Citation Nr: 1610567 Decision Date: 03/16/16 Archive Date: 03/23/16 DOCKET NO. 13-06 376A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to an increased rating in excess of 50 percent for posttraumatic stress disorder (PTSD) prior to June 14, 2013. 2. Entitlement to an increased rating in excess of 70 percent for PTSD from June 14, 2013. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Zi-Heng Zhu, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from November 1967 to November 1969. These matters come before the Board of Veterans' Appeals (Board) on appeal of an April 2011 rating decision of the Portland, Oregon, Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran appealed his rating in a notice of disagreement (NOD). In July 2013, the RO issued a rating decision granting the Veteran's claim for increased rating, and assigned a 70 percent rating for the period from June 14, 2013, the date of his last VA Compensation and Pension (C&P) examination. The RO continued his 50 percent rating for the period prior to June 14, 2013. Subsequently, the Veteran filed a substantive appeal (VA Form 9) to his staged ratings in March 2013. The claims are now appropriately before the Board for adjudication. During the pendency of this appeal, the Veteran, through his representative, raised the issue that the Veteran's service-connected disabilities precluded him from securing or following a substantially gainful occupation. Although the Veteran failed to raise the issue of TDIU in his substantive appeal, the issue is ancillary to the Veteran's claim for increased rating and, therefore, may be considered by the Board. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran presented testimony at a Board videoconference hearing before a Veterans Law Judge (VLJ) on January 5, 2016. A copy of the transcript has been associated with the record. This appeal was processed using the VBMS paperless claims processing system. Accordingly, any future consideration of this Veteran's case should review this electronic record. FINDINGS OF FACT 1. For the entire claims period, the Veteran's service-connected PTSD has been manifested by isolation, sleep difficulties (including nightmares), flashbacks, impaired judgment, hypervigilance, depressed and anxious mood, avoidance, and thoughts of suicide and angry outburst; these symptoms more nearly approximate occupational and social impairment with deficiencies in most areas such as family relations, judgment, thinking, or mood. 2. The Veteran is not currently employed, due to his service-connected PTSD. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for a rating of 70 percent, but not higher, for PTSD, prior to June 14, 2013, have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.21, 4.130, Diagnostic Code (DC) 9411 (2015). 2. The criteria for an increased rating in excess of 70 percent for PTSD, from June 14, 2013, have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.3, 4.21, 4.130, DC 9411. 3. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist VA has satisfied its duties under the Veteran's Claims Assistance Act of 2000 (VCAA) to notify and assist. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2015). The RO provided VCAA notice with respect to the Veteran's claims. As here, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been substantiated, thereby rendering section 5103(a) notice no longer necessary because the purpose the notice is intended to serve has been fulfilled. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 491 (2006). VA's duty to assist under the VCAA includes helping claimants to obtain service treatment records and other pertinent records, including private medical records. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The claims file contains the Veteran's service treatment records, private medical records, and VA medical records. The duty to obtain relevant records is satisfied. See 38 C.F.R. § 3.159(c). VA's duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79 (2006). An adequate examination must consider the issue at hand and provide sufficient analysis for the Board to weigh that examination against others. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). However, "there is no reasons or bases requirement imposed on examiners." Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). Rather, a medical opinion is adequate when it is based on consideration of the veteran's prior medical history and examinations, and the final report describes the disability in sufficient detail so that the Board's "'evaluation of the claimed disability will be a fully informed one.'"Ardison v. Brown, 6 Vet. App. 405, 407 (1994) (quoting Green v. Derwinski, 1 Vet. App. 121, 124 (1991)). The Board finds that the VA examinations provided are adequate under the law. Increased Rating - Generally Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4 (2015). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2015). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. See 38 C.F.R. § 4.2; see also Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. See Powell v. West, 13 Vet. App. 31, 34 (1999). In a claim for a greater original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran's claim is to be considered. In initial rating cases, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); 38 C.F.R. § 4.2 (2015). It is the responsibility of the rating specialist to interpret reports of examination in the 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 present. See 38 C.F.R. § 4.2. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3. 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 general, all disabilities, including those arising from a single disease entity, are rated separately, and disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In accordance with 38 C.F.R. §§ 4.1, 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the Veteran's service-connected disability. The Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether the Veteran raised them, as well as the entire history of his disability in reaching its decision. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Increased Rating - PTSD, Prior to June 14, 2013 The Veteran asserts that the severity of his PTSD, prior to June 14, 2013, warrants a higher rating than his currently assigned 50 percent. Specifically, the Veteran contends that his PTSD has caused him to be estranged from his family and friends, causes anxiety and depression, disturbed sleep, as well as angry uncontrollable outbursts, and suicidal thoughts. The Board notes that a review of the evidence of record, to include a VA Compensation and Pension (C&P) examination from June 2011, treatment records, and lay statements, reveals evidence that the Veteran's condition, during that period, was productive of occupational and social impairments with deficiencies in most areas such as work, family relationships, judgment, and mood, as well as an inability to establish and maintain effective relationships. Therefore, the Board finds that the Veteran's condition warrants a higher 70 percent rating, but not higher, under Diagnostic Code 9411, prior to June 14, 2013, and as such, the Veteran's claim for a higher rating for this relevant time period must be granted. The Veteran's PTSD is evaluated pursuant to Diagnostic Code 9411. The criteria for rating psychiatric disabilities other than eating disorders are set forth in a general rating formula. See 38 C.F.R. § 4.130, General Rating Formula for Mental Disorders. A 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence) spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. A 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of 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. 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. See 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. 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 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (5th ed. 1994) (DSM-V). The United States Court of Appeals for the Federal Circuit acknowledged the "symptom-driven nature" of the General Rating Formula and that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The Federal Circuit has explained that "'symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Id. at 117. The Court has held that Global Assessment of Functioning (GAF) scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed.) (DSM-IV), p. 32). Scores ranging from 51 to 60 reflect 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). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). Id. Words such as "moderate," "moderately severe" 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. Use of terminology such as "severe" by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a). When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). During the relevant time period, in June 2011, the Veteran was afforded a VA C&P examination to assess the nature and severity of his already service-connected PTSD. As part of his evaluation, the VA examiner conducted an in-person interview of the Veteran. Upon evaluation, the examiner determined an Axis I diagnosis of PTSD, with depression and substance abuse. The examiner noted that the Veteran's psychological condition had dramatically worsened since his retirement less than nine month prior to that examination. The Veteran's worsening symptoms include panic attacks, severe sleep disturbance, hypervigilance, anxiety, and avoidance, with severe depression and no energy. Most significantly, the examiner noted that the Veteran was extremely tense and anxious regarding his anger and temperament, especially with regards to outbursts, of which the Veteran noted could result in potentially hurting someone, to include one of his loved ones. Indeed, the Veteran consistently expressed his fear that of hurting someone, even his children and wife. While there is no evidence that the Veteran has ever resorted to violence, he seems to be extremely nervous that such could happen; and as a result the Veteran was described as being on eggshells all the time, which significant stress and anxiety. The examiner concluded that the resulting effect has been estrangement from his immediate and extended family, and isolation from nearly all social contact, to include work. The examiner also noted that the Veteran has also thought about suicide. Specifically, the Veteran, while having no plans to take his own life, says that he has thought about doing so. However, during the interview, the Veteran explained that if nothing changes in the quality of his life that he would eventually commit suicide. In analyzing the totality of the of the Veteran's examination and medical history, the examiner ultimately concluded that the Veteran's condition was indicative of a GAF score of 50, and describes the Veteran's condition as having profound problems with social and familial relationship, as well as self-esteem. While the examiner did not provide a conclusion in which specifically matches the language outlined under the appropriate diagnostic code, the Board finds that the description of the severity of the Veteran's condition is productive of occupational and social impairment with reduced reliability and productivity, warranting a 70 percent rating. As noted above, a 70 percent rating requires occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Here, the Board notes that there is no question that the Veteran suffers severe impairment to both his social and occupational life because of his symptoms such as angry outbursts, depression, irritability, excessive drinking and substance dependence. The Veteran also was noted having problems with his family, keeping them at a distance and isolating himself for fear of what he might do when he "lose it" around them. The June 2011 examiner also noted extremely depressed mood, with no energy because of disturbed sleep and severe panic attacks and flashback. Indeed, the VA examiner afforded the Veteran's condition a GAF score of only 50, which is indicative of serious impairments in social, occupational or school functioning, and finally described the Veteran as having "profound problems" with social and familial relationships. While such symptoms are not exhaustive of the symptoms cited in the appropriate diagnostic code for a 70 percent rating, such is not necessary to establish that level of disability. See Mauerhan, supra. As such, the Board finds that the symptoms and their effects outlined in the June 2011 VA examination report is sufficient to demonstrate that the Veteran's PTSD did rise to the level of severity in which a 70 percent rating is warranted. A review of the VA treatment records during the relevant time period does not reveal any significant analysis regarding the severity of the Veteran's condition. While the Veteran's accounts of suicidal ideations during such treatment records are inconsistent, the Board finds that such psychiatric reviews are too brief to outweigh the probative value of those opinions provided in a VA psychiatric examination described above. Indeed, these treatment records do not even show any analysis or reviews were done on the Veteran's claims file or medical history. The June 2011 examination, therefore, remains the most comprehensive analysis of the severity of the Veteran's PTSD, and as such carries the most probative weight. Consequently, the Board finds that the Veteran's condition, during the relevant period prior to June 14, 2013, was productive of occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, and warrants a 70 percent rating. A 100 percent rating is not warranted as the Veteran's condition does not manifest in a total occupational and social impairment, as the Veteran is still married, and maintains some semblance relationship with his family and kids. There is also no evidence of a gross inability to interact with the public, as he is still is able to maintain an independent lifestyle, and has shown that he is cognizant of the effects of his disability. Therefore, the Board finds the Veteran's disability picture does not more nearly approximate total occupational and social impairment. Increased Rating - PTSD, From June 14, 2013 As part of his claim for increased rating, the Veteran, through his representative, during his January 2016 hearing before the undersigned VLJ, noted that he would like to pursue a rating in excess of 70 percent for the period after June 14, 2013. A review of the Veteran's claims file, to include another VA C&P psychiatric examination in June 2013, VA treatment records, and lay statements from friends and family, does not reveal that the Veteran's PTSD was productive total occupational and social impairment during the relevant time period. Therefore, as the preponderance of evidence is against the finding for a higher rating, the Board finds that the Veteran's claim for a rating in excess of 70 percent for his service-connected PTSD must be denied. Under the appropriate diagnostic code, a 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions of 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. The Veteran was afforded another VA C&P examination in June 2013. During that examination the examiner concluded that the Veteran suffered from much of the same symptoms described by the March 2011 examination. Specifically, the examiner pointed out that the Veteran was not a social person, and was very isolated to include from his immediate family and friends. This was again due to the Veteran's fear of uncontrolled outbursts and his irritability. The Veteran was noted to "blow-up" at friends and family with unprovoked irritability and impaired impulse control, and with increased frequency. As a result, the Veteran was noted to have few friends and a similarly estranged relationship with his family as before. The examiner noted that while the Veteran was in significant distress regarding potentially hurting someone, and his outbursts, the Veteran noted no actual incident of violence. The report also noted that the Veteran had started working in woodwork and carpentry, of which he has been somewhat successful in completing some training. However, the Veteran expressed that he still had suicidal thoughts without any plans. Overall, the examiner noted that his condition and symptoms has worsened since his last examination, and required in-patient care. The examiner ultimately concluded an Axis I diagnosis for PTSD, and noted that the Veteran suffered from significant social and occupational impairments with reduced reliability and productivity. The examiner also gave the Veteran a GAF score of 48, which is productive of serious impairments in social, occupational or school functioning. As noted above, a 100 percent rating under the appropriate diagnostic code is productive of a total occupational and social impairment; some symptoms include gross impairment to thought process, disorientation of place, time, and people to include remembering family member's names, and gross inappropriate behavior. Here, the Veteran has exhibited no such traits, during his examinations or as described by the lay statements from his friends and family. During his examinations, the Veteran has never shown to be disoriented to where he was or what he was doing. Neither examiners noted any gross impairment to the Veteran's memory, or ability to remember the names of his family, nor can identify any grossly inappropriate behavior. While the Veteran may have expressed some suicidal thoughts, and his constant fear of hurting someone during his outbursts, such has yet to happen. Throughout the claims period, there has been no evidence of actual violence against other people, or any evidence of him hurting himself. Finally, the mere fact that the Veteran has repeatedly expressed his desire to stay away from people because of fear of hurting them, demonstrates his judgment and thought process is not grossly impaired. Additionally, a review of the available VA treatment records reveal no additional information in which demonstrates a psychiatric condition indicative of complete impairment in social and occupational settings. In fact, a July 2013 treatment record showed improving symptoms after further psychiatric treatments by the VA, with some participation in social/family events, and church activities. Likewise, a review of those lay statements from the Veteran's friends, family, and boss demonstrates a severe condition of isolation, anger, and anxiety, with panic attacks and flashback, but none of such suggests a condition so severe as to be productive of complete social and occupational impairment. Most of such statement revolved around how the Veteran has changed and how he cannot hear fireworks of he would suffer from severe flashbacks and panic attacks. Finally, the Board notes that during his hearing before the undersigned in January 2016, the Veteran was not only corporative, but oriented with where he was, and was able to communicate with the VLJ. To this end, the Veteran spoke to his hobbies such as his woodwork and carpentry, as well as increased interaction with his family and his church. Again, the Board finds that such evidence does not show a total social and occupational impairment. Therefore, the Board finds that the preponderance of the evidence remains against the finding that the Veteran's condition is productive of total social and occupational impairment, and a rating in excess of 70 percent is not warranted. As such, the doctrine of benefit-of-the-doubt is inapplicable, and the Veteran's claim for an increased rating must be denied. Extraschedular Consideration The rating schedule represents, as far as is practicable, the average impairment of earning capacity. Ratings will generally be based on average impairment. See 38 C.F.R. § 3.321(a), (b). In exceptional cases, an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of this VA regulation, for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of his disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board has considered whether the Veteran's disabilities present 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 an extraschedular rating is warranted. See 38 C.F.R. § 3.321(b)(1) (2014); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996). The Veteran's service-connected PTSD, decided herein, is manifested by symptoms that are fully contemplated by the rating schedules. The evidence does not show such an exceptional disability picture that the available schedular evaluations for the Veteran's service-connected disabilities are inadequate. A comparison between the level of severity and symptomatology of the Veteran's disorders with the established criteria shows that the rating criteria reasonably describe the Veteran's disability levels and symptomatology. Therefore, those criteria are not inadequate, and referral for extraschedular consideration is not warranted. 38 C.F.R. § 3.321(b); Thun v. Peake, 22 Vet. App. 111 (2008). Further, the Board notes that under Johnson v. McDonald, 2013-7104, 2014 WL 3562218 (Fed. Cir. Aug. 6, 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, in this case, after applying the benefit of the doubt under of Mittleider v. West, 11 Vet. App. 181 (1998), there are no additional service-connected disabilities that have not been attributed to a specific service-connected conditions. 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 only to the combined effect of multiple conditions. TDIU A TDIU requires impairment so severe that it is impossible for the average person to obtain and maintain a substantially gainful occupation. Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or impairment caused by disabilities that are not service connected. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19 (2015). In making this determination, the critical inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). If there is only one service-connected disability, it must be ratable at 60 percent or more. If there are two or more service-connected disabilities, at least one must be ratable at 40 percent or more with sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). A total disability rating may also be assigned on an extra-schedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). As the Veteran has a rating of 70 percent for PTSD, to include the relevant period granted herein, the Veteran meets the percentage requirement for the schedular criteria for a TDIU. 38 C.F.R. § 4.16(a). The Board finds that the evidence of record reveals that the Veteran has been precluded from obtaining and maintaining a substantially gainful occupation consistent with his education and work experience as a result of his service-connected disabilities. The Board notes that Veteran is currently service-connected for three disabilities, to include diabetes mellitus, type II, erectile dysfunction, and PTSD. The Veteran, through his representative, has claimed that although the Veteran retired in 2010, he could no longer work due to his service-connected conditions, specifically his PTSD. To this end, during the Veteran's June 2013 VA psychiatric examination, the examiner noted that the Veteran left his job, or retired, from his last job at the phone company because he started having angry and uncontrolled outbursts on a regular basis at work prior to him retiring. The examiner noted that the Veteran's condition caused him to be uncontrollably irritable and to blow-up at his co-works. Indeed, the Veteran's irritability has been noted throughout the claims period, and has resulted to not only in problems at his work, but also the source of his severe impairment in social activities. In his earlier March 2011 VA examination, the examiner noted that his irritability and outbursts results in "profound" social impairment. While neither VA examiner specifically spoke to the Veteran's ability to work, or the exact functional impairment his service-connected disability could have on employment, the Board finds that the examiner's descriptions of "profound" and significant social and occupational impairment to be sufficient to demonstrate the Veteran's inability to obtain or retain gainful employment. The Board also notes that among the lay statements provided by the Veteran's friends and family, in support of his claim, was a statement provided by the Veteran's old manager, J. L., prior to his retirement. The statement codifies the analysis provided directly above, in that she describes the Veteran's irritability affecting the Veteran's effectiveness and ability to perform at his job. Specifically, she describes incidents where the Veteran had an outburst at customers and co-works, to include a supervisor, with threats of violence, and then would just walk off. See Statement by J. L., dated June 12, 2013. Other statements from family and friends echo the Veteran's problems with irritability and anger, to also include his excessive drinking, which the VA examiners have attributed to his PTSD. Therefore, the Board finds that in viewing the totality of the Veteran's psychiatric disability, to include lay statement from his friends and family, and VA examinations, that the Veteran's service-connected PTSD prevents him from obtaining and retaining gainful employment. As such, given the evidence above, a TDIU is warranted. ORDER Entitlement to an increased rating of 70 percent, but not higher for PTSD, prior to June 14, 2013, is granted. Entitlement to an increased rating in excess of 70 percent for PTSD, from June 14, 2013, is denied. Entitlement to a TDIU is granted. ____________________________________________ BRADLEY W. HENNINGS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs