Citation Nr: 1513657 Decision Date: 03/31/15 Archive Date: 04/03/15 DOCKET NO. 09-35 828 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to an effective date earlier than October 24, 2006 for service connection for posttraumatic stress disorder (PTSD). 2. Entitlement to an initial rating in excess of 30 percent for PTSD. 3. Entitlement to a total disability rating based on individual unemployability (TDIU) due to PTSD. REPRESENTATION Veteran represented by: Robert A. Friedman, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and her friend ATTORNEY FOR THE BOARD Jeremy J. Olsen, Associate Counsel INTRODUCTION The Veteran served on active duty in the U.S. Army from December 1983 to July 1984, September 1985 to September 1987, and from November 1990 to March 1991. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. The Board notes that the issue of entitlement to a TDIU was not certified for appeal. However, when evidence of unemployability is submitted during the course of an appeal from an assigned disability rating, a claim for a TDIU will be considered part and parcel of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The evidence of record suggests that the Veteran may be unemployed due, primarily, to symptoms of her service-connected PTSD. As such, the Board finds that the issue of entitlement to a TDIU due to PTSD has been raised during the appeal period. Therefore, as the Board has jurisdiction over such issue as part and parcel of the Veteran's higher rating claim, it has been listed on the first page of this decision. In September 2014, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board Hearing conducted at the RO in Seattle, Washington. A transcript of that hearing is contained in the claims file. The Board notes that in September 2006, the Veteran appointed the Veterans of Foreign Wars as her accredited representative via a properly completed Appointment of Veterans Service Organization as Claimant's Representative (VA Form 21-22). However, in August 2013, the Veteran submitted a new VA Form 21-22 appointing attorney Robert A. Friedman as her accredited representative. The Board recognizes this change in representation. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. The Board notes that, in addition to the VBMS, there is a separate electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in that file reveals all documents therein are either duplicative of those contained in the VBMS or irrelevant to the claims on appeal. FINDINGS OF FACT 1. For the entire period under consideration, the Veteran's PTSD more closely approximated occupational and social impairment with deficiencies in most areas, such as work, family relations, judgment, thinking and mood, due to suicidal ideation; near-continuous depression affecting the ability to function independently, appropriately and effectively; impaired impulse control with unprovoked irritability; difficulty in adapting to stressful circumstances, to include work, and an inability to establish and maintain effective relationships. 2. Resolving all reasonable doubt in the Veteran's favor, the evidence shows that she is unable to secure or follow a substantially gainful occupation as a result of her service-connected disability. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for an initial 70 percent rating, but no higher, for PTSD are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2014). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for a TDIU are met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.18, 4.19 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Withdrawal of Claim The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105 (West 2014). An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204 (2014). Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, at the September 2014 hearing, the Veteran's representative withdrew the appeal regarding the issue of entitlement to an effective date earlier than October 24, 2006 for service connection for PTSD. Hence, with respect to such issue, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed. II. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2014). The notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his or her possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353 -23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Id. With respect the September 2014 hearing, the Veteran was provided an opportunity to set forth her contentions before the undersigned VLJ. The RO Decision Review Officer or VLJ who chairs a hearing must fulfill two duties: (1) to fully explain the issues, and (2) to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010); 38 C.F.R. § 3.103(c)(2). Here, during the September 2014 hearing, the VLJ identified the issues on appeal. In addition, information was solicited regarding the Veteran's conditions, including the symptoms associated with her current disability, and why she believed she warranted a higher initial rating for her service-connected PTSD. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. As such, the Board finds that, consistent with Bryant, the undersigned VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2), and the hearing was legally sufficient. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (here, the RO). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. A November 2006 pre-rating letter provided pertinent notice to the Veteran in connection with what was then a claim for service connection for PTSD. The letter indicated what information and evidence was needed to substantiate the claim, as well as what information and evidence must be submitted by the Veteran and what information and evidence would be obtained by VA. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file includes the Veteran's VA treatment records, private treatment records, and the reports of VA examinations. Prior to the hearing, the Veteran and her representative submitted a private medical opinion and addendum, along with a waiver of RO consideration of the evidence. Also of record and considered in connection with the appeal are various written statements provided by the Veteran and her friend. The Board finds that no additional RO action to further develop the record in connection with the claim for higher rating, prior to appellate consideration, is required. III. Increased Rating for PTSD Disability evaluations are determined by the application of the Schedule For Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where a veteran appeals the initial rating assigned for a disability at the time that service connection for that disability is granted, evidence contemporaneous with the claim and with the initial rating decision granting service connection are most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous . . .." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. The Veteran's service-connected PTSD has been rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9411. Under this regulatory provision, a 30 percent disability rating is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 70 percent is warranted when the Veteran experiences occupational and social impairment, with deficiencies in most area, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. Use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of 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 a Veteran's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). 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. Vasquez-Claudio v. Shinseki, F.3d 112, 117 (Fed. Cir. 2013). The Court further held that, in assessing whether a particular disability rating is warranted requires a two-part analysis, including (1) an initial assessment of the symptoms displayed by the Veteran and, if they are of the kind enumerated in the regulation and (2) an assessment of whether those symptoms result in the occupational and social impairment contemplated by that particular rating. Id. at 118; see also March 2014 Memorandum decision. Indeed, considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). In addition, the evaluation must be 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. Vasquez-Claudio, supra. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126(b). The Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994). A GAF score between 31 and 40 is indicated when there is, 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; and a GAF score of 41 to 50 is defined as denoting 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). GAF scores ranging from 51 to 60 are assigned when there are moderate symptoms (like flat affect and circumstantial speech, and occasional panic attacks), or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). The Board also observes that the words "slight," "moderate" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C.A. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. In addition, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. The pertinent evidence of record consists of VA examinations conducted in May 2007 and May 2012; private and VA outpatient treatment records dated from 2005 to 2014; an August 2014 private psychiatric evaluation, including a September 2014 addendum to same; the September 2014 testimony of the Veteran and her friend; and lay statements submitted by the Veteran and her friend in support of her claim-all of which have been reviewed and considered. In a February 2007 statement, the Veteran's friend B.N. explained that he noticed the Veteran had a diminished interest in activities that used to be pleasurable, a significant detachment from other people, expressed guarded feelings and a sense of a foreshortened future. He noted her significant sleep disturbances, irritability, unusual anger outbursts and difficulty concentrating. In his opinion, these symptoms impaired the Veteran's ability to perform daily activities. The May 2007 VA examiner noted the Veteran reported experiencing frequent intrusive recollections of traumatic events that occurred to her during Operation Desert Storm, including an incident where she and others were huddled together in a building that was being bombed and expecting to die. She reported episodic nightmares of this experience, problems with hypervigilance, startle response, avoidance or reminders of her military experiences. The Veteran reported suffering from chronic severe anger outbursts ever since serving in the military. The Veteran had great difficulty with intimacy. She described chronic symptoms of depression, including low motivation, low energy levels, chronic dysphoric mood, suicidal ideation without a plan, frequent crying episodes, feelings of worthlessness and hopelessness, low appetite and lack of interest in pleasurable activities. The Veteran was unemployed, having recently been fired from her job as a phlebotomist due to problems interacting with coworkers and patients. On examination, the Veteran was cooperative, casually dressed, adequately groomed and properly oriented. She displayed a wide range of affect but no evidence of hallucinations, delusions or significant cognitive impairment. She denied a past history of homicidal or psychotic ideation, but admitted to experiencing episodic suicidal ideation without a specific plan. The Veteran was noted to suffer from moderate overall social, industrial, and emotional impairment due to PTSD. The VA examiner concluded that the Veteran suffered from daily severe PTSD caused by both military and non-military traumas. He estimated that approximately 50 percent of the Veteran's PTSD symptoms were caused by military trauma and 50 percent were caused by pre- and post-military traumas, to include spousal abuse and an attempted sexual assault. However, the examiner did not explain which PTSD symptoms he attributed to which event. The examiner noted that the Veteran also suffered from severe occupational impairment, given her inability to maintain stable employment since discharge. He found that the Veteran also suffered from depressive disorder NOS, secondary to PTSD and a panic disorder unrelated to service. He assigned the Veteran an overall GAF score of 45-50, indicating serious overall social, industrial and emotional impairment, but a GAF score of 60, indicating moderate symptoms, based solely on her military PTSD. In a November 2009 statement, the Veteran indicated experiencing anxiety, a loss of joy, the loss of a future, having disturbing dreams and nightmares, and panic. She described an inability to track time and memory problems. The Veteran described becoming an isolated person unable to keep a career or marriage, raise children or lead a happy normal life. The Veteran explained that she had a short temper, was easily distracted, and was constantly anxious. In a December 2009 statement, B.N. noted the Veteran exhibited impairment in work, judgment, thinking and mood. She expressed suicidal ideation, irrelevant speech, and a near-continuous depression. She no longer had the ability to appropriately and independently function at a job. She experienced memory problems and was unable to handle her finances or financial affairs appropriately. The May 2012 VA Examiner noted the Veteran had been diagnosed with PTSD, with mild to moderate ongoing symptoms related to her fear of hostile military or terrorist activity. The examiner noted that the Veteran reported relatively mild combat exposure when compared to other combat veterans. The Veteran reported having nightmares of combat, as well as undertaking efforts to avoid talking about combat and avoiding reminders of same. The Veteran experienced feeling distant from others although she did report having a social life. She slept well with medication but had problems sleeping without it. She reported experiencing hypervigilance and an exaggerated startle response. The VA examiner also noted a diagnosis of Borderline Personality Disorder (BPD) which caused the Veteran to experience difficulty controlling anger, conflict with others, a fear of abandonment, and a history of cutting herself. On examination, the Veteran was found to suffer from occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although the Veteran was generally functioning satisfactorily, with normal routine behavior, self-care and conversation. The examiner indicated the Veteran's difficulty with irritability on the job was related to both disorders, and, despite her claims of difficulty socializing, the Veteran appeared to be quite socially active. He concluded that her PTSD symptoms caused clinically significant distress or impairment in social, occupational or other important areas of functioning. The VA examiner was able to assign the symptoms of PTSD and BPD to their respective disorders, indicating that the re-experience, avoidance and hypervigilance experienced by the Veteran were PTSD symptoms and her anger issues, fear of abandonment and self-harm were all symptoms of her BPD. The Veteran was examined by a private psychiatrist in August 2014. The psychiatrist reviewed the Veteran's claims file and noted a history of anxiety, inappropriate affect, difficulty maintaining concentration, some confusion, a depressed mood, low self-esteem, and difficulty with anger. She noted the Veteran experienced apathy, memory problems and depression following her return from the Persian Gulf. The Veteran experienced limited insight into her condition. On examination, the psychiatrist noted the Veteran was emotionally labile, agitated, and spoke in a nonstop, tangential fashion. The Veteran exhibited a great deal of irritability and annoyance with others, and endorsed experiencing hallucinations. She displayed a strong paranoid quality to her thought processes and an irritable, dysphoric mood. The psychiatrist noted that the Veteran went few places by herself, and that her companion, B.N., took her to medical appointments, church and bingo. The Veteran had difficulty getting along with others, including her companion. The Veteran had marked difficulty with emotional regulation, emotional lability, irritability, and appropriate expression of anger. The psychiatrist found that these symptoms increased when the Veteran left service and were at a point where they would worsen even more if the Veteran were to return to work. The psychiatrist noted that the Veteran's feelings of paranoia, anxiety, emotional issues and difficulty getting along with others are related to the PTSD as well as other mental health diagnoses, which included schizoaffective disorder, bipolar type. The psychiatrist indicated she would be unable to determine which disorder was the cause of which symptoms. The psychiatrist found that the Veteran's prognosis for improvement was poor and assigned a GAF score of 46. In the September 2014 addendum, the psychiatrist followed up to clarify the impossibility of being able to segregate the degree of impairment caused by the Veteran's different mental health disorders. She explained in great detail why the 2007 VA examination, which determined the Veteran's PTSD symptoms could be half attributed to military trauma and half to other traumas, and the 2012 VA examination, which diagnosed the Veteran with BPD, were flawed. The psychiatrist explained that the Veteran's military stressor of being on a base attacked by missiles was a life-threatening stressor which, by itself, is "sufficient to account for all of her severe occupational and social impairment since 2006." The psychiatrist explained that the Veteran does not have a personality disorder of any kind, but rather experiences suicidal ideation, affective instability and anger issues, all of which arose after her military discharge and are likely caused by her PTSD. The psychiatrist reiterated that the Veteran's PTSD symptoms-impaired impulse control, unprovoked irritability, difficulty controlling her anger, her conflict with and distance from others, and her fear of abandonment-are of a severe nature and impossible to assign to individual disorders. At the hearing, the Veteran testified that after losing her last job in 2006, she became overly anxious, nervous, and depressed. She indicated that since then she had trouble leaving the house unless B.N. took her, and she spent most of her time in the bathtub watching television. B.N. took her to church services and bingo, as well as her medical appointments, and was always with her at these activities so that he could keep her calm and remember the things she was told. The Veteran experienced suicidal ideation weekly, and was chronically exhausted. She reported losing friends, and no longer visited her family, although she did have a friend with whom she occasionally played cards or did light shopping with. The Veteran testified that her children were removed from her custody because she was unable to take care of them due to her refusal to leave the house. She indicated she had lost employment due to her inability to deal with patients and co-workers when working as a phlebotomist. The Veteran testified she could not go outside and was once hospitalized because it was feared she was suicidal. She occasionally sought medical treatment for panic attacks, and was arrested in 2005 for driving under the influence, which she described as being due to her medication, not alcohol. The Veteran described periods of extreme anger and violent outbursts, resulting in broken doors, screens, locks and dishes in the home she shared with B.N. She was constantly irritable and frustrated. The Veteran reported she slept 12 hours a day and rarely felt rested. She spent most of her day watching television from her bathtub and doing some housework before going back to bed. She no longer managed her own money. Since 2006, the Veteran reported, she experienced hair trigger anger, did not trust other people, was afraid to go out in public, and was anxious or nervous all of the time. She reiterated her inability to trust others, as well as her feelings of paranoia, hysteria, irritability, confusion, nervousness and anxiety. Her companion, B.N., testified that the Veteran used to work for him before coming to live with him, and that the Veteran was unable to maintain employment because she had to be under his direct supervision in order to do her job. B.N. further testified that he was now the Veteran's caretaker. He testified to the Veteran's lack of trust of others, her confusion and nerves. He described the incident where her children were removed from her custody because she could no longer handle them properly. B.N. testified that he took the Veteran to her bingo games, appointments and church, and described how agitated she became if he wasn't there to assist her. The Veteran preferred to be at home and alone. B.N. described her violent outbursts in the past, mostly on an unprovoked basis. B.N. testified that he did not believe the Veteran was able to live on her own in her own apartment, or handle her finances, due to her nerves and her inability to do her shopping or attend appointments. The Board notes that the Veteran's treatment records are consistent with the symptoms reported in the VA examination reports, private report, and the testimony presented at the hearing, as they show the Veteran has consistently reported experiencing suicidal ideation, near-continuous depression, an inability to function appropriately, unprovoked irritability, difficulty in adapting to stressful circumstances, such as work, and an inability to maintain effective relationships. The treatment records do not show any illogical, obscure or irrelevant speech, spatial disorientation, or significant neglect of personal appearance and hygiene. As an initial matter, the Board also notes that, in addition to PTSD, the Veteran has been diagnosed with other mental health disorders, including depressive disorder, a panic disorder and Borderline Personality Disorder (BPD). Because reasonable doubt on any issue is to be resolved in the Veteran's favor, such signs and symptoms should be attributed to the service-connected condition when it is not possible to separate the effects of the service-connected condition from a non-service-connected condition. See Mittleider v. West, 11 Vet. App. 181 (1998); 38 C.F.R. § 3.102. In the instant case, the 2007 examiner attributed half of the Veteran's PTSD effects to the trauma she suffered in service, and half to non-military stressors. The examiner, however, did not differentiate and therefore, the Board finds that it is not possible to separate the PTSD symptoms found by that examiner. In addition, the May 2012 VA examiner specifically determined that it was possible to differentiate symptoms attributable to the Veteran's PTSD and her BPD. Specifically, he noted that the Veteran's anger control issue, fear of abandonment and self-harm were due to her BPD diagnosis. Therefore, such symptomatology will not be attributed to the Veteran's PTSD in the context of the May 2012 VA examination report. After resolving all doubt in favor of the Veteran, and after considering the lay and objective evidence of record, the Board finds that the schedular criteria for a 70 percent rating, but no higher, are met, as the Veteran's PTSD results in occupational and social impairment with deficiencies in most areas. The preponderance of the evidence shows that the Veteran's service-connected PTSD has been consistently manifested by suicidal ideation, near-continuous depression affecting her ability to function independently, appropriately and effectively, unprovoked irritability, difficulty in adapting to stressful circumstances, including work, and an inability to establish and maintain effective relationships. In this regard, the evidence shows that the Veteran has been able to establish some relationships, especially with B.N.; however, it appears from the evidence and their testimony that their relationship is more that of caregiver and patient, rather than an effective friendship. Despite the foregoing, the evidence consistently describes the Veteran as adequately groomed and oriented to time, person, and place. Her speech is predominately described as normal, although there are occasional references to the Veteran rambling. The Veteran's does not suffer from delusions and there is little evidence of disorientation during the pendency of this appeal. While the Veteran has not demonstrated all of the symptoms associated with the 70 percent rating criteria, the Board acknowledges that not all of the demonstrative symptoms must be shown to warrant a higher rating. See Mauerhan, supra. For example, there is little or no evidence in the record of gross of impairment in communication, grossly inappropriate behavior, disorientation to place; memory loss for names of close relatives, own occupation or own name. However, it is apparent that the Veteran's symptoms, especially her depression, irritability and social isolation and avoidance behavior, have been of the frequency, severity, and duration to have rendered the Veteran impaired in her social and occupational functioning throughout the pendency of this appeal. See Mauerhan, supra; Vasquez-Claudio, supra. Indeed, the evidence shows that the Veteran's symptoms have consistently resulted in occupational and social impairment. The May 2007 VA examiner indicated the Veteran's PTSD caused moderate overall social, industrial, and emotional impairment. He noted severe occupational impairment given the Veteran's inability to maintain stable employment since her discharge from the military. The May 2012 VA examiner found the Veteran suffered from occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. He concluded that her PTSD symptoms caused clinically significant impairment not only in the Veteran's social and occupational functioning, but also in other important areas in her life. During the appeal period, the August 2014 private examiner found, the Veteran's racing thoughts, flight of ideas, agitation, preoccupation with her internal emotional state, low stress tolerance, anxiety, paranoia, irritability and hypervigilance prevented her from obtaining and maintaining employment. She confirmed that the Veteran's diagnosis of PTSD was sufficient to account for the severe occupational and social impairment since 2006. Based on the evidence of record, the Board finds that a rating of 100 percent is not applicable in the present case. The evidence does not show that the Veteran has total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, disorientation to time or place, or memory loss for names of close relatives, own occupation, or her own name. In this regard, the Veteran has shown some signs of an intermittent ability to perform activities of daily living. As noted above, the Veteran spends most of her day isolated in her bathroom, watching television. She requires the assistance of B.N. to help her attend medical appointments and help with shopping. B.N. testified that the Veteran would be unable to live on her own. However, there was also testimony that the Veteran had taken steps to attempt shopping on her own, and with a friend. The Veteran also indicated that she did housework when she was not watching television. In addition, at no time has the Veteran exhibited grossly inappropriate behavior. In her VA examination reports and the report of the private psychiatrist, the Veteran's behavior has been consistently described as appropriate. Regarding a persistent danger of hurting herself or others, the Veteran has consistently reported suicidal ideation. However, she does not express any specific plan of self-harm, and no examiner has found that she is in persistent danger of hurting herself. In addition, the Veteran has not exhibited a disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The Veteran is noted to have an impaired memory. A July 2006 VA treatment note shows the Veteran complaining of lapses in memory. The August 2014 private examination report shows memory problems since the Veteran returned from military service. In addition, both the Veteran and B.N. testified in September 2014 that the Veteran had problems with her memory. However, the evidence of record does not show that the Veteran exhibits a level of memory impairment severe enough to forget the names of close relatives, her own occupation, or her own name. Therefore, the Board finds that the Veteran is not entitled to a rating in excess of 70 percent for her PTSD. The Board has considered whether staged ratings under Fenderson are appropriate; however, the Board finds that her symptomatology has been stable throughout the appeal. Therefore, assigning staged ratings for such disability is not warranted. Additionally, the Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if 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 application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 38 C.F.R. § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that 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. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the 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 extra-schedular rating. Id. at 115-16. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD with the established criteria found in the rating schedule. The Board finds that the Veteran's PTSD symptomatology is fully addressed by the rating criteria under which such disability is rated. A higher rating was contemplated in this decision and rejected as her symptoms did not more closely approximate the 100 percent rating. There are no additional symptoms of her PTSD that are not addressed by the rating schedule. In this regard, all of the Veteran's psychiatric symptomatology is contemplated by the rating criteria, to include those symptoms which are not specifically enumerated. See Mauerhan, supra. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of her service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture and, therefore, the Board need not proceed to the second factor to consider whether there are related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Thun, 22 Vet. App. at 115-16; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). In view of the foregoing, the Board concludes that the evidence of record clearly indicates that the Veteran's PTSD results in occupational and social impairment in most areas of her life. Therefore, the Board resolves doubt in her favor and finds that her PTSD has been manifested by serious symptoms that more nearly approximate the criteria for a 70 percent rating. See 38 C.F.R. § 4.21 (not all cases will show all findings specified in the rating criteria, but the rating must in all cases be coordinated with actual functional impairment). Thus, the Board concludes, with resolution of doubt in the Veteran's favor, that a 70 percent rating is warranted under DC 9411. 38 C.F.R. §§ 4.3, 4.7. IV. TDIU The Board notes that the Veteran filed a claim for TDIU in September 2014, which was denied by the AOJ in December of that year. As noted in the introduction, the Board has inferred a TDIU claim based on a review of the claims file. The Veteran's treatment records suggest that she is unable to find and keep a job as a result of the symptomatology associated with her service-connected PTSD. The Board observes that, in general, the schedular rating criteria are designed to compensate for average impairments in earning capacity resulting from service-connected disability in civil occupations. 38 U.S.C.A. § 1155. Generally, the degrees of disability specified in the rating schedule are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. A Veteran may be awarded a TDIU upon a showing that she is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from her service-connected disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. A total disability rating may be assigned where the schedular rating is less than total when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). Consideration may be given to a Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to her age or the impairment caused by any non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. The term unemployability, as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. See VAOPGCPREC 75-91 (Dec. 17, 1991). The issue is whether the Veteran's service-connected disability or disabilities preclude her from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a living wage). See Moore v. Derwinski, 1 Vet. App. 356 (1991). In a claim for TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that the Veteran's service-connected disability or disabilities do not prevent her from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995), citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994). In determining whether a Veteran is entitled to a TDIU, neither her nonservice-connected disabilities nor her age may be considered. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The central inquiry in determining whether a Veteran is entitled to a TDIU is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). The test of individual unemployability is whether a Veteran, as a result of her service-connected disabilities alone, is unable to secure or follow any form of substantially gainful occupation which is consistent with her education and occupational experience. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (2013). The Board observes that, as discussed supra, a higher initial rating of 70 percent has been assigned for the Veteran's service-connected PTSD. The Board finds that the evidence supports granting entitlement to a TDIU and notes initially that the Veteran meets the schedular criteria for a TDIU. See 38 C.F.R. § 4.16(a). The Veteran reported that she had not worked since 2006, when she was terminated for having arguments with coworkers and her inability to work with patients. Prior to that job, the Veteran experienced multiple episodes of unemployment since returning from military service in 1991. The May 2012 VA examiner found the Veteran experienced a decrease in work efficiency and intermittent periods of inability to perform occupational tasks. He attributed the Veteran's irritability on the job to her PTSD. The August 2014 private psychiatrist found that it would be difficult, if not impossible, for the Veteran to successfully maintain full-time employment. She opined: In the workplace, related to racing thoughts, flight of ideas, agitation, preoccupation with her internal emotional state, [the Veteran] would have marked to severe difficulty concentrating on tasks [and] completing tasks. Stress tolerance would be markedly diminished. Ability to cope with any unforeseen problems, changes in circumstances would be markedly diminished. She would undoubtedly become more floridly anxious [and] paranoid in a work setting. Ability to interact consistently and appropriately with other related to irritability, emotional lability, anxiety, hypervigilance, would be severely impaired... Except as noted above, the Board attributes all signs of the Veteran's psychiatric impairment to her service-connected PTSD. See Mittleider, 11 Vet. App. at 182. Resolving all reasonable doubt in favor of the Veteran, the competent evidence suggests that the Veteran's service-connected PTSD precludes her from securing or maintaining substantially gainful employment. Accordingly, the Board finds that the criteria for a TDIU are met. See 38 C.F.R. § 4.16. ORDER Entitlement to an effective date earlier than October 24, 2006 for service connection for PTSD is dismissed. An initial 70 percent disability rating, but no higher, for PTSD is granted, subject to the laws and regulations governing payment of monetary benefits. A TDIU is granted, subject to the laws and regulations governing the payment of monetary benefits. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs