Citation Nr: 1320326 Decision Date: 06/24/13 Archive Date: 07/02/13 DOCKET NO. 09-04 734 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to a rating in excess of 30 percent for the service-connected posttraumatic stress disorder (PTSD) for the period prior to January 25, 2010. 2. Entitlement to a rating in excess of 50 percent for the service-connected PTSD for the period from January 25, 2010 to November 2, 2012. 3. Entitlement to a rating in excess of 70 percent for PTSD beginning on November 2, 2012. 4. Entitlement to a total disability rating based upon individual unemployability by reason of service-connected disability (TDIU). ATTORNEY FOR THE BOARD G. Jackson, Counsel INTRODUCTION The Veteran had active military service from January 1969 to November 1970. This matter initially came to the Board of Veterans' Appeals (Board) on appeal from August 2007 and February 2008 rating decisions issued by the RO. In the August 2007 rating decision, the RO granted service connection for PTSD and assigned a 10 percent rating effective on October 13, 2004. In the February 2008 rating decision, the RO denied entitlement to a TDIU rating. In September 2012, the Board increased the rating for the service-connected PTSD from 10 to 30 percent effective on October 13, 2004; the Board remanded the claims for a rating in excess of 30 percent and a TDIU rating for further development. Thereafter, in a February 2013 rating decision, the RO increased the rating for the service-connected PTSD from 30 to 50 percent effective from January 25, 2010 and also increased the rating for the Veteran's PTSD from 50 to 70 percent beginning on November 2, 2012. As higher schedular ratings for the PTSD are possible, the issues remain before the Board on appeal and have been characterized as noted on the title page. See AB v. Brown, 6 Vet. App. 35 (1993). The Veteran was previously represented by the American Legion. In April 2013, the Veteran revoked the service organization's authority to act on his behalf with regard to the claims on appeal. The Board recognizes this revocation of representation. The Board notes that, in addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the documents in the electronic file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The issue of entitlement to a TDIU rating is remanded to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The service-connected PTSD is shown to have been productive of a disability picture that more nearly approximated that of occupational and social impairment with deficiencies in most areas for the initial period of the appeal. 2. The service-connected PTSD currently is shown to be productive of a disability picture manifested by total occupational and social impairment. CONCLUSION OF LAW 1. The criteria for the assignment of a 70 percent rating for the service-connected PTSD prior to November 2, 2012 are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130 including Diagnostic Code (DC) 9411 (2012). 2. The criteria for the assignment of a rating in excess of 70 percent for the service-connected PTSD beginning on November 2, 2012 are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130 including Diagnostic Code (DC) 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012) redefined VA's duty to assist a claimant in the development of a claim. The VA regulations for the implementation of VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2012). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In this case, in a May 2006 letter issued prior to the decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claim for service connection for PTSD, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. The letter advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. However, as this appeal stems from the initial grant of service connection for PTSD, the notice letters did not contain an explanation of the general rating criteria relevant to his PTSD. The June 2008 Statement of the Case (SOC) set forth applicable criteria for ratings for the service-connected PTSD. After issuance of the June 2008 SOC, and opportunity for the Veteran to respond, the February 2013 Supplemental SOC (SSOC) reflects readjudication of the claims. Hence, the Veteran is not shown to be prejudiced by the timing of the latter notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the VA treatment records and examination reports and private treatment records. The VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by providing evidence and argument and presenting for VA examinations. Thus, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any defect in the sequence of events or content of the notices is not shown to have any impact on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Laws and Regulations Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on 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 ratings shall be applied, the higher rating 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. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 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). The Court has held that "staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App 119 (1999). The initial rating for the Veteran's PTSD has been assigned pursuant to Diagnostic Code 9411. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Under the formula, a 30 percent rating is assigned 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, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty 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 rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions; 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 closes relatives, own occupation, or own name. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." GAF scores between 41 and 50 reflect serious symptoms, (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting), or any serious impairment in social, occupational, or school functioning, (e.g., no friends, unable to keep a job). GAF scores between 51 and 60 reflect moderate symptoms, (that is, flat affect, circumstantial speech, occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, contacts with peers or co- workers). There is no question that the GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, 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). Analysis A January 2005 private treatment record reflects that the Veteran was having nightmares at least four times per week and waking with panic and sweat lasting for 10 minutes. He also was having flashbacks five times per week accompanied by panic attacks. He complained of having panic attacks, five times per month, that lasted at least 15 minutes. The Veteran reported that he averaged approximately 3-4 hours of sleep per day. He had a lot of intrusive thought, startled easily, was extremely hypervigilant and could not tolerate having anybody behind him. He did not socialize at all or like to interact with anybody. His recent memory was moderately impaired, and he felt that his mind was drifting frequently preventing him from relaxing. The Veteran complained of auditory hallucinations in that he frequently heard someone calling him about two times per day. He also heard cars drive up to his residence and noises in his house a few times per week. He also reported frequently waking at night and thinking that he was still in the war. He felt depressed and had poor energy and interest in things. Sometimes he felt like crying. The Veteran was noted to be irritable and impatient and to have had difficulty maintaining employment. Anger outbursts and impatience played a major role in his failed marriage and inability to maintain employment. On mental status examination, the Veteran was noted to be pleasant, cooperative and able to relate well. He maintained good eye contact, was spontaneous and was a reliable historian. He reported some depression and looked anxious and restless. He denied any suicidal or homicidal ideation and any auditory or visual hallucinations. His cognitive function seemed to be intact, and he was oriented times three. He had good insight and judgment. The examining psychiatrist diagnosed the Veteran with PTSD and assigned the a GAF score of 40. The psychiatrist explained that the Veteran was unable to sustain social relationship and that his symptoms moderately compromised his ability to sustain work relationship. The examiner concluded that the Veteran was permanently disabled. An August 2007 report of VA examination reflects the Veteran's complaint of sporadic PTSD symptoms. He reported that his concentration was not good and that he would get anxious and need to move around. He complained of sleep impairment, nightmares, intrusive thoughts, exaggerated startle response and hypervigilance. He was short tempered and avoided talking about his experiences. The Veteran reported having been through alcohol/drug rehabilitation twice (last in 1988) and being clean and sober since 1991. His drug of choice was cocaine. He reported previously taking medication for his PTSD symptoms prescribed by a private provider, but it did not help. The Veteran reported last working full-time in 1998 as an electrician. He had an issue with high blood pressure so he quit to get his blood pressure under control. He did light jobs occasionally, and his girlfriend helped him out financially. He lived with his girlfriend and did some chores around the house, but had no close friends. He did attend church. The Veteran was divorced and had two children who were a product of that marriage. He had two or three other children outside of that marriage and reported being fairly close to his children. On mental status examination, the Veteran was noted to be alert, cooperative, casually and appropriately dressed and pleasant and to answer questions and volunteer information. There were no loosened associations, flight of ideas or bizarre motor movements or tics. His mood was calm and pleasant, and his affect was appropriate. The Veteran reported having some nightmares and intrusive thoughts, but not having homicidal or suicidal ideation or intent. There was no impairment of thought processes or communication. There were no delusions, hallucinations, or ideas of reference or suspiciousness. He was oriented times three. His memory appeared to be intact, and his insight, judgment and intellectual capacity appeared to be adequate. The examining psychiatrist reported that the Veteran's symptoms were consistent with a diagnosis of PTSD and assigned a GAF score of 60. The psychiatrist commented that the Veteran was doing part-time work and not interested in doing any full-time work right then. The Veteran stayed to himself, did not have a lot of friends, had limited interests and took no psychotropic medications. He did go to church. The psychiatrist concluded that the Veteran's symptoms made employment more difficult, but did not preclude employment. A January 2010 report of VA examination included the Veteran's report of having been married for approximately two years. He described the relationship with his wife as, "all right." He had six children (four adult children and two minor children). He saw his minor children once per month on the weekends. The Veteran noted that he preferred to be by himself. He watched television, "every once in a while" and denied maintaining any other types of hobbies or interests. He had no history of a suicide attempt. He offered vague information regarding violent/assaultive behavior, "a guy put his hand on me and I had to let him know what the deal was." He alluded to other episodes of violence, but offered no specific information. The Veteran reported currently using no alcohol or illicit drugs and added that he had never used any such substances. The psychologist noted that this was in contrast to records on file. The Veteran revised his statement to indicate that he had not used any alcohol or illicit substances in the past several years. On mental status examination, the Veteran was noted to be clean, neatly groomed and appropriately dressed. His psychomotor activity was unremarkable, and his speech was soft or whispered, clear and coherent. His attitude was cooperative, attentive, irritable and guarded; his affect was constricted and irritable. His underlying mood appeared irritable and distrustful. The Veteran's attention was noted to be intact. He was oriented to person, time and place. Thought process and thought content were unremarkable. He had no delusions and understood the outcome of his behavior. His intelligence was average and he understood that he had a problem. The Veteran reported having persistent auditory and visual hallucinations. The auditory and visual hallucinations had been ongoing for the past 20 years. He reportedly saw people come through the walls in his home and sometimes heard them talking. He felt as though the people were trying to reach out and pull him in with them. The Veteran reported being previously prescribed medication to make the hallucinations go away, but the medication had other side effects and he stopped taking it. He did not demonstrate any behavior suggesting that he was responding to or experiencing hallucinatory activity during the current evaluation. He had no obvious impairment in thinking or communication and demonstrated no inappropriate behavior. He demonstrated obsessive/ritualistic behavior in that he checked the locks and sometimes checked outside at night. He had suicidal and homicidal thoughts, but had no specific plan, intent or target. The Veteran had good impulse control, had had no episodes of violence and was able to maintain minimum personal hygiene. Although he reported some memory deficits, there was no obvious memory deficits noted during the evaluation. He reported sometimes getting lost driving so that his wife would have to get him and help him back home. Also, he sometimes forgot people's names, including the names of his children. The Veteran reported not working for three or four years and currently supporting himself through his wife's income. The psychologist noted that the Veteran was not entirely clear about the reason he could not obtain or maintain employment, but from the Veteran's report, it did not appear that he had sought any employment in the recent past. The Veteran did report difficulty getting along with supervisors and co-workers when he was working. He denied problems with tardiness, absenteeism or taking time off due to mental health related problems. He contended that he could not find employment because of his age and because he could not get along well with other people. The examining psychologist concluded that the Veteran's symptoms were consistent with a diagnosis of PTSD and assigned the Veteran a GAF score of 60. The psychologist commented that the Veteran described some mild irritability and difficulty getting along with other people. The Veteran also described mild daytime fatigue that occurred as a result of not getting an adequate amount of sleep at night. The psychologist concluded that there were no other psychiatric disorders co-occurring with the PTSD. The psychologist found that the Veteran's PTSD symptoms were transient or mild and decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. Pursuant to the September 2012 remand, the Veteran was afforded another VA examination in November 2012 to evaluate the severity of the service-connected PTSD. The examining psychologist diagnosed the Veteran with PTSD, psychotic disorder, not otherwise specified and cognitive disorder, not otherwise specified. The psychologist found that it was impossible to differentiate what symptoms were attributable to each diagnosed disorder. The psychologist explained that PTSD and psychotic disorder were mutually aggravating disorders and shared multiple symptoms that could not be separated without resorting to mere speculation. The cognitive disorder was based upon problems with attention, short-term memory and recall. The psychologist concluded that the Veteran's psychiatric disabilities were productive of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood The Veteran reported that he was still married (for 4-5 years), but they slept in different rooms because she slept too rough. He reported that his wife instigated him, and they often got into shouting matches. There were no reports of domestic violence, but he did report an incident of punching the wall out of anger directed towards his wife. He reported "if [he] hit her, [he] might kill her." The Veteran had three grown children and two minor children. His 17 year old daughter lived with him and his wife. His 16 year old son did not get along with his wife so he lived with the Veteran's great aunt. He had three adult children ranging in age from 43 to 30s. He saw his adult children occasionally. He reported that he did not belong to any churches or organizations. His wife told him that he had demonic spirits and that she wanted to "pray them out." The Veteran reported that he liked to hang by himself. He messed around with a few guys, but was easily irritated. He watched the discovery channel and history channel during the day and a lot of old comedy shows. He watched sports, but never to conclusion of the game because it was too long. The Veteran reported that he had not worked since 2004 and was not actively looking for work because he could not stand on his feet for too long and his knees and back hurt. Reportedly, he was let go from his job in 2004 because his attention level was not right. When he did work, he got in trouble with his bosses because "[he] and my supervisors always had problems." The Veteran reported that previously using prescribed medications for his hallucinations, but stopping the medication because it made him feel like a "zombie." He had not received any therapy or hospitalization for psychiatric reasons. The Veteran reportedly hit a guy with a wrench about two months earlier. It was a guy he saw on occasion and would borrow his tools. Sometimes he was glad to see the guy, but often times not. He misconstrued playful overtures by the guy as attempts to hurt him. He reported drinking a beer every chance he got, about a can or two once a week (or month). He denied illegal drug use or abuse of prescription medication. He reported feeling a combination of anger, sadness and depression. If he was watching a comedy show, he had a good laugh and felt good. The Veteran reported having occasional suicidal thoughts, but no intent or plan because the voices would torment him when he was dead and he wanted to see his two minor children graduate. He had no ideation, intent or plan to hurt others. He had sleep impairment, averaging about 3-4 hours of sleep per night. He had nightmares, usually about someone trying to hurt him. Occasionally, he had nightmares about his service experiences. He reported that he showered and brushed his teeth when he needed to, approximately every 3 days. Most of the time, he did not think about it. His son would come over and try to shave the Veteran. The psychologist observed that the Veteran's mood and affect were within normal limits. The Veteran stated that he was surprised that he was sharing so much information with the psychologist. His eye contact and attention span were good. There was no evidence of overt psychosis, although the Veteran's thought content was paranoid. The psychologist found that the Veteran had significant interpersonal problems due to suspiciousness and paranoid ideation. The psychologist explained that these problems would pose severe limitations on his occupational and social functioning. The psychologist stated that she was not competent, as a medical professional, to opine as to whether the Veteran was able to obtain or maintain substantially gainful employment because that was not a medical determination but rather a vocational (legal) determination. However, the psychologist found that the PTSD and psychotic disorder impaired the Veteran's ability to work to a moderate to severe degree in several areas (interpersonal relatedness; attention, concentration and memory; and motivation and drive). Finally, the psychologist noted that she had compared the Veteran's reported symptoms in the current examination to his reports of symptoms in the previous examination reports of record. The psychologist found that the Veteran had been consistent in his description of auditory and visual hallucinations. The psychologist found that the quality of the hallucinations differed from the transitory psychosis that might be found in PTSD. Additionally, the Veteran had significant paranoid ideation that could not be fully ascribed to the claimed PTSD stressor (from service origin). The psychologist opined that all previous examiners failed to diagnose the Veteran with psychotic disorder, not otherwise specified in addition to the diagnosis of PTSD. The psychologist explained that psychological testing supported the addition of psychotic disorder to his already service-connected PTSD. The psychologist reiterated that she could not separate the impairments of the two diagnoses as they were mutually aggravating and shared multiple symptoms. She also found that, based upon reported history, the symptoms of both disorders began around the same time. The Veteran explained that the service personnel records supported this conclusion in that it showed the Veteran got low marks in professional performance and military behavior assessments due to having difficulty adapting to a new environment and having to be supervised excessively because of a lack of motivation. The psychologist also noted that discharge paperwork documented, "[Veteran's] performance during his entire enlistment ha[d] been at best marginal. He ha[d] had commanding officer's NJP on 5 (five) separate occasions." The psychologist opined that the Veteran's PTSD symptoms were considered to be mild while his psychotic disorder was considered to be moderate to severe. The psychologist again reiterated that based upon the interactive and mutually aggravating nature of the two disorders, she was unable to separate the impairments of the two. Based on the entire, despite his lack of most of the specific symptomatology listed in the criteria for a 70 percent rating, the evidence reasonably demonstrates that the service-connected disability picture overall had been productive of symptomatology of a severe nature, i.e., he exhibits occupational and social impairment with deficiencies in most areas. The evidence clearly demonstrates that the Veteran has serious impairment in social/familial, occupational and/or intrapersonal areas of his functioning. He is shown to have marital discord and chooses to withdraw and isolate himself rather than engage in social interactions. Additionally, he is unable to make reasonable adjustments to cope with routine demands of a work setting. He was irritable and had trouble getting along with other co-workers and supervisors. While the Board is aware that the August 2007 and January 2010 reports of VA examinations were indicative of PTSD of less severity, the psychologist in the November 2012 report of VA examination explained that was due in large part to the missed diagnosis of psychotic disorder, not otherwise specified (symptoms of which were found to be moderate to severe while the PTSD symptoms were considered to be mild). The psychologist, in the report of the November 2012 examination, explained that it was impossible to differentiate what symptoms were attributable to each diagnosed disorder (PTSD and psychotic disorder) as they were mutually aggravating disorders and share multiple symptoms. See Mittleider v. West, 11 Vet. App. 181 (1998). The Board has also considered the lay assertions and found the Veteran to be credible. This taken with the totality of the other evidence of record persuades the Board to conclude that the Veteran's PTSD has more nearly approximated occupational or social impairment with deficiencies in most areas throughout the period of the appeal. In finding that a 70 percent rating is warranted, the Board has not required that an exhaustive list of symptoms be met. Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). Rather, the Board finds the Veteran's overall disability picture more closely resembles the criteria warranting a 70 percent rating for the service-connected PTSD. The Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). However, the evidence does not serve to establish that the service-connected PTSD in not productive of a disability picture manifested by total occupational and social impairment, particularly given the fact that the evidence noted above indicates at most severe impairment. Hence, on this record, a 100 percent scheduler rating is not assignable. The above determinations are based on application of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point has the disability been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extraschedular basis. See 38 C.F.R. § 3.321. Consideration of referral for an extraschedular rating requires a three-step inquiry. See Thun v. Peake, 22 Vet. App. 111 (2008), aff'd sub nom. Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The first question is whether the schedular rating adequately contemplates the Veteran's disability picture. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. If the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, then the second inquiry is whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as governing norms. If the Veteran's disability picture meets the second inquiry, then the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether an extraschedular rating is warranted. The discussion reflects that the symptoms and effects of the service-connected PTSD are fully contemplated by the applicable rating criteria. The Board's analysis reflects that the symptoms, effects, and overall disability picture from the PTSD is contemplated by the 70 percent rating, which takes account of both the individual symptoms and the overall impairment caused by the PTSD. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required. In any event, the above evidence reflects that the effects of the PTSD on the Veteran's employment did not constitute marked interference with employment, i.e., beyond that contemplated by the assigned 70 percent rating. See 38 C.F.R. § 4.1 ("Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability"). For the foregoing reasons, the Board finds that the service-connected PTSD is shown to be productive of a disability picture that more nearly approximates the criteria warranting a 70 percent rating since the October 13, 2004 effective date for the award of service connection. 38 C.F.R. § 4.7. ORDER An increased rating of 70 percent for the service-connected PTSD is granted, prior to November 2, 2012, subject to controlling regulations governing the payment of monetary awards. An increased rating in excess of 70 percent for the service-connected PTSD beginning on November 2, 2012 is denied. REMAND In cases where the schedular rating is less than 100 percent, a total disability rating may be assigned when the individual is unable to secure or follow a substantially gainful occupation as the result of service-connected disability, without regard to advancing age. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). Total disability ratings for compensation may be assigned, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Disabilities resulting from common etiology or a single accident will be considered as one disability. Id. The Veteran claimed that he is unable to work due to his service- connected PTSD. The record is conflicting as to this issue. In the August 2007 VA examination report, the psychiatrist concluded that the PTSD symptoms made employment more difficult, but did not preclude employment. In the January 2010 VA examination report, the psychologist noted that it was unclear why the Veteran was not working. To that end, the Veteran reported that he could not be employed due to his age; however, he denied having actually attempted to seek employment in the recent past. In the November 2012 VA examination report, the psychologist found that the Veteran's PTSD and psychotic disorder impaired the Veteran's ability to work to a moderate to severe degree in several areas (interpersonal relatedness; attention, concentration and memory; and motivation and drive). However, the psychologist did not answer whether the Veteran was able to obtain or maintain substantially gainful employment. In view of the Board's favorable determination regarding the Veteran's claim for an increased rating for his PTSD effective beginning on October 13, 2004 (date of original claim), the RO should once again address the Veteran's claim for a TDIU rating. Accordingly, this remaining matter is REMANDED to the RO via the AMC for the following action: 1. The RO should undertake to opinion a vocational opinion, to include examination if deemed necessary, as to whether the Veteran is prevented from securing and following substantially gainful employment due to his service-connected PTSD. The RO should send the claims folder to the examiner for review in conjunction with this opinion. 2. After completing all indicated development, the RO should readjudicate the Veteran's claim for a TDIU rating in light of all the evidence of record. If the benefit sought on appeal remains denied, the Veteran should be furnished a fully responsive SSOC and afforded a reasonable opportunity for response. Thereafter, if indicated, the case should be returned to the Board for the purpose of appellate disposition. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ STEPHEN L. WILKINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs