Citation Nr: 1336112 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 12-34 322 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to an initial evaluation in excess of 30 percent for PTSD to include MDD for the period prior to June 28, 2012. 1. Entitlement to an initial evaluation in excess of 70 percent for posttraumatic stress disorder (PTSD) to include major depression disorder (MDD) from June 29, 2012 to present. 3. Entitlement to total disability rating based on individual unemployability due to service-connected disabilities (TDIU) for the period prior to June 29, 2012. REPRESENTATION Veteran represented by: Bryan Held, Accredited Agent ATTORNEY FOR THE BOARD J. Acosta, Associate Counsel INTRODUCTION The Veteran had active service from April 1978 to June 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a May 2012 rating decision of the San Diego, California, regional office (RO) of the Department of Veterans Affairs (VA), that assigned a 30 percent evaluation for PTSD, after granting service connection for the same. The Veteran appealed; and, by a rating decision dated April 2013, the 30 percent rating assigned for PTSD was increased to 70 percent effective from June 29, 2012. That decision also assigned a TDIU, effective from June 28, 2012. FINDINGS OF FACT 1. Prior to December 22, 2011, the Veteran's service connected PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent period of inability to perform occupational tasks. 2. From December 22, 2011 to June 29, 2012, the Veteran's service connected PTSD resulted in occupation and social impairment with reduced reliability and productivity. 3. At no point during the appeal period has the Veteran's service-connected PTSD resulted in total impairment of occupational and social functioning. 4. Prior to June 29, 2012, the Veteran's service-connected disabilities are not of such severity as to preclude substantially gainful employment. CONCLUSIONS OF LAW 1. For the period prior to December 22, 2011, the criteria for a disability rating in excess of 30 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.59, 4.130, Diagnostic Code 9411 (2013). 2. From December 22, 2011 to June 30, 2012 the criteria for a 50 percent rating evaluation, but no greater, for service-connected PTSD have been met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.321, 4.59, 4.130, Diagnostic Code 9411 (2013). 3. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, DC 9411 (2013). 4. The criteria for the assignment of a TDIU are not met for the period prior to June 29, 2012. 38 U.S.C.A. § 1155, 5102, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 3.340, 3.341, 4.16, 4.19 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). The Veteran has appealed the propriety of the initially assigned rating for her PTSD from the original grant of service connection. VA's General Counsel has held that no additional notice is required for such downstream issues. VAOPGCPREC 8-2003. The United States Court of Appeals for Veterans Claims (Court) specifically held that "the statutory scheme contemplates that once a decision awarding service connection, a disability rating, and an effective date has been made, § 5103(a) notice has served its purpose, and its application is no longer required because the claim has already been substantiated." Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). The Veteran's claim for service connection for his PTSD was granted and an initial rating was assigned in the rating decision on appeal. He was subsequently awarded an increased rating and a TDIU as a part of that appeal. Therefore, as the Veteran has appealed with respect to the initially assigned rating, no additional notice is required because the purpose that the notice is intended to serve has been fulfilled. VA also satisfied its duty to assist the Veteran in the development of her claim and to seek relevant records. VA's duty to assist includes assisting the claimant in the procurement of service and other relevant records. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159 (2013). The RO associated the Veteran's service treatment records, Social Security records, private treatment records identified, and VA treatment records with the claims file. The Veteran has not identified any treatment records aside from those that are already of record. Thus, the Board concludes that VA has made every reasonable effort to obtain all records relevant to the Veteran's claim. In December 2012 and earlier in December 22, 2011, VA provided the Veteran with a medical examination and obtained a medical opinion addressing the current state of her disability. The examination and opinion are adequate as the examination report shows that the examiner considered the relevant history of the Veteran's PTSD. The examiner provided a sufficiently detailed description of this disability, and the examiner provided an analysis to support his opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (holding that once VA undertakes the effort to provide an examination when developing a claim, even if not statutorily obligated to do so, VA must ensure that the examination provided is adequate). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. While the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degrees of disability specified by the schedule are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2013). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2013). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2013). Where the Veteran timely appeals the rating initially assigned for the service-connected disability within one year of the notice of the establishment of service connection for it, VA must consider whether the Veteran is entitled to "staged" ratings to compensate her for times since filing her claim when her disability may have been more severe than at other times during the course of her appeal. See Fenderson v. West, 12 Vet. App. 119 (1999). PTSD Under Diagnostic Code 9411, the General Rating Formula for Mental Disorders is used for PTSD. The General Rating Formula provides that a 30 percent rating is assigned for 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 rating is assigned for 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 rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Finally, 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 or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). The use of the term 'such as' in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase 'such symptoms as,' followed by a list of examples, provides guidance as to the severity of the symptoms contemplated for each rating, in addition to permitting consideration of other symptoms particular to each veteran and disorder, and the effect of those symptoms on his/her social and work situation. Id. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit stated that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." It was further noted that "§ 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Within the DSM-IV, Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The same is true of any physician's statement as to the severity of a disability. It remains the Board's responsibility to evaluate the probative value of any doctor's opinion in light of all the evidence of record. A GAF score of 31 to 40 reflects 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; child frequently beats up other children, is defiant at home, and is failing at school). A GAF of 41 to 50 is defined as serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A GAF score of 51 to 60 is defined as 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). Scores ranging between 61 and 70 reflect 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, and has some meaningful interpersonal relationships. See Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). When evaluating a mental disorder, the Board shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. The extent of social impairment is to be considered but neither the Board nor the RO shall assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Merits of the Claim The Veteran contends that the treatment notes of record document her unemployability, the VA examiner in the December 2012 examination stated the Veteran is unemployable, and the fact that the Veteran is currently receiving Social Security benefits demonstrate she cannot work. The Board at the onset notes that SSA decisions are not controlling, but pertinent to determining a veteran's ability to engage in substantially gainful employment. Martin v. Brown, 4 Vet. App. 136 (1993); Murincsak v. Derwinski, 2 Vet. App. 363, 369-370 (1992). The Board observes that the same principle must also be applied in determining whether a veteran meets the rating criteria of total impairment of occupation and social functioning. The RO assigned June 29, 2012 as the effective date for the Veteran's 70 percent evaluation of PTSD and TDIU. An April 2013 rating decision refers to the Veteran having filed her claim for an increased rating on June 29, 2012. However, the June 2012 was clearly a notice of disagreement with the May 2012 decision that had assigned an initial rating of 30 percent for PTSD. She also perfected her appeal of that decision in a timely manner. The fact that the Veteran may have failed to report for an earlier October 2012 is not necessarily a determinative factor in assigning the effective date. See Turk v. Peak, 21 Vet App. 565 (2008) (In a claim for an increased initial rating, if the veteran misses the VA examination without good cause, the claim should be decided based on the evidence of record instead of being denied). In other words, the entire appeal period (June 30, 2011 to the present) is for consideration. I. PTSD Rating in Excess of 30 Percent prior to June 28, 2012 The Veteran was first afforded a VA psychiatric examination to evaluate her PTSD for benefit purposes in December 22, 2011. The examiner described the Veteran's occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner states the Veteran currently lives with her 28 year old daughter. When discussing the Veteran's current occupation history with the VA examiner the Veteran reported that she was employed up until January 2010 when she was fired. The VA examiner reports the following: She states she was having a great deal of difficulty carrying out her job duties due to daytime fatigue from lack of sleep, difficulty concentrating and quick startle response and nervousness. She state[s] that she "could not keep up with the work" and was eventually terminated. The claimant stated she has not worked since that time. The VA examiner in addressing social impairment and occupational impairment found: markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others. The examiner indicates that the symptoms of increased arousal that were not present before the trauma included: difficulty falling or staying asleep, irritability or outburst of anger difficulty concentrating, hypervigilance, and an exaggerated startle response. The examiner then concludes that the PTSD symptoms described clinically significant distress or impairment in social, occupation, or other important areas of functioning. The VA examiner also notes the following symptoms included depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and suicidal ideation. However, the examiner states that the Veteran does not have difficulty adapting to stressful circumstances, including work or a work like setting. Additionally, the VA examiner adds that the Veteran's PTSD is specifically related to the following symptoms: "fatigue and lack of energy, avoidant behavior, feelings of detachment from others, distressing dreams, recurring thoughts, hypervigilance and exaggerated startle response." Finally, the examiner noted that the Veteran is capable of managing her financial affairs. The examiner assigned a GAF score of 60 for this examination. Earlier in October 2011 in the Veteran's application for Social Security (SSA), she filled out a function report. In this report the Veteran details that she sleeps for only an hour at a time due to nightmares, that her daughter opens up her mail and reminds her to pay bills. The Veteran also states that she has to write notes to herself, and she can only pay attention for 20 to 30 minutes at a time. A SSA psychological examination in October 2011 reports that the Veteran she stopped working in January of 2010 because she could not keep up with her work. She reports that she "sometimes does not eat enough and get sick" and that her concentration and memory is described as, "forget things I'm told." However, the SSA examiner notes there are no suicidal or homicidal ideations. The examiner reports that the claimant lives in a house with her family. She is able to take care of her hygiene and grooming without assistance. She is able to do household chores, errands, shopping and a "little" cooking. She has no outside activities or hobbies. Her activities of daily living include "dress, eat, read, TV, computer." Her relations with family, friends, neighbors and others are described as, "fair" and "good." The examiner while not providing a GAF scores states: In the absence of medical records and SSA forms, based on the history and mental status examination today, my overall assessment is the claimant's occupational and social functioning impairment is none too mild from the psychiatric standpoints. The record also includes various VA treatment records dating from March 2010 t0 October 2012. A March 2010 record refers to the Veteran as living at home with her daughter and grandchild. There is also a reference to her complaints of depression as being secondary to the residuals of a back injury. Increased nightmares, constant depression, and low interest were reported in June and July 2010. When she was seen in July 2010, the Veteran was assigned a GAF score of 65 and noted to have persistent depression, decreased appetite and fatigue. In March 2012, she indicated that her depression as stable. Her depression was described as "intermittent" in October 2012. For the period from June 29, 2011 to December 22, 2011, the Board finds that the evidence during that period does not establish the criteria to evaluate the Veteran's PTSD in excess of 30 percent. The SSA examination in October 2011 indicates that the Veteran at this time had "none to mild" occupational impairment. The Veteran was able to accomplish most of her activities of daily living and had "good" to "fair" social interaction with neighbors and friends indicating that the Veteran did not have difficulty in establishing and maintaining effective social relationships. While there is some indication that the Veteran had memory impairment in the SSA examination that examiner concluded that the Veteran had "none to mild" occupational impairment. The GAF score of 65, which was assigned in July 2012, also suggests mild symptomatology and impairment. It is true that the Veteran at times endorsed constant/persistent depression. There is also her depression was "intermittent." Nevertheless, even if it were constant, there is no evidence that this depression rose to level to result in difficulty in establishing and maintaining effective work and social relationships. Such was simply not demonstrated at that time. However, for the period from December 22, 2011 to June 28, 2012, the Board finds that the Veteran is entitled to a 50 percent rating for her PTSD. The December 22, 2011 VA examination found that the significant impairment with social and occupational functioning. The total disability picture indicated by the examination more closely aligned to the 50 percent rating. The Veteran's symptoms indicated by the examiner which included depressed mood, difficulty maintaining effective work and social relationships reflect a 50 percent evaluation. The assignment of a higher (70 percent) rating is not warranted. The Board acknowledges that in the Veteran experienced problems with suicidal ideation, which would support an increased rating. However, here is no indication that the Veteran experiences problems with obsessional ritual which interfere with routine activities; speech that is intermittently illogical, obscure or irrelevant, near-continuous panic or depression affecting her ability to function independently appropriately and effectively or impaired impulse control and spatial disorientation. The presence (or lack of presence) of certain symptoms is not necessarily determinative. Demonstrated symptoms such as suicidal ideation or depression must also cause the occupational and social impairment in the referenced areas. See Vazquez-Claudio, supra. There is no indication that the Veteran's occupational and social functioning was demonstrative of deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. To the contrary, the Veteran is shown to be capable of establishing and maintaining social interaction (Veteran's relationship with her daughter). There is also an absence of evidence showing that the Veteran has difficulty in adapting to stressful circumstances, including work or a work like setting. The GAF score of 60 conveys a level of impairment that is moderate at its worst. The opinion offered by of the VA examiner and the symptoms cited therein more closely approximates a 50 percent evaluation. II. PTSD Rating in Excess of 70 Percent after June 28, 2012 The Veteran most recently underwent a VA examination for her service connected PTSD in December 2012. In addressing whether the Veteran has total social impairment, the Board draws attention to this VA examiners note stating: Claimant's mother is still alive and well. [...] Claimant states her relationship with her mother is "excellent." Claimant has two sisters, one older and one younger. Claimant states her younger sister has passed away claimant states her relationship with her sisters was and is "good." In addressing whether the Veteran has total occupation impairment, the Board notes the VA examiner also states: The Veteran is unemployable at the present time [...] because this is claimant's current state her ability to perform in a work environment wit[h] timeliness and competence is severely impaired. Further because this is claimant's current state her ability [to] interact appropriately with others in the workplace environment is also severely impaired. The VA examiner also later remarks that the "Veteran has occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood." The examiner continues and states the Veteran has: markedly diminished interest or participation in significant activities, inability to establish and maintain effective relationships, difficulty in adapting to stressful circumstances, including work or a work like setting. (Emphasis added). In the same period, a VA treatment note from July 2012 indicates the Veteran babysits. Thus, in light of the foregoing, the evidence of record does not establish that the Veteran's service-connected PTSD warrants a rating in excess of 70 percent for the period from June 30, 2011 to present. The Veteran did not, nor does she presently appear to, experience total occupational and social impairment. Although the VA examiner stated the Veteran is "unemployable," it is reiterated throughout the opinion that this is due to an occupational ability which is severely impaired. The Veteran's statement that she babysits emphasizes that her occupational ability, while being severely impaired, is not totally impaired as required for a 100 percent evaluation. The Board does not believe that a person that has total occupational impairment would possess the ability judgment, productivity, and responsibility to care for another. See Vazquez-Claudio, supra. Likewise, the evidence indicates the Veteran's social ability, while being severely impaired, is not totally impaired. This is evident from the VA examination where the VA examiner notes the Veteran's ability to carry on "excellent" relationship with her mother and "good" relationship with her sister. Again, the fact that the Veteran is able to babysit shows some ability to interact socially with others. Therefore, the Board finds that the Veteran's occupational and social ability while being severely impaired is not totally impaired. The Board also highlights that the VA examiner stated the Veteran "does not appear to pose any threat of danger or injury to self or others." The VA examiner also states that the Veteran does not have: memory loss for names of close relatives, her own occupation, own name; gross impairment in thought process or communication; persistent delusions or hallucinations; grossly inappropriate behavior; or neglect of personal appearance and hygiene. Therefore the Board finds that the Veteran does not suffer from a total occupational and social impairment due to her PTSD, and thus an evaluation in excess of 70 percent for the Veteran's PTSD is not warranted. Other Considerations The Board acknowledges that the Veteran is competent to report symptoms of her psychiatric disability. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465 (1994). Additionally, she is credible in his reports of symptoms and their effect on her activities. She is not however competent to identify a specific level of disability of her disability according to the appropriate diagnostic code. Such competent evidence concerning the nature and extent of the Veteran's service-connected psychiatric disability has been provided by VA medical professionals who have examined her. The medical findings directly address the criteria under which this disability is evaluated. The Board finds these records to be the only competent and probative evidence of record, and therefore is accorded greater weight than the Veteran's subjective complaints of increased symptomatology. See Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board has also considered the potential application of other various provisions, including 38 C.F.R. § 3.321(b)(1), for exceptional cases where scheduler evaluations are found to be inadequate. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Ordinarily, the VA Schedule will apply unless there are exceptional or unusual factors which 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 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 scheduler standards. See 38 C.F.R. § 3.321(b)(1) (2013); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court set forth a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. First, as a threshold issue, the Board must determine whether the veteran's disability picture is contemplated by the rating schedule. If so, the rating schedule is adequate and an extraschedular referral is not necessary. If, however, the veteran's disability level and symptomatology are not contemplated by the rating schedule, the Board must turn to the second step of the inquiry, that is whether the veteran's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." These include marked interference with employment and frequent periods of hospitalization. Third, if the first and second steps are met, then the case must be referred to the VA 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. The evidence of record does not reflect that the Veteran's disability picture is so exceptional as to not be contemplated by the rating schedule. There is no unusual clinical picture presented, nor is there any other factor which takes the Veteran's disabilities outside the usual rating criteria. The Veteran's service-connected PTSD currently assigned 70 percent, 50 percent, and 30 percent disability ratings is contemplated under the rating criteria for her symptoms. Further, as the Board must consider any additional psychiatric symptoms that the Veteran exhibits, even if they are not specifically identified in the rating criteria, the Veteran's disability picture is adequately contemplated by the rating schedule. See Mauerhan, supra. Therefore, this disability picture is also adequately contemplated by the rating schedule. As such, the threshold issue under Thun is not met for the disability on appeal and any further consideration of governing norms or referral to the appropriate VA officials for extraschedular consideration is not necessary. The evidence does not support the proposition that the Veteran's service-connected PTSD presents such an exceptional or unusual disability picture as to render impractical the application of the regular scheduler standards and to warrant the assignment of an extraschedular rating under 38 C.F.R. § 3.321(b)(1) (2013). Thus, referral of either of these issues to the appropriate VA officials for consideration of an extraschedular evaluation is not warranted. TDIU Prior to June 28, 2012 The Veteran in her substantive appeal raises the issue of individual unemployability due to service-connected disabilities (TDIU). The Board notes the RO granted TDIU from June 29, 2012 to present. The RO did not address the time period before June 29, 2012. Thus, the Board ascertains that the issue of TDIU prior to June 28, 2012 has been raised by the Veteran but has yet to be addressed. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). A Veteran may be awarded TDIU upon a showing that he is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.26. Consideration may be given to his level of education, special training, and previous work experience in making this determination, but not to his age or the impairment caused by any nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). TDIU may be assigned where the schedular rating is less than total when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In addition, there must be evidence that the disabled person is unable to secure or follow a substantially gainful occupation. Id. For the discrete time period from June 30, 2011 to June 28, 2012, the Veteran's highest possible combined rating is 50 percent. She is also in receipt of a combined 30 percent rating for the period prior to December 22, 2011. This results follows the application of the combined rating table found in 38 C.F.R. 4.25 to the highest possible combination of the Veteran's two ratable disabilities, PTSD rated at 50 and 30 percent, respectively, and a left foot disability rated at 0 percent. Therefore, the Board finds that under the provisions of 38 C.F.R. 4.16(a), an award of TDIU is not warranted. Consequently, the only remaining question in this case is whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, for purposes of a possible extra-schedular evaluation. 38 C.F.R. § 4.16(b). The Board emphasizes that entitlement to an extra-schedular rating under 38 C.F.R. § 3.321(b)(1) and a TDIU extra-schedular rating under 38 C.F.R. § 4.16(b), although similar, are based on different factors. See Kellar v. Brown, 6 Vet. App. 157, 162 (1994). An extra-schedular rating under 38 C.F.R. § 3.321(b)(1) is based on the fact that the schedular ratings are inadequate to compensate for the average impairment of earning capacity due to the Veteran's disabilities. Exceptional or unusual circumstances, such as frequent hospitalization or marked interference with employment, are required. In contrast, 38 C.F.R. § 4.16(b) merely requires a determination that a particular Veteran is currently rendered unable to secure or follow a substantially gainful occupation by reason of his or her service-connected disabilities. See VAOPGCPREC 6-96. The Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed under 38 C.F.R. § 4.16(b). The Board itself cannot assign an extra-schedular rating in the first instance. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). Although Bagwell and Floyd only dealt with ratings under § 3.321(b)(1), the analysis in those cases is analogous to TDIU ratings under § 4.16(b) as well, in view of that section's similar requirement of referral to the Director of VA's Compensation and Pension (C&P) Service, in addition to Court precedents requiring consideration of § 4.16(b) when the issue is raised in an increased-rating case. See Stanton v. Brown, 5 Vet. App. 563, 570 (1993); Fanning v. Brown, 4 Vet. App. 225, 229 (1993). That is, since the Board itself cannot assign an extra-schedular rating in the first instance, it must specifically adjudicate whether to refer a case to the Director of C&P Services for an extra-schedular evaluation when the issue is either raised by the claimant or is reasonably raised by the evidence of record. See Thun v. Peake, 22 Vet. App. 111, 115 (2008); Barringer v. Peake, 22 Vet. App. 242 (2008). If, and only if, the Director determines that an extra-schedular evaluation is not warranted, does the Board then have jurisdiction to decide the extra-schedular claim on the merits. In fact, the Court held that although the Board is precluded from initially assigning an extraschedular rating, there is no restriction on the Board's ability to review the adjudication of an extraschedular rating once the Director of C&P determines that an extraschedular rating is not warranted. Anderson v. Shinseki, 22 Vet. App. 423, 427-28 (2009). See also Floyd, 9 Vet. App. at 96-97 (stating that once Board properly refers an extraschedular rating issue to Director of C&P for review, appellant may "continue[ ] to appeal the extraschedular rating aspect of this claim"); see also 38 U.S.C.A. §§ 511(a), 7104(a) ("All questions in a matter ... subject to decision by the Secretary shall be subject to one review on appeal to the Board."). Where, as in this case, a Veteran fails to meet the applicable percentage standards, an extra-schedular rating is for consideration where the Veteran is found unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities. 38 C.F.R. § 4.16(b). Individual unemployability must be determined without regard to any non-service connected disabilities or a Veteran's advancing age. 38 C.F.R. § 3.341(a), 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in a Veteran's favor. 38 C.F.R. § 4.3. While the regulations do not provide a definition of "substantially gainful employment," VA Adjudication Procedure Manual, M21-1 MR, Part IV, Subpart ii, Chapter 2 (Dec. 13, 2005) (previously cited at M21-1, Part IV, paragraph 7.09), defines the term as that "at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the veteran resides." Also, in Faust v. West, 13 Vet. App. 342 (2000), the Court defined "substantially gainful employment" as an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days that a Veteran actually works and without regard to a Veteran's earned annual income. In Hatlestad v. Derwinski, 5 Vet. App. 524, 529 (1993), the Court held that the central inquiry in determining whether a veteran is entitled to TDIU is whether his service-connected disabilities alone are of sufficient severity to produce unemployability. The determination as to whether a total disability is appropriate should not be based solely upon demonstrated difficulty in obtaining employment in one particular field, which could also potentially be due to external bases such as economic factors, but rather to all reasonably available sources of employment under the circumstances. See Ferraro v. Derwinski, 1 Vet. App. 326, 331-332 (1991). The Board finds that a remand for a referral for TDIU is not warranted. The Board notes that although the Veteran was readmitted to a depression clinic, as reported in a March 2012 VA treatment notes, the VA records up until March 2012 indicate that the Veteran was stable with her medication. This evidence aligns with the October 2011 SSA examination, noted above, where a SSA examiner indicated that the Veteran has "none to mild" occupation impairment. The Veteran also states in a May 2012 VA treatment note that "having to re-write the events, of the sexual trauma, which occurred while in the military [...] was causing her to relive the events." In the same treatment note, the Veteran states "[s]ometimes I'm depressed, eventually it goes away." Later, in a June 2012 treatment notes, the Veteran is reported to having been "readmitted to the PCMHI/Depression Car clinic for medication titration. [at this time] she appeared to have a more animated voice to[n]e. She still has period of tearfulness, thinking about the trauma." The June 2012 VA treatment note further states that "she is stable on medication, but, she does need continued psychotherapy." The Board also emphasizes that although, as referenced above, a higher rating for the Veteran's PTSD was warranted, partly on the basis that the Veteran had difficulty establishing and maintaining work relationships, this conclusion does not equate to an inability to follow substantially gainful employment. Turning to the left foot, the Board refers to the February 2011 VA treatment and later June 2012 VA examination. The February 2011 VA treatment note states: Patient with history of numbness bilateral feed (middle of foot toes) for over a year, now c/o of increasing pain 5/10 right foot and 4/10 left foot, started 3 weeks ago now progressively worse. Nothing makes pain better, walking and climbing stairs makes pain worse. Patient on Vicodin back pain, states does not make pain in feet better. However, later, in a June 2012 VA examination for service connection for her left foot disability, the VA examiner opines that "[t]he impact of the foot condition, on the claimant's ability to work is minimal due to pain with prolonged standing and walking". Following this examination a May 2012 RO rating decision assigned a noncompensable rating to the Veteran's left foot disability which was not appealed to the Board. Thus, the Board acknowledges that the Veteran had pain in her left foot between June 30, 2011 and June 28, 2012, however, this pain, as referenced in the June 2012 VA examination, did not preclude her from following substantially gainful employment. The Board acknowledges that the VA treatment notes for the June 30, 2011 to June 28, 2012 period indicate that the Veteran was suffering from other disabilities during this period including anemia and back pain, however, the Board is restricted in examining only whether a service connected disability has led to the inability to follow substantially gainful employment. 38 C.F.R. § 4.16(b). Here, the evidence is insufficient to find that the Veteran service connected PTSD and left foot disability cumulatively led to an inability for the Veteran to secure and follow a substantially gainful occupation. ORDER Entitlement to an initial disability rating in excess of 30 percent from June 30 2011 to December 22, 2011 is denied. Entitlement to an initial disability rating in excess of 30 percent but not to exceed 50 percent from December 22, 2011 to June 28, 2012 is granted. Entitlement to an initial disability rating in excess of 70 percent for PTSD from June 29, 2011 is denied. Entitlement to TDIU for the period prior to June 29, 2012 is denied ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs