GAF score of 45-55. A March 2006 Vet Center intake form showed the Veteran underwent a mental status evaluation. Specifically, the Veteran had a neat appearance with appropriate speech. He was fully oriented with normal memory function, an appropriate affect, and fair judgment. The report noted evidence of delusions and disorganized thinking. The report also noted that the Veteran experiences olfactory and visual hallucinations. The Veteran also showed signs of depression. In a June 2006 treatment record, the Veteran's physician noted that the Veteran reported increasing levels of distress related to an upcoming VA examination. To cope with his increased symptoms, the Veteran increased his medication. Another June 2006 treatment record showed a diagnosis of PTSD and an assigned GAF score of 45-55. The Veteran underwent a VA examination in June 2006. The Veteran reported a good family relationship with his wife of 39 years and two grown daughters. He also stated that he had friends and a social life. A psychiatric examination showed the Veteran was clean, pleasant, and cooperative. He had normal, well-balanced thinking and no depression or anxiety was noticed. He described nightmares and sleep disturbances that occurred weekly, on average. The examiner diagnosed PTSD, moderate to serious. He was assigned a GAF score of 55. The examiner opined that the Veteran's cognitive status was completely normal and there were no other psychiatric problems. An August 2006 mental status report showed that the Veteran had no psychotic symptoms, fair memory and judgment, a fair ability to relate to others and sustain work, and a limited ability to respond to change or stress. The Veteran's readjustment counselor at the Vet Center submitted a letter in August 2006 regarding the Veteran's PTSD symptoms. He stated that the Veteran experiences recurrent and intrusive distressing recollections of the traumatic event, including images, thoughts, and perceptions. Additionally, the Veteran experiences flashbacks, distressing dreams, and intense psychological and physiological distress when exposed to cues that resemble the traumatic event. The Veteran also avoids thoughts, feelings, and conversations associated with the trauma, leading the Veteran to avoid social interaction. The Veteran has markedly diminished interest and participation in significant activities, experiences feelings of detachment and estrangement, and displays a restricted range of affect. The counselor also stated that the Veteran experiences persistent symptoms of increased arousal as evidenced by his difficulty falling and staying asleep, irritability and outbursts of anger, physical violence, difficulty concentrating, hypervigilance, and exaggerated startle response. A September 2006 treatment record showed the Veteran was maintaining improvement in his PTSD symptoms, but continued to experience nightmares. The Veteran denied having thoughts of harm to himself or others. A mental status examination showed the Veteran had good self care and hygiene and had no psychomotor abnormalities. His speech was of average time and volume. His mood was subjectively better and objectively improving, with no thoughts or plans of harm to himself or others. The Veteran's affect was appropriate and congruent with improving range and reactivity. His thought process was purposeful and goal directed; however his thought content was anxious cognition with combat related nightmares. The Veteran was fully oriented with improving concentration and attention and his cognition was grossly intact. The examiner diagnosed chronic PTSD and assigned a GAF score of 55. Counseling records from August 2006 through April 2007 showed the Veteran's symptoms regularly worsening and improving due to various stressors. A May 2007 Vet Center report showed that the Veteran complained of recurrent recollections of traumatic war events, distressing dreams of war trauma, inability to trust others, irritability, depression with suicidal ideation with no plan, auditory hallucinations, outbursts of anger, difficulty concentrating and staying organized, hypervigilance, and an inability to maintain meaningful relationships. The Veteran and his wife stated that his negative symptoms had increased over the prior six months. The Veteran's counselor reported that the Veteran reported increased anxiety, depression, hypervigilance, social and emotional isolation and paranoia as the most severe of his symptoms. Family members are fearful of him and will not enter his home without first announcing themselves. The Veteran sleeps with a firearm beneath his pillow and he maintains ready weapons in case of an intrusion. He reported feeling angry all the time but controls his behavior with fear of repercussions. The Veteran maintains a social isolation that includes no meaningful relationships. In June 2007, the Veteran submitted lay statements from his family members in support of his claim. The statements described the Veteran as an angry man, who was withdrawn and isolative. A July 2007 letter from the Veteran's counselor showed that the Veteran continued to have irritability, nightmares, sleeping difficulties, explosive anger, hypervigilance, exaggerated startle response, and other symptoms of hyperarousal. The Veteran also experienced feelings of detachment and estrangement from others, avoidance of thoughts or emotions related to the trauma, and recollections of the trauma. The counselor opined that the Veteran is severely and permanently disabled as a result of his PTSD. The Veteran underwent a VA examination in October 2007. The Veteran reported a full range of PTSD symptoms, including re-experiencing traumatic events, avoidance and numbness, and increased arousal. He also reported frequent nightmares, inability to sleep, and daily flashbacks. He also has symptoms of depression with a significantly depressed mood. Regarding employment, the Veteran reported that he had not worked since 2005. He held approximately 20 jobs since service, including 15 years as a truck driver. He stated that left approximately half of his jobs due to anger and was fired from the rest due to his inability to control his anger. The examiner concluded that the Veteran presented with severely impaired occupational functioning. Regarding his social impairment, the Veteran and his wife agreed that the Veteran has a bad temper and can be mean. He has a decent relationship with his daughters and grandchildren. Otherwise, he does not socialize at all. He reported discomfort in crowds, precluding participation in many social activities. A mental status examination revealed the Veteran was causally and appropriately dressed with good grooming and hygiene. He had normal psychomotor activity and was cooperative, attentive, friendly, and appropriate. His speech was normal and thought processes were logical, clear, and goal directed. He had no history of delusions or hallucinations. The Veteran's mood was self-reported to be "just lost." He stated that he did not know why he had symptoms of anger, depression, anxiety, irritability, and sadness. His affect was restricted and tearful. The Veteran denied suicidal or homicidal ideations. The Veteran was fully oriented, but his attention and concentration were significantly impaired. He had a mildly impaired memory and abstract reasoning skills. His social judgment was intact but his insight was poor. The examiner opined that "it is very likely that the Veteran's difficulties with attention, concentration, and memory would lead to impaired functioning in an occupational setting." His symptoms do not impair his activities of daily living. The examiner diagnosed the Veteran with PTSD, chronic, severe, and major depressive disorder, recurrent, moderate. A GAF score of 45 was assigned. The examiner stated that "[T]he Veteran's psychological adjustment is very poor. He has had chronic problems with irritability and outbursts of anger over the course of his adult life. For many years, he was physically and verbally abusive of his wife. He has discontinued the physical abuse, but continues to lose his temper easily, scream, holler, and can be mean as well. Therefore, his verbal aggression has continued. The Veteran does give history consistent with inappropriate behaviors in the workplace resulting in occupational impairment. The Veteran is also very isolated on a social level and has shown significant social impairment since his return from Vietnam." A May 2008 activity questionnaire for Disability Determination Services showed that the Veteran reported a poor memory, having no friends and angering his family, excessive anger, nightmares and flashbacks, and an inability to leave home on his own. A June 2008 psychiatric review found that from the period from March 2006 through May 2008, the Veteran had anxiety and recurrent and intrusive recollections of a traumatic experience. The report notes that the Veteran had a mild restriction in activities of daily living, and moderate difficulties in maintaining social functions, concentration, persistence, or pace. The psychiatrist concluded that the Veteran had severe social and occupational impairments with deficiencies in areas of work, family, judgment, thinking, mood, anger, depression, impaired impulse control, decreased concentration and attention, hypervigilance, hyperarousal, nightmares, flashbacks, exaggerated startle response, decreased sleep, and impaired memory. His psychological adjustment capability was poor. In a July 2008 mental health note, the Veteran reported increased irritability and anger, increased intensity of nightmares, and poor motivation. The Veteran denied suicidal or homicidal ideation or other psychotic symptoms. Upon examination, the physician noted an anxious and mildly irritable mood, and appropriate affect with restricted range and reactivity, and anxious and depressive cognition with chronicity in the context of symptoms of chronic and prolonged PTSD. A GAF score of 55 was assigned. In a September 2008 letter, the Veteran's counselor stated that the Veteran continued to have irritability, nightmares, sleeping difficulties, explosive anger, hypervigilance, exaggerated startle reflex, and other symptoms of hyperarousal. He noted that the Veteran also had feelings of detachment and estrangement from others, and avoidance of thoughts and feelings associated with the traumatic events. The counselor opined that the Veteran is severely and permanently disabled due to his PTSD. The counselor further stated that since the Veteran's open heart surgery in May 2007, his negative symptoms of PTSD had become more severe and he would be unlikely to perform any type of work, due to his anti-social attitudes and mental and physical health. A VA examination was conducted in January 2009. The Veteran reported that his PTSD symptoms have increased since his October 2007 examination. He stated that he forgets names of family members and often experiences anxiety and has difficulty spelling his own name. He also reported re-experiencing trauma, avoidance, numbing of responsiveness, and increased arousal. He has nightmares on a nightly basis and daily, unremitting flashbacks. He also claimed depression. Regarding social functioning and impairment, the Veteran has been married for 41 years. His relationship with his wife had been difficult, including many years of physical abuse. That abuse discontinued approximately 20 years prior, but his wife reported that the Veteran is irritable and loses his temper easily. The Veteran reported a good relationship with his daughters, but otherwise does not like to be around people. The examiner noted that the Veteran had serious social impairment. A mental status examination showed that the Veteran was appropriately dressed with good grooming and hygiene. His psychomotor activity was normal and he was cooperative, attentive, and friendly. The Veteran's speech and communication were normal and his thought processes were clear, logical, and coherent. He has no diagnoses of delusions or hallucinations. His mood was anxious and affect was constricted and the Veteran became tearful when asked to perform mental status tasks. The Veteran denied suicidal and homicidal ideation. The Veteran was fully oriented, but his attention and concentration were impaired. The Veteran's remote memory was intact but he was unable to recall one out of three items after five minutes. The Veteran exhibited impairment in abstract reasoning skills and his psychological insight was poor. The examiner opined that the Veteran was experiencing a decline in his cognitive functioning that is most likely age related or due to an early phase of dementia, but is not likely secondary to the Veteran's PTSD symptoms. The examiner diagnosed the Veteran with PTSD, chronic, severe; depressive disorder; and cognitive disorder and assigned a GAF score of 45. In a March 2010 treatment record, the Veteran reported an increase in nightmares, irritability, anger, and frustration. The Veteran denied suicidal or homicidal ideations or psychotic symptoms. The Veteran's physician noted that the Veteran's emotional health had worsened since his last visit with deterioration in his mood and PTSD symptoms. The Veteran appeared at a Board hearing before the undersigned Veterans Law Judge in May 2010. He testified that he rarely leaves the house, except to take his wife grocery shopping or to the hospital. During those trips, he often waits for her in the car. He stated that he has audio and visual hallucinations and denied homicidal or suicidal thoughts. He reported trouble remembering his location and the names of close family members. He stated that the symptoms that he currently reports have existed since his discharge from service. The Veteran reported poor sleep, an inability to care for himself without reminders from his wife, isolation, and poor memory. The Veteran's wife testified that the Veteran had inappropriate behavior, particularly with regard to anger and irritability. The Veteran's wife submitted a lay statement in January 2012 in which she stated that the Veteran symptoms have increased. She stated that his temper worsened and he no longer participates in any activities. Treatment records from February and July 2012 show that the Veteran endorsed no new symptoms and described fair control over his chronic symptoms. He reported fair sleep with occasional nightmares. He denied suicidal or homicidal ideations or psychosis. The physician found that he displayed fair judgment and insight into his symptoms and was cognitively intact. The physician concluded that the Veteran is maintaining fair improvement in his PTSD symptoms with depressed mood. A GAF score of 55 was assigned. The Veteran underwent a VA examination in September 2012. The examiner diagnosed PTSD and opined that his symptoms reflected occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking, and/or mood. The Veteran's symptoms included anxiety, chronic sleep impairment, mild memory loss, impairment of short and long-term memory, impaired abstract thinking, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances. Analysis Considering the evidence, the Board finds that, with resolution of all reasonable doubt in the Veteran's favor, the evidence reflects that Veteran's psychiatric symptoms warrant a 100 percent rating for PTSD for the entire period on appeal. As stated above, a 100 percent disability rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. For the entire period on appeal, the Board finds that the Veteran's psychiatric symptoms have collectively persistent hallucinations and delusions, grossly inappropriate behavior, intermittent inability to perform activities of daily living, social isolation, sleep disturbance, impaired impulse control shown as irritability, an inability to adapt to stressful circumstances, and total occupational and social impairment. The Board notes that the Veteran has maintained a tumultuous relationship with his wife and his children. His family has submitted multiple lay statements describing the difficulties they encountered in maintaining a relationship with the Veteran, given his anger, temper, and other PTSD symptoms. The Veteran has also stated that he does not socialize with anyone outside his family and withdraws from social situations. Records from November 17, 2005 through February 12, 2007 show that the Veteran had continuous depression, uncontrollable anger, an inability to adapt to stressful situations, and an inability to establish effective relationships. Specifically, the March 2006 mental health record showed that the Veteran had irritability, anger, and intrusive memories. He also reported physical and social isolation, poor concentration and attention, and difficulty sleeping. His thought content was anxious and depressed with themes of helplessness, hopelessness, and worries about the future. The Veteran's March 2006 Vet Center report showed evidence of delusions and disorganized thinking. Additionally, the records from the Veteran's counselor also revealed avoidance of social interaction, intense anger and irritability, difficulty concentrating, outbursts of anger, and irritability. Furthermore, the Veteran has been assigned GAF scores of 45 and 55. These scores are indicative of moderate to serious symptoms and serious impairment in social and occupational functioning. The records and examination reports show a consistent pattern of irritability and outbursts, cognitive trouble with concentration and attention, and mood-related difficulties as evidenced by his depression. Additionally, the Veteran testified that he occasionally becomes disoriented or forgets his children's names. The records also show the Veteran has experienced hallucinations, as are noted in the 2006, 2007, 2010, and 2012 records. With regard to the Veteran's occupational impairment, at the October 2007 VA examination he stated that he had been unable to work since 2005. Although a March 2006 income and net worth statement shows that the Veteran had stopped working in March 2006, there are no records that show substantial, gainful employment between November 2005 and March 2006. Additionally, the Veteran stated that he held approximately 20 jobs since service and that he left approximately half of his jobs due to anger and was fired from the rest due to his inability to control his anger. Finally, in July 2007, his mental health counselor found him permanently and total disabled for work due to his PTSD. With resolution of the doubt in favor of the Veteran, the Board finds that the Veteran has a longstanding history of occupational impairment and that he was totally occupationally impaired during the entire period on appeal. The Board must determine the value of all evidence submitted, including lay and medical evidence. The Board has also considered the Veteran's lay statements and sworn testimony regarding the severity of his PTSD. The Board acknowledges the Veteran's belief that his symptoms are of such severity as to warrant a higher rating for his PTSD; however, disability ratings are made by the application of a schedule of ratings which is based on average impairment of earning capacity as determined by the clinical evidence of record. While the Board finds the Veteran competent to testify as to his symptoms and the Board finds his statements credible, the medical findings, which directly address the criteria under which the service-connected disabilities are evaluated are more probative than his assessment of the severity of his disabilities. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). As the evidence shows that the Veteran has experienced total occupational and social impairment since the inception of his claim, the Veteran's claim for an increased rating is granted and with resolution of the doubt in favor of the Veteran, the Board finds that the Veteran is entitled to a rating of 100 percent, effective November 17, 2005. See 38 C.F.R. § 4.7 (2012). Extraschedular rating The Board has also considered whether referral for extraschedular consideration is warranted, but finds that it is not. The determination of whether a claimant is entitled to an extraschedular rating is a three-step inquiry. Thun v. Peake, 22 Vet. App. 111, 115 (2008). The first step is to determine whether the "evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate." Id. If it is determined that this is so, the second step of the inquiry requires a determination of "whether the claimant's exceptional disability picture exhibits other related factors," such as marked interference with employment or frequent periods of hospitalization. Id. at 116. Finally, if the first two steps of the inquiry have been satisfied, the third step requires referral of the claim to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination of whether an extraschedular rating is warranted. Id. With respect to the initial inquiry posed by Thun, the Board finds that the Veteran's disability level and symptomatology are adequately described by the rating criteria. Without sufficient evidence reflecting that the Veteran's disability picture is so "exceptional or unusual," such that the available scheduler evaluation for is PTSD is inadequate, referral for a determination of whether the Veteran's disability picture requires the assignment of an extra-schedular rating is not warranted. Thun, supra. TDIU The Court has held that a total compensation rating based upon individual unemployability (TDIU) is encompassed in a claim for increased rating or the appeal of an initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, the Veteran's claim for a higher evaluation includes a claim for TDIU. However, if VA has found a Veteran to be totally disabled as a result of a particular service-connected disability or combination of disabilities pursuant to the rating schedule, there is no need, and no authority, to otherwise rate that Veteran totally disabled on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding request for TDIU moot where 100 percent schedular rating was awarded for the same period). Therefore, the instant grant of a 100 percent disability rating for the entire appeal period renders any claim for a TDIU raised by the evidence of record moot. See Green v West, 11 Vet. App. 472, 476 (1998) (holding that if a 100 percent schedular rating is warranted, the Veteran is not also entitled to TDIU). ORDER A rating of 100 percent for PTSD is granted, effective November 17, 2005. ____________________________________________ CHERYL L. MASON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs