Citation Nr: 1320287 Decision Date: 06/24/13 Archive Date: 07/02/13 DOCKET NO. 09-11 454 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent for an anxiety disorder (not otherwise specified) with features of posttraumatic stress disorder (PTSD). 2. Entitlement to a total rating based on unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and his wife ATTORNEY FOR THE BOARD M. Prem, Counsel INTRODUCTION The Veteran served on active duty from January 1968 to November 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota, which granted the Veteran's claim for service connection for an anxiety disorder, and assigned a 30 percent rating, effective January 22, 2008. In a March 2009 rating decision, the RO increased the Veteran's rating to 50 percent, effective January 22, 2008 (the date of receipt of the claim). By way of an October 2009 rating decision the RO granted a temporary rating of 100 percent based on hospitalization for more than 21 days. The 100 percent rating was effective July 27, 2009; the rating was returned to 50 percent effective November 1, 2009. In May 2010, the Veteran and his wife testified before the undersigned Acting Veterans Law Judge at the RO in St. Paul; a copy of the transcript is of record. FINDINGS OF FACT 1. Prior to May 17, 2010, the Veteran's anxiety disorder (not otherwise specified) with features of PTSD was not manifested by 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. 2. Effective May 17, 2010, the Veteran's anxiety disorder (not otherwise specified) with features of PTSD was manifested by occupational and social impairment, with deficiencies in most areas. It is not manifested by 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; and memory loss for names of closest relatives, own occupation, or own name. 3. Prior to May 17, 2010, the medical and other evidence of record did not indicate the Veteran's service-connected disabilities precluded him from securing or following a substantially gainful occupation consistent with his education and occupational experience. 4. Effective May 17, 2010, the medical and other evidence of record indicate that the Veteran's service-connected disabilities precludes him from securing or following a substantially gainful occupation consistent with his education and occupational experience. CONCLUSIONS OF LAW 1. Prior to May 17, 2010, the criteria for entitlement to a disability evaluation in excess of 50 percent for the Veteran's service-connected anxiety disorder (not otherwise specified) with features of PTSD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.7 and Code 9413 (2012). 2. Effective May 17, 2010, the criteria for entitlement to a disability evaluation of 70 percent, but no higher, for the Veteran's service-connected anxiety disorder (not otherwise specified) with features of PTSD have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. Part 4, including § 4.7 and Code 9413 (2012). 3. Prior to May 17, 2010, the criteria for entitlement to a TDIU have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.16 (2012). 4. Effective May 17, 2010, the criteria for entitlement to a TDIU have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran's increased rating claim arises from an appeal of the initial evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, and additional notice is not required as 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). Therefore, no further notice is needed under VCAA. Veterans Claims Assistance Act of 2000 (VCAA) - Duty to Assist Next, VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file contains the Veteran's service treatment records, as well as post-service reports of VA and private treatment and examination. Moreover, his statements in support of the claim are of record, including testimony provided at a May 2010 Board hearing. The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified. The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim. For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Increased Ratings Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. 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. Where, as in the instant case, 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). The Veteran's service-connected anxiety disorder with features of PTSD has been rated by the RO under the provisions of Diagnostic Code 9413. Under this regulatory provision: a noncompensable rating is warranted when a mental condition has been diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. a 10 percent 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 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; and difficulty in establishing and maintaining effective work and social relationships. a 70 percent 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. 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; and memory loss for names of closest relatives, own occupation, or own name. 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 Veteran underwent a VA examination in March 2008. The examiner reviewed the claims file in conjunction with the examination. The Veteran reported that following military service, he began drinking heavily, but he has not consumed alcohol in 8-10 years. He stated that he has been seeing a counselor at the Vet Center, which helped settle him down. He had been thinking about Vietnam. He has never had any other mental health treatment or taken any psychotropic medication. He had some friends, but they live far away. He reported being close with his brother-in-law and with his family (mother, three brothers, and three sisters). His father died of cancer. Upon examination, the Veteran was alert and oriented, but his cognitive functioning was not formally tested. His speech, eye contact, and gait were within normal limits. He was logical, cooperative, and coherent. His affect was euthymic. He reported that he liked to be by himself. He stated that sometimes he became depressed, but he denied that it has ever been a problem for him. He became tired easily. He denied self esteem problems. He reported feeling "all right" about the future; and he did not appear to feel hopeless. He engaged in pleasurable activities and he denied anhedonia. He stated that once in a while, he felt anxious but he denied excessive worry or tension. He denied problems with memory, suicidal ideation, homicidal ideation, hallucinations, delusions, and paranoid ideations. The Veteran complained of unwanted memories of Vietnam on a daily basis. It was difficult to get the thoughts out of his mind and for him to concentrate on his job. Approximately once per week, his heart raced and he would sweat for 10-20 while thinking about combat experiences. He was emotionally numb and could not cry when his father died (in 1991), but he denied any recent emotional numbing. He reported difficulty sleeping (only getting 5-6 hours) and was irritable several times per week. He was hypervigilant (looking out the window at night, checking the windows and door, choosing a safe place to sit, etc.). He also reported a strong startle reaction (particularly when he hears loud noises). The examiner opined that the Veteran had a moderate level of distress related to these symptoms and that his social functioning was mildly impaired because he was fairly socially isolated. His occupational functioning appeared mildly impaired due to concentration problems. The examiner diagnosed anxiety disorder with features of PTSD. He was assessed with a Global Assessment of Functioning (GAF) score of 65. A GAF of 61-70 indicates 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 with some meaningful interpersonal relationships. A GAF 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 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 of 31-40 indicates some impairment in reality testing or communication (e.g. speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g. depressed man avoids friends, neglects family, and is unable to work). A GAF of 21-30 indicates behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment (e.g. sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) or inability to function in almost all areas (e.g. stays in bed all day; no job, home, or friends.) American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) (Fourth Edition); see 38 C.F.R. § 4.130 (2012). A July 2008 outpatient treatment report reflects a diagnosis of PTSD. In October 2008, Citalopram was prescribed, resulting in improved sleep and mood. He also noted that he was thinking about Vietnam less often. He was starting a new job and looking forwards to working. A March 2009 treatment record reflects that he continued to do well on medication. He had a noticeable improvement in his energy levels; he felt much calmer and less anxious; and, he denied any recent flashbacks related to Vietnam. The Veteran underwent another VA examination in June 2009. He reported being depressed a lot of times, and having daily thoughts of Vietnam. He also reported occasional, very brief flashbacks that occurred a couple of times per month. He felt anxious and wanting to avoid crowds. He and his wife get along most of the time, although he acknowledged that they fought a lot. He reported fair relationships with his family (mother, brothers, sisters, and daughters). He was close with his brother-in-law but he had no close friends outside of family. He enjoyed working on things around the house, fishing, and occasionally target shooting. He reported drinking "3-4-5- cans" a few times per week. Upon examination, psychomotor activity, speech, thought process, and thought content were unremarkable. The Veteran was cooperative and his affect was constricted. He was mildly depressed/anxious. He was oriented to person, place, and time. He denied delusions and understood the outcome of his behavior. He reported having sleep impairment in that he only gets six hours (on average) per night. He had irritability towards his wife, with occasional yelling. He had an aggressive interpretation of proverbs, and obsessive/ritualistic behavior in the form of frequently ruminating about Vietnam. He denied panic attacks, suicidal thoughts, and homicidal thoughts. He reported anxiety when shopping; and the examiner found this to moderately impair his ability to go shopping. The examiner also opined that the Veteran experienced mild impairment in traveling. There was no impairment to other activities of daily living. The Veteran's remote and recent memory were mildly impaired. The examiner noted that the Veteran worked in November 2008 as an iron worker. He completed the shutdown of a mine. He denied that his unemployment was due to psychiatric problems. The examiner diagnosed anxiety disorder, not otherwise specified, with PTSD features. He assigned a GAF score of 65; and stated that the Veteran's level of functioning is similar to that of his most recent examination. He stated that the Veteran was not unemployable due to anxiety symptoms. He opined that there was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to mental disorder signs and symptoms, but with generally satisfactory functioning. The Veteran underwent another VA examination in June 2009 for the express purpose of determining whether his service-connected disabilities preclude him from securing or following a substantially gainful occupation consistent with his education and occupational experience. The examiner opined that the Veteran should not work in positions where acute hearing is necessary for his safety or the safety of others. He opined that the Veteran would be able to work in his chosen profession and would be able to perform substantial gainful employment. The Veteran was hospitalized (and has already received a 100 percent disability rating) from July 27, 2009 through October 31, 2009. In an October 2009 treatment report, the Veteran denied any recent flashbacks to Vietnam. He continued to have some avoidance and hypervigilance. He went through a PTSD program that he found useful. He denied any manic or psychotic symptoms. He denied recent or current suicidal or homicidal ideation. He denied any current or recent feelings of hopelessness or helplessness. He reported difficulties falling asleep and frequent awakening at night. He also reported having some anxiety related to medical issues. He was oriented x 3; and was friendly and cooperative. His mood was euthymic and his affect was full, fluid, and appropriate. Thoughts were goal directed; and no delusions were elicited. Memory and concentration were good. He denied suicidal/homicidal ideation as well as auditory/visual/olfactory/tactile hallucinations. Insight and judgment were fair. He was given a GAF score of 60. A January 2010 outpatient treatment report reflects findings identical to the October 2009 report. An April 2010 outpatient treatment report also reflects identical objective findings and a GAF score of 60. However, the examiner also noted that the Veteran had been doing well for the past few weeks, despite the fact that his mother recently passed away. His sleep had improved since his dose of Trazadone was increased, and his energy level had improved since his Bupropion was increased. The Veteran submitted correspondence from the Vet Center and the Twin Ports VA Outpatient Clinic. Both are dated May 2010. Dr. O.A. of the VA Outpatient Clinic stated that the Veteran was seen "for a chronic service connected condition that makes him unable to work." Readjustment Therapist C.M. opined that the Veteran should be considered totally and permanently unemployable due to combat related disabilities. She stated that the Veteran had attended her weekly Veteran's support group for the past six months. She stated that he regularly participated appropriately. His awareness of how much Vietnam has affected him had grown weekly. She opined that he used alcohol to cope with troubling thoughts and feelings. She stated that in addition to the PTSD, the Veteran is very hard of hearing and that this affects all areas of his life. She believed that either one of these disabilities would make employment difficult but that combined, it was almost impossible. A May 2010 outpatient treatment report reflects that the Veteran sought an appointment when none was scheduled. He reported that he was facing a difficult financial situation because his daughter and her baby moved in with him and his wife. He reported losing sleep and thinking about how to cover his financial needs. He reported felt edgy and short tempered and was having Vietnam related nightmares. He was started on Clonazepam for insomnia. Use of it was to be temporary. The Veteran testified at a Board hearing in May 2010. He explained that he had worked construction full time until approximately three years prior to the hearing. His complaints at the hearing included decreased ability to concentrate. He would begin working on a project and then would forget about it. He reported that he did not socialize with anyone except on Thursday nights when he attended group therapy sessions at the Vet Center. He complained of sleep impairment, hypervigilance, and irritability. He remained married to his wife of 35 years and he got along well with his children and grandchildren. A July 2010 outpatient treatment report reflects that the Veteran continued to be sober and was struggling with financial difficulties. His main complaints were low energy and agitated sleep. He was oriented x 3 and was friendly and cooperative. His mood was euthymic and his affect was full, fluid, and appropriate. Thoughts were goal directed; and no delusions were elicited. Memory and concentration were good. He denied suicidal/homicidal ideation as well as auditory/visual/olfactory/tactile hallucinations. Insight and judgment were fair. He was given a GAF score of 60. Outpatient treatment reports through February 2011 were consistent with this July 2010 report. The Veteran underwent a VA examination in June 2011. The examiner reviewed the claims file in conjunction with the examination. He reported that his mood was "not too good" and "just agitated." When asked why he was depressed, he stated that he thinks about Vietnam all the time. This affected his sleep and kept his stomach in knots. He spent most of his time in the garage and did not enjoy things like he used to. He had not consumed alcohol in two years. He lived with his wife, daughter, daughter's boyfriend, and grandson (age 2). He claimed to have no friends except the person that picked him up to go to the Vet center. Upon examination, psychomotor activity was unremarkable. Speech was hesitant, clear, and coherent. However, his responses were vague. He could not pronounce the names of his medications; and he had difficulty hearing. He was a bit aloof and he gazed around the room (but not hypervigilantly). His affect was flat. His mood was anxious and dysphoric. He stated that his concentration was "not good." He was oriented to person, place, and time. His thought process was unremarkable. His thought content included suicidal ideation, which he claimed to have once or twice a week, or "whenever." He denied having a suicide plan. Generally, he seemed preoccupied with one or two topics. He denied delusions. He understood the outcome of his behavior; and he understood that he has a problem. He reported that he had trouble getting to sleep, as he would lie awake for 2-3 hours thinking about Vietnam. He would sleep and hour or two before waking up again. He reported that he slept 3-4 hours most nights, which he believed is enough for him. He became angry with his wife and yelled at her once a day. He was able to interpret proverbs appropriately. With regard to obsessive or ritualistic behavior, he spent time organizing things in his garage and he counted things, such as stairs. He reported panic attacks in which his stomach started rolling, his heart started pounding, and he would become sweaty. Impulse control was fair. He reported getting frustrated when things did not go well. He had thrown something in anger the previous week. Additionally, he was unable to maintain minimum personal hygiene. He bathed once or twice per week and hardly ever brushed his teeth. The examiner opined that the Veteran would have moderate difficulties in performing household chores, grooming, shopping, bathing, driving, and engaging in sports/exercise. He had slight difficulty in traveling and dressing/undressing. The Veteran was unemployed had retired 3-4 years ago because he was eligible by age or duration of work. The diagnosis was anxiety disorder with features of PTSD; depressive disorder; and alcohol dependence in full remission. The examiner found it less likely than not that the Veteran is unemployable due to anxiety disorder and/or depressive disorder. However, he did find that his psychiatric disorder results in deficiencies in judgment (in the form of losing control); thinking (in that he has trouble with sustained concentration, and he ruminates about Vietnam); work (in that his stress tolerance is below average); and mood (in that he is depressed, anxious, and lacks interest and pleasure in activities). The Board notes that in order to warrant a rating in excess of 50 percent, the Veteran would have to experience 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. The Board notes that prior to May 17, 2010, the Veteran's symptoms included ruminating about Vietnam, being depressed, becoming tired easily, trouble concentrating, difficulty sleeping, and feeling irritable. The March 2008 VA examiner found the Veteran's symptoms to be moderate and assigned a GAF score of 65 (indicative of mild symptoms). Treatment reports over the next several months (July 2008, October 2008, and March 2009) reflect that the Veteran's symptoms seemed to be improving. He showed improvement in sleep and mood; he began looking for a new job; he reported feeling less anxiety and improved energy levels; and he denied flashbacks related to Vietnam. The June 2009 VA examination report reflects symptoms consistent with the March 2008 report. The examiner also assigned a GAF score of 65 (again, indicative of mild symptoms). The examiner opined that there was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to mental disorder signs and symptoms, but with generally satisfactory functioning. The Veteran was hospitalized (and has already received a 100 percent disability rating) from July 27, 2009 through October 31, 2009. In October 2009, the Veteran reported that he found a PTSD program that was useful; and he denied flashbacks to Vietnam. He was assigned a GAF score of 60 (indicative of moderate symptoms). He was consistently found to have a GAF score of 60 through February 2011 (the last treatment report prior to his June 2011 VA examination). In May 2010, opinions were received from Readjustment Therapist C.M. and Dr. O.A. indicating that the Veteran should be considered totally and permanently unemployable. There are no contemporaneous records to verify the exact symptoms, and their severity, experienced by the Veteran at that time. However, the next VA examination in June 2011 clearly evidences a worsened disability picture. Specifically, there was increased irritability, increased panic attacks, and increased difficulties with sleep. Additionally, the Veteran was unable to maintain minimum personal hygiene. For the first time he denied having any friends and also indicated suicidal ideation, which had previously been consistently denied. Thus, affording the Veteran the benefit of the doubt, the Board finds that that the record supports the next-higher 70 percent evaluation from May 17, 2010, the date of the earliest May 2010 correspondence indicating the Veteran's inability to work. While a 70 percent evaluation is deemed warranted from May 17, 2010, a rating in excess of that amount is not supported by the record for any portion of the rating period on appeal. In order to warrant a rating in excess of 70 percent, the Veteran's disability would have to be manifested by 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; and memory loss for names of closest relatives, own occupation, or own name. There has been no evidence that his disability is manifested by total social impairment. Indeed, he still has good (though certainly not ideal) relationships with his family. Thus, his social impairment cannot be fairly characterized as "total." Moreover, following examination in June 2011, the VA examiner assigned a GAF score of 59, signifying only moderate symptoms or moderate difficulty with social and occupational functioning. Similarly, concentration and mood were both deemed to moderately impair the Veteran. Such moderate impairment is at odds with a 100 percent rating. Thus, the preponderance of the evidence weighs against a finding that a rating in excess of 70 percent is warranted. The potential application of various provisions of Title 38 of the Code of Federal Regulations have also been considered but the record does not present such "an exceptional or unusual disability picture as to render impractical the application of the regular rating schedule standards." 38 C.F.R. § 3.321(b)(1). However, as discussed above, the evidentiary record in this case persuasively shows that the Veteran's psychiatric symptoms squarely match the type and degree of the examples set forth under the criteria for the current 50 and 70 percent schedular ratings. Likewise, the consideration of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) is not appropriate in such a case where the rating criteria reasonably describe the Veteran's disability level and symptomatology. See generally Thun v. Peak, 22 Vet.App. 111 (2008). The Board therefore finds that referral for extraschedular consideration under 38 C.F.R. § 3.321(b)(1) is not warranted in this case. TDIU In order to establish service connection for a total rating based upon individual unemployability due to service-connected disability, there must be an impairment so severe that it is impossible to follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. VA regulations establish objective and subjective standards for an award of total rating based on unemployability. When the Veteran's schedular rating is less than total (for a single or combination of disabilities), a total rating may nonetheless be assigned provided that if there is only one service-connected disability, this disability shall be rated at 60 percent or more. When there are two or more disabilities, at least one disability must be ratable at 40 percent or more, and any additional disabilities must result in a combined rating of 70 percent or more, and the disabled person must be unable to secure or follow a substantially gainful occupation. See 38 C.F.R. § 4.16(a). A total disability rating may also be assigned on an extra-schedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for Veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). Thus, the Board must evaluate whether there are circumstances, apart from any non-service-connected conditions and advancing age, which would justify a total rating based on unemployability. A TDIU claim is an alternate way to obtain a total disability rating without recourse to a 100 percent evaluation under the rating schedule. See Parker v. Brown, 7 Vet. App. 116, 118 (1994). Prior to May 17, 2010 The Veteran is service connected for anxiety disorder (not otherwise specified) with features of PTSD; and bilateral sensorineural hearing loss. Prior to June 29, 2011, the disabilities were rated as 50 percent disabling and 30 percent disabling respectively. His combined rating was therefore 70 percent. See 38 C.F.R. § 4.25. Thus, the Veteran met the schedular requirements for a total disability rating based on individual unemployability due to service-connected disabilities under 38 C.F.R. § 4.16(a). However, the Board must still determine whether the Veteran's service-connected disabilities resulted in impairment so severe that it was impossible to follow a substantially gainful occupation. The Board emphasizes that a total rating based on individual unemployability is limited to consideration of service-connected disabilities. Following a full and thorough review of the evidence of record, the Board concludes that the preponderance of the evidence is against the Veteran's claim of entitlement to a TDIU prior to May 17, 2010. During such period, the evidence does not demonstrate that the Veteran was unable to secure or follow a substantially gainful occupation solely by reason of his service-connected disabilities. The May 2010 opinions of Readjustment Therapist C.M. and Dr. O.A. indicate that the Veteran should be considered totally and permanently unemployable. While not accompanied by objective findings, as explained above, the next VA examination in June 2011 clearly showed a worsening of his overall symptomatology and particularly his ability to concentrate. Affording the Veteran the benefit of the doubt, the Board finds that such worsening was present at the time of the May 2010 letters and thus an award of TDIU is appropriate as of that date. The Board recognizes that the examiner found that it was less likely than not that the Veteran was unemployable due to anxiety disorder and/or depressive disorder. However, the examiner failed to take into account the Veteran's service connected hearing loss. Given this, and in light of the May 2010 opinions (which are largely substantiated by the subsequent medical evidence), an award of TDIU is appropriate from May 17, 2010. ORDER Prior to May 17, 2010, entitlement to a rating in excess of 50 percent for anxiety disorder (not otherwise specified) with features of PTSD, and a TDIU are denied. Effective May 17, 2010, entitlement to a rating of 70 percent, but no higher, is granted for anxiety disorder (not otherwise specified) with features of PTSD. Effective May 17, 2010, entitlement to a TDIU is granted. ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs