Citation Nr: 1644035 Decision Date: 11/21/16 Archive Date: 12/01/16 DOCKET NO. 13-09 505A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to an initial disability rating for posttraumatic stress disorder (PTSD) with alcohol dependence in excess of 70 percent. 2. Entitlement to a total disability rating based on individual unemployability (TDIU). 3. Entitlement to special monthly compensation (SMC) based on housebound status. REPRESENTATION Veteran represented by: Robert J. Bratch, Attorney WITNESSES AT HEARING ON APPEAL The Veteran, the Veteran's son ATTORNEY FOR THE BOARD K.C. Spragins, Associate Counsel INTRODUCTION The Veteran had active service in the United States Army from August 1967 to December 1970. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2010 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. The December 2010 rating decision granted entitlement to service connection for PTSD with alcohol dependence and assigned a 30 percent disability rating effective from May 18, 2009. During the pendency of the appeal, a February 2013 Decision Review Officer (DRO) decision increased the Veteran's disability rating to 70 percent effective from May 18, 2009. As the maximum benefit was not granted, the issue remains in appellate status. See AB v. Brown, 6 Vet. App. 35 (1993). The Veteran and his son testified at a videoconference hearing before the undersigned Veterans Law Judge in November 2015. The Veteran's daughter-in-law was also present as an observer. A transcript from that proceeding is associated with the Veterans Benefits Management System (VBMS) folder. The record shows that the Veteran was previously represented by attorney Kenneth LaVan. However, the Veteran discontinued this attorney's representation in July 2015. That same month, the Veteran appointed attorney Ralph J. Bratch as his representative. The Veteran also submitted a claim for a TDIU in April 2016. A claim for a TDIU is part of an increased rating claim when such claim is raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453 (2009). As such, the Board has taken jurisdiction over this issue. In addition, the Veteran's representative has raised the issue of entitlement to SMC based on housebound status. See April 2016 Appellate Brief. Entitlement to SMC is an "inferred issue" in the context of an increased rating claim that must be considered when the record indicates that it may be available, even if the claimant does not place eligibility for this ancillary benefit at issue. See Akles v. Derwinski, 1 Vet. App. 118, 121 (1991). Thus, this issue is properly before the Board for appellate consideration. The Board notes that after the February 2013 DRO decision, the Veteran submitted additional VA treatment records dated from April 2014 to April 2015. However, the Veteran also submitted a waiver of the AOJ's initial consideration of this evidence. See 38 C.F.R. § 20.1304(c). This appeal was processed using the Virtual VA paperless claims processing system and VBMS. Accordingly, any future consideration of this case should take into consideration the existence of these records. The issue of entitlement to SMC based on housebound status is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. For the entirety of the appeal period, the Veteran's PTSD with alcohol dependence has been productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; but not total social impairment. 2. The Veteran meets the schedular criteria for TDIU, and his service-connected PTSD with alcohol dependence renders him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. For the entirety of the appeal period, the criteria for an initial disability rating in excess of 70 percent for PTSD with alcohol dependence have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.321, 4.1, 4.4, 4.7, 4.130, Diagnostic Code 9411 (2015). 2. The criteria for entitlement to TDIU have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.59, 3.340, 3.341, 4.1, 4.3, 4.16, 4.18, 4.25 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 as amended (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). In this case, the Veteran is challenging the initial evaluation assigned following the grant of service connection for his PTSD with alcohol dependence. In cases where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service-connection claim has been more than substantiated, it has been proven, and thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490-91 (2006); VAOPGCPREC 8- 2003 (December 22, 2003). Thus, VA's duty to notify has been satisfied. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. 3.159(c), (d). This duty to assist contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that the VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In this case, the AOJ obtained the Veteran's service treatment records and all identified and available post-service treatment records. The Veteran was also afforded a VA examination in October 2010 in connection with the claim on appeal. The Board finds that the October 2010 examination is adequate for rating purposes as it fully addresses the rating criteria and evidence of record that are relevant for rating the Veteran's psychiatric disorder. Consequently, the Board finds that there is adequate medical evidence of record to make a determination on the claim. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As noted above, the Veteran testified at videoconference hearing in November 2015 before the undersigned Veterans Law Judge. During this hearing, the Veterans Law Judge clearly set forth the issues to be discussed, sought to identify the pertinent evidence not currently associated with the claims folder, and elicited further information when appropriate. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony and questioning by her representative, demonstrated his actual knowledge of the elements necessary to substantiate the claim. As such, the Board finds that VA complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). There has been no allegation otherwise. In light of the foregoing, the Board finds that VA's duties to notify and assist have been satisfied, and, thus, appellate review may proceed without prejudice to the Veteran. (CONTINUED ON NEXT PAGE) II. Law and Analysis Entitlement to an Initial Disability Rating for PTSD with Alcohol Dependence in Excess of 70 Percent Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service connected disorder. 38 U.S.C.A. § 1155. The evaluation of a service-connected disorder requires a review of a veteran's entire medical history regarding that disorder. 38 U.S.C.A. § 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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. Consideration of the whole-recorded history is necessary in order for a rating to accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Evidence to be considered in an appeal from an initial disability rating was not limited to that reflecting the then current severity of the disorder. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where an initially assigned disability evaluation has been disagreed with, it is possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. Fenderson, 12 Vet. App. at 126-27; Hart v. Mansfield, 21 Vet. App. 505 (2007). Such separate disability ratings are known as staged ratings. The Veteran's psychiatric disability has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411; however, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, or for the Veteran's own occupation or name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact occupational and social impairment. Vasquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). Nevertheless, as all ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vasquez-Claudio, 713 F.3d at 118. Psychiatric examinations frequently include assignment of a Global Assessment of Functioning (GAF) score. The GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). The GAF score and interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which must provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). The Board also notes that the GAF scale was removed from the more recent DSM-V for several reasons, including its conceptual lack of clarity, and questionable psychometrics in routine practice. See DSM-V, Introduction, The Multiaxial System (2013). Entitlement to an initial disability rating for PTSD with alcohol dependence in excess of 70 percent On May 18, 2009, a VA treatment record noted that the Veteran's appearance was disheveled. He was alert and attentive with no speech abnormalities. His mood and affect were congruent. Although the Veteran's insight was good, his judgment was impulsive. The Veteran experienced an impairment in his concentration as well as his recent and immediate memory. The record also stated that the Veteran's need for frequent redirection demonstrated a tangential thought process. The Veteran reported suffering from nightmares and intrusive memories. He also avoided situations, people, and places that would remind him of traumatic events. In addition, the Veteran experienced symptoms of hyperarousal such as anger, insomnia, hypervigilance, and anxiety. The Veteran also frequently had symptoms of a sad mood, decreased energy, and decreased appetite. He was noted to experience delusions as well as auditory and visual hallucinations. The record also stated that the Veteran had passive/non-specific homicidal ideation with no potential target or victim identified. The Veteran denied symptoms of obsessive compulsive disorder, panic, and mania. No suicidal ideation was present. According to the record, his acute risk factors included anxiety, intoxication and/or recent history of intoxication, impulsive behavior, and the presence of psychosis. Regarding the Veteran's social relationships, he lived alone and described himself as a recluse that did not want to leave the house. However, he reported having good relationships with each of four children. The Veteran also stated that his three sons were his only friends, but noted that they were all incarcerated. In terms of employment, the record noted that the Veteran completed high school and a year and a half of college. The Veteran previously worked as a heavy equipment operator until 1980. He then worked for a laborers union for 20 years. The Veteran reported that he resented authority and was unemployable due to his unpredictable behavior. He explained that his symptoms led to erratic behavior at work. The Veteran also experienced difficulty getting along with co-workers and stated that he could not hold a job for a more than a few months. At the time of the visit, the Veteran drank 8 to 10 cans of beer each day, but did not use illicit drugs or abuse prescriptive drugs. The Veteran's legal history included 22 DUIs and a period of incarceration for aggravated manslaughter. In addition, he reported past enrollment in substance abuse treatment programs at different points in the 1970's, 1980's, and 1990's. The Axis I diagnosis included chronic PTSD, alcohol dependence, and recurrent major depressive disorder. It was also noted that major depressive disorder with psychotic features needed to be ruled out. The GAF score was 55. A subsequent VA treatment record from May 18, 2009 stated that no current homicidal ideation was present. In June 2009, a record noted that in addition to the Veteran's previously reported symptoms, he had difficulty experiencing loving feelings. He stated that he could not relax around his children. In July 2009, the Veteran's Axis I diagnoses were PTSD, alcohol dependence, and recurrent major depression. A subsequent September 2009 VA treatment record noted the Veteran's report that he was sleeping better with his psychiatric medications, but still experiencing nightmares. He did not suffer from any side effects. The Veteran's thoughts were logical, linear, and coherent. However, he was thinking obsessively about his service connection claim for PTSD. The Veteran displayed an irritable mood during the visit, but he behaved cooperatively. His affect transitioned from irritable to blunted over the course of the visit. At this time, the Veteran denied suicidal or homicidal ideation. The diagnoses were depression not otherwise specified (NOS), rule out alcohol-induced; alcohol dependence; chronic PTSD; and recurrent major depression by history. The GAF score remained unchanged at 55. In a March 2010 VA treatment record, the Veteran expressed financial worries regarding his service connection claim for PTSD. He also continued to experience depression and had difficulty sleeping past the early morning hours. No problems were noted with the Veteran's dress, demeanor, or eye contact. His speech was normal, but he lacked spontaneous speech. The Axis I diagnoses and GAF score were the same. During the October 2010 VA examination, the Veteran's orientation and concentration were within normal limits. His behavior was appropriate, but his appearance and hygiene showed signs of neglect. The Veteran was noted to be disheveled. There were no abnormalities in the Veteran's speech or ability to communicate. The examiner determined that the Veteran's thought processes, judgment, abstract thinking, and memory were normal. The Veteran described difficulty concentrating. The examiner determined that the Veteran did not experience difficulty understanding commands or performing self-care. The examiner also discussed the Veteran's social relationships, noting that he had very few friends and did not socialize with others as had done previously. However, the Veteran had a good relationship with his mother and a very good relationship with his children. The Veteran reported that he worked as a laborer for 20 years, but had not worked for the past 15 years. The examiner opined that the Veteran's unemployment was primarily due to the effects of his mental condition as the Veteran's irritability affected his ability to get along with others. The Veteran experienced symptoms of a depressed mood, suspiciousness, panic attacks weekly or less often, and a chronic sleep impairment. The Veteran reported having problems with irritability and outbursts of anger when he felt threatened. There was no reported history of delusions, and no delusions were observed by the examiner. Obsessive compulsive behavior was also absent. However, he had a history of intermittent hallucinations. Regarding his alcohol use, the Veteran reported a history of drinking 24 to 30 beers a day. However, the examiner stated that he was no longer abusing the substance and had not taken the substance for 4 years. The examiner stated that the nature of the Veteran's sleep impairment, flashbacks, panic attacks, and periods of violence was severe. The Veteran's panic attacks were triggered by periods of extreme anxiety. The examiner also explained that the Veteran's aggravated manslaughter occurred when, in the midst of a flashback, the Veteran killed a man who the Veteran believed to be a Viet Cong soldier. The Veteran denied a history of suicide attempts. He reported that he often feels homicidal if he feels threatened by others. However, no homicidal or suicidal ideation was present at the time of the examination. The examiner stated that the Veteran was intermittently unable to perform activities of daily living due to flashbacks that led him to react suddenly and cause harm to others and, occasionally, himself. Despite this assessment, the examiner opined that the Veteran was not a threat to himself or others. The examiner opined that the Veteran's psychiatric symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally functioning satisfactorily with routine behavior, self-care, and normal conversation. The examiner also determined that the Veteran was capable of managing his benefits. The Axis I diagnoses were PTSD and alcohol dependence. The examiner noted that the alcohol dependence was related to the PTSD as the Veteran calmed himself with alcohol. The GAF score was reduced to 50. Following this examination, a January 2012 VA treatment record noted the Veteran's report of numerous nightmares and vivid flashbacks. He reportedly drank 8 to 10 beers the previous day, which was his average amount. The record indicated that the Veteran was casually dressed and well-groomed. He was cooperative and his both his speech and eye contact were normal. His mood was "so-so," but he had a full range of affect. His thoughts were logical, linear, and coherent. Although the Veteran had adequate judgment, he did not have any insight. The Veteran denied homicidal or suicidal ideation. He also denied the presence of auditory or visual hallucinations. The Axis I diagnoses were chronic PTSD that was military-related, alcohol dependence with continuous drinking behavior, and alcohol-induced mood disorder. The GAF score increased to 52. In February 2012, a VA treatment record reported that the Veteran had a somewhat neat and clear appearance. The Veteran also stated that his mood was "half-way decent." While most of the mental status findings were unchanged from those documented in January 2012, his judgment had become poor. This record also revealed that the Veteran drank a case of beer each day when he was working. Later in June 2014, a VA treatment record noted that the Veteran continued to drink approximately 8 beers every day. The Veteran understood the risks of this habit, but he refused to quit. The Veteran's son was living with him at this time. The assessment was alcohol abuse and malnutrition. A subsequent June 2014 VA treatment record stated that the Veteran tested positive for marijuana. In October 2014, the Veteran's hydrocodone medication was stopped due to his positive test results for marijuana. Nothing abnormal was detected in the Veteran's state of dress. He was described as thin. His speech continued to be normal and his mood was euthymic. The Veteran reported that he was still smoking marijuana in February 2015. During the November 2015 Board hearing, the Veteran and his son provided additional details regarding the symptoms of his psychiatric disability. The Veteran's son testified that he had a close relationship with his father, and had been living with the Veteran for the past three years. See November 2015 Board Hearing Transcript (Tr.), page 7. According to the Veteran's son, the Veteran was often paranoid, irritable, reactive to nonthreatening situations, and kept a pocket knife on his person. See Tr., page 8, 10-11. The Veteran stated that his flashbacks occurred without warning, and he described feeling worried that he would hurt someone during one of these events. See Tr., page 5. The Veteran also reportedly heard sounds when no one was there and responded to conversation that had not occurred. See Tr., page 6, 8-9. The Veteran's son additionally testified that he could go through periods when he did not attend to his hygiene, such as foregoing brushing his teeth. See Tr., page 11-12. The Veteran's son reported having difficulty understanding what his father was talking about a few times a week. See Tr., page 13. The Veteran's son further stated that the Veteran had memory problems and struggled to accurately recall whether events had occurred in the recent or distant past. See Tr., page 9-10, 12. Regarding his ability to function in a work environment, the Veteran stated that he had difficult relationships with other coworkers when he was working and even engaged in physical fights in the workplace. See Tr., page 4. He also reported that he was unable to function in a crowd, indicating that he would not be able to tolerate working in a plant where he would be surrounded by 500 other workers. See Tr., page 6. He noted that he always tried to work by himself or with only one other partner in such an environment. After reviewing the evidence of record from this period, the Board finds that the Veteran's symptoms do not justify the award of an initial disability rating in excess of 70 percent. Apart from considerations of occupational impairment, the Board finds that the evidence does not reflect total social impairment. Records from this period show that the Veteran engaged in isolative behavior, felt unconformable in crowds of people, had few or no friends, and experienced difficulty in maintaining work relationships. However, the Veteran has reported having a good relationship with family members throughout the appeal period. The Veteran's reports are supported by the November 2015 testimony of his son that they had a close relationship. Although the evidence suggests that the Veteran has a significant impairment in social functioning, he did not have a total impairment. In addition, the Board finds that the Veteran's symptoms are not of the severity or frequency to warrant a 100 percent evaluation. The Board acknowledges the November 2015 testimony of the Veteran's son that it was sometimes difficult to understand what the Veteran was talking about in conversation. The Veteran's son also reported that the Veteran had problems with memory and judgment. However, the Board does not find that the Veteran exhibited gross impairment in thought processes or communication during this period. The Veteran was able to provide clear testimony on his own behalf during the November 2015 hearing. In addition, the majority of the medical records from this period stated that his speech was normal. Moreover, despite the finding of a tangential thought process in May 2009, subsequent VA determinations from September 2009, October 2010, and January 2012 did not reflect that the Veteran had any significant problems in his thought processes. Although the Veteran's was noted to have a memory impairment in May 2009, the October 2010 VA examiner later determined that no such impairment was present. The Board also notes that the Veteran's son did not indicate that the Veteran's current memory complaints rose to the level of forgetting his own occupation, name, or the names of close relatives. In addition, the treatment records from this period did not report that the Veteran's level of orientation to time and place was outside of normal limits. The evidence from this period also fails to reflect grossly inappropriate behavior. The Veteran was noted to behave impulsively in May 2009, and he described having unpredictable and erratic behavior at work. However, the Veteran was able to behave appropriately and/or cooperatively in September 2009, October 2010, and January 2012. The Board notes that the Veteran neglected his personal appearance and hygiene at different points during this appeal period. Although the October 2010 VA examiner stated that the Veteran did not have difficulty performing self-care, the November 2015 testimony from the Veteran's son indicated that the Veteran did have periods when he did not maintain personal hygiene. In addition, both the examiner and the Veteran's son reported that the nature of the Veteran's flashbacks rendered him intermittently unable to perform activities of daily living. However, despite the presence of this symptom, the Veteran did not have a total social impairment. Regarding whether the Veteran was in persistent danger of hurting himself or others, the Board notes that that the Veteran reported carrying a pocket knife during the November 2015 Board hearing, and feeling homicidal when threatened in October 2010. The Veteran's son also indicated that he was wary of the Veteran accidentally hurting someone with the pocket knife during one his flashbacks. In this regard, the Board finds it notable that while the October 2010 VA examiner was aware of the Veteran's potential to cause harm during a flashback, he determined that the Veteran was not a threat to himself or others. The Veteran also denied the presence of any current homicidal ideation in September 2009, October 2010, and January 2012. In addition, the Veteran consistently denied having suicidal ideation during this period. In light of this evidence, the Board does not find that the Veteran was in persistent danger of hurting himself or others. In addition, the Board acknowledges that the Veteran was noted to have a history of intermittent hallucinations during the October 2012 VA examination. Although the Veteran denied having hallucinations in January 2012, he described experiencing auditory hallucinations during the November 2015 Board hearing. The Board also notes that the delusions that were documented in May 2009 were not found during the subsequent October 2012 VA examination. It does not appear from this evidence that the Veteran's delusions or hallucinations were a persistent problem. Moreover, as noted above, they did not result in total social impairment. The Board also notes that the Veteran's GAF scores during this period have ranged from 50 to 55. These scores contemplate serious to moderate symptoms in social, occupational, or school functioning. However, the 70 percent evaluation contemplates serious impairment and the GAF scores from this period do not automatically mandate the assignment of a 100 percent evaluation. Based upon the Veteran's symptoms, as noted above, there is not total social impairment, despite significant effects on social functioning. Furthermore, when the GAF scores are considered as part of the overall social and occupational functioning picture, the Board finds that the descriptions in the treatment records and the VA examiner's explanations are the most probative evidence of the Veteran's psychological symptomatology. The Board therefore finds that the preponderance of the evidence is against the assignment of a 100 percent disability rating for PTSD with alcohol dependence at any point during the appeal period. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 54-55. Entitlement to a TDIU In order to establish entitlement to a TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to follow a substantially gainful occupation. See 38 U.S.C.A. § 1555; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). 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 to the impairment caused by non-service-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2014); Van Hoose v. Brown, 4 Vet. App. 361 (1993). The regulatory scheme for a TDIU provides both objective and subjective criteria. Hatlestad, 5 Vet. App. at 529; VAOPGCPREC 75-91 (Dec. 27 1991), 57 Fed. Reg. 2317 (1992). The objective criteria, set forth at 38 C.F.R. § 4.16(a), provide for a TDIU when, due to a service-connected disability, a veteran is unable to secure or follow a substantially gainful occupation, and has a single disability rated 60 percent or more, or at least one disability 40 percent or more with additional disability sufficient to bring the combined evaluation to 70 percent. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where the veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). The Veteran's only current service-connected disability is PTSD with alcohol dependence, which is rated as 70 percent disabling. As such, the Veteran meets the minimum percentage requirements for consideration of a TDIU under 38 C.F.R. § 4.16(a). The Veteran contends that he has been unable to maintain employment since May 2009 as a result of his PTSD with alcohol dependence. See November 2015 Board Hearing Transcript, page 6. As previously discussed, the Veteran worked as a laborer for approximately 20 years until the year 2000. During this period, he also worked for one year as a piper layer. The Veteran completed high school and one year of college. See June 2015 Veteran's Application for Increased Compensation Based on Unemployability. He has not received any education or training since he became too disabled to work. As noted above, the October 2010 VA examiner opined that the Veteran's unemployment was primarily due to the effects of his mental condition as the Veteran's irritability affected his ability to get along with others. The Board finds the examiner's opinion to be highly probative as it was based on the Veteran's reported history and an examination of the Veteran. Throughout the appeal period, the record has contained reports of the Veteran's irritability and difficulty getting along with coworkers. During the November 2015 Board hearing, the Veteran further indicated that his irritability with coworkers led to physical fights. It is notable that these fights occurred despite the Veteran's report that he tried to work by himself or with only one other partner. He also described being unable to function within the crowd of people in the plant environment that was characteristic of his work as a laborer. In addition, there is no indication from the record that the Veteran has received training that would be applicable to a different type of employment. The Board has considered the Veteran's functional capacity and work experience in determining that no type of employment would appear to be appropriate for the Veteran. 38 C.F.R. §§ 3.341(a), 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). The Board acknowledges that the Veteran appears able to perform certain aspects of daily living. However, the law recognizes that a person may be too disabled to engage in employment although he or she is fairly comfortable at home or upon limited activity. See 38 C.F.R. § 4.10. In addition, a Veteran does not have to prove that he is 100 percent unemployable in order to establish an inability to maintain a substantially gainful occupation, as required for a TDIU award. See 38 C.F.R. § 3.340(a); Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). Based on the most probative evidence of record, and resolving all benefit of the doubt in the Veteran's favor, the Board finds that the Veteran's service-connected PTSD with alcohol dependence renders him unable to secure or follow a substantially gainful occupation, and a TDIU is warranted. See 38 U.S.C.A. § 5107(b); Gilbert 1 Vet. App. at 53-56. ORDER Entitlement to an initial disability rating for PTSD with alcohol dependence in excess of 70 percent is denied. Entitlement to a TDIU is granted. REMAND As noted above, the Veteran contends that his service-connected PTSD with alcohol dependence renders him housebound. The Veteran's son also testified that he does not go out in public by himself. See Tr., page 11. However, the Board finds that the evidence is unclear as to whether the Veteran is substantially confined to his dwelling or immediate premises (ward or clinical areas, if institutionalized) due to disability or disabilities which it is reasonably certain will continue throughout his lifetime. 38 U.S.C.A. § 1502(c); 38 C.F.R. § 3.351(d)(2). The Board therefore finds that a VA examination and opinion should be obtained to determine whether the Veteran meets the regulatory criteria for an award of SMC based on housebound status. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his PTSD with alcohol dependence. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding, relevant VA medical records, to include records from the Atlanta VA Medical Center dated since April 2015. 2. Schedule the Veteran for a VA examination for housebound status to determine whether his service-connected PTSD with alcohol dependence renders him housebound. The claims file should be made available to the VA physician for review, and such review should be noted in the report. All indicated studies and tests should be conducted. It is requested that the guides for conducting housebound examinations be used, and that all clinical findings as to the service-connected PTSD with alcohol dependence be set forth in detail. The VA examiner is requested to opine as to the following questions: (a) Whether the Veteran is substantially confined to his dwelling and immediate premises, or if institutionalized, to the ward or clinical areas, due to his service-connected PTSD with alcohol dependence. If the answer to question (a) is yes, answer question (b). (b) Whether it is reasonably certain that this disability and confinement will continue throughout the Veteran's lifetime. A complete rational should be given for all opinions and conclusions expressed. 3. Review the examination report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). 4. After completing the above actions, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claims must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. 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 2014). ____________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs