Citation Nr: 1441368 Decision Date: 09/16/14 Archive Date: 09/22/14 DOCKET NO. 10-00 572 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for schizophrenia. 2. Entitlement to an effective date prior to March 16, 2006, for the grant of a total disability evaluation based on individual unemployability (TDIU). REPRESENTATION The Veteran represented by: Ralph Bratch, Attorney at Law WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD J.B. Freeman, Counsel INTRODUCTION The Veteran had active service from January 1969 until May 1970. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from August 2006 and January 2009 rating decisions from the RO in Indianapolis, Indiana. The Veteran appeared before the undersigned Acting Veterans Law Judge at a Board hearing held at the RO in August 2010. The Board remanded these issues for additional development in July 2011. At the time, the TDIU was effective February 28, 2007. While the case was on remand, the RO awarded an earlier effective date of March 16, 2006, in an October 2013 Supplemental Statement of the Case (SSOC). The Veteran continues to contest the effective date; thus, the March 2006 effective date was not a complete grant of the benefit sought on appeal and the Board retains jurisdiction. Although the Boards grants an earlier effective date of January 26, 2006, for TDIU, the issue of entitlement to an effective date prior to January 26, 2006, for the grant of a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's service-connected disabilities prevented the Veteran from obtaining or maintaining substantially gainful employment as of January 26, 2006. 2. Prior to December 17, 2009, the Veteran's service-connected schizophrenia has not been manifested by occupational or social impairment with deficiencies in most areas. 3. From December 17, 2009, to February 17, 2010, the Veteran's service-connected schizophrenia was manifested by total occupational and social impairment. 4. On and after February 18, 2010, the Veteran's service-connected schizophrenia has not been manifested by occupational or social impairment with deficiencies in most areas. 5. The schedular criteria are adequate to rate the Veteran's service-connected schizophrenia prior to December 17, 2009, and on and after February 18, 2010. CONCLUSIONS OF LAW 1. The criteria for an effective date of January 26, 2006, for assignment of a TDIU are met. 38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.400 (2013). 2. Prior to December 17, 2009, the criteria for an evaluation greater than 50 percent for schizophrenia are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.130, Diagnostic Code (DC) 9203 (2013). 3. The criteria for an evaluation of 100 percent for schizophrenia are met between December 17, 2009, and February 17, 2010. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.130, DC 9203. 4. On and after February 18, 2010, the criteria for an evaluation greater than 50 percent for schizophrenia are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.130, DC 9203. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Earlier Effective Date for TDIU The Veteran has been awarded TDIU based on the combined effects of his service-connected disabilities. The Veteran challenges the effective date of March 16, 2006, for the TDIU. Prior to October 18, 2005, the Veteran was service-connected for schizophrenia and an appendectomy scar, with a combined 50 percent disability rating. Service connection for diabetes mellitus, type II, was awarded effective October 18, 2005, with a 20 percent disability rating resulting in a combined disability rating of 60 percent. Service connection for ischemic heart disease, coronary artery disease with a history of myocardial infarction, has been awarded effective January 26, 2006, with a 60 percent disability rating resulting in a combined disability rating of 80 percent. The TDIU award has been assigned as of March 16, 2006, the effective date of the award of service connection for peripheral neuropathy of the left lower extremity. However, the Veteran met the schedular criteria for a TDIU as of January 26, 2006. See 38 C.F.R. § 4.16(a) (2013). Pursuant to the Board's July 2011 remand, the RO associated the Veteran's VA VRE Services file with the Veteran's Compensation claims file. The VRE file indicates that the Veteran had been participating in a vocational rehabilitation program in 2005. The Veteran participated until October 2005, at which time his services were interrupted due to his diabetes mellitus, type II. The Veteran's area of developed skills was in "OTR" truck driving. Due to being on insulin, the Veteran could no longer hold a commercial driver's license and could not, therefore, be employed in the field. The VRE Service determined that an employment goal was not reasonably feasible for the Veteran at that time, considering his inability to work as a commercial driver, his struggles in training, and his age. The Board considers the VRE determination competent and credible evidence of unemployability prior to March 16, 2006. Although age is not a valid basis for an award of TDIU, the Board notes that the Veteran became legally barred from working as a commercial driver in October 2005 due to his service-connected diabetes. He had minimal education qualifications in the form of a high school diploma and had struggled in an education environment in 2005, which indicate that retraining around his service-connected disabilities would be difficult at best. Finally, his ischemic heart disease reduced his ability to perform physical labor. In light of the foregoing, the Board finds that the evidence is at least in equipoise that the Veteran's service-connected disabilities prevented the Veteran from obtaining or maintaining substantially gainful employment as of January 26, 2006, the effective date of the grant of service connection for ischemic heart disease, coronary artery disease with a history of myocardial infarction. 38 C.F.R. § 4.16(a). An effective date of January 26, 2006, is granted for the award of a TDIU. 38 U.S.C.A. § 5110; 38 C.F.R. § 3.400. The issue of entitlement to an effective date prior to January 26, 2006, is remanded below. II. Disability Rating for Schizophrenia The Veteran contends that he is entitled to a rating in excess of 50 percent for his schizophrenia. For the reasons that follow, the Board concludes that an increased rating is warranted only for the period of December 17, 2009, to February 17, 2010. 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; 38 C.F.R. § 4.1. 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. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's service-connected schizophrenia is evaluated as 50 percent disabling under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9203 (2013). Ratings are assigned according to the manifestation of particular symptoms. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Under the provisions for rating psychiatric disorders, a 50 percent disability rating requires evidence of the following: 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: 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 worklike setting; inability to establish and maintain effective relationships.) The criteria for a 100 percent rating are: 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 9203. 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, the VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including (if applicable) those identified in the DSM-IV (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994)). See Mauerhan, supra. 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). While not determinative, a GAF score is highly probative as it relates directly to the veteran's level of impairment of social and industrial adaptability, as contemplated by the rating criteria for mental disorders. See Massey v. Brown, 7 Vet. App. 204, 207 (1994). According to DSM-IV, a score of 61-70 illustrates "[s]ome mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships." Id. A score of 51-60 represents "[m]oderate 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)." Id. A score of 41-50 illustrates "[s]erious 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)." Id. A score of 31-40 represents "[s]ome 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 younger children, is defiant at home, and is failing at school)." Id. Prior to December 17, 2009 The Board finds that the Veteran's schizophrenia did not manifest in occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, prior to December 17, 2009. The Veteran has an extensive record of care through VA for his schizophrenia. At the time of claim filing, the Veteran was on an extensive medication management regime and was only seen every few months for evaluation. VA mental health clinic notes from August 2004 through October 2006 indicate that the Veteran was cooperative and friendly. His psychomotor activity was within normal range. His speech was coherent and relevant. Thought processes were well organized and goal-directed. Thought content revealed that he had no hallucinations or paranoid ideation. The Veteran was attending class to complete his education. The Veteran had been doing well, without side effects of medications. He had very good insight into his problems and judgment was good. He did not show psychotic symptoms. During this period, VA psychiatrists assigned GAF scores in a range from 60 to 75. Such scores indicate at most moderate symptoms. The Veteran had significant stressors in his life due to his loss of income in October 2005. The Veteran's schizophrenia was evaluated at a July 2006 VA examination. The Veteran drove and appeared for the examination independently. The Veteran reported completed a semester at a technical college in 2005, receiving three A's, one B, and one D. The Veteran reported that his psychiatric symptoms were well controlled on medication. The Veteran reported compliance with the medication regime. Review of the Veteran's VA psychiatric treatment over the previous year did not reveal psychotic symptoms. The examiner found the Veteran's symptoms to be of mild severity, occur infrequently, and to have been present over the last several months. The Veteran was dressed neatly with average grooming and hygiene. He was able to care independently for his personal hygiene and other basic activities of daily living. The Veteran maintained good eye contact, established appropriate rapport, and displayed no inappropriate behaviors. He was alert and fully oriented with good memory and concentration. His speech was fluent, of normal rate, and well articulated. His speech patterns were logical, relevant, coherent, and goal directed. The Veteran denied any psychotic symptoms such as hallucinations, delusions, or disorder of thought or communication when taking his medication. His mood was mildly depressed, primarily due to situational issues of being out of work and resulting financial problems. His affect was appropriate to content. The Veteran denied impulse control problems, suicidal or homicidal thoughts, ideations, plans, or intent. He did not report panic attacks or panic-like symptoms. No obsessive or ritualistic behaviors that might interfere with routine activities were reported. The examiner assigned a GAF score of 68, which indicates mild symptoms. The Veteran's VA treatment records through 2008 show that his schizophrenia was consistent with the level of impairment shown between August 2004 to October 2006. The Veteran began reporting increasing conflict with his wife, who was working long hours to make ends meet. The Veteran was considered stable and did not report psychotic symptoms or appear psychotic to psychiatrists, nurse practitioners, or primary care physicians. A September 2008 note indicates that the Veteran reported feeling down and hearing voices. His medication was changed to include Risperdal. In October 2008, the Veteran was seen by a psychiatrist and reported quitting Risperdal but denying further psychotic symptoms and did not present any to the psychiatrist. Many treatment records dwell on the Veteran's financial situation and his inability to obtain a job due to his diabetes. An April 2007 social work note indicates that the Veteran's behavior was withdrawn and his mood dysthymic. He denied suicidal or homicidal ideations and was compliant with medications. The Veteran participated in physical therapy in 2007 due to back pain. The Veteran was also hospitalized in July 2007 following a cardiac stress test. A June 2007 VA Vocational Rehabilitation and Employment (VRE) Services case note indicates that the Veteran had been participating in vocational rehabilitation in pursuant of an employment goal until October 2005, when the onset of diabetes resulted in the interruption of services. The June 2007 note indicates that the Veteran was found entitled to independent living services instead of vocational training in 2006. The Veteran was found to need training to maximize mental health, increase exercise to improve overall health, increase socialization, and to address problems of memory loss. This finding of memory loss is not confirmed in any of the Veteran's medical evaluations. The Veteran's schizophrenia was evaluated again at a December 2008 VA examination. At that time, the Veteran reported he had anxiety and depression due to financial problems and that his medical issues hindered his ability to work. The Veteran also reported "command hallucinations" but contemporaneous notes indicate that the Veteran was stable on his medications. The examiner assigned a GAF score of 60. The Veteran's VA treatment records do show a temporary increase in symptoms in schizophrenia twice in 2009. In April 2009, the Veteran reported that he ran out of medicine and began hearing voices. In June 2009, the Veteran was back on medication and doing well. A November 2009 VA mental health note from the Veteran's psychiatrist indicates that the Veteran made good eye contact. His speech was logical and goal-directed. His cognitive abilities appeared very good. His judgment and insight were good. He still had problems from time to time waking up at night and being afraid and hearing noises that bother him. He denied suicidal or homicidal ideation. The second period of increased symptoms in 2009 began on December 17, 2009, and will be addressed at greater length below. The Veteran's schizophrenia was also evaluated during the course of a Social Security Administration (SSA) disability appeal. The April 2008 administrative law judge decision finding the Veteran disabled noted that the Veteran's mental disorder resulted in mild restriction in activities of daily living and maintaining social functioning, moderate difficulties in maintaining concentration, persistence, or pace, and no episodes of decompensation. The disability benefits were ultimately awarded on the basis of the effects of diabetes mellitus, type II. The Board finds that these medical records do not tend to show that the Veteran had occupational and social impairment, with deficiencies in most areas prior to December 17, 2009. The medical records show that the Veteran had adequate control of his schizophrenia so long as he was compliant with medication, which he was for all but a brief period in April 2009. The Veteran ran out of medication at that time, at which point his schizophrenia symptoms reappeared. The underlying schizophrenia was not shown to have changed at this time. Instead, the medication regime was not followed, allowing some symptoms to assert at their full level. Moreover, the Veteran's occupational and social functioning was not reported to have been impaired to any greater degree during that time versus the periods directly before or after it. The Board finds that this brief period was not a worsening of symptoms. Thus, a staged rating for this period is not warranted. The medical evidence also shows that the Veteran had good insight and good judgment. The record prior to December 17, 2009, also shows that, to the extent he did work, that the Veteran did not have deficiencies in the area of work due to his schizophrenia. The instant appeal arises from an October 2005 claim for a TDIU. At that time, the Veteran indicated that he had been unable to work as a result of his diabetes mellitus, type II. The Veteran completed several authorized release forms for past employers in connection with the TDIU claim. Responses from four employers, received in April 2006, cover the Veteran's employment from August 2002 to September 2005 and indicate that the Veteran did not receive concessions for disability from any employer. The Veteran has alleged and the record shows that he stopped working in 2005 when he was prescribed insulin for diabetes. The Veteran had worked as a truck driver for many years, before leaving that job to work as a machine operator in 2005. See July 2006 VA examination report. The Veteran quit that job because he could not earn enough, so he attempted to resume truck driving in September 2005. Id. The Veteran's VA treatment records show that the Veteran obtained a job offer to work as a driver, but was hospitalized at a commercial driver's license physical examination when his blood glucose was found to be 764. See October 2005 VA treatment note. Given the lack of disability concessions and steady employment in truck driving and machine operating, the evidence does not indicate that the Veteran had a deficiency in the area of work due to his schizophrenia at the time of claim filing. The Veteran testified before the undersigned that he had stopped driving a truck because he was hallucinating a couple times a week because he could not get his medications as he needed them on the road. August 2010 Board Hearing Tr. at 6. He also testified that his schizophrenia was much worse when he was trying to work. Id. at 8. The Board notes that the report of hallucinations conflicts with his contemporaneous statements in 2004 and 2005. The Board places greater weight on contemporaneous statements of symptoms, particularly in this case, when the witness has psychological difficulty. The October 2013 VA examination report indicates that the Veteran's current level of functioning is comparable to what it was in 2005 and 2006. The Board places greater weight on the medical evidence that does not show hallucinations a couple times week prior to October 2005. The Veteran has also maintained a steady family relationship throughout the period on appeal. The Veteran has been married since December 1977. He and his wife have a daughter, with whom the Veteran reports a good relationship. See July 2006, December 2008, October 2013 VA examination reports. The Veteran reported in October 2013 that he and his wife had separated and reconciled often; however, the Veteran has consistently reported living with his wife in the period on appeal prior to December 17, 2009. In light of the foregoing evidence of adequate or good functioning in the areas of insight, judgment, work, and family relationships, the Board finds that the Veteran's schizophrenia was not manifest in occupational and social impairment with deficiencies in most areas prior to December 17, 2009. There is evidence of some impairment in school, with the Veteran earning mixed grades in 2005. The Veteran's mood was also depressed in this period. However, these two areas of deficiencies do not constitute most areas. Thus, the Board concludes that the criteria for a rating in excess of 50 percent for schizophrenia are not met prior to December 17, 2009. December 17, 2009 to February 9, 2010 The Veteran suffered an increase in schizophrenia, first shown on December 17, 2009. A December 29, 2009 telephone triage note states that the Veteran called and reported that he started a Fentanyl patch on December 17, 2009, and since then he was having severe mood swings with verbal aggression, with yelling at his wife and daughter. The Veteran called again in January 2010 asking for a psychiatric care appointment, reporting auditory hallucinations. On January 8, 2010, he was at a VFW post behaving erratically. The police were called and took him to a private hospital before taking him to a VA Medical Center. The Veteran was hospitalized from January 8 to 14, at which time he had stabilized and was discharged. The Veteran was hospitalized again a week later on January 21 for acute psychotic symptoms. The Veteran was confused and not coherent but was able to acknowledge that he had been more confused since using a Fentanyl patch, which he removed. The Veteran was psychotic, claiming to be the archangel Michael and that California was in danger. The Veteran's daughter spoke to a nurse practitioner, reporting that the Veteran thought a dog was saving them from unseen forces. The Veteran's medications were adjusted and his psychotic symptoms disappeared. The Veteran was discharged home with his wife on February 10, 2010, having stabilized again. His GAF score at discharge was 60. The discharge summary indicates that the Fentanyl patch had been placed for management of chronic pain. The summary also indicates that the Veteran could resume his previous level of activity and states that the Veteran was unemployable due to severe mental illness and other physical conditions. As of December 17, 2009, the Veteran's schizophrenia was manifest in total occupational and social impairment. The Veteran's bizarre behavior and thoughts resulted in two psychiatric admissions. The Board concludes that a 100 percent rating is warranted as of December 17, 2009, the date on which the Veteran's social impairment, shown by mood swings and verbal aggressive, is first shown. As of February 18, 2010, the Veteran's acute psychotic symptoms had subsided and he was deemed stable for discharge to his home and wife. The GAF score at discharge indicates that the Veteran's symptoms had returned to the level comparable to that shown in the 2004 to 2008 VA treatment records. The Veteran's hallucinations, delusions, and erratic behavior had resolved by discharge. As will be discussed further below, after February 17, 2010, the Board finds that the Veteran's schizophrenia was not productive of total occupational and social impairment as of that date. Therefore, the Board concludes that a 100 percent rating was not warranted on that date. The grant of a 100 percent rating is effective only through February 17, 2010. On and After February 18, 2010 The evidence is also clear that the Veteran's schizophrenia symptoms were exacerbated by a temporary medication change. Once the Veteran's medications were changed and maintained, his schizophrenia symptoms subsided. A February 18, 2010 psychiatry inpatient note indicated that the Veteran met with the treatment team. He reported feeling much better. He denied recurrence of any psychotic symptoms and had not been grandiose or inappropriate in his behaviors. His thoughts were much more organized and he was focused on providing for his family. The signing psychiatrist indicated that the Veteran could return home as soon as his wife could provide transportation. A February 19 social work note indicates that the Veteran's wife had met with him and indicated that he was doing very well. The Veteran was actually discharged the following February 22. The Veteran's VA treatment records on and after February 18, 2010 and through October 2013, are substantially similar to those prior to December 17, 2009. The Veteran appeared at mental health follow-ups with his VA psychiatrist every three or four months. He was typically friendly, alert, and oriented times three. He denied suicidal or homicidal ideation. No delusions were noted. His thought processes were sequential. His speech was logical, goal-directed, and normal in rate and rhythm. His judgment and insight were good. The October 2013 VA examination report contains similar assessments of his symptoms. A March 15, 2010 telephone encounter recorded a call from the Veteran's daughter who claimed that the Veteran was becoming verbally aggressive and very argumentative. She reported he had increasing paranoia and looked depressed and tearful. She claimed the symptoms were like before his recent hospitalization but milder. A March 20, 2010 telephone encounter note recorded a call from the Veteran's daughter who stated that she had just spoken to the Veteran and that he sounded bizarre. The Veteran presented normally at a social work visit to his home two days later on March 22, 2010. An April 2010 social work note indicates that the Veteran's daughter confirmed that there had been no recent unusual or bizarre behaviors. A November 2012 mental health note indicated that the Veteran ran out of medications and was beginning to hear things, but restarted his medications and was doing well. The Veteran's social functioning was mixed but effective during the period on and after February 18, 2010. The Veteran was released to his home. The Veteran reported that his wife moved out and wanted a divorce in March 2010. March 22, 2010 VA Social Work Note. The Veteran also reported going to the VFW or American Legion to talk with people which made him feel better. VA Social Work Note. The Veteran reported that he had reunited with his wife at an August 2010 mental health visit. Throughout this period the Veteran maintained his relationship with his daughter, who occasionally participated at his social work visits in 2010. An August 2011 mental health note states that the Veteran and his wife were supporting their daughter after she lost her job. He also reported attending his grandson's birthday party and occasionally attending church. The psychiatrist encouraged him to get out more and meet people. The Veteran reported that he and his wife planned to host a large Christmas gathering at a November 2012 mental health follow-up. At the October 2013 VA examination, the Veteran reported that he and his wife had their daughter and her infant living with them for a time, but the daughter had since moved out. The Veteran reported continuing to support his daughter financially because she was working and going to school. They also provided care for their grandchild at times. The Veteran's brother in law lived with them as of October 2013. Overall, the Veteran had difficulty, but not inability, in forming and maintaining relationships. In this regard, his level of functioning in this period was more akin to the 50 percent criteria set out above. The preponderance of the evidence shows that the Veteran's schizophrenia was not productive of occupational and social impairment with deficiencies in most areas after February 18, 2010. The Veteran's social functioning was impaired, but in a manner consistent with the 50 percent rating currently assigned. As before, the Veteran did not work or attempt to work in an employment setting on or after February 18, 2010. Similarly, he did not attend school or engage in formal education in this period. Otherwise, his insight into his disability and his judgment in managing it and his life were intact. The Board concludes that the criteria for a rating in excess of 50 percent for schizophrenia were not met on and after February 18, 2010. See Vazquez-Claudio, supra. Additional Considerations Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has considered the possibility of staged ratings and assigned them accordingly above. The Board, however, concludes that further staged ratings are not applicable as the criteria for a rating in excess of 50 percent were not met for any portion of the appeal before December 17, 2009, or after February 17, 2010. See id. The Board has also considered whether a referral for extraschedular rating is warranted. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). 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. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule; therefore, the assigned schedular evaluation is adequate, and no referral is required. See VAOPGCPREC 6-96; see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993). The schedular evaluation for the Veteran's schizophrenia is not inadequate. The Veteran's symptoms are behavioral in nature. The General Ratings Formula applied above is open-ended and able to accommodate the behaviors the Veteran displayed during the period on appeal. The Veteran does not have any symptoms from his service-connected disorder that are unusual or are different from those contemplated by the schedular criteria. The available schedular evaluations reasonably describe the service-connected disability; thus, the schedular evaluations are adequate to rate the Veteran's disability. The Board need not determine whether the claimant's disability picture exhibits other related factors such as those provided by the regulation as "governing norms" such as "marked interference with employment" and "frequent periods of hospitalization." See Thun, 22 Vet. App. at 115. As alluded to above, the Veteran is also in receipt of service connection for additional disabilities, including ischemic heart disease, diabetes mellitus, type II, peripheral neuropathy of the lower extremities, erectile dysfunction, and an appendectomy scar. A TDIU has been awarded effective January 26, 2006. The effective date of that award is remanded below. Prior to October 18, 2005, the Veteran was only service-connected for schizophrenia and an appendectomy scar. Service connection for diabetes mellitus, type II, has been awarded effective October 18, 2005. Extraschedular ratings are for situations in which a Veteran's overall disability picture establishes something less than total unemployability, but where the collective impact of a Veteran's disabilities are nonetheless inadequately represented. Johnson v. McDonald, No. 2013-7104, 2014 WL 3844196, slip op. at 7-8 (Fed. Cir. Aug. 6, 2014) (emphasis added). The Veteran's disability picture does establish total unemployability; therefore, inquiry into the collective impact of the Veteran's service-connected disabilities is moot on and after January 26, 2006. Moreover, the record above demonstrates that the Veteran's schizophrenia had been stable for many years through 2005 and 2006, during which time he had been gainfully employed in truck driving without disability concessions. The appendectomy scar had not been alleged to have any impact on his ability to function. The interaction of the schizophrenia and diabetes mellitus, type II, is discussed in the remand section below. Referral for extraschedular consideration is not warranted either for the service-connected schizophrenia alone or for evaluation of the collective impact of all the service-connected disabilities. See VAOPGCPREC 6-96. TDIU is an alternative theory of all claims for a higher disability rating. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). As discussed in greater detail below, the Veteran is pursuing entitlement to an earlier effective date for TDIU as a separate issue primarily on the basis of the effects of service-connected diabetes mellitus, type II. The receipt of a TDIU evaluation based on the cumulative effects of all service-connected disabilities does not necessarily moot the issue of entitlement to a TDIU with regard to a single issue. See Bradley v. Peake, 22 Vet. App. 280, 293 (2008) (holding that, in the situation of a schedular 100 percent rating, a TDIU rating based on a single disability may still form the basis for assignment of special monthly compensation under 38 U.S.C.A. § 1114(s) should the other service-connected disability or disabilities meet the remaining eligibility criteria independently). Thus, the Board will consider whether TDIU has been raised solely on the basis of the effects of schizophrenia prior to December 17, 2009, or on and after February 18, 2010. The Veteran's representative stated during the hearing before the undersigned that the unemployability was a symptom and a basis for a higher rating for schizophrenia. August 2010 Board Hearing Tr. at 7. The Board takes this as an attempt to raise unemployability sole on the basis of schizophrenia. Jackson v. Shinseki, 587 F.3d 1106, 1109-10 (Fed. Cir. 2009). Initially, the Board notes that the Veteran has been pursuing TDIU as a related, but separate claim since October 2005. In the intervening years, he has been represented by an attorney and been informed both by letter and the contents of various adjudicatory documents of the requirements of TDIU. The Veteran and his representative have been made aware of the evidentiary requirements and have been given the opportunity to present evidence regarding the severity of his schizophrenia and whether he is rendered unemployable thereby, resulting in a paper claims file of eight volumes with several hundred additional pages of evidence in his electronic claims file. In particular, the Veteran's representative is charged with knowledge of the law, to include the holding of Bradley, supra, and is deemed to have zealously pursued the Veteran's claims. The Board concludes that the Veteran is not prejudiced by the Board's consideration of TDIU solely on the basis of schizophrenia at this time. The Veteran has been in receipt of service connection for schizophrenia since 1970. His present 50 percent disability rating has been in effect since 1996. As described at length above, the Veteran has not worked since September 2005 because of the effects of his diabetes mellitus, type II, which prevented him from holding a commercial driver's license. The SSA determination held that his disability was due to the effects of diabetes mellitus, type II, and peripheral neuropathy. Although not binding on VA, the SSA determination is evidence that the schizophrenia was not sufficient to render the Veteran unemployable on its own. Although the schizophrenia undoubtedly impacts his ability to obtain or follow substantially gainful employment in conjunction with his diabetes mellitus, the evidence does not indicate that the Veteran has such a severe degree of impairment that he may be unemployable based solely on his schizophrenia. Thus, the Board concludes that the Veteran's schizophrenia does not result in unemployability by itself. As such, the Board finds that the preponderance of the evidence is against the Veteran's increased rating claim. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. III. Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claim for an increased rating for schizophrenia. See 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.326 (2013). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). A March 2006 letter fully satisfied the duty to notify provisions, including notice of the degree of disability prior to initial adjudication of the Veteran's claim in August 2006. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). The Board also concludes VA's duty to assist in obtaining records has been satisfied. The Veteran's service, VA treatment, and VA Vocational Rehabilitation and Employment (VRE) Services records are in the file. The Veteran's Social Security Administration records have been associated with the file. The Veteran indicated in January 2006 that he received care through VA for his psychiatric disability; he has not identified private treatment during or before the period on appeal records of which he thought might be relevant. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The Veteran has received several VA examinations in conjunction with this appeal, most recently in October 2013. The Veteran has not reported receiving any recent treatment specifically for this condition (other than at VA treatment mentioned above, records of which are in the file). There are no statements from the Veteran or evidence in the record indicating that there has been a material change in the severity of the Veteran's service-connected disorder since he was last examined. The examination report provides sufficient evidence to apply the ratings schedule and to determine that the schedular rating is adequate to rate the disability. The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007) (mere passage of time does not require VA to provide a new medical examination); see also VAOPGCPREC 11-95. The 2013 VA examination report is thorough and supported by VA outpatient treatment records. The examination report in this case is an adequate basis on which to adjudicate the claim. The Board remanded this case in July 2011 to obtain all outstanding VA treatment records relating to the schizophrenia, including a January to March 2010 hospitalization, and any VRE records, and to provide the Veteran with a VA examination in assess the current severity of the schizophrenia and its effect on the Veteran's social and industrial capacity. The Veteran's VA treatment records from through October 1, 2013, have been associated with the Veteran's Virtual VA file. The Veteran was seen for an October 2013 VA examination, which addressed. The Board finds that the RO complied substantially with July 2011 remand instructions. Further remand for additional development of the prior remand instructions is not warranted. See Stegall. ORDER Entitlement to a disability rating in excess of 50 percent for schizophrenia is denied prior to December 17, 2009. Entitlement to a disability rating of 100 percent for schizophrenia is granted from December 17, 2009, to February 17, 2010. Entitlement to a disability rating in excess of 50 percent for schizophrenia is denied on and after February 18, 2010. Entitlement to an effective date of January 26, 2006, for the assignment of a TDIU is granted. REMAND The Board must remand the appeal for an effective date earlier than January 26, 2006, for the assignment of a TDIU. Prior to January 26, 2006, the Veteran was service-connected for schizophrenia, rated as 50 percent disabling, for diabetes mellitus, type II, rated as 20 percent disabling, and for an appendectomy scar, rated as noncompensable. His combined rating was 60 percent. See 38 C.F.R. § 4.25 (2013). The AOJ determined that the Veteran did not meet the schedular criteria for TDIU and the evidence did not otherwise show that the Veteran was unemployable due to service-connected disabilities prior to January 26, 2006. See 38 C.F.R. § 4.16 (2013). Pursuant to the Board's July 2011 remand, the RO associated the Veteran's VA VRE Services file with the Veteran's Compensation claims file. The VRE file indicates that the Veteran had been participating in a vocational rehabilitation program in 2005. The Veteran participated until October 2005, at which time his services were interrupted due to his diabetes mellitus, type II. The Veteran's area of developed skills was in "OTR" truck driving. Due to being on insulin, the Veteran could no longer hold a commercial driver's license and could not, therefore, be employed in the field. The VRE Service determined that an employment goal was not reasonably feasible for the Veteran at that time, considering his inability to work as a commercial driver, his struggles in training, and his age. The Board considers the VRE determination competent and credible evidence of unemployability prior to January 26, 2006. The Board remands to refer the issue of an extraschedular TDIU prior to January 26, 2006, to the Office of the Director of the Compensation Service. See 38 C.F.R. § 4.16(b). Accordingly, the case is REMANDED for the following action: 1. Refer extraschedular consideration of TDIU prior to January 26, 2006, to the Director of the Compensation Service pursuant to 38 C.F.R. § 4.16(b). 2. Then, the AOJ should readjudicate the claim on the merits. If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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. 2013). ______________________________________________ K.A. Kennerly Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs