Citation Nr: 1339241 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 10-28 894 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. For the period prior to December 17, 2012, entitlement to an initial disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. For the period prior to December 17, 2012, entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESSES AT HEARING ON APPEAL The Veteran and her son ATTORNEY FOR THE BOARD J. Juliano, Counsel INTRODUCTION The Veteran served on active duty from October 1983 to June 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2008 rating decision of the Department of Veterans Affairs (VA) regional office (RO) located in Portland, Oregon that granted service connection for PTSD and assigned a 30 percent disability rating, effective October 10, 2006. A March 2010 rating decision granted an earlier effective date of September 29, 2006 for the grant of service connection for PTSD. In March 2012, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing at the RO located in Portland, Oregon. A transcript of the proceeding has been associated with the claims file. In November 2012, the Board remanded the Veteran's claims for further development. Such development has been completed and associated with the claims file, and these matters were subsequently returned to the Board for further review. A February 2013 rating decision granted a higher rating of 100 percent for the Veteran's PTSD, the maximum available rating, effective December 17, 2012. Therefore, the issue remains as to whether the Veteran is entitled to an initial disability rating in excess of 30 percent for PTSD for the period prior to December 17, 2012. With regard to the issue of entitlement to TDIU, the Board notes that this issue was raised by the record in the context of the Veteran's claim for a higher initial rating for her service-connected PTSD. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Because the February 2013 rating decision granted a 100 percent disability rating for the Veteran's PTSD effective December 17, 2012, the issue remains as to whether the Veteran is entitled to a TDIU for the period prior to December 17, 2012 (as entitlement after that time is moot). As the issue was addressed in the September 2013 supplemental statement of the case, there is no prejudice for the Board to render a decision on it. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2013). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. For the period prior to January 16, 2012, the Veteran's PTSD manifested by no more than occupational and social impairment with reduced reliability and productivity due to such symptoms as disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. 2. For the period from January 16, 2012 to August 23, 2012, the Veteran's PTSD manifested by no more than occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work-like setting), and an inability to establish and maintain effective relationships. 3. For the period beginning on August 24, 2012 (to December 16, 2012), the Veteran's PTSD is manifested by total occupational impairment. 4. The Veteran's PTSD is assigned a 50 percent rating prior to January 16, 2012, a 70 percent rating from January 16, 2012 to August 23, 2012, and a 100 percent rating thereafter, which are her combined ratings as she had no other service-connected disability. 5. For the period prior to August 24, 2012, the Veteran's service-connected disabilities are not shown to have rendered her unable to secure or follow a substantially gainful occupation; effective August 24, 2012, the Veteran's PTSD is assigned a 100 percent disability rating, and consideration of a TDIU for that period is moot. CONCLUSIONS OF LAW 1. For the period prior to January 16, 2012, the criteria for an initial evaluation of 50 percent disabling for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130 (Diagnostic Code 9411) (2013). 2. For the period from January 16, 2012 to August 23, 2012, the criteria for an initial evaluation of 70 percent disabling for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130 (Diagnostic Code 9411) (2013). 3. For the period beginning on August 24, 2012, the criteria for an initial evaluation of 100 percent disabling for PTSD have been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.7, 4.130 (Diagnostic Code 9411) (2013). 4. The criteria for a TDIU have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With regard to the Veteran's claims for a higher initial rating for her PTSD and for entitlement to TDIU, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5102, 5103(a), 5103A, 5106 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2013). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is generally required to "notify the claimant and the claimant's representative, if any, of any information and any medical or lay evidence not previously provided . . . that is necessary to substantiate the claim." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). As part of that notice, VA must "indicate which portion of that information and evidence, if any, is to be provided by the claimant and which portion, if any, the Secretary . . will attempt to obtain on behalf of the claimant." 38 U.S.C.A. § 5103(a)(1) (West Supp. 2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). With regard to the PTSD rating claim, where service connection has been granted and the initial rating has been assigned, the claim of service connection has been more than substantiated, as it has been proven. As such, 38 U.S.C.A. § 5103(a) notice is no longer required since the purpose that the notice was intended to serve has been fulfilled. Furthermore, once a claim for service connection has been substantiated, the filing of a notice of disagreement with the rating of the disability does not trigger additional 38 U.S.C.A. § 5103(a) notice. Therefore, any defect as to 38 U.S.C.A. § 5103(a) notice is nonprejudicial. See Dingess v. Nicholson, 19 Vet. App. 473, 490-491 (2006), aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); Goodwin v. Peake, 22 Vet. App. 128 (2008) (where a claim has been substantiated after the enactment of the VCAA, the appellant bears the burden of demonstrating any prejudice from defective VCAA notice with respect to any downstream elements). With regard to the Veteran's TDIU claim, a December 2012 VCAA letter fully satisfied the notice requirements of the VCAA. The December 2012 letter informed the Veteran of the requirements for entitlement to TDIU, what evidence was to be provided by her, and which VA would obtain. The letter also explained how VA assigns disability ratings and effective dates. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran's claim was later readjudicated by way of August 2013 and September 2013 Supplemental Statements of the Case (SSOCs). The Board also concludes that VA's duty to assist has been satisfied. All of the Veteran's VA and private treatment records have been associated with the claims file, as well as her VA vocational rehabilitation file (which was reviewed by the RO and by the Board). The Board notes that the Veteran has not identified any outstanding treatment records relating to her claims for VA to obtain. VA's duty to assist includes the duty to conduct a thorough and contemporaneous examination of the Veteran. Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Where the evidence of record does not reflect the current state of a veteran's disability, a VA examination must be conducted. See Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991); 38 C.F.R. § 3.327(a) (2013). With regard to the Veteran's PTSD, she was provided with VA examinations in December 2007, June 2010, and December 2012. There is no evidence indicating that there has been a change in the severity of the Veteran's PTSD since the time of the last VA examination. See 38 C.F.R. § 3.327(a) (2013). The Board notes that the duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate examination was conducted. VAOPGCPREC 11-95. The Board finds the above VA examinations to be thorough and adequate upon which to base a decision with regard to the Veteran's claim. The VA examiners personally interviewed and examined the Veteran, reviewed the claims file, and provided the information necessary to evaluate her PTSD under the applicable rating criteria. With regard to the Veteran's claim for TDIU, the Board notes that above VA examination reports relating to the Veteran's PTSD also addressed the effect of her PTSD on her occupational functioning and, therefore, are sufficient upon which to base a decision with regard to the Veteran's TDIU claim. The Board notes that the Veteran is not service-connected for any other condition. As a final matter, the Board notes that in November 2012, the Board remanded the Veteran's PTSD rating claim so that she could be provided with a new VA examination due to evidence indicating her PTSD condition worsened since the last VA examination. Also, in remanding the issue of entitlement to TDIU, the Board directed that the new PTSD VA examination address the effect of the Veteran's PTSD on her employability, that the Veteran be provided with VCAA notice regarding claims for TDIU, and that her claim for a TDIU be adjudicated by the agency of original jurisdiction in the first instance. The Board also directed that the Veteran be afforded another opportunity to identify any outstanding treatment records relating to her claims. Pursuant to the Board's remand directives, the Veteran was provided with VCAA notice relating to claims for TDIU in December 2012, and that notice also requested that she identify any outstanding treatment records relating to her claims. Also, the Veteran was afforded the December 2012 VA examination that addressed both her PTSD and TDIU claims, and her claims were readjudicated by way of August 2013 and September 2013 Supplemental Statements of the Case (SSOCs). Therefore, the Board finds that there has been substantial compliance with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Analysis 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 degree of disabilities specified 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. 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. 38 C.F.R. § 4.7 (2013). Any reasonable doubt regarding the degree of disability will be resolved in favor of a veteran. 38 C.F.R. § 4.3 (2013). A veteran's entire history is reviewed when making a disability determination. 38 C.F.R. § 4.1 (2013). When a veteran timely appeals an initial rating for a service-connected disability within one year of the rating decision, VA must consider whether the veteran is entitled to "staged" ratings to compensate him or her for periods of time since the filing of his or her claim when the disability may have been more severe. Fenderson v. West, 12 Vet. App. 119 (1999). The Veteran's service-connected PTSD is evaluated under Diagnostic Code 9411. The regulations establish a general rating formula for mental disabilities. 38 C.F.R. § 4.130 (2013). Ratings are assigned according to the manifestation of particular symptoms. Notably, the term "such as" in 38 C.F.R. § 4.130 precedes lists of symptoms that are not exhaustive, but rather serve as examples of the type and degree of symptoms and their effects that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F. R. § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The criteria for a 30 percent rating are as follows: 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). The criteria for a 50 percent rating are as follows: 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. The criteria for a 70 percent rating are as follows: 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. The criteria for a 100 percent rating are as follows: 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. 38 C.F.R. § 4.130, Diagnostic Code 9411 (2013). Within the DSM-IV, Global Assessment 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. GAF scores from 61 to 70 indicate some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. GAF scores from 51 to 60 represent moderate symptoms, such as flat affect and circumstantial speech, and occasional panic attacks, or moderate difficulty in social, occupational, or school function (such as few friends, conflicts with peers or coworkers). GAF scores ranging from 41 to 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). For the period prior to December 17, 2012, the Veteran's PTSD is assigned a 30 percent disability rating, effective September 29, 2006. See 38 C.F.R. § 4.130 (Diagnostic Code 9411). The Veteran seeks a higher initial rating for that period. As explained in the introduction above, effective December 17, 2012, the Veteran's PTSD is assigned a 100 percent rating, which is the maximum schedular rating available. As an initial matter, with regard to the Veteran's employment history, the Board notes that records in her vocational rehabilitation file reflect that from September 2004 until June 2006, the Veteran was a fulltime student and obtained a bachelors degree in women's studies from Portland State University and earned a 3.5 grade point average. From June 2006 to October 2006, she reported working fulltime as a utility worker. Then, from October 2007 to September 2012, she worked fulltime at a bakery. See Rehabilitation Needs Inventory (RNI), December 2012. She noted on a March 2008 questionnaire that gaps in her employment history were due to caretaking for her parents (who both apparently passed away within three weeks of each other in January 2008, see VA treatment record, February 2008). She reports that she was suspended by her employer in August 2012 due to making a mistake at work, and was ultimately terminated effective September 1, 2012. See Statement, September 2012. In December 2012, she applied for chapter 31 vocational rehabilitation. Subsequently, she worked in a temporary position with the Internal Revenue Service from January 2013 to April 2013, but was not offered a permanent position. The Board also notes that she had previously applied for chapter 31 vocational rehabilitation in 2008, 2009, and 2010, expressing an interest in pursuing a career in social work, but each time her program was discontinued for failure to follow up and formulate a rehabilitation plan, and it appears that she had not gained acceptance into a masters of social work program. A December 2007 VA PTSD examination report reflects the Veteran's history of witnessing in service (in July 1986) her then-boyfriend being murdered, while pregnant with their son. Her subsequent history of being married in 1989 and separating in 1998 was noted, followed by dating two men in 2003. She reported that dating was presently the farthest thing from her mind. It was noted that she had been working at the bakery for five years, and she denied any difficulties there. The Veteran reported experiencing nightmares, feeling depressed every day, mild difficulty with motivation, and losing 40 pounds in the last year. Examination revealed that she was well groomed, her speech was articulate, there were no signs of any thought problems, hallucinations, or delusions, her affect was slightly agitated, her mood was dysphoric and anxious, attention, concentration, and memory were grossly intact. The examiner recorded a diagnosis of PTSD, chronic, mild, and dysthymia secondary to PTSD, and a GAF score of 62. The examiner noted that the Veteran's PTSD was having a mild impact on her occupational/educational life, and a moderate impact on her emotional life. A June 2010 VA examination report reflects that the Veteran reported that "my son is my caregiver," and that she did not have many friends or feel like having any over at her house. It was noted that her leisure pursuits including knitting and sewing, that she was still working at the bakery, and she was able to maintain stability at her job and in her living situation. Examination revealed an anxious, dysphoric, labile mood, and full affect. The Veteran declined to do serial 7s, saying that she was no mathematician, and she was not able to recite the months backwards. The Veteran related some ongoing difficulties with her concentration and focus. Examination revealed that she was oriented to time, place, and person. No hallucinations or delusions were noted, and her judgment was fair. She reported some transient suicidal thoughts, see page 10, but no plan or intent. She had irritability, but without episodes of violence. She was noted as maintaining at least minimum personal hygiene, and she had no problems with activities of daily living. Her short-term memory was noted as mildly impaired. She had markedly diminished interest in participation in significant activities, as well as feelings of detachment and estrangement from others. The examiner recorded a diagnosis of PTSD, chronic, moderate, and a GAF score of 60. The examiner opined that the Veteran's PTSD resulted in mild impairment in her occupational functioning, and mild to moderate impairment in her psychosocial functioning. The examiner further opined that the overall effect of the Veteran's PTSD on her occupational and social functioning was an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but with generally satisfactory functioning. The examiner also opined that the Veteran's PTSD were at about the same level as at the time of the December 2007 VA examination. It was also noted that over time, the Veteran reported mild symptoms during mental health visits. A January 16, 2012, emergency treatment record from St. Vincent's hospital reflects that the Veteran's friend brought her there because she told him she may lose her housing and she implied she may suicidal, albeit she dismissed that to the clinician at the hospital and said that she indeed was not going to kill herself. Examination revealed that she was lucid, oriented, and insightful, but depressed. She did not want or think she needed hospitalization. Her suicide risk was estimated to be low. A history of PTSD was noted. A diagnosis of situational depression was recorded. The March 2012 Board hearing transcript reflects that the Veteran testified that she was only working 25 to 30 hours per week and was experiencing conflicts at work with her supervisor. She also testified that her relationships with her siblings and her son were strained. Her son testified that there were days when he needed to remind the Veteran to shower, eat, clean, and go to work, and that at times she would not sleep. He testified that he witnessed her experience anxiety attacks once per day. He also testified that she would forget to pay bills. The Veteran testified that at times while working with customers, she would "let them know how I feel" and later apologize for her unprofessional behavior. As noted above, in a September 2012 letter in support of her claim, the Veteran wrote that she had been suspended for a week by her employer in August 2012 due to making a mistake at work, and was ultimately terminated effective September 1, 2012. See Statement, September 2012. The Board notes that subsequent VA treatment records in the electronic claims file reflect that she obtained a temporary position in January 2013 that lasted until April 2013, such that she did not have employment between September 2012 and December 2012. The Veteran was provided with another VA examination on December 17, 2012, based on which the Veteran's disability rating was increased to 100 percent disabling, effective December 17, 2012. To the extent that this VA examination report may be relevant with regard to rating the Veteran's disability for the period immediately preceding it, the report reflects that the Veteran reported experiencing depressed mood, anxiety, suspiciousness, and chronic sleep impairment. Her speech was noted as intermittently illogical, obscure, or irrelevant, and impaired judgment was noted. Disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, including work or a work-like setting, an inability to establish and maintain effective relationships was noted. Suicidal ideation was also noted, in that she stated, "I just wish I would pass on," albeit she later explained that she believed that God would not want anyone to commit suicide. She reported avoiding people, stating, "I hate people," and she denied pleasure in activities and reported looking forward to the day ending so she can go to bed. The examiner noted that she endorsed symptoms of PTSD to a severe degree. The examiner recorded a diagnosis of PTSD, chronic, and a GAF score of 40. The examiner opined that the Veteran's level of occupational and social impairment was best summarized as involving occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner further opined that it is at least as likely as not that the Veteran's PTSD rendered her unemployable. The Board notes that it has reviewed all of the medical evidence of record, including the Veteran's VA treatment records dated through 2013, which reflect that the Veteran has been followed at the VA medical center for her diagnosed PTSD, but which do not reflect symptoms more severe than that shown in the evidence described above. In light of the above medical evidence of record and all of the statements made by the Veteran and her son, the Board finds that for the period on appeal prior to January 16, 2012, the impact of the Veteran's PTSD on her occupational and social functioning more nearly approximated the degree of impairment contemplated by a 50 percent rating. Criteria for the assignment of a 50 percent rating, which have arguably been met or approximated prior to January 16, 2012, include disturbances of motivation and mood, and difficulty in establishing effective work and social relationships. Also, the Board notes that a 50 percent rating is consistent with the fact that the December 2007 and June 2010 VA examiners described the Veteran's symptoms as mild to moderate, and with the fact that her GAF scores at these examinations were 62 and 60, respectively, which scores are consistent with moderate impairment. As such, the Board concludes that a higher initial rating of 50 percent is warranted prior to January 16, 2012. See 38 C.F.R. § 4.7 (2013). The Board finds the preponderance of the evidence is against the assignment of a rating in excess of 50 percent for the period prior to January 16, 2012. In this regard, the Board notes that the Court of Appeals for the Federal Circuit (Federal Circuit) recently held in Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013) that "in the context of a 70 percent rating, § 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." In this case, however, prior to January 16, 2012, even if the evidence were to imply that the Veteran experienced some difficulty adapting to stressful circumstances, the evidence does not show that the Veteran's overall disability picture due to her PTSD involves occupational and social impairment with reduced reliability and productivity or with deficiencies in most areas so as to warrant a 70 percent disability rating. In this regard, the Board emphasizes that the evidence fails to demonstrate symptomatology of a level of severity contemplated by the 70 percent rating criteria, such as obsessional rituals to the extent that they interfere with routine activities, or near-continuous panic or depression to the extent that it affects her ability to function independently. Likewise, the evidence prior to January 2012 does not show speech intermittently illogical, obscure, or irrelevant, spatial disorientation, neglect of personal appearance and hygiene, impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation. While the Board acknowledges that the Veteran has expressed suicidal thoughts during this period, she explained that she had no actual plan or intent. Also, while the Board acknowledges that the Veteran had difficulty in establishing effective work and social relationships, the evidence of record does not indicate an inability to establish and maintain effective relationships prior to January 16, 2012. Pertinently, she lived with her adult son during this period, with whom she appears to have a very close relationship, and she explained at the Board hearing that her supervisor at the bakery was sympathetic regarding her PTSD symptoms and was essentially willing to work with her. The June 2010 VA examiner noted that the Veteran was able to maintain stability at her job and in her living situation. It was a friend who brought the Veteran to the hospital on January 16, 2012 (showing that she had at least one friend during this period). There are no other factors which would lead the Board to conclude that a 70 percent disability rating is warranted. See Mauerhan v. Principi, supra [the specified factors for each incremental rating are examples rather than requirements for a particular rating; analysis should not be limited solely to whether the claimant exhibited the symptoms listed in the rating scheme]. For the period from January 16, 2012 to August 23, 2012, i.e., from the date the Veteran presented to the St. Vincent's hospital emergency room to the date prior to her suspension from work, the Board finds that the Veteran's symptoms worsened, and a 70 percent disability rating for her PTSD symptoms is appropriate for this period. As shown above, the 70 percent rating criteria that have been met or approximated beginning on January 16, 2012, include neglect of personal appearance and hygiene, difficulty adapting to stressful circumstances (including work), and inability to establish and maintain effective relationships. As described above, the Veteran's son testified at the March 2012 Board hearing that he needed to remind the Veteran to shower. The Veteran testified that she was experiencing conflicts at work with her supervisor and with customers, and that her relationships with her siblings and her son were strained. In essence, the evidence reflects symptoms that are contemplated by the criteria for a 70 percent evaluation in that the Veteran was experiencing deficiencies in most areas due to those symptoms, but which symptoms did not show total occupational and social impairment so as to warrant the next higher, 100 percent rating. Subsequently, the Veteran reports that she was suspended from her job at the bakery effective August 24, 2012, and that she was terminated effective September 1, 2012. Shortly thereafter, the RO awarded a 100 percent rating for her PTSD, effective December 17, 2012 (the date of her VA examination). In light of the fact that the Veteran was suspended on August 24, 2012 and ultimately terminated from her employment, which appears to have resulted from her PTSD symptoms, and in light of the fact that shortly thereafter, the December 2012 VA examination confirmed that the Veteran's PTSD symptoms were severe and are at least as likely as not to render her unemployable, the Board will grant a 100 percent disability rating for the period from August 24, 2012 to December 16, 2012, which is the maximum schedular rating under Diagnostic Code 9411. Accordingly, the Board concludes that a 50 percent evaluation is warranted for the Veteran's PTSD symptoms prior to January 16, 2012, 70 percent is warranted for the period from January 16, 2012 to August 23, 2012, and 100 percent beginning on August 24, 2012. For the period prior to August 24, 2012 (prior to the 100 percent rating), the Board has considered whether referral for an extraschedular rating is appropriate. "The determination of whether a claimant is entitled to an extraschedular rating under 38 C.F.R. § 3.321(b) is a three-step inquiry. . . The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. . ." Thun v. Peake, 22 Vet App 111, 115 (2008) (citing Fisher v. Principi, 4 Vet.App. 57, 60 (1993), and Floyd v. Brown, 9 Vet.App. 88, 95 (1996)). "Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. . .[I]f 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." Thun at 115. With respect to the first prong of Thun, the Board finds that the evidence in this case does not show such an exceptional disability picture that the available schedular evaluation for the Veteran's PTSD is inadequate. A comparison between the level of severity and symptomatology of the Veteran's PTSD with the established criteria shows that the rating criteria reasonably describe the Veteran's disability level and symptomatology as discussed above. Specifically, during the time on appeal, her difficulty establishing and maintaining relationships, her depression, and her varying degrees of occupational impairment. As such, an extraschedular rating is not appropriate. In sum, the preponderance of the evidence is in favor of granting a higher 50 percent initial rating for the Veteran's PTSD prior to January 16, 2012, a 70 percent rating for the period from January 16, 2012 to August 23, 2012, and a 100 percent rating thereafter; the benefit of the doubt rule is not for application. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. B. TDIU Generally, under 38 C.F.R. § 3.340(a)(1), total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Total disability may or may not be permanent. If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. For the purpose of one 60 percent disability, disabilities resulting from a common etiology or a single accident will be considered as one disability. 38 C.F.R. § 4.16(a) (2013). Under 38 C.F.R. § 4.16(b), a TDIU might be awarded even if the requisite schedular criteria is not met if a claimant is nevertheless shown to be "unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities." In determining whether an individual is unemployable by reason of service-connected disabilities, consideration must be given to the type of employment for which the veteran would be qualified. Such consideration would include education and occupational experience. Age may not be considered a factor. 38 C.F.R. § 3.341 (2013). Unemployability associated with advancing age or intercurrent disability may not be used as a basis for assignment of a total disability rating. 38 C.F.R. § 4.19 (2013). The Veteran's PTSD is her only service-connected disability. For the period prior to January 16, 2012, the Board has awarded herein a 50 percent rating. For this period prior to January 16, 2012, because the Veteran does not have a single service-connected disability rated at 60 percent or more and her combined rating is less than 70 percent, she does not meet the minimum schedular criteria for consideration of a TDIU. Nevertheless, the Board does not find evidence of unemployability sufficient to warrant referral to the Under Secretary for Benefits for extraschedular consideration. She maintained employment up until her termination. To the extent that this could be considered employment in a protected environment, the Board notes that her job was not with her family, and that as she was ultimately fired, she was not protected from discipline due to her behavior. For the period beginning on January 16, 2012, the Board awarded herein a disability rating of 70 percent for the Veteran's PTSD, and then 100 percent beginning on August 24, 2012. Therefore, because she has had a single disability rated as at least 60 percent disabling since January 16, 2012, the minimum schedular criteria for consideration of a TDIU have been met. For the period from January 16, 2012 to August 23, 2012, the Board finds that the Veteran has not been shown to have had marked interference with employment due to her PTSD. During this period, the Veteran maintained her employment at the bakery, a job that she worked since October 2007. She herself testified at the Board hearing that although her relationship with her supervisor was strained, at the same time, her supervisor was essentially sympathetic to her situation with her PTSD and was willing to work with her. Therefore, the Board finds that she was not shown at this time to have experienced marked interference with employment so as to entitle her to a TDIU. For the period beginning on August 24, 2012, the Veteran has been assigned a 100 percent disability rating for her PTSD. Therefore, the issue of entitlement to a TDIU for this period is moot. Therefore, the Board concludes that for the period prior to August 24, 2012 (after which her PTSD is rated 100 percent disabling), the preponderance of the evidence is against finding that the Veteran was unable to secure or follow a substantially gainful occupation; referral of the claim for a TDIU for extraschedular consideration is not warranted. ORDER For the period prior to January 16, 2012, entitlement to an initial evaluation of 50 percent disabling for PTSD is granted, subject to regulations applicable to the payment of monetary benefits. For the period from January 16, 2012 to August 23, 2012, entitlement to an evaluation of 70 percent disabling for PTSD is granted, subject to regulations applicable to the payment of monetary benefits. For the period beginning on August 24, 2012, entitlement to an evaluation of 100 percent disabling for PTSD is granted, subject to regulations applicable to the payment of monetary benefits. Entitlement to a TDIU is denied. ____________________________________________ BETHANY BUCK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs