Citation Nr: 1622372 Decision Date: 06/03/16 Archive Date: 06/13/16 DOCKET NO. 14-41 089A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to an increased evaluation for major depressive disorder with secondary alcohol abuse, posttraumatic stress disorder (PTSD) and generalized anxiety disorder rated at 50 percent prior to May 20, 2015, and at 70 percent since then. 2. Entitlement to an increased evaluation for right knee bursitis (previously evaluated as patellar tendonitis, right knee) currently rated at 10 percent. 3. Entitlement to an increased evaluation for left knee bursitis (previously evaluated as patellar tendonitis, left knee) currently rated at 10 percent. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). The Veteran served on active duty from January 2001 to January 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). By December 2010 rating decision the RO in Winston-Salem, North Carolina increased from 30 to 50 percent the assigned rating for major depressive disorder with secondary alcohol abuse, effective August 12, 2010. The Veteran appealed, notwithstanding the increase, as was her decision under the law to seek the maximum schedular rating available. See A.B. v. Brown, 6 Vet. App. 35 (1993). An August 2014 Roanoke, Virginia RO rating decision also on appeal denied the issues of a TDIU and increased evaluations for right and left knee bursitis. By January 2016 rating decision, the RO did increase from 50 to 70 percent the rating for psychiatric disability, effective May 20, 2015. As indicated below, the Veteran now wishes to withdrawal the appeal on the claims for increased evaluation for right and left knee bursitis. A Board videoconference hearing was held March 2016. At the hearing, the Veteran provided a VA psychiatrist's statement accompanied by waiver of consideration by the RO as Agency of Original Jurisdiction (AOJ). See 38 C.F.R. §§ 20.800, 20.1304 (2015). The issue of a TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. Through request at the March 2016 Board hearing the Veteran and her representative withdrew from appeal the claims for increased evaluation for right and left knee bursitis. 2. From August 12, 2010 to May 19, 2015, the Veteran's service-connected psychiatric disability involved occupational and social impairment with deficiencies in most areas. 3. During the rating period in question the Veteran has not demonstrated total occupational and social impairment due to her psychiatric disorder. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal of the claims for increased evaluation for right and left knee bursitis have been met. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2014); 38 C.F.R. § 20.204 (2015). 2. With resolution of reasonable doubt in the Veteran's favor, the criteria are met for a 70 percent rating for major depressive disorder with secondary alcohol abuse, PTSD and generalized anxiety disorder from August 12, 2010 to May 19, 2015. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9434 (2015). 3. The criteria for a maximum 100 percent rating for increased rating for psychiatric disability are not met throughout pendency of the claim. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9434 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Claims Withdrawn on Appeal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. In March 2016, the Veteran withdrew the appeal regarding the issues of entitlement to increased ratings for right and left knee bursitis. There remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review these claims on appeal and they are dismissed. II. Claim Under Appellate Review The Duty to Notify and Assist the Claimant The Veterans' Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2014), prescribes several requirements as to VA's duty to notify and assist a claimant with the evidentiary development of a pending claim for compensation or other benefits. See also 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2015). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must inform the claimant of any information and evidence (1) that is necessary to substantiate the claim; (2) that the claimant is expected to provide; and (3) that VA will seek to provide on the claimant's behalf. See also Pelegrini v. Principi, 18 Vet. App. 112, 120-121 (2004). As to the claim being decided for increased evaluation for PTSD, the Veteran has received timely VCAA notice through August 2010 RO correspondence sent to him regarding how to substantiate her claim. Proper action has been undertaken to comply with the duty to assist the Veteran through obtaining extensive records of VA outpatient and inpatient treatment, and arranging for the Veteran to undergo VA Compensation and Pension examinations. See 38 C.F.R. §4.1 (for purpose of application of the rating schedule accurate and fully descriptive medical examinations are required with emphasis on the limitation of activity imposed by the disabling condition). The November 2015 VA examination is sufficiently recent in time to provide a clear depiction of service-connected disability, and there is no indication of likely circumstantial worsening since. In furtherance of her claim, the Veteran provided several personal statements. The Veteran testified at a Board hearing, during which she received proper assistance in developing the claim. 38 C.F.R. § 3.103. The record as it stands includes sufficient competent evidence to decide the claim. Under these circumstances, no further action is necessary to assist the Veteran. In sum, the record reflects that the facts pertinent to the claim have been properly developed and that no further development is required to comply with the provisions of the VCAA or the implementing regulations. Accordingly, the Board will adjudicate the claim on the merits. Merits of Claim for Increased Rating for PTSD Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by diagnostic codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, the degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1. The Veteran's service-connected psychiatric disability from prior AOJ adjudication is characterized as major depressive disorder with secondary alcohol abuse, PTSD and generalized anxiety disorder. While several disorders are implicated, the rating criteria applied is clearly the same, a general rating formula given below. Technically, the diagnostic code used is Diagnostic Code 9434 for major depressive disorder -- again, exact diagnostic code used does not matter because all disability is rated identically under a rating formula. According to VA's General Rating Formula for Mental Disorders, a 0 percent (noncompensable) evaluation is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. A 10 percent rating is assigned for occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication. A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating 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-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating may be assigned where there is 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; obsessed 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 is warranted where there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130. The symptoms and manifestations listed under the above rating formula are not requirements for a particular evaluation, but are examples providing guidance as to the type and degree of severity of these symptoms. Consideration also must be given to factors outside the rating criteria in determining the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). A veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). Additionally, while symptomatology should be the primary focus when deciding entitlement to a given disability rating, § 4.130 requires not only the presence of certain symptoms but also that those symptoms have caused the requisite occupational and social impairment. Id. Turning to the facts of this particular matter, the Veteran filed her claim for increased rating in August 12, 2010. At that point her psychiatric disorder was rated at 30 percent, but has since progressed over different stages to a rating of 50 percent up until May 19, 2015, and 70 percent since that time. Recounting evidence of symptomatology and condition, August 2010 lay witness statement from the Veteran's mother indicates that the Veteran needed help with treatment of being unusually depressed, with some days sleeping the entire day, the condition appearing episodically. A September 2010 co-worker stated having observed the Veteran being very depressed to a point she would cry at work and be unable to complete her work. Apparently, the Veteran had been written up for missing too many days. (The Veteran herself has provided documentation from a former employer, independently substantiating this fact.) The co-worker continued he would call the Veteran to check on her, and the Veteran would not pick up the phone for days at a time. It was recalled the Veteran had been on medication for years, and the Veteran did go to church and exercised when she could to fight the depression. VA outpatient psychology consult of October 2010 indicates that the Veteran stated she did not feel good about herself and believed was staying in bad relationships and being treated badly, as if she were "punishing herself." She indicated wanted to work towards a higher self-esteem and find healthier relationships. She reported some continuance of drinking alcohol. Objectively, she was well-oriented. Mood was depressed and she presented with full range of affect. Her emotional expression was appropriate to content and situation. She became tearful several times throughout the session as she spoke of her recent break-up with a significant other. She spoke with normal rate, rhythm, and volume. She did not display any psychomotor agitation or psychomotor slowing. The Veteran's thought process was logical, linear, and goal directed. No thought disorder or other psychotic symptoms were reported or observed. She did not appear to be in acute distress. No suicidal or homicidal ideation was reported. On November 2010 VA Compensation and Pension examination, the Veteran was noted to have been in individual therapy at a VA medical facility for treatment of major depressive disorder and alcohol abuse. She was taking psychotropic medication. There were no prior hospitalizations for a mental disorder. She was on anti-depressants, and reported that medication was poor at treating the condition. Outwardly, the Veteran was clean, neatly groomed, and appropriately dressed. Psychomotor activity was tense. Speech was clear and coherent. Attitude toward the examiner was cooperative and attentive. Affect was labile. Mood was anxious. Orientation was intact in all spheres. Thought process was linear and goal-oriented. The Veteran made self-deprecating statements. Delusions and hallucinations were not present. As to judgment the Veteran understood the outcome of behavior. Intelligence was average. As to insight, the Veteran understood she had a problem. She described her sleep as sporadic; she fell asleep at 11pm or 12am and then was up three hours later. There was not inappropriate behavior, panic attacks, homicidal thoughts, or suicidal thoughts. Extent of impulse control was fair. The Veteran did report that she spent impulsively (planned a trip, bought her son a $100 item), also impulsively entered into a relationship that she know was bad for her. There were no episodes of violence. There was ability to maintain minimum personal hygiene. As to recreational activities, the Veteran reportedly had lost interest in hobbies that she used to enjoy (reading, dancing), and reported having lost motivation to do things around the house. Remote memory was good, recent memory mildly impaired, immediate memory mildly impaired. The Veteran was considered capable of managing financial affairs. The Veteran was employed full-time with a shipping company, where she had worked several years. Time lost from work over the last year however was 24 days. Some were vacation days, also some related to depression, and having gone over her allotted 21 days was written up for this. Problems related to occupational functioning were decreased concentration, increased absenteeism, increased tardiness, poor social interaction. The diagnosis given was major depressive disorder, recurrent, moderate; and alcohol abuse. According to the VA examiner, the alcohol abuse appeared secondary to the Veteran's depression. She drank to try to cope with her emotions. The major depressive disorder and alcohol abuse were mutually aggravating conditions and therefore the impact on psychosocial functioning could not be separated without undue speculation. There were symptoms directly attributed to major depressive disorder of: depressed mood most of day, nearly every day; diminished interest in activities; weight loss or gain/appetite change; sleep disturbance, trouble staying asleep; agitation/retardation (psychomotor agitation); fatigue/loss of energy; worthlessness/guilt nearly every day; decreased ability to think/concentrate or indecisive. According to the examiner, these symptoms appeared moderate. Noted was that the Veteran drank once a week, and had six beers at one time. No illicit substance abuse. There were no significant impairments in thought or communication observed during this examination. The estimated impairment was that mental disorder signs and symptoms resulted in deficiencies in several areas - judgment, thinking, family relations, work, mood and school. In so finding, the examiner further noted frequent depressive cognitions, and feeling overwhelmed taking classes at night school in addition to working full time. December 2012 lay witness statement from the Veteran's mother indicates having had cared for the Veteran on many occasions when she had been in bed for two weeks almost. According to the author of the statement, the Veteran needed to be treated with more intensity. She was now very moody, depressed, anxious and drank way too much. In her own December 2012 statement, the Veteran described being full of anxiety and could only find temporary relief by drinking, which she believed had ruined her life. Topamax medication decreased the craving for alcohol, but she still felt loneliness and consistent amount of depression. According to the Veteran, she had missed 10 days of work already this year and was close to being let go. July 2014 VAMC records denote a several month inpatient psychiatric stay due to symptoms brought on by alcohol abuse and coping with a diagnosis of cancer. The Veteran had presented with feeling depressed, hopeless, anergic, helpless, worthless, with poor appetite and sleep, and passive suicidal thoughts, but denying active ideation. There were no psychotic symptoms. On August 2014 VA re-examination, the diagnosis was major depressive disorder, recurrent, moderate; and alcohol use disorder, severe, in early remission. According to the examiner, the Veteran's cravings for alcohol and degree and course of using it were attributable to alcohol use disorder. Meanwhile, symptoms pertaining to sadness, sleep disturbances, decreased energy, hopelessness and guilt, concentration deficits, and suicidal ideation were associated with major depressive disorder. It was estimated the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks. Major depressive disorder was considered to be the Veteran's primary diagnosis, and accounted for the largest portion of impairment. The Veteran was now residing within an inpatient VA mental health facility. She reported that a three-year dating relationship ended in 2014 and attributed the dissolution to her alcohol use. After continued drinking problems she was hospitalized at Hampton VA Medical Center (VAMC) where she had remained since early July 2014. She listed past leisure activities as socializing with others, jogging, but noted that cancer treatments had interfered, although she still exercised regularly every morning. She earned a Master's Degree in 2012 in Business Administration. She was now three credits short of a second Master's Degree in Acquisition and Contract Management. She denied impairments in relationships with peers and teachers. She reported she maintained employment at Fort Eustis as a program support assistant since February 2012, although she took a leave of absence while undergoing cancer treatment. She had a long-term history of employment. The Veteran's statements and available records indicated that she had continued to experience chronic symptoms of depression that predated 2010. She recalled that about four or five years ago she did not get out of bed for two weeks, did not eat, missed work, and almost lost her job as a result. She stated that she had experienced subjective sadness, avolition, ahedonia, and sleep disturbances. She had participated in individual therapy at VA Medical Centers. Therapy had been an outlet, but she did not believe she had gotten better. She was on various psychotropic medications and reported little benefit. She noted her VAMC hospitalization recently was prompted by excessive use of alcohol and making impulsive statements about self-harm. The Veteran indicated a pattern of impulsive, reckless and dangerous behavior when intoxicated, not when sober. The VA examiner further indicated symptoms that applied to the Veteran's diagnosis were depressed mood, chronic sleep impairment, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work or a worklike setting, and suicidal ideation. The Veteran was on-time for the interview. She was oriented and presented as alert. She sustained her attention and did not display signs of distractibility. She successfully completed a reverse-order sequencing task and had two mild errors on a serial subtraction task. She did not evidence significant deficits in her memory, as she provided remote biographical information corroborated by available records. She also recalled more recent events and information provided earlier in the examination. Motor behavior was unremarkable. She did not display impulsive behavior. She sustained appropriate eye contact. She was dressed in clean and neat business attire. Her hygiene and grooming were appropriate. Speech was spontaneous and productive. She did not display signs of comprehensive deficits. Thought content was goal-directed and future-oriented. She did not evidence signs of disorganized thinking and delusional beliefs. Interpersonally, she was pleasant and cooperative. Other symptoms attributable to mental disorders were decreased energy, thoughts of guilt and hopelessness, deficits in concentration, and irritability. She was competent for purpose of managing financial affairs. Further, it was summarized, during the examination the Veteran's mood appeared dysphoric, and her affect was appropriate for the topics discussed. She became tearful when discussing distressing topics. Current mood was described as somewhat depressed. She noted feeling irritable and sad during the past month. A diagnosis of breast cancer had exacerbated her decreased energy and dysphoria, though she noted chronic difficulties with depression had preceded the diagnosis of cancer. While she denied avolition and anhedonia, as she enjoyed exercising daily, she described disturbances falling asleep and remaining asleep, and feeling drained during the day. She endorsed suicidal ideation but denied having plans or intentions to act on her thoughts. She said she had not engaged in self-harm. She endorsed feeling irritable and expressing anger towards others, which had negatively affected relationships with a dating partner, family members, a work supervisor, and mental health provider. However, she indicated not functioning any worse than in the past. She had missed significant periods of work due to depression, received discipline, and was on the verge of termination. She had though completed additional Master's Degrees. Her current condition of depression was however best described as recurrent, moderate. The Veteran's self-report and available records did not reveal signs indicative of psychosis, post-traumatic reactions, obsessions, compulsive behaviors, excessive or unreasonable fears, panic episodes, hypomania, mania, or other mental disorders. After this, on an October 2014 VA consult the Veteran's mental status examination revealed appearance casually dressed and appropriately groomed, speech within normal limits, behavior appropriate, level of cooperation moderate, mood depressed, affect euthymic, suicidal and homicidal ideation denied, thought and speech patterns logical and goal-directed, absent hallucinations and delusions, flashbacks denied, insight and judgment fair. Diagnostic impressions major depressive disorder, recurrent, moderate; alcohol abuse, in partial remission. On VA re-examination of November 2015, the diagnosis was indicated as posttraumatic stress disorder, residual, combat-related; major depressive disorder, recurrent, moderate; generalized anxiety disorder; alcohol use disorder, severe, in sustained remission. Estimated level of impairment was occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. Symptoms consisted of irritable mood with verbal/physical outburst/frequency daily, and occasionally throwing things. There was anxiety/nervousness/always tense/being on edge, on a daily basis. There were episodes of not getting out of bed for days at a time. She tried to keep herself from getting down in mood, and felt like she lived in a depressed state and that her condition was not being treated. There was no suicidal or homicidal ideation or plan. Energy and motivation levels were very poor. There were problems with concentration, focus and attention. There were sleep problems and nightmares. The VA examiner then substantiated a diagnosis of PTSD, and related it to in-service stressors. The Veteran was also found to manifest symptoms of: depressed mood, anxiety, suspiciousness, panic attacks that occurred weekly or less often, chronic sleep impairment, mild memory loss such as forgetting names or directions, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances including work or a work-like setting, impaired impulse control such unprovoked irritability with periods of violence, neglect of personal appearance and hygiene. The Veteran otherwise found herself reportedly procrastinating on school assignments more than before causing undue anxiety and pressure. The Veteran was considered capable of managing her financial affairs. Finally, by March 2016 letter a psychiatrist treating the Veteran at the VAMC based on telephone interview with the Veteran (though having last treated her in person about two months prior) gave information regarding her history, noting that she had been depressed for a while and this had worsened to the point of seeming quite treatment resistant. The Veteran now "suffered severe anhedonia." She could barely leave her home. It was a great effort for her even to call him to request this letter. As of two months ago, it was clear the Veteran had many of the vegetative symptoms of depression, particularly, sleep problems and attention concentration deficits. She had been doing alright at the level of conversation. But now on speaking with the Veteran, while it was not completely accurate as an interview in person, the Veteran's test of attention and recall was concerning. Her pattern of inability to learn the second sentence indicated severe attention/concentration problems consistent with depression. According to the psychiatrist, further, while "I realize that often to be considered totally disabled as a result of depression one needs to be psychotic... [and] she is not having hallucinations at this time... [once again] her anhedonia, her attention concentration deficits, and her general inability to do even simply activities because they seem too difficult, indicates to me that she is indeed totally disabled at this time, and should be considered by the VBA to be unemployable." The Board having reviewed closely the above, and mindful of the applicable rating criteria, will award a partial grant of benefit sought, raising to 70 percent the evaluation for service-connected psychiatric disability in effect from August 12, 2010 to May 19, 2015 (previously rated at 50 percent). The Board believes that the rating standard for this higher 70 percent is more than met, given consideration of the Veteran's near continuous mood disturbances with depression and anxiety; substantial difficulty in maintaining a job due to mental health symptoms; self-reported impulsive behavior at times, including due to alcohol abuse (in this particular case, already adjudicated as part of service-connected disability); and periodic but fortunately not active suicidal ideation. The Board is also aware that the scope of service-connected disability expanded to clearly include PTSD in the most recent examination. Affording the Veteran the benefit of the doubt, as required and expressly provided under VA law, there is sufficient indication of occupational and social impairment in most areas to warrant a 70 percent rating. See 38 C.F.R. § 4.3. Therefore, 70 percent is granted from August 12, 2010 to May 19, 2015. As to the potential application of the rating criteria to support a 100 percent evaluation for service-connected psychiatric disability, this however is not shown. The Veteran retained the capability for occupational functioning on some level, at least up until her most recent leave of absence (and stated disability retirement), to some extent brought upon by non-psychiatric physical health issues. She very fortunately had retained capacity to study towards more than one Master's Degree. It is understood that there are considerable mood disturbances, continued sleep impairment, irritability, loss of energy, alcohol overuse (which recently prompted a several month VAMC hospitalization), loss of days from work, and seeming difficulty in getting certain treatment options to conclusively work. Her treatment provider at the VAMC a psychiatrist has identified attention/concentration deficits and anhedonia as very significant obstacles. The Veteran is also dealing continuously with a cancer diagnosis and treatment. As to how service-connected psychiatric disability in particular affects her though none of the overall tenor of or individual symptoms reflect a psychotic, or profoundly mentally deficient state of mind. The very application of criteria for "total" occupational and social impairment, as defined under the rating criteria for 100 percent, does not fit this situation. On this subject, the criteria for 100 percent includes such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation or own name. See 38 C.F.R. § 4.130. These are not shown. Nor are analogous symptoms. The Veteran has effective communication on recent VA examination (if somewhat more limited in recent telephonic evaluation of March 2016 just a couples months after), and rationale thought process. There were no delusions or hallucinations. Behavior was impulsive at times when having taken too much alcohol, but never bordering on grossly inappropriate. The Veteran never presented a severe threat to herself or others. There was never disorientation to time and place, or profound memory loss. Notably, the Veteran's psychiatrist describes "general inability to do even simple activities because they seem too difficult"; this on its face is very disconcerting, and yet, there is no detailed basis in medical evaluation to support inability to perform activities of daily living, based alone on this telephonic consult. Additionally, the Veteran's reported symptoms in that consult should be accorded weight, but should be also weighed against the very signs and symptoms reported just three months prior on last VA examination when many of the same issues did not present themselves, and even by the March 2016 psychiatrist's own account when he last saw the Veteran personally in January of that year (and had not interviewed her in person in that two-month interval). A lay witness is clearly competent to admit their observations, that is established. Yet all the competent evidence must be weighed together, when ultimately complete, to create a whole medical picture, and including concerning how much weight to give each individual piece of evidence in that overall picture. See generally, 38 C.F.R. § 4.2. There also was not similarly qualifying total impairment outside that discussed in the rating criteria. For instance, the Veteran has been law abiding, had some continued effective interpersonal relationships including with family members, and remained financially competent and capable of activities of daily living. While there were episodes where she could not bring herself to get out of bed for days, there is no sign or indication that there were psychotic or otherwise extremely pronounced attendant symptoms. Her treating psychiatrist mentions anhedonia (inability to derive pleasure from participate in meaningful activities and interactions), again, very disconcerting but not alone automatically reaching the threshold for having total disability given the limited factual basis for in-person evaluation, the limited notation of how and why, the relative similarity of the symptoms to depressive mood which is contemplated in lesser degrees of impairment, and, given that until very recently there was definite residual capacity for participation in life activities in personal and educational endeavors. In so finding, the Board is mindful of the fact that the March 2016 letter identifies the Veteran as "totally disabled"; and while this assessment is acknowledged, any one treatment provider's conclusory estimation of degree of mental health disability is not, in itself, the final determining factor, particularly when the objective and reported given signs and symptoms of that condition do not immediately correspond to that conclusion stated. See 38 C.F.R. § 4.126(a). Indeed, the Board does not assign any more validity to the November 2015 VA Compensation and Pension examination which found at most, a "moderate" level of depression -- given actual symptomatology which shows a more severe and advanced condition, if not then further meeting the threshold of total occupational and social impairment. It is noted that since the March 2016 letter she has attended additional VA examinations, so has been able to leave her abode at least on occasion. In summary, the best approximation given from the above signs and symptoms is that the Veteran's condition throughout is best rated at 70 percent, and a higher 100 percent is not warranted under the VA rating schedule. Apart from the rating schedule, the Board has also considered an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1). The threshold factor for extraschedular consideration is that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). The evidence in this case does not show such an exceptional disability picture. Comparison between the Veteran's assigned rating with the established criteria found in the rating schedule shows that the rating criteria reasonably describe disability level and symptomatology. The Veteran and his representative have not identified any symptoms not recognized by the rating criteria, nor have alleged that the rating criteria are inadequate. This includes such allegations regarding the service-connected psychiatric disability in itself, and/or in combination with other present service-connected disability. In summary, the requirements for an extraschedular evaluation under 38 C.F.R. § 3.321(b)(1) have not been met. Accordingly, an increased 70 percent rating prior to May 20, 2015 is granted, though no higher. The preponderance of the evidence supports the claim to this extent. ORDER The claim for higher evaluation than 10 percent for right knee bursitis (previously evaluated as patellar tendonitis, right knee) is withdrawn from appeal and the appeal as to this issue is dismissed. The claim for higher evaluation than 10 percent for left knee bursitis (previously evaluated as patellar tendonitis, left knee) is withdrawn from appeal and the appeal as to this issue is dismissed. An increased rating of 70 percent from August 12, 2010 to May 19, 2015 for major depressive disorder with secondary alcohol abuse, PTSD and generalized anxiety disorder is granted, subject to applicable law and regulations on VA compensation benefits. A higher rating than 70 percent from August 12, 2010 onward is denied. REMAND To properly resolve the TDIU claim, the Board requires a clear medical opinion addressing the Veteran's overall employment capability in light of service-connected disability. Present information reflects she is not working in part due to mental health symptoms, and from nonservice-related physical condition with ongoing treatment for and recovery from cancer. It is not clear whether the Veteran is now substantially capable, or incapable of employment due to service-connected disabilities. On this subject, the Board has received a March 2016 letter from treating VA psychiatrist stating that attention/concentration and anhedonia precluded employability, and while helpful to the claim, the factual basis for reaching this determination is not clear including how supported in absence of an in-person mental health examination. The Board also notes relatively recent consistent educational and employment history of the Veteran. This is not without acknowledging the serious problems implicated in the March 2016 letter. Consequently, thorough VA general medical and psychiatric examinations should be ordered to address employability in light of all service-connected disability. Meanwhile, records of an identified recent disability retirement should also be obtained and made of record. Accordingly, this claim is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Contact the Veteran and request information regarding any recent disability retirement, Federal employment or non-Federal job position, and request name of employer, dates of employment and date of receipt of any disability award. Then obtain all available records. 2. Schedule the Veteran for a VA general medical and psychiatric examinations for purpose of her TDIU claim. The VBMS and Virtual VA electronic claims files must be made available for the examiners to review, and the examiners should confirm this review was completed. The examiners are then requested to provide an opinion as to whether the Veteran is incapable of securing and maintaining substantially gainful employment due to the severity of her service-connected disabilities. In providing the requested determination, the examiners must consider the degree of interference with ordinary activities, including capacity for employment, caused solely by the Veteran's service-connected disabilities, as distinguished from any nonservice-connected physical or mental condition. The requested opinion must also take into consideration the relevant employment history and educational history. Also expressly indicate review and consideration of the March 2016 opinion given by a VA psychiatrist. If an opinion cannot be rendered without resorting to pure speculation, please explain why this is not possible. 3. Review the claims file. If any directive specified in this remand has not been implemented, take proper corrective action before readjudication. Stegall v. West, 11 Vet. App. 268 (1998). 4. Then readjudicate the TDIU claim on appeal based upon all additional evidence received. If the benefit sought on appeal is not granted in full, the Veteran and her representative should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ MICHAEL D. LYON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs