Citation Nr: 1315276 Decision Date: 05/09/13 Archive Date: 05/15/13 DOCKET NO. 08-33 004 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Albuquerque, New Mexico THE ISSUE 1. Entitlement to a higher initial disability rating for posttraumatic stress disorder (PTSD), evaluated as 50 percent disabling. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Chapman, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from September 1963 to September 1965. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision by the Albuquerque, New Mexico Regional Office (RO) of the Department of Veterans Affairs (VA) which granted service connection for PTSD and assigned a 30 percent initial disability rating. A March 2011 rating decision increased the Veteran's rating for PTSD to 50 percent, effective May 4, 2006 (the date of his claim). Applicable law provides that absent a waiver, a claimant seeking a disabling rating greater than assigned will generally be presumed to be seeking the maximum benefit allowed by law and regulation, and that a claim remains in controversy where less than the maximum available benefits are awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran has not withdrawn the appeal as to the issue of the disability rating greater than assigned, and the issue therefore remains in appellate status. A hearing before the RO was held in January 2009; a transcript is of record. The issue of TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to August 17, 2010, the Veteran's PTSD symptomatology more nearly approximated occupational and social impairment with reduced reliability and productivity due to such symptoms as panic attacks, impairment of short-term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood was not shown. 2. From August 17, 2010, the Veteran's PTSD symptomatology more nearly approximates occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Total occupational and social impairment is not shown. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation higher than 50 percent for service-connected PTSD from May 4, 2006 until August 17, 2010 have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). 2. Resolving the benefit of the doubt in the Veteran's favor, the criteria for an evaluation of 70 percent, but no higher, for service-connected PTSD from August 17, 2010 has been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 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, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. 3.326(a). The VCAA applies to the instant claim. A letter dated in May 2006 advised the Veteran of the legal requirements for supporting his claim. The Board notes that the Veteran's claim for a higher rating arises from his disagreement with the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Thus, the notice requirements have been met. The Board also notes that the Veteran's medical treatment records have been obtained, and he was afforded two VA examinations to assess the current severity of the disorder. The Board finds that the examinations were adequate to allow proper adjudication of the issue on appeal. The examiner conducted a complete examination, recorded all findings considered relevant under the applicable diagnostic code, and considered the full history of the disability. No further development is required. The Board notes that it has reviewed all of the evidence in the Veteran's claims file and in the "Virtual VA" electronic records storage system. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss in detail every piece of evidence of record. See Gonzales v. West, 218 F. 3d 1378, 1380-81 (Fed. Cir. 2009). Hence, the Board will summarize the relevant evidence as appropriate, and the Board's analysis will focus specifically on what the evidence shows or fails to show as to the claim. Legal Criteria Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher one 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When VA grants a claim for an increased rating, it may assign an effective date up to one year before the date the claimant's application for increase was received, provided it is factually ascertainable that an increase in disability occurred within that timeframe. 38 U.S.C.A. § 5110(b)(2); Hart, 21 Vet. App. 505, 509 (2007). Here, the relevant evidentiary window begins May 2007 (one year before the Veteran filed his claim for an increased rating), and continues to the present time. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). An extraschedular evaluation will be assigned if the case presents an unusual or exceptional disability picture with such related factors as marked interference with employment or frequent periods of hospitalization such as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321(b)(1). The Veteran's service-connected PTSD has been rated as 50 percent disabling by the RO under the provisions of Diagnostic Code 9411, which refers to the same set of rating criteria for mental disorders as set forth at 38 C.F.R. § 4.130. Under this regulatory provision, a noncompensable rating is warranted where the disorder has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent disability rating is warranted when the Veteran experiences occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. 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). 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. A 70 percent disability rating is warranted when the Veteran experiences 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 work like setting); inability to establish and maintain effective relationships. A 100 percent 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. The Board recognizes that the Court in Mauerhan v. Principi, 16 Vet. App. 436 (2002), stated that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. However, the Court further indicated that without those examples, differentiating a 30 percent evaluation from a 50 percent evaluation would be extremely ambiguous. Id. at 442. 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). 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). The Global Assessment of Functioning (GAF) scale reflects the psychological, social and occupational functioning under a hypothetical continuum of mental illness. See American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). See also Carpenter v. Brown, 8 Vet. App. 240, 243 (1995); 38 C.F.R. § 4.130. According to the DSM-IV, a GAF score of 61-70 denotes some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships. A GAF score of 51-60 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). 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). A GAF score of 31-40 indicates some impairment in reality testing or communications or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. Factual Background and Analysis In July 2006, a private provider submitted a statement that she treated the Veteran in the mid 1980s and recalled that he had been the victim of a sexual assault and rape while serving in the Army and that the Veteran was continuing to struggle with the psychological ramifications of the attack decades later. The Veteran submitted a private psychological examination in August 2006. The examiner noted that the Veteran has many emotional problems, is fearful of going to bed, is constantly preoccupied with thoughts of the rape, and is still very angry at the incident itself and the fact that the Army did not support him. Since the rape, the Veteran has been unable to be close or to trust anyone. The examiner noted that the Veteran has problems with intimacy, would react violently if someone shook him to awaken him if he was asleep, and could not deal with authority figures. He noted that the Veteran has constant thoughts about being raped and has symptoms of depression, which he tries to deal with by controlling his environment. Prior to becoming sober, he noted that the Veteran had many incidents of suicidal ideation. On mental status examination, the examiner found the Veteran to be alert, oriented, and cooperative, of above average intelligence, who appeared to be moderately to markedly depressed. There was no evidence of psychotic ideation and he had good insight into his illness and the need for appropriate treatment. The examiner provided an Axis I diagnosis of severe, chronic PTSD and a GAF score of 45. In December 2007, this same examiner again performed an examination and provided an opinion. At this time, the examiner noted the presence of suicidal thoughts, constant preoccupations of the sexual trauma, fear of going to sleep and severe problems with being touched while in bed, and an inability to function in a work or social situation. The examiner stated that the Veteran has frequent flashbacks of the rape incident, and is definitely in need of ongoing psychotherapy. The examiner found his prognosis to be guarded, stated that he was unable to be employed and provided a GAF score of 40, which the examiner noted was indicative of the seriousness and chronicity of his symptoms. The Veteran was afforded a VA examination in December 2006. The examiner noted that the Veteran reported symptoms of depression and PTSD, at a mild to moderate level. The Veteran reported that he has had problems keeping jobs due to his irritability, lack of trust, and difficulties with authority. The Veteran stated that he has 2 good friends, but otherwise is socially isolated. The examiner noted that the Veteran's psychosocial status is in the low average range and that this status represents a decrease from his reported status prior to military service. On mental status evaluation, the Veteran was articulate and had no difficulty with communication. There was no evidence of delusions or hallucinations; his eye contact was good; he denied current and past suicidal or homicidal thoughts; he was well groomed and oriented times three. The Veteran reported short term memory loss and some difficulties with concentration. The Veteran also reported being rather rigid and obsessive in his habits, but denied frank obsessive or ritualistic behavior. He denied panic attacks. The examiner noted that the Veteran did endorse depressed mood and low concentration, as well as feelings of guilt and pessimism, and feelings of worthlessness and low energy. The examiner stated that the Veteran has not shown any signs of impaired impulse control, and his sleep is adequate. After examination, the examiner stated that the Veteran met the DSM-IV stressor criteria for PTSD. The examiner noted the Veteran's reports of being fearful of others, less trusting, difficulty with authority, irritability, being more isolative, and experiencing daily intrusive memories of the event. The examiner noted that the Veteran also reported nightmares several times per week, heightened physiological arousal, and avoiding treatment for PTSD because of not wishing to come to the VA and being reminded of military triggers. The examiner noted that the Veteran appeared to be having frequent symptoms, in the mild to moderate range. He provided an Axis I diagnosis of PTSD and a GAF score of 60. The examiner stated that the Veteran has a good prognosis for improvement if he receives targeted exposure treatment focused on the military sexual trauma. VA treatment records from July 2007 until January 2012 reveal an Axis I diagnosis of PTSD and continued treatment for PTSD, including PTSD group therapy. In July 2007, a PTSD and depression screen was positive. In June 2008, a depression screen was positive, but a suicidal evaluation was negative. A November 2007 psychiatry consultation noted the Veteran was alert, calm, had fluent speech, had no thought disorder, no obsessions, no delusions or compulsions, and was not homicidal or suicidal; his mood was mildly anxious with a full range of affect. A December 2008 mental health note recorded that the Veteran was feeling depressed, but was not suicidal. In July 2009, the Veteran was seen for an initial psychiatry evaluation. The Veteran stated that his life is "incredibly good" but that his negative attitude is the problem. The Veteran stated that he thinks about suicide, but has no plan to kill himself. He reported that his relationship with his wife is generally good. An examination revealed a depressed mood and a GAF score of 42. An August 2009 psychiatry note revealed that the Veteran worried about his health and engaged in compulsive behaviors. The Veteran reported continuing to feel depressed, but having no thoughts of suicide. A November 2010 treatment record noted an exacerbation of chronic depression with mild neurovegetative symptoms. The examiner noted that the Veteran was primarily feeling despondent, restless, irritable, and discontent; no serious lethal ideation. He remained clean and sober and requested resuming use of antidepressants. The examiner provided an Axis I diagnosis of PTSD and a GAF score of 42. June 2011 and September 2011 mental status examinations noted that the Veteran was clean and well-groomed, calm and cooperative, with a normal rate of speech and memory and cognition intact. The examiner noted that he had a depressed and anxious mood, with poor insight and judgment, but that he experienced linear thought processes, and no active suicidal or homicidal ideation, no delusions, and no hallucinations. A GAF score of 60 was provided. In December 2011 and January 2012 records, the provider noted intermittent depression symptoms, but no suicidal or homicidal ideation. The Veteran testified at a hearing before a decision review officer at the RO in January 2009. The Veteran testified that he feels sad all the time, has trouble concentrating, has difficulty finishing tasks, experienced memory problems, and doesn't trust anyone. He further testified that he has flashbacks daily, has a lot of fear and anxiety, has very few friends, and is afraid of people and places. He stated that he feels like he doesn't belong and isolates himself. He also stated that coming to the VA upsets him and that he has a huge aversion for the military and anything to do with the government. The Veteran testified that he has had problems with violence, including beating his former wife. The Veteran also stated that he felt like the first VA psychologist who evaluated him compared him to other people and judged him; as such, he didn't feel safe revealing his symptoms and instead tried to make himself look good. Thus, he contended that the December 2006 VA examination did not reveal the extent of his disability. A January 2009 statement from the Veteran's wife noted that the Veteran has panic attacks on a small scale daily, and larger panic attacks weekly/monthly. She stated that he has difficulty understanding things, has memory problems, obsesses over things, and socially isolates himself. She noted that he has not worked in 10 years because of his mental health issues. The Veteran also provided a statement at this time explaining that he felt defensive during the VA examination interview and felt his symptoms warranted a higher rating. In August 2010, the Veteran was afforded another VA examination. During his examination, the Veteran reported that he had been married for 16 years, was married prior to this and has had many broken relationships. The Veteran stated that he is easy to anger, is judgmental with other people, very controlling (his wife is not allowed to cook), has trouble sleeping, and is socially isolated (wife is frustrated that he doesn't like to socialize). The Veteran stated that he has a couple of friends, one who lives out of state and the other he sees every couple of weeks. As for his activities, he used to fish, but no longer enjoys this. Now, he reported watching TV, taking a walk by himself, grocery shopping, reading, or using the computer. He stated that his last suicide attempt was 25 years ago, and that he was violent when he got out of the Army. After reviewing this history, the examiner noted that the Veteran has major deficits in his current psychosocial functioning, including social isolation, lack of intimacy with significant others, poor memory and concentration, poor self esteem, very limited interests, suicidal ideation, inability to function effectively outside the home, few significant occupational activities, and depressed mood secondary to PTSD. On examination, the Veteran was clean and appropriately dressed. His psychomotor activity was lethargic, fatigued, and tense, while his speech was slow and mumbled. His attitude was guarded and irritable and his affect was flat. The Veteran's mood was anxious, hopeless, depressed, fearful; he was not able to do serial 7's or to spell a word forward and backward. His thought process was rambling and his thought content was marked by suicidal ideation and preoccupation with one or two topics. The examiner noted no delusions or hallucination and stated that the Veteran understood the outcome of his behavior. His intelligence was average and he seemed to understand that he has a problem. The Veteran also had sleep impairment, which interferes with his marriage, as it interrupts his wife's sleep. Further, the examiner noted that the Veteran has inappropriate behavior (overly controlling, difficulty managing anger and excessively judgmental of others), has obsessive/ritualistic behavior (obsessive about food preparation), has panic attacks several times per week (which are moderately severe and chronic, and which contribute to the Veteran's social isolation and increasing fears about being in situations he cannot control), has suicidal thoughts (nearly daily; the tentative plan is to overdose on valium and Seconal), and has fair impulse control. The examiner noted that the Veteran does interpret proverbs appropriately, has no homicidal thoughts, has no episodes of violence (although the examiner noted that the Veteran's concern about acting out angrily toward others contributes to his social isolation, which deepens his depressive symptoms and causes more strife with his wife), and is able to maintain minimum personal hygiene. As for activities of daily living, the examiner noted moderate grooming difficulty, slight difficulty shopping and bathing, moderate difficulty engaging in sports/exercise, traveling, and driving, and severe difficulty with other recreational activities (Veteran is fearful of many things which leads to greater social isolation over time). The Veteran's recent and immediate memory was found to be moderately impaired. The examiner found the frequency, severity and duration of the Veteran's PTSD symptoms to be daily, severe and chronic. The examiner also noted that the Veteran retired in 1997 due to his psychiatric problems. The examiner provided an Axis I diagnosis of PTSD and a GAF score of 45. The examiner observed that the Veteran's functioning and quality of life has deteriorated markedly over the last 4 years; he continues to be unable to work due to high levels of fear in social situations, which leads to anger spikes, panic attacks, episodes of derealizations, which also interferes with memory and concentration. The examiner also stated that the Veteran has a pervading sense of hopelessness and suicidal ideation because he observes himself getting worse; he is not interested in taking care of himself, avoids outside activities with his wife, has few friends, and has lost interest in recreation/leisure pursuits he used to enjoy. The examiner noted that his current quality of life is poor; his prognosis for improvement is guarded. Given the foregoing evidence, the Board concludes that a disability rating of more than 50 percent is not warranted prior to August 17, 2010, but that a 70 percent rating is warranted from August 17, 2010. The Board finds that the Veteran's symptoms prior to his VA examination in August 2010, to include panic attacks, impairment of short-term memory, impaired judgment, disturbances of mood, and difficulty in establishing and maintaining effective work and social relationships, more closely approximate the criteria for a 50 percent evaluation. Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood was not shown. In this regard, although there is some evidence of suicidal ideation, the evidence from that period does not reflect other symptoms contemplated by the regulation as examples of symptoms warranting 70 percent, such as 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. On the contrary, the evidence specifically shows that such symptoms or comparable symptoms resulting in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood were not shown. The Board finds that a rating higher than 50 percent disability is not warranted prior to August 17, 2010. On August 17, 2010, the Veteran received another VA examination and the Board finds that his symptomatology from this date more nearly approximates the criteria for a 70 percent rating. The VA examiner noted occupational and social impairment with deficiencies in judgment, thinking, family relations, work, and mood. A GAF score of 45 was provided, which denotes serious symptoms. Further, the examiner noted suicidal ideation with a tentative plan for overdose, obsessive/ritualistic behavior, panic attacks several times per week, some neglect of personal hygiene, difficulty in adapting to stressful circumstances, and an inability to establish and maintain effective relationships. The examiner found the Veteran's quality of life to be poor. Considering the evidence from this examination and affording the Veteran the benefit of the doubt, the Board finds that such symptomatology warrants an increase in the Veteran's rating to 70 percent from the date of this examination. The Board further finds, however, that a 100 percent rating is not warranted as the evidence does not show 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. Such symptoms and such levels of impairment are not shown by the evidence. On the contrary, the record shows that he has maintained some social relationships as he has been married for over 16 years. Furthermore, the VA Schedule of Disability Ratings will apply unless there are exceptional or unusual factors that would render application of the schedule impractical. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993). According to the regulation, an extraschedular disability rating is warranted based upon a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that would render impractical the application of the regular schedular standards. See 38 C.F.R. § 3.321(b)(1). Under Thun v. Peake, 22 Vet App 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular rating. First, the Board must first determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the Board must determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extraschedular rating. With respect to the first prong of Thun, the evidence in this case does not show such an exceptional disability picture that the available schedular evaluations for the service-connected appendectomy scar is inadequate. A comparison of the level of severity and symptomatology of the Veteran's disability with the established criteria found in the rating schedule for PTSD shows that the rating criteria reasonably describes the Veteran's disability level and symptomatology. In short, there is nothing in the record to indicate that this service-connected disability on appeal causes impairment with employment over and above that which is contemplated in the assigned schedular rating. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993) (noting that the disability rating itself is recognition that industrial capabilities are impaired). The Board therefore has determined that referral of this case for extraschedular consideration pursuant to 38 C.F.R. 3.321(b)(1) is not warranted. ORDER Entitlement to a rating higher than 50 percent for PTSD prior to August 17, 2010 is denied. Entitlement to a 70 percent disability rating for PTSD from August 17, 2010 is granted, subject to the regulations applicable to the payment of monetary benefits. REMAND A total disability rating based on individual unemployability (TDIU) is also a component of a claim for a higher initial or increased rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). TDIU may be granted when a Veteran's service-connected disabilities are rated less than total, but prevent him from obtaining or maintaining all gainful employment for which his education and occupational experience would otherwise qualify him. 38 C.F.R. § 4.16. Where a Veteran: (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability, the requirement in 38 C.F.R. § 3.155(a) that an informal claim "identify the benefit sought" has been satisfied and VA must consider whether the Veteran is entitled to a TDIU. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). A TDIU claim is not raised unless the Roberson requirements are met. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). In this case, the Veteran has raised the issue of TDIU. He is service-connected for PTSD, and he has made a claim for the highest rating possible. Additionally, the Veteran and his wife have submitted statements that the Veteran is unemployable due to his mental disability. Further, August 2010 VA examiner stated that the Veteran is unemployed chiefly as a consequence of his PTSD-related symptoms, and a private examiner found that the Veteran is unable to be employed. The Veteran has also submitted an IRS earnings statement, which he claims shows his inability to earn a living in the years in which he was using drugs and alcohol or when he was depressed. In this regard, the RO/AMC should send the Veteran a VCAA notice letter for the TDIU claim. This letter should notify the Veteran and his representative of any information, including lay or medical evidence, that was not previously provided and that is necessary to substantiate the TDIU claim. The notice should also indicate what information or evidence should be provided by the Veteran, and what information or evidence VA will attempt to obtain on the Veteran's behalf. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). The RO should then provide the Veteran with a new VA examination to assess the effects on the Veteran's ability to hold a job. Following this development, the RO should adjudicate the Veteran's claim for a TDIU, to include consideration of whether the Veteran's TDIU claim should be referred to the Director of Compensation and Pension Service for extraschedular consideration. 38 C.F.R. § 4.16(b). Accordingly, the case is REMANDED for the following actions: 1. Issue to the Veteran and his representative an appropriate VCAA notice letter explaining how to establish entitlement to a TDIU, to include on an extra-schedular basis pursuant to 38 C.F.R. § 4.16(b). 2. Schedule the Veteran for a new VA examination to determine whether the Veteran's service-connected disabilities prevent the Veteran from being employed. The examiner should review the Veteran's claims file, to include this remand, and provide the rationale for his opinion(s). The Veteran is reminded that he also has a duty to assist in his case and it is his responsibility to show up for the scheduled examination. 3. When the development requested has been completed, the RO should readjudicate the claim for a TDIU, including considering whether referral of the claim under 38 C.F.R. § 4.16(b) for extraschedular consideration is warranted. If the benefit sought remains denied, the RO must furnish to the Veteran and his representative an appropriate supplemental statement of the case that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs