Citation Nr: 1614443 Decision Date: 04/08/16 Archive Date: 04/25/16 DOCKET NO. 08-06 462 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to an increased rating for post-traumatic stress disorder (PTSD), currently rated as 50 percent disabling. 2. Entitlement to rating in excess of 50 percent for bilateral hearing loss from February 21, 2014. 3. Entitlement to a compensable rating for bilateral hearing loss prior to February 21, 2014. 4. Entitlement to a total rating based on individual unemployability due to service connected disabilities (TDIU) prior to May 7, 2013. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran had active duty from August 1967 to December 1972. This matter comes before the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Columbia, South Carolina, regional office (RO) of the Department of Veterans Affairs (VA). This matter was before the Board in February 2012, when it was remanded for further development. It has been returned for additional appellate consideration. The evaluation of the Veteran's hearing loss was increased to 50 percent during the course of this appeal, effective from February 21, 2014. A veteran is generally presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). Therefore, this matter remains on appeal. The Board notes that it has assumed jurisdiction of the claim for TDIU prior to May 7, 2013, because such claim has been raised by the record and by the Veteran. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The issue of entitlement to a compensable rating for bilateral hearing loss prior to February 21, 2014 is addressed in the REMAND portion of the decision below and is REMANDED to the agency of original jurisdiction (AOJ). FINDINGS OF FACT 1. Throughout the rating period on appeal, the Veteran's PTSD has been productive of occupational and social impairment with deficiencies in most areas, due to symptoms that include sleep problems and nightmares; flashbacks; intrusive thoughts; hypervigilance; exaggerated startle response; difficulty being around others; and irritability, with previous reports of suicidal ideations and attempts at self-harm. 2. As of February 21, 2014, the Veteran has Level VI hearing for the right ear and Level XI hearing for the left ear. 3. The Veteran's service connected disabilities include coronary artery disease, PTSD, bilateral hearing loss, bilateral tinnitus, scars of the chest and left leg due to coronary artery bypass surgery, degenerative joint disease of the right knee, and degenerative joint disease of the left knee; he has had a combined rating of at least 70 percent from August 2007, with a rating of 50 percent or higher for PTSD. 4. The Veteran has not been able to obtain or maintain gainful employment due to his service connected disabilities since June 30, 2009. CONCLUSIONS OF LAW 1. The criteria for a 70 percent rating, but no higher, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2014); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.130, Code 9411 (2014). 2. The criteria for a rating in excess of 50 percent for bilateral hearing loss from February 21, 2014 have not been met. 38 U.S.C.A. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.85, Codes 6100 (2014). 3. The criteria for a total rating based on individual unemployability due to service connected disabilities have been met from June 30, 2009; they were not met prior to that date. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2014); C.F.R. § 3.159(b)(1) (2015). Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this case, the Veteran was provided with complete VCAA notification for the claim for an increased rating for hearing loss in a June 2007 letter that contained all the information required by Pelegrini v. Principi, 18 Vet. App. 112 (2004) and Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). This was provided before the initial adjudication of his claim. Complete VCAA notification for the increased rating for PTSD was provided in a March 2008 letter. This was also provided before the initial adjudication of the claim. The duty to notify has been met. The Board also finds that the duty to assist has been met. The Veteran has been afforded numerous VA examinations of his disabilities, including audiological and psychiatric examinations that were ordered by the February 2012 remand. The Board recognizes that this remand requested that the Veteran be afforded ABR frequency specific testing at his audiological examination. This does not appear to have been done. However, the purpose of this testing was to obtain a usable audiological examination, as multiple previous examinations were determined to be unusable for rating purposes. As a usable audiological examination was obtained in February 2014 without the ABR frequency specific testing, the Board finds that this constitutes substantial compliance. The other development requested in the remand has been completed, to include obtaining clarification regarding the reliability of the private audiological examinations and comments on these examinations from the VA examiner. The Veteran's VA treatment records have also been obtained. He has not identified any other pertinent private medical records, and he has declined his right to a hearing. There is no indication that there is any relevant evidence outstanding in these claims, and the Board will proceed with consideration of the Veteran's appeal. Increased Ratings The evaluation of service-connected disabilities is based on the average impairment of earning capacity they produce, as determined by considering current symptomatology in the light of appropriate rating criteria. 38 U.S.C.A. § 1155. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, the entire history of the veteran's disability is also considered. Consideration must be given to the ability of the veteran to function under the ordinary conditions of daily life. 38 C.F.R. § 4.10. If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board will consider whether or not a staged rating is appropriate for the period on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). PTSD Entitlement to service connection for PTSD was granted in an April 2007 rating decision. A 50 percent rating was assigned effective from December 22, 2005. In February 2008, the Veteran, through his representative, noted that he believed a February 2008 psychiatric consultation demonstrated an increase in severity in his PTSD, and he submitted his claim for an increased rating. The veteran's PTSD is evaluated under the General Rating Formula for Mental Disorders. Under this formula, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as gross impairment in thought process or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, or memory loss for names of close relatives, own occupation or own name. A 70 percent evaluation is merited 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 that is 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 an inability to establish and maintain effective relationships. The current 50 percent evaluation is warranted for 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. 38 C.F.R. § 4.130, Code 9411. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but 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). On the other hand, if the evidence shows that the Veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan v. Principi, at 443. The Court of Appeals for the Federal Circuit has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The nomenclature employed in the rating schedule is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (also known as "the DSM-IV"). 38 C.F.R. § 4.130 (2015). The DSM-IV contains a Global Assessment of Functioning (GAF) scale, with scores ranging between zero and 100 percent, representing the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health-illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). The DSM-IV contemplates that the GAF scale will be used to gauge a person's level of functioning at the time of the evaluation (i.e., the current period) because ratings of current functioning will generally reflect the need for treatment or care. While GAF scores are probative of the Veteran's level of impairment, they are not to be viewed outside the context of the entire record. Therefore, they will not be relied upon as the sole basis for an increased disability evaluation. The Board notes VA implemented DSM-V, effective August 4, 2014. The Secretary, VA, has determined, however, that DSM-V does not apply to claims certified to the Board prior to August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). Since the Veteran's appeal was certified to the Board prior to August 4, 2014, DSM-IV is still the governing directive for his appeal. Turning to the evidence of record, The February 2008 VA treatment referenced by the Veteran in his claim includes a suicide assessment which determined that he was at low risk for suicide. He reported poor sleep with nightmares. He had weekly nightmares of his experiences in Vietnam. Intrusive memories also persisted. He checked doors and locks regularly. The Veteran sometimes felt on guard and occasionally had trouble with crowds. Loud noises bothered him and he was easily startled. He was not a worrier but reported anxiety after nightmares. He also reported hearing noises that were not really there, but denied hearing voices and was vague when questioned about paranoia. He denied a history of violence. The Veteran went to church and socialized with other church members. On mental status examination, the Veteran was casually dressed and well groomed. He had trouble hearing everything the examiner said, which did not appear to be feigned. His motor functions and speech were within normal limits. The Veteran was pleasant and cooperative, and had good eye contact. His mood was okay and his affect was mildly constricted. The Veteran denied suicidal and homicidal ideations. He was coherent and linear, and his judgment and insight were fair. The diagnosis was chronic PTSD, and the examiner assigned a score of 51 on the Global Assessment of Functioning (GAF) scale. The examiner noted the Veteran had never had a trial of medication and determined that he would give the Veteran a low dosage trial prescription. 2/29/2008 VBMS entry, Medical Treatment Record - Government Facility at pp. 6-12. The Veteran was afforded a VA PTSD examination in April 2008. The claims folder was reviewed by the examiner. The Veteran reported difficulty sleeping and insisted he got two to three hours each night but he denied napping. He reported nightmares almost every night, which would wake him up. He had begun using medications about one month ago. He reported having experienced suicidal ideation and trying to harm himself by banging his head against the wall. He also reported homicidal ideations at nobody in particular. The Veteran was not working and had stopped the previous year due to health reasons. He had been married for 40 years. On mental status evaluation, the Veteran was adequately dressed and groomed. His speech was limited and he gave vague responses with long response latencies. However, he was alert and oriented. He denied current suicidal or homicidal ideation, and was not exhibiting perceptual or thought disorders. His affect was blunted and his mood dysphoric. The diagnosis was PTSD and the GAF was 55. The examiner remarked that the Veteran was reporting symptoms that were consistent with PTSD but he was unwilling or unable to describe these symptoms. This made the examiner unable to determine if the Veteran was any better or worse. The Veteran underwent an additional VA examination in May 2009. The claims folder was reviewed by the examiner. The Veteran reported flashbacks when he smells diesel fuel and intrusive thoughts when it was raining. He was isolated and withdrawn from others. He continued to have poor sleep with difficulty initiating and maintaining sleep. His spouse was at the examination. She reported restless sleep and said the Veteran would often tell her he was dreaming of Vietnam. He would hide during lightning strikes and was hypervigilant to unexpected noise. He had a depressed mood. The Veteran reported a distant relationship with his wife and son. On mental status examination, the Veteran was poorly dressed and groomed. He was relatively disorganized at first, although he was able to organize his thoughts and present himself better as the interview progressed. The Veteran's speech was limited, and his thought process was coherent and goal directed. There was no evidence of any thought or perceptual disorder. The diagnosis was PTSD, and the GAF was 48. The examiner summarized that the Veteran continued to experience significant impairment in social and occupational functioning due to his PTSD. In a May 2009 statement from the Veteran's wife, she described his difficulty with sleeping and his nightmares. She also noted that he was short tempered. 5/26/2009 VBMS entry, Buddy/Lay Statement. At an April 2013 VA examination, the examiner found that the current diagnoses were PTSD and dementia, not otherwise specified. The Veteran reported having nightmares of Vietnam, intrusive thoughts, hypervigilance, exaggerated startle response, difficulty being around others, and irritability. There were no current suicidal or homicidal ideations. The dementia was productive of memory problems. The examiner opined that the Veteran's disability was productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The examiner noted it was possible to distinguish between the levels of impairment caused by each of the Veteran's diagnoses. He said that the Veteran's PTSD was productive of moderate to severe occupational and social impairment, and the dementia was productive of severe occupational and social impairment. The current GAF due to PTSD was 50; with consideration of the dementia the GAF was 45. A February 2014 VA psychological examination notes that the Veteran has diagnoses of more than one mental disorder, but that it was possible to differentiate what symptoms were attributable to each diagnosis. The examiner stated that the Veteran's dementia resulted in severe impairment, and the PTSD resulted in moderate to considerable impairment. The Veteran reported intrusive memories, distressing dreams, psychological distress at reminders of his traumatic events, avoidance of these reminders, feelings of anger or guilt, feelings of detachment from others, irritability, exaggerated startle response, problems with concentration, and sleep disturbance. The examiner observed that the Veteran's mood was dysphoric and his affect congruent, his speech had a regular rate and rhythm, his thought process was circumstantial, there was mild evidence of psychomotor agitation, and he demonstrated memory problems. The Veteran denied suicidal and homicidal ideations. The examiner did not believe he was competent to handle his affairs. The examiner opined that the Veteran's PTSD alone did not render him unable to secure or maintain substantially gainful employment but did result in reduced reliability in the work setting. Other disabilities such as dementia and hearing loss also negatively impacted his ability to work, with the dementia resulting in the more severe impairment. The VA psychiatrist who conducted the February 2008 consultation has continued to treat the Veteran on a periodic basis, and notes he has seen the Veteran on at least 17 occasions through 2014. These records show that the Veteran has displayed a consistent symptomatology throughout this period. A July 2014 consultation is typical, in that the Veteran complained of problems sleeping at night. He also reported being on guard most of the time. He enjoyed going out for walks. The mental status examination reads almost exactly the same as the previous entries. It says that the Veteran was well groomed. His motor functions and speech were within normal limits, and he was pleasant and cooperative. The examination report has conflicting statements regarding eye contact, stating initially that there was little eye contact but stating there was good eye contact only a few sentences later. His mood was down, and his affect was mildly constricted. He denied suicidal and homicidal ideations. His memory was impaired and his insight and judgment were fair. The diagnoses were Other Specified Neurocognitive Disorder, and PTSD. An addendum notes that the examiner found that the Veteran was incapable of working, and he states in the original report that he has held this view since November 2011. 6/8/15 VBMS entry, Capri - p. 57. A GAF score was not assigned at the July 2014 consultation. However, GAF scores were assigned by this examiner during previous visits and varied very little throughout the appeal period. For example, a May 2008 entry provides a GAF score of 51, 6/8/15 VBMS entry, Capri - p. 531; the GAF was 50 in February 2009, 6/8/15 VBMS entry, Capri - p. 502; 45 in June 2009, 6/8/15 VBMS entry, Capri - p. 461; 45 in January 2010, 6/8/15 VBMS entry, Capri - p. 442; 45 in May 2010, 6/8/15 VBMS entry, Capri - p. 428; 45 in July 2010, 6/8/15 VBMS entry, Capri - p. 404; 50 in October 2011, 6/8/15 VBMS entry, Capri - p. 320; 50 in November 2011; 6/8/15 VBMS entry, Capri - p. 304; 50 in January 2012, 6/8/15 VBMS entry, Capri - p. 296; 45 in October 2012, 6/8/15 VBMS entry, Capri - p. 229; 45 in March 2013, 6/8/15 VBMS entry, Capri - p. 216; and 45 in July 2013, 6/8/15 VBMS entry, Capri - p. 163. Private treatment records dating from November 2014 to December 2014 show the Veteran had daily flashbacks to Vietnam. He was also under treatment for delusional thoughts. Insight and judgment were fair, and perception was normal. Recent memory was poor and remote varied. Thought and speech were normal, and the Veteran was oriented. His affect was constricted. The Veteran reported that he was able to sleep. 6/1/2015 VBMS entry, Medical Treatment Record - Non- Government Facility, pp. 1-2, 7-8. After careful consideration, the Board finds that entitlement to a 70 percent rating for PTSD is warranted for the entire period on appeal. The Veteran's symptoms have consistently included sleep problems and nightmares. Flashbacks were reported in May 2009, and were said to occur daily in 2014. The Veteran has also shown tendencies to isolate himself from family and friends, although not completely. Other symptoms have included intrusive thoughts, hypervigilance, exaggerated startle response, difficulty being around others, and irritability. He reported suicidal ideations and attempts at self-harm in April 2008 although he has denied these symptoms on all subsequent occasions. While the Veteran was given the additional diagnosis of dementia during the course of this appeal, VA examiners state that they are able to distinguish the symptoms of that disability and the service connected PTSD. The February 2014 examiner found that PTSD was productive of occupational and social impairment with reduced reliability and productivity, which is consistent with the current 50 percent rating. However, previous examiners have characterized the occupational and social impairment due to PTSD as "significant" in May 2009, and moderate to severe in April 2013. Furthermore, the majority of GAF scores recorded in this period fall within the 45 to 50 range, including the two most recent. This signifies 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)." Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). When considered as a whole, and resolving all doubt in the Veteran's favor, the Board finds that his symptomatology more nearly resembles the occupational and social impairment with deficiencies in most areas required for a 70 percent rating. 38 C.F.R. §§ 4.7, 4.130, Code 9411. The Board has considered entitlement to a 100 percent rating, but this has not been demonstrated. A 100 percent rating requires total social impairment, but the evidence shows that the Veteran has been married for over 40 years. He also maintains a relationship with his son, attends his church, and sometimes socializes with other church members. This evidence does not support a finding of total social impairment and precludes a 100 percent rating. 38 C.F.R. §§ 4.7, 4.130, Code 9411. Hearing Loss Entitlement to service connection for hearing loss was established in a September 2006 rating decision. A noncompensable rating was assigned. The claim for an increased rating was received in May 2007. A June 2015 rating decision increased the evaluation to 50 percent, effective from February 21, 2014. An examination for hearing impairment must be conducted by a state-licensed audiologist and must include a controlled speech discrimination test (Maryland CNC) and a puretone audiometry test. Examinations are to be conducted without the use of hearing aids. To evaluate the degree of disability from defective hearing, the rating schedule establishes 11 auditory acuity levels from Level I for essentially normal acuity through Level XI for profound deafness. These are assigned based on a combination of the percent of speech discrimination and the puretone threshold average, as contained in a series of tables within the regulations. The puretone threshold average is the sum of the puretone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four. 38 C.F.R. § 4.85; Table VI and Table VII; 4.87, Codes 6100, 6101. When the puretone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Each ear will be evaluated separately. When the puretone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. That numeral will then be elevated to the next higher Roman numeral. Each ear will be evaluated separately. 38 C.F.R. § 4.86. A VA examination that was reliable for rating purposes was obtained on February 21, 2014. For the right ear, the Veteran had puretone thresholds of 50, 70, 80, and 80 decibels at 1000, 2000, 3000, and 4000 Hertz, respectively. The left ear had puretone thresholds of 60, 100, 105, and 105 at these same frequencies. The average threshold for the right ear was 70 and the average threshold for the left ear was 93. The test results were deemed valid for rating purposes. On speech discrimination testing, the right ear scored 72 percent. The left ear was zero percent. The Board finds that entitlement to a rating in excess of 50 percent for bilateral hearing loss from February 21, 2014 is not warranted. When applied to 38 C.F.R. § 4.85; Table VI, the results of the February 2014 examination translate to Level VI hearing for the right ear and Level XI hearing for the left ear. This results in a 50 percent rating under 38 C.F.R. § 4.85; Table VII. The Board has considered the provisions of 38 C.F.R. § 4.86 in reaching this decision. This is of no benefit to the Veteran. Each ear is to be evaluated separately, and the right ear does not qualify for this provision as not all puretone thresholds are 55 or higher, or 30 decibels or lower at 1000 Hertz and 70 decibels or higher at 2000 Hertz. For the left ear, the puretone thresholds translate to Level XI hearing under both Table VI and Table VIA. It follows that the Veteran merits a 50 percent rating under either provision. At this juncture, the Board acknowledges Martinak v. Nicholson, 21 Vet. App. 447 (2007), in which the Court held that, in addition to dictating objective test results, a VA audiologist must fully describe the functional effects caused by a hearing disability in the final examination report. Id. at 455. In this regard, on the February 2014 VA examination, the examiner indicated that the Veteran's hearing loss impacted the ordinary conditions of daily life, including difficulty hearing and understanding conversational speech. Thus, the examiner is deemed to have been adequately responsive to Martinak. In any event, as noted above, the schedular rating for hearing loss is dictated by the application of the tables found at 38 C.F.R. § 4.85, and such fail to establish entitlement to a rating higher than 50 percent, as demonstrated above. Extraschedular Considerations Consideration has been given regarding whether the schedular evaluation is inadequate for the Veteran's service connected disabilities, thus requiring that the RO refer a claim to the Under Secretary for Benefits or to the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2015); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1); Thun, 22 Vet. App. at 116. The schedular evaluation in this case is not inadequate for either the PTSD or the hearing loss. The Board notes that all symptoms are considered in the evaluation of psychiatric disabilities regardless of whether or not they are listed in the rating schedule. See Mauerhan. As for hearing loss, the Veteran has not reported any symptoms other than difficulty hearing, the severity of which was evaluated by the testing conducted in February 2014. Accordingly, referral for consideration of an extra-schedular rating is not warranted. Further, applying the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there are no symptoms for the disabilities on appeal that have not been attributed to a specific service-connected condition. Furthermore, TDIU has been awarded from May 7, 2013. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate for a disability that can be attributed only to the combined effect of multiple conditions. Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Entitlement to TDIU Prior to May 7, 2013 A claim for TDIU is considered a component of a claim for an increased rating, if raised by the record or the Veteran. Although the Veteran's formal claim for TDIU was not received until May 7, 2013, there is medical evidence that raises the question of employability prior to that date. Therefore, the Board must consider entitlement to TDIU before May 7, 2013. See Rice. TDIU 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, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). The record shows that the Veteran met the scheduler criteria for TDIU even before the increase rating to 70 percent for PTSD granted in this decision. His service connected disabilities include coronary artery disease, PTSD, bilateral hearing loss, bilateral tinnitus, scars of the chest and left leg due to coronary artery bypass surgery, degenerative joint disease of the right knee, and degenerative joint disease of the left knee. He has had a combined rating of 70 percent since August 2007, and his PTSD has been rated as at least 50 percent disabling from December 2005. The remaining question concerns whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. See 38 C.F.R. § 4.16(a). The fact that a veteran is unemployed or has difficulty finding employment does not warrant assignment of a TDIU alone as a high rating itself establishes that his disability makes it difficult for him to obtain and maintain employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Rather, the evidence must show that he is incapable "of performing the physical and mental acts required" to be employed. See Van Hoose, 4 Vet. App. at 363. Thus, the central question is "whether the [V]eteran's service connected disabilities alone are of sufficient severity to produce unemployability," and not whether the Veteran could find employment. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to a veteran's education, training, and special work experience, but not to his age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361, 363. The April 2008 VA PTSD examination states that the Veteran was not currently working. He reported that he had stopped working the previous year for health reasons. When asked to explain this statement, he said that he had difficulty in understanding what was required of him. However, the examiner did not provide an opinion regarding the Veteran's employability. As noted earlier, the Veteran has been followed for his PTSD by the same VA examiner since February 2008. After a June 30, 2009 psychiatric consultation, the examiner opined that the Veteran was not capable of obtaining or maintaining employment at this time. 6/8/15 VBMS entry, Capri - p. 464. He repeated this opinion at a May 24, 2010 consultation. 6/8/15 VBMS entry, Capri - p. 432. In a July 2014 treatment record he notes that he had considered the Veteran incapable of working since November 2011. 6/8/15 VBMS entry, Capri - p. 57. At the April 2013 VA PTSD examination, the examiner opined that the Veteran's PTSD alone did not render the Veteran unable to secure or maintain substantially gainful employment. However, it was noted that the Veteran had other significant limitations due to his dementia and hearing impairment. The Board observes that hearing loss is a service connected disability. The Board finds that the evidence supports entitlement to TDIU from June 30, 2009. This is the date that the VA psychiatrist who was the Veteran's regular care provider first opined that he was not capable of obtaining or maintaining employment. The Board observes that the nonservice-connected diagnosis of dementia was not yet entered at the time of this opinion or the May 24, 2010 opinion. There is no subsequent medical opinion that directly contradicts this finding, and entitlement to TDIU is established. The Board has considered entitlement to TDIU prior to June 30, 2009, but this is not supported by the evidence. Although the April 2008 examiner noted that the Veteran had not worked since the previous year, there was no opinion stating that he was unemployable, and he had made no such assertion. The Board observes that the same VA psychiatrist who provided the opinion finding the Veteran was unemployable has been treating him on a regular basis since February 2008, but did not find that he was unemployable until June 30, 2009. Entitlement to TDIU prior to that date is not warranted. 38 C.F.R. § 4.16(a). ORDER Entitlement to a 70 percent rating for post-traumatic stress disorder is granted. Entitlement to rating in excess of 50 percent for bilateral hearing loss from February 21, 2014 is denied. Entitlement to a total rating based on individual unemployability due to service connected disabilities from June 30, 2009 is granted. REMAND In part, the February 2012 remand requested that the RO take appropriate action to clarify whether or not Maryland CNC speech discrimination tests were used on private hearing examinations in April 2007, March 2008, and January 2010. The hearing thresholds were to also be clearly documented, and the reliability of the audiograms discussed. This had been accomplished, and replies received in December 2012 and January 2013 indicate that speech discrimination tests were not performed. Subsequently, the report of another private audiological examination dated May 8, 2013 was submitted by the Veteran. A preliminary review by the Board shows that this examination includes word recognition testing, and raises the possibility of a compensable rating prior to February 21, 2014. Unfortunately, the puretone thresholds are provided in chart form, and the results are not discernable to a layman at all of the required frequencies. Furthermore, there is no indication as to whether or not the word recognition testing was the required Maryland CNC speech discrimination test. Therefore, the findings of this report must also be clarified. See Savage v. Shinseki, 24, Vet. App. 259 (2011). Accordingly, the case is REMANDED for the following action: 1. The RO should take appropriate action to request that the private examiner who conducted the May 2013 audiological examination clarify whether or not the Maryland CNC speech discrimination test was used when conducting the hearing test. The examiner should also clearly document in written form the hearing threshold levels found as opposed to providing them on a chart. Finally, the private examiner should also be requested to opine as to the reliability of the audiogram. 2. In the event that additional private audiological examination reports are received before this appeal is returned to the Board, similar action should be taken if it is not documented that the Maryland CNC was utilized or the hearing thresholds provided in written form. 3. If any benefit sought on appeal remains denied, issue a supplemental statement of the case. Then return the case to the Board, if otherwise in order. (CONTINUED ON NEXT PAGE) The Veteran 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 2015). ____________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs