Citation Nr: 1608418 Decision Date: 03/02/16 Archive Date: 03/09/16 DOCKET NO. 13-03 334 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a rating higher than 50 percent for panic disorder. 2. Entitlement to a total disability rating based upon individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran served on active duty from August 1962 to July 1964. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In February 2015 the Veteran testified at a video conference Board hearing before the undersigned Veterans Law Judge. A transcript of that proceeding is of record. The case was previously before the Board in March 2015 when it was remanded for additional development. The issue of service connection for coronary artery disease was previously on appeal and remanded by the Board. By rating action dated in July 2015, the Appeals Management Center granted service connection for coronary artery disease. Therefore, this issue has been resolved and is no longer on appeal before the Board. See generally Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997), and Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). The claim for entitlement to 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 The Veteran's psychiatric symptomatology results in impairment that most closely approximates occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for a rating higher than 50 percent for panic disorder are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. § 4.130, Diagnostic Code 9412 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duty to Notify and Assist Under the Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist a claimant in the development of a claim. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2015). The notice requirements of the VCAA require VA to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2015). Here, VCAA notice was provided by correspondence in September 2010. The case was last readjudicated in July 2015. Concerning the duty to assist, the record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran including service treatment records, Social Security Administration (SSA) records, post-service treatment records, and VA examination reports. The Veteran was afforded a hearing before the Board, at which he presented oral testimony in support of his claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing explain the issues and suggest the submission of evidence that may have been overlooked. Here, the undersigned identified the issues and the Veteran testified as to his symptomatology and treatment history for the disability on appeal as well as the impact of his disabilities on employment. The hearing focused on the elements necessary to substantiate the claims and the Veteran testified as to those elements. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. As such, the Board finds that there is no prejudice to the Veteran in deciding this case and that no further action pursuant to Bryant is necessary. Based on a review of the record, the Board finds that there is no indication that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007). Moreover, the AOJ has substantially complied with the previous remand directives such that no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). Therefore, the Board finds that duty to notify and duty to assist have been satisfied and will proceed to the merits of the issue on appeal. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). A claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran's psychiatric disability is rated under Diagnostic Code 9412 which utilizes General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. Under that Formula, a 50 percent rating is assigned when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and the inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions 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. Under such regulations, ratings are assigned according to the manifestation of particular symptoms. The use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment. Often, treatment records and examination reports contain a Global Assessment of Functioning score. The Global Assessment of Functioning (GAF) score is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266 (1996); DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, Fourth Edition (DSM-IV). GAF scores from 51 to 60 indicate more moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores from 41 to 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals) or any serious impairment in social or occupational functioning (e.g., no friends, unable to keep a job). GAF scores from 31 to 40 indicate some impairment in reality testing or communication 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 was unable to work). 38 C.F.R. § 4.125; DSM-IV. In August 2010, the Veteran's treating physician noted Axis I diagnoses of major depressive disorder, moderate recurrent; anxiety disorder not otherwise specified (NOS); insomnia; and posttraumatic stress disorder (PTSD), and opined that that the Veteran was unable to work even a desk job. VA mental health treatment notes from 2009 to 2015, show ongoing treatment for the Veteran's psychiatric disorder with GAF scores that ranged from 51 to 60 with most scores being 55. In a statement in September 2010, the Veteran's former supervisor of 8 years, D.P., reported that the Veteran retired early from the company because of his anxiety condition which the Veteran felt was worsening his heart condition. D.P. indicated that he took him home a couple times when he had panic attacks that were so severe he could not drive. On one occasion the Veteran was also taken to the emergency room after he started crying and complaining of chest discomfort and trouble breathing. Reportedly, this episode was attributed to an anxiety attack. It was also noted that the Veteran had to miss work frequently because of his nerves. D.P. also noted that the Veteran was easily upset when stressed at work, which sometimes caused confrontations between him and other employees. On VA examination in May 2011, the Veteran reported symptoms of depression daily, low energy, feelings of worthlessness and excessive guilt, poor appetite, mild problems with memory, and mild problems with attention, concentration, and following directions. He slept 7 hours per night on average and took naps frequently throughout the day, but did not feel rested upon awakening. His spouse noted how it took him hours and hours to put a TV stand together. The Veteran denied a history of psychiatric hospitalizations. The Veteran reported that he retired five years earlier as a heavy equipment operator, after 38 years. He stated that he stopped working due to his nerves and heart, as he felt the pressure was too much. While employed, he experienced weekly panic attacks and his spouse noted that they were severe enough that his boss had to bring him home twice. He indicated that the panic attacks lasted between 10 minutes and 2 hours, but denied that they prevented him from performing job duties. He reported his relationships with coworkers and supervisors were good overall but noted that he was easily irritated by others and would get into a verbal argument with coworkers almost every day. The Veteran denied any particular difficulty performing job tasks. He denied having any reprimands or counseling. He reported that her hardly ever missed work and denied any significant periods of unemployment. The Veteran has been married for 46 years and described the relationship with his spouse as good. The Veteran's wife indicated that his nervousness had contributed to mild marital discord. The Veteran reported having a good relationship with his two children, whom he had contact with several times a month. On a typical day he played on the computer, talked to friends over the phone, watched TV and spent time bird watching. The Veteran reported having one close friend with whom he talked on the phone several times a day, and another friend with whom he got together every week. He denied engaging in any formal social activities. The Veteran was described as casually, cleanly and appropriately dressed. He was alert and oriented. Behavior was cooperative. Psychomotor activity was within normal limits. Eye contact was good. Speech rate, volume and tone were unremarkable. Communication was fair but limited by a tendency to not answer questions directly. Mood was anxious. Affect was flattened. Thought process and thought content were unremarkable. There were no signs of delusions or hallucinations at the time of the examination. He denied suicidal or homicidal ideation plan or intent. He was a good historian. There was no inappropriate behavior displayed during the evaluation. The examiner assigned a GAF score of 70 indicating that the Veteran's panic disorder appeared to have a mild impact on social and occupational functioning. Concerning the Veteran's reports of panic attacks and related problems at work, the examiner noted that although credible to assume they caused subjective distress, there was no evidence that these episodes significantly impacted his performance at work. In this regard, the Veteran denied any history of reprimand or counseling, missing work or significant periods of unemployment. Socially, the Veteran reported a good relationship overall with his spouse of 46 years, although difficulties managing anger, irritability, and social withdrawal contributed to distress in family relationships. Accordingly, the examiner opined that the Veteran's panic disorder was productive of occasional decreases in work efficiency and productivity, but there was no evidence that these were of sufficient severity to prevent him from securing or maintaining employment. VA treatment notes in March 2013 showed the Veteran complained that his memory and concentration had worsened. He also indicated that his medication was not effectively treating his symptoms as he was having at least 4 panic attacks a week. The Veteran was described as well presented with good eye contact. While communicative, he relied on his spouse to answer questions for him. He was oriented to person, place, time and situation. Attention span was good. Insight and judgment were fair. His speech was normal, productive, logical and goal directed. His mood was depressed and affect was tired. Thought process was intact. He denied suicidal or homicidal ideations. There were no auditory, visual or tactile hallucinations or delusions. He was assigned a GAF score of 54. In January 2015, the Veteran's spouse reported that the Veteran fought in his sleep. He continued to self-isolate and still had panic attacks with chest pain, shortness of breath and palpitations. He exhibited crying spells and depressive spells, despite medication. At the February 2015 Board hearing, the Veteran and his spouse reported that he experienced one to two panic attacks per week. He also noted crying spells, depression, avoidance of crowds, social isolation, problems sleeping and unprovoked irritability. He attended counseling every three months. Recently, his medication had been increased. A VA treatment note in March 2015 showed complaints of self-isolation, nightmares and loss of interest in activities. He continued to have at least 4 panic attacks a week. The Veteran's speech was soft logical clear with evident frustration at times. His mood was frustrated. Affect was relaxed. Thought process was intact. He denied delusions or hallucinations. The Veteran denied suicidal or homicidal ideations. Insight and judgment were fair. On VA examination in May 2015, the Veteran reported anxiety and worry about having a panic attack, procrastination and avoidance of potential triggers. His panic attacks were accompanied by racing heart, shakiness, difficulty breathing, muscle tension, restlessness, and feeling feint. Other symptoms included sudden terror/fear accompanied by thoughts that he may be going crazy. He required high doses of medication to cope with panic symptoms. Regarding symptom severity, the examiner noted that the Veteran retired early, per his report, due in large part to panic disorder symptoms. The Veteran reported, and a review of the clinical treatment notes showed, significantly increased social isolation and avoidance of familial/social events, which caused increased strain on his interpersonal relationships with his spouse, children, and grandchildren. The examiner noted depressed mood, anxiety, panic attacks more than once a week, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work like setting. The Veteran received Social Security disability. The examiner found that the Veteran's psychiatric symptoms were productive of occupational and social impairment with reduced reliability and productivity The Veteran remained married to his spouse. The couple described marital stress related to the Veteran's panic disorder, in that it limited their ability to engage in meaningful, pleasant, and value-oriented activities. Essentially, the Veteran continued to self-isolate in the home, preferring a very structured and rigid, controlled routine to avoid potential triggers of panic attacks. For example, the Veteran would seclude himself when his grandchildren visited, in order to reduce potential frustration, which typically precipitated a panic episode. The Veteran's isolation from family reportedly caused strife with his son, resulting in numerous panic episodes. As a result, the Veteran reported an even stronger desire to distance and isolate himself from potentially provocative situations. The examiner noted that grooming, dress, and appearance were all within normal limits. The Veteran was alert and oriented to all spheres. Speech was normal in rate, tone, and volume, produced with reduced spontaneity. Content of speech was concrete and with sparse details, logical and coherent. Thought processes were mildly slowed, linear, and goal-directed, with no overt indications of serious thought dysfunction or gross memory impairment. Mood was overtly anxious at times, with obvious signs of autonomic arousal, such as facial flushing, mild tremor, rapid breathing. There was no evidence of suicidal or homicidal ideation, mania, hypomania, or psychosis. The examiner opined that the Veteran's psychiatric symptoms were severe enough to cause intermittent distress in his social, marital, and familial relationships. Specifically, he was not able to partake in social and familial activities, which he identified as valuable and meaningful, due to his experience of anxiety and potential for panic episode. Throughout the period on appeal, the medical evidence recorded symptoms of depression, anhedonia, social withdrawal, avoidance of stimuli, irritability, lethargy/fatigue, loss of appetite, insomnia, problems sleeping, nightmares, low energy, feelings of worthlessness and excessive guilt, poor appetite, mild problems with memory, crying spells, and mild problems with attention and concentration, as well as following directions. There was no history of inpatient psychiatric treatment. He attended counseling approximately every 3 months. The Veteran reported an average of at least 2 to 4 panic and anxiety attacks weekly, which were managed with medication. The medication dosage was increased during the appeal and was recently noted to be quite high. The attacks could last anywhere from a few minutes to a couple of hours. His panic attacks were accompanied by racing heart, shakiness, difficulty breathing, muscle tension, restlessness, and feeling feint. There was no evidence of hallucinations, mania, psychosis, delusions or suicidal or homocidal ideation. As previously noted, VA mental health treatment notes from 2009 to 2015, indicated GAF scores that ranged from 51 to 60 with most scores being 55. GAF scores from 51 to 60 indicate moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). On review of the evidence of record, the Board finds that the Veteran's panic disorder most closely approximates the criteria for the assigned 50 percent rating during the period on appeal. In Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013), the Federal Circuit held that a Veteran may only qualify for a given disability rating under 38 C.F.R. § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. This holding is of particular significance as the claimant in that case, like the Veteran here, was seeking a rating in excess of 50 percent for a psychiatric disorder. The Federal Circuit held that in the context of a 70 percent rating, 38 C.F.R. § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas. Although a Veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the Veteran's level of impairment in "most areas." The Federal Circuit also stated that entitlement to a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation. While the Veteran had some social impairment, an inability to maintain effective relationships was not shown. Despite reports of family discord due to the Veteran's psychiatric symptoms, specifically social isolation, the Veteran and his spouse of approximately 50 years, remained married and overall had a good relationship. He also described his relationship with his children as good, although he did have an altercation with his son recently that had provoked increased anxiety and panic attacks. As a result, the Veteran reported an even stronger desire to distance and isolate himself from potentially provocative situations. He found the presence of his children and grandchildren at home stressful and would at times retrieve to his room when people visited. The Veteran indicated he had one close friend with whom he talked over the phone daily and one other close friend whom he saw once per week. The Veteran no longer partook in activities he used to enjoy, such as fishing. Rather, on a typical day he played on the computer, talked to friends over the phone, watched TV and spent time bird watching. The VA examiner in 2015 opined that the Veteran's psychiatric symptoms were severe enough to cause intermittent distress in his social, marital, and familial relationships. Specifically, he was not able to partake in social and familial activities, which he identified as valuable and meaningful, due to his experience of anxiety and potential for panic episode. Occupationally, the evidence shows that the Veteran reporting that he retired in 2006 due, in part, to his psychiatric symptoms and the effect these had on his heart condition. Prior to retiring, he started experiencing panic and anxiety attacks on a weekly basis, which were manifest by complaints of chest pain, racing heart and breathing difficulties. Once he went to the emergency room and twice his former supervisor reported taking the Veteran home. While the Veteran's former supervisor noted that the Veteran frequently missed work because of his nerves, the Veteran stated that he hardly ever missed work and denied any significant periods of unemployment. Moreover, he indicated that his symptoms did not present any particular difficulty performing job tasks and he mostly worked through episodes of anxiety. He denied having any reprimands or counseling during his employment. Although the Veteran's former supervisor also noted that the Veteran was easily upset when stressed at work which sometimes caused confrontations between him and other employees, the Veteran overall reported having a good relationship with his supervisors and co-workers while employed. Significantly, the VA examiner in 2011 opined that the Veteran's panic disorder was productive of occasional decreases in work efficiency and productivity, but there was no evidence that these were of sufficient severity to prevent him from securing or maintaining employment. The VA examiner in 2015 determined that the Veteran's psychiatric symptoms were productive of occupational and social impairment with reduced reliability and productivity. As for the effect of the Veteran's symptoms on judgment, thinking, or mood, the Veteran was consistently described as well-groomed with good eye contact. He was cooperative, alert and oriented in all spheres. Speech was normal in rate, tone, and volume, produced with reduced spontaneity. Content of speech was concrete and with sparse details, logical and coherent. Communication was fair but limited by a tendency to not answer questions directly. Mood was described as anxious, depressed and frustrated. Affect was noted as flattened, tired and relaxed. Thought processes were mildly slowed, linear, and goal-directed, with no overt indications of serious thought dysfunction or gross memory impairment. He exhibited no inappropriate behaviors. Upon review of the record, the Board finds the Veteran's symptoms did not result in deficiencies in most areas consistent with a higher 70 percent rating. See Vazquez-Claudio, supra. Indeed, impairment in motivation and mood, judgment, and work and social relationships are all specifically contemplated in the 50 percent rating presently assigned. While the Veteran reported at least two to four anxiety/panic attacks a week, the GAF scores assigned on examination do not suggest that such symptoms impacted the Veteran's functioning to a degree suggesting a higher rating. Indeed, panic attacks greater than once a week are contemplated in the 50 percent criteria, and the Veteran's report of 2 to 4 panic attacks per week lasting 10 minutes to 2 hours does not reflect near constant anxiety such that a higher rating is warranted. Moreover, the GAF scores of 50 and 55 assigned do not reflect that the examiners felt the Veteran experienced deficiencies in most areas, as would be suggested by a GAF score of 40 or less. As such, his claim for a rating in excess of 50 percent is not warranted. The Board has also considered whether the Veteran's disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of extraschedular ratings is warranted. See 38 C.F.R. § 3.321(b)(1) (2015); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The threshold factor for extraschedular consideration is a finding that the established schedular criteria are inadequate to describe the severity and symptoms of the claimant's disability. See Thun v. Peake, 22 Vet. App. 111, 118 (2008). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology and provide for additional or more severe symptoms than currently shown by the evidence. Throughout the appeal, the Veteran's service-connected panic disorder has manifested with symptoms that are contemplated in the applicable rating criteria. With regard to the service-connected panic disorder, for all mental disorders, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant a particular evaluation; they are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). In other words, the schedular criteria for mental disorders contemplate a wide variety of psychiatric manifestations, and the Board has considered all psychiatric symptomatology reflected in the evidence when considering this appeal. Moreover, the schedular criteria specifically allow for occupational impairment (even total occupational impairment) and therefore do not warrant the conclusion that employment impairment renders the Veteran's disability picture exceptional or unusual. Under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a Veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, there are no symptoms caused by service-connected disability that have not been attributed to and accounted for by a specific service-connected disability. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed to the combined effect of multiple conditions. ORDER A rating in excess of 50 percent for panic disorder is denied. REMAND The Veteran seeks a TDIU and contends that he is unemployable due to his panic disorder and coronary artery disease. A TDIU rating may be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). If there is only one such disability, it must be rated at 60 percent or more; if there are two or more disabilities, at least one disability must be rated at 40 percent or more, with sufficient additional disability to bring the combined rating to 70 percent or more. For purposes of TDIU, disabilities of common etiology will be considered a single disability. Id. As the Veteran's coronary artery disease has been found to be secondary to his panic disorder, those disabilities may be considered as a single disability for TDIU purposes. Moreover, the Veteran's panic disorder is evaluated as 50 percent disabling and his coronary artery disease is rated as 10 percent disabling, which combine to a 60 percent rating. Accordingly, he meets the threshold criteria for a TDIU. 38 C.F.R. § 4.16(a). The Veteran retired in 2006 at the age of 62, after 38 years working as a heavy equipment operator. On his TDIU application, he reported that his highest level of education attained was 5th grade, but his original claim for compensation in 1964 listed an 8th grade education. The Veteran was awarded disability benefits from the Social Security Administration (SSA) based on a claim filed in 2006, wherein he reported multiple disabilities caused him to be unable to work, including diabetes, coronary artery disease, mini-stroke, back and shoulder pain, chronic obstructive pulmonary disease, neurological complaints in the extremities, and anxiety. Social Security listed a primary diagnosis of coronary artery disease and a secondary diagnosis of anxiety related disorders. However, the conclusion by SSA included consideration of the Veteran being close to retirement age at 62, and a reported education of 5th grade, rather than 8th grade. While age is a consideration in SSA entitlement, age may not be a factor for determining TDIU. 38 C.F.R. § 4.19. In August 2010, the Veteran's treating physician noted Axis I diagnoses of major depressive disorder, moderate recurrent; anxiety disorder; insomnia and PTSD, and opined that that the Veteran was unable to work even a desk job. By contrast, VA examiners in 2011 and 2015 opined that the Veteran's psychiatric symptoms were productive of no more than occupational and social impairment with reduced reliability and productivity. On VA general examination in May 2011, the examiner opined that the Veteran was able to secure and maintain gainful employment in any capacity requiring sedentary light medium or heavy physical work when considering his service connected conditions of eczema and panic disorder. As the opinions of record are in conflict as to the effect of the Veteran's service connected disabilities on the Veteran's employability, and in light of the recent grant of service connection for coronary artery disease, the Board finds that a medical opinion should be obtained. On remand, relevant ongoing VA treatment records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. Ongoing VA treatment records since April 2015 should be obtained and associated with the claims file. 2. Send the claims file to a VA vocational specialist if available, and if not to a VA physician, to obtain an opinion as to whether the Veteran's service-connected disabilities, when considered together, render him unemployable. If an examination is deemed necessary to respond to this request, one should be scheduled. Following review of the claims file, the reviewer should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's service-connected panic disorder and coronary artery disease, considered together, render him unable to secure or follow a substantially gainful occupation. In rendering this opinion, the examiner should consider the Veteran's limited education of 8th grade and his longtime occupation as a heavy equipment operator, but not his age or nonservice-connected disabilities. The examiner should provide the reasoning for the conclusions reached. 3. After the above has been completed to the extent possible and after undertaking any other development deemed necessary, the AOJ should readjudicate the claim for a TDIU. If the benefit sought remains denied, issue a supplemental statement and allow the appropriate time for response. Then, return the case to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ K.A. BANFIELD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs