Citation Nr: 1704948 Decision Date: 02/17/17 Archive Date: 02/24/17 DOCKET NO. 11-16 711 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent prior to August 20, 2014 for posttraumatic stress disorder (PTSD) with agoraphobia. 2. Entitlement to a total disability rating based on individual unemployability (TDIU) prior to August 20, 2014. 3. Entitlement to service connection for a left foot disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his son ATTORNEY FOR THE BOARD S. Kim, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1966 to October 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from November 2009, April 2010, and May 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In the November 2009 rating decision, the RO granted PTSD with agoraphobia and assigned a 50 percent rating, effective July 15, 2009. In the April 2010 rating decision, the RO denied entitlement to a TDIU. In the May 2013 rating decision, the RO denied service connection for a left foot disability. In September 2012, with respect to the issues of a higher initial rating for PTSD and TDIU, the Veteran testified during a Board video-conference hearing before the undersigned Acting Veterans Law Judge. A transcript of that hearing is of record. In May 2014, the Board remanded the case for additional development. In an October 2014 rating decision, the Appeals Management Center (AMC) granted a 100 percent rating for PTSD with agoraphobia, effective August 20, 2014. This award represents a full grant of benefits sought for the higher rating claim for PTSD for the appellate period beginning on August 20, 2014. Inasmuch as a higher rating is available for PTSD for the appellate period prior to that date, the Veteran's higher rating claim for PTSD prior to August 20, 2014 remains viable before the Board. See AB v. Brown, 6 Vet. App. 35, 38 (1993). With respect to the claim for entitlement to a TDIU, in a March 2016 rating decision, the RO in Nashville, Tennessee granted entitlement to special monthly compensation (SMC) based on the housebound criteria under 38 U.S.C.A. § 1114 (s) (West 2014), effective August 20, 2014. This award was based on the 100 percent rating for PTSD with agoraphobia, effective August 20, 2014, and additional disabilities independently ratable at 60 percent or more, and is the maximum benefit allowable under the law for the appeal period beginning on August 20, 2014. Because a total rating is in effect for a service-connected disorder and SMC has been awarded at the housebound rate, the TDIU issue is moot from August 20, 2014. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008); DVA Sum. Op. Gen. Counsel Prec., 75 Fed. Reg. 11229-04 (Mar. 10, 2010) (withdrawing VAOPGCPREC 6-99, 64 Fed. Reg. 52375 (1999)). As a total rating and SMC at the housebound rate is not in effect prior to August 20, 2014, the issue of entitlement to TDIU remains on appeal prior to that date. The Board notes that additional evidence, to include VA treatment records through August 2016, was added to the record after the issuance of an October 2014 supplemental statement of the case for the TDIU and higher rating for PTSD claims. While the Veteran has not submitted a waiver of AOJ consideration of this evidence, these newly associated documents are duplicative or irrelevant to these claims and such a waiver is not required. See 38 C.F.R. § 20.1304 (c) (2016). This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. A review of the Virtual VA file reveals VA treatment records dated through August 2016. The remaining documents in the Virtual VA file are either duplicative of those contained in the VBMS file or are irrelevant to the issues on appeal. The issue of entitlement to service connection for a left foot is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. From the date of award of service connection, July 15, 2009 and prior to August 20, 2014, the Veteran's PTSD with agoraphobia has been manifested by occupational and social impairment, with deficiencies in most areas, due to such symptoms of near-continuous panic and anxiety affecting the ability to function independently, appropriately, and effectively, difficulty adapting to stressful situations, obsessional ritualistic behaviors that interfere with routine activities, sleep impairment, and hypervigilance, without more severe manifestations that more nearly approximate total occupational and social impairment. 2. From July 15, 2009 and prior to August 20, 2014, the Veteran is unable to secure and follow a substantially gainful occupation due to service-connected PTSD with agoraphobia. 3. From August 20, 2014, the Veteran is already in receipt of a 100 percent disability rating and SMC based on housebound criteria. 4. From April 1, 2010, the Veteran has a total evaluation due to his service-connected PTSD with agoraphobia, and an additional disability of bilateral hearing loss, rated as 60 percent disabling. CONCLUSIONS OF LAW 1. From the date of award of service connection, July 15, 2009, and prior to August 20, 2014, the criteria for a 70 percent rating, but no higher, for PTSD with agoraphobia have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.130, Diagnostic Code 9411 (2016). 2. From July 15, 2009 and prior to August 20, 2014, the criteria for entitlement to a TDIU based on PTSD with agoraphobia are met. 38 U.S.C.A. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2016). 3. From August 20, 2014, the claim of entitlement to a TDIU is moot. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.16 (2016). 4. From April 1, 2010, the criteria for entitlement to special monthly compensation at the housebound rate have been met. 38 U.S.C.A. § 1114(s) (West 2014); 38 C.F.R. § 3.350 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2016). With respect to the Veteran's claim herein, the Veteran has not alleged that VA has not fulfilled its duty notify or assist in the development of his claim. Moreover, review of the record fails to reveal any deficiency with respect to either the duty to notify or assist. In sum, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2015); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Therefore, the Board finds it may proceed to a decision. II. PTSD with Agoraphobia Pertinent Statutes and Regulations Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson, 12 Vet. App. at 126. The Court has held that, in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. 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). 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, are expected in all instances. 38 C.F.R. § 4.2. PTSD is evaluated under VA's General Rating Formula for Mental Disorders. Under the formula, a 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty 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; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is warranted 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; 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; 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. Id. A 100 percent rating is warranted when 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. Id. The nomenclature employed in the portion of VA's Rating Schedule that addresses service-connected psychiatric disabilities is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). 38 C.F.R. § 4.130. 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. Higher scores correspond to better functioning of the individual. The Board observes that the newer DSM-V has now been officially released. An interim final rule was issued on August 4, 2014, that replaced the DSM-IV with the DSM-V. 79 Fed. Reg. 45093 (Aug. 4, 2014). However, the provisions of the interim final rule apply to all applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014. Thus, the newer DSM-V does not apply to the present case. Under DSM-IV, a GAF score of 71 to 80 indicates that, if symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). A GAF score of 61 to 70 reflects some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. A GAF score of 51 to 60 indicates moderate symptoms, or moderate difficulty in social, occupational, or school functioning. DSM-IV; 38 C.F.R. §§ 4.125, 4.130; see Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, supra. An assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126 (a). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126, VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (a). The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Vasquez-Claudio v. Shinseki, F.3d 112, 117 (Fed. Cir 2013). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely the basis of social impairment. 38 C.F.R. § 4.126 (b). Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Factual Background Pertinent evidence as to the level of severity of the Veteran's PTSD with agoraphobia prior to August 20, 2014 includes VA examinations dated in September 2009 and June 2011, the September 2012 hearing transcript, and VA treatment records during the pertinent appeal period. A June 2009 VA mental health consult note provides a diagnosis of PTSD with agoraphobia. The psychologist noted the Veteran's "unexplainable fears of going out or leaving his home." The Veteran reported that his PTSD symptoms, to include panic attacks and "fears of having additional attacks" "really affected his quality of life" because "[m]oving away his comfort zone ma[de] him feel very anxious, such that he could not travel" more than 5 miles from his house." He further reported that he "fears places where escape may pro[ve] challenging" and that he wanted "his family to always accompany him wherever he goes." Mental status examination showed that he was alert and attentive with good hygiene. Speech was normal and thought process was goal directed and logical. There were no hallucinations. Suicidal and homicidal ideations were denied at this time. A GAF of 65 was given. An August 2009 VA psychiatry note reflects the Veteran's report that he was "afraid of traveling far away from home," resulting in panic attacks. Also noted was that his "chances of getting a job were limited and that his overall functioning is grossly impaired." Also reported were "periods of anxiety attacks, evidenced by palpitation, diaphoresis, [shortness of breath], tremors, and feelings of impending doom," lasting about 10 minutes. The psychologist observed that the Veteran had "good hygiene" and that he was alert and attentive. He was cooperative and calm. Thought process was described as goal directed and logical. The Veteran denied suicidal or homicidal ideation at this time. No delusions were found. Judgment and insight were found to be good. For cognition, there were no significant deficits noted. A September 2009 VA examiner noted the Veteran's report of difficulty falling asleep and regular nightmares. The examiner also noted his finding of obsessive and ritualistic behavior. The examiner explained that the Veteran "patrols house at night; checks all locks on doors and windows and even car doors, and often conducts the ritual more than once." Also noted was the Veteran's inability to "travel beyond a half-mile from his home without a second veh[icle] in tow out of fear of being stranded alone." The examiner indicated that the Veteran had "severe panic attacks at an average of three times per month." Symptoms included hyperventilating, shaking, and sweating, and feeling as though "he is choking to death." The Veteran reported that "he will invariably experience some form of anxiety attack when he travels away from his home, and often before he travels." The examiner observed that the Veteran was appropriately dressed and neatly groomed. Speech was soft or whispered. Attitude was cooperated and attentive. Affect was constricted and mood depressed. Thought process and content were unremarkable. No homicidal or suicidal thoughts were noted. Impulse control was good, and no episode of violence was noted. The examiner noted other PTSD symptoms, to include difficulty concentrating, hypervigilance, exaggerated startle response, and avoidance of large crowds. With regard to the extent of social and occupational impairment, the examiner noted the Veteran's report that he has been married to his spouse for the past 41 years and that they enjoyed "a good relationship," although his PTSD symptoms have "significantly detracted from the quality of the relationship." The Veteran also reported that he enjoyed time with "some fri[en]ds and immediate family," but that he "mainly socializes at home." With regard to employment, the examiner noted that the Veteran has been employed in a grocery store for the past "5 to 10 years" and that less than 1 week was lost during the last 12 month period. Cause of time lost from work was due to "routine illness." Effect on work was that the Veteran had "limited job opportunities" because of his "inability to travel" beyond a short distance from home. The examiner then determined that PTSD symptoms resulted in deficiencies in judgment, thinking, family relations, work, and mood. PTSD impaired judgment because the Veteran "perceives unrealistic threats and danger on a frequent basis." Thinking was impaired due to "thoughts of danger" and "sad and melancholy thoughts." Family relations were impacted due to "anxiety attacks and fears of crowds" detracting from the quality of martial relations. Work was impacted because the Veteran was limited to working in a grocery store near his house "secondary to inability to travel beyond." Mood was affected because of "persistently depressed mood." An October 2009 VA mental health note reflects the Veteran's reported fear of being away from home. He reported that, at times, he required two drivers to travel, such that one drove while the other "follow[ed] in another car due to his fear of being stranded on the road." The psychologist noted that the Veteran could still "drive to and from work at his part-time job," but that he "ma[de] extremely short drives, and that on his way back, he called his family to inform them "that he is on his way home so that someone can watch for him." On mental status examination, the Veteran was alert and oriented with no suicidal/homicidal ideation or psychosis. A November 2009 VA psychiatry note indicates that the Veteran "has not come to Memphis VA [medical center] except for absolutely necessary visits in 20 years, due to the anxiety . . . ." The Veteran reported that 'as long as [he] stay[s] closer to the house, [he is] hanging in there.' He denied any suicidal or homicidal ideation or depressed at this time and reported that he was living with his wife and her mother. He reported that in addition to caring for his mother-in-law, he was "working his part-time job" and that he "stay [end] busy by working in his yard." Also noted was the Veteran's report of continued sleep impairment and nightmares. On mental status examination, the Veteran appeared alert and attentive, with appropriate hygiene and grooming. Attitude was observed to be calm, cooperative, and pleasant. His sense of humor was noted. Speech was noted to be spontaneous, fluent, and normal rate and tone. Mood was neutral. Affect was mood-congruent and full. Thought process was noted to be goal-directed and logical. Thought content was without any delusions or paranoia. There was no suicidal or homicidal ideation, intent or plan. Judgement and insight were found to be good. As for cognition, the psychologist observed that the Veteran was grossly intact, based on his ability to provide details for that assessment. A February 2010 VA mental health note reflects that the Veteran complained of "having more nightmares" and that he was able to talk "openly about Vietnam experience without crying [during] this visit." On mental status examinations, normal mood and affect were found. The Veteran was observed to be alert and oriented, as well as friendly and cooperative. He denied suicidal or homicidal ideation at this time. Psychosis and delusions were also denied. A June 2011 VA examiner noted the Veteran's report of frequent nightmares and "nightly problems with sleep." The Veteran reported that he "typically does not drive long distances and when he does drive he stated that he will be careful to maintain the speed limit and will try to use things such as the radio to distract him to not become overwhelmed. He described "feelings of being constantly on guard while driving surveying his environment," as well as symptoms of becoming easily started in cases of loud noise. During mental status examination, the examiner observed that the Veteran was casually groomed and cooperative. His mood was depressed and affect was appropriate. He appeared "extremely somber" when describing death of a friend during service. Thought process was rational. The Veteran was oriented as to time, place, and person, and there was no evidence of delusional thoughts or hallucinations. Adequate judgment and insight were noted. The Veteran denied any thoughts of harm to himself or others. The examiner also noted that the Veteran worked in the grocery store and that he retired over a year ago. The Veteran reported to have a "good relationship with his family" and stated that he had a few friends. His leisure activities included fishing. The examiner also commented that while the Veteran's PTSD symptoms, specifically his problems with driving, "likely . . . limit[ed] his employment options significantly," his PTSD symptoms did not otherwise "preclude employment." During the September 2012 hearing, the Veteran testified that he suffered from anxiety attacks and trouble sleeping. He reported that he had problems working with other people. At work, he reported suffering from "a vision of being trapped" and that he used to "carry water with [him] . . . because [he had] trouble swallowing when it [got] to [him]." The Veteran indicated that anxiety caused him to feel "trapped" at work on daily basis and that such precluded him from working at the grocery store. He also reported that he did not socialize with friends and that he had no significant problems with his wife. The Veteran's son testified that he "blows up easily" and described a time when he "just went ballistic" after a boat motor stopped working at a family gathering. A November 2013 VA psychiatry note indicates that the Veteran "continues to struggle with depression" and that he had difficulty with sleeping. On mental status examination, the Veteran was alert and pleasant, logical and goal directed, and sad with restricted affect. No homicidal or suicidal ideation was detected. Analysis Based on the foregoing, the Board resolves all reasonable doubt in the Veteran's favor and finds that from July 15, 2009, the date of the award of service connection for PTSD with agoraphobia, and prior to August 20, 2014, a 70 percent rating, but no higher, is warranted for the Veteran's PTSD with agoraphobia. During this appeal period, the Veteran's PTSD symptomatology was manifested by near-continuous panic and anxiety, difficulty adapting to stressful situations, ritualistic behaviors that interfere with routine activities, sleep impairment, and hypervigilance. As noted, a 70 percent rating is warranted 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; 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; 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. Prior to August 20, 2014, clinical evidence demonstrates that the Veteran experienced anxiety on near-continuous basis, affecting his ability to function independently and effectively. In this regard, the examiners have consistently noted that the Veteran suffered from anxiety from his fear of leaving his home. The June 2009 VA psychologist noted the Veteran's report of "unexplainable fears of going out or leaving his home" and that such fear "really affected his quality of life." Also noted was that the Veteran required "his family to always accompany wherever he goes," indicative of his anxiety affecting his ability to function independently. Likewise, the August 2009 VA psychologist noted the Veteran's "periods of anxiety attacks, evidenced by palpitation, diaphoresis . . . and feelings of impending doom," in conjunction with his fear of "travelling far away from home." Further, the September 2009 VA examiner stated that the Veteran had "several panic attacks" that worsened "when he travels away from his home." At the September 2012 hearing, the Veteran reported continued anxiety attacks. The Veteran has also suggested his difficulty with adapting to stressful situations, to include work-like settings. During the September 2012 hearing, he testified that while previously working at a grocery store, he often suffered from "a vision of being trapped" and that he used to "carry water with [him] . . . because [he had] trouble swallowing when it [got] to [him]." The Veteran reported that such feeling of being "trapped" at work occurred on daily basis and that it precluded him from working at the grocery store. The Veteran's son also testified that he "blows up easily" and described a time when he "just went ballistic" after a boat motor stopped working at a family gathering." The record also reflects that the Veteran has exhibited obsessive behaviors interfering with his daily activities that "really affected his quality of life." See June 2009 VA mental health consult note. The June 2009 VA psychologist noted the Veteran's unexplainable fears of going out or leaving his home." The September 2009 examiner observed that stemming from such "unrealistic threats and danger on a frequent basis," the Veteran engaged in obsessive and ritualistic behaviors. As an example, the examiner noted that the Veteran "patrols house at night; checks all locks on doors and windows and even car doors, and often conducts the ritual more than once." The October 2009 VA mental health note reflects that, as result of fear of being away from home, the Veteran regularly required two drivers to travel with him, usually his two children, such that one drove while the other "follow[ed] in another car due to his fear of being stranded on the road." While the Veteran has not demonstrated all of the symptoms associated with the 70 percent rating criteria, the Board acknowledges that not all of the demonstrative symptoms must be shown to warrant a higher rating. See Mauerhan v. Principi, 16 Vet. App 436, 442-43 (2002). For example, there is little or no evidence in the clinical evidence of suicidal or homicidal ideation, inability to maintain effective relationships, or neglect of personal hygiene. However, the Veteran's symptoms, especially his near-continuous anxiety, hypervigilance, and obsessional and ritualistic behaviors, have been of the frequency, severity, and duration to have rendered impairment in his social and occupational functioning throughout the pertinent appeal period. See Mauerhan, 16 Vet. App at 442-43; Vasquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir. 2013). Therefore, resolving all reasonable doubt in the Veteran's favor, the Board finds that a 70 percent rating, but no higher, is warranted for PTSD with agoraphobia, from July 15, 2009 to prior to August 20, 2014. The Board has also considered whether the Veteran's PTSD with agoraphobia warrants a higher rating. The Board concludes that his disability does not more closely approximate the criteria for a 100 percent rating prior to August 20, 2014. The Veteran's symptoms have not been manifested by 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); and disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. During the pertinent appeal period, the Veteran consistently denied thoughts of harming himself or others. He was persistently noted to be appropriately groomed and oriented as to place, person, and time at the mental status examinations conducted during the pertinent appeal period. Thought process and content were noted to be rational and without problems. There is no indication of memory loss for names of close relatives, own occupations, or own name. The Veteran consistently denied thoughts of suicide or past attempts of suicide, as well as hallucinations and delusions. Consequently, the Board finds that the Veteran's symptomatology does not result in total occupational and social impairment prior to August 20, 2014. Therefore, the Board resolves all reasonable doubt in the Veteran's favor and finds that, from July 15, 2009, the date of award of service connection, and prior to August 20, 2014, his PTSD with agoraphobia, a 70 percent rating, but no higher, is warranted. See 38 C.F.R. § 4.21 (not all cases will show all findings specified in the rating criteria, but the rating must in all cases be coordinated with actual functional impairment). Extraschedular Consideration The Board has contemplated whether the case should be referred for extra-schedular consideration. An extra-schedular disability rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of regular scheduler standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the Court explained how the provisions of 38 C.F.R. § 3.321 are applied. Specifically, the Court stated that the determination of whether a claimant is entitled to an extra-schedular rating under 38 C.F.R. § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. at 115-16. The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected PTSD with agoraphobia with the established criteria found in the rating schedule. The Board finds that the Veteran's PTSD symptomatology is fully addressed by the rating criteria under which such disability is rated. A higher rating was contemplated in this decision and rejected as his symptoms did not more closely approximate the 100 percent rating. There are no additional symptoms of his PTSD that are not addressed by the rating schedule. In this regard, all of the Veteran's psychiatric symptomatology is contemplated by the rating criteria, to include those symptoms which are not specifically enumerated. See Mauerhan, supra. Therefore, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology of his service-connected disability. As such, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture and, therefore, the Board need not proceed to the second factor to consider whether there are related factors such as marked interference with employment or frequent periods of hospitalization. Consequently, the Board concludes that referral of this case for consideration of an extra-schedular rating is not warranted. Thun, 22 Vet. App. at 115-16; Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996). A discussion of entitlement to a TDIU is not necessary as that claim is being granted herein, as discussed below. III. TDIU Pertinent Statutes and Regulations The Veteran maintains that he is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, to include his PTSD with agoraphobia, bilateral hearing loss, and tinnitus. He has reported that he has been unemployed since December 2009. See February 2010 Application for Increased Compensation based on Unemployability. A TDIU is warranted where the evidence of record shows that a veteran is unable to secure or follow a substantially gainful occupation, consistent with his education and occupational experience, as a result of service-connected disability, without regard to advancing age. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2016). Provided that there is only one such disability, that disability must be rated at 60 percent or more. 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. §§ 3.340, 3.341, 4.16(a) (2016). The term unemployability, as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. See VAOPGCPREC 75-91 (Dec. 17, 1991). The issue is whether a veteran's service-connected disability or disabilities preclude him from engaging in substantially gainful employment (i.e., work which is more than marginal, that permits the individual to earn a living wage). See Moore v. Derwinski, 1 Vet. App. 356 (1991). In a claim for a TDIU, the Board may not reject the claim without producing evidence, as distinguished from mere conjecture, that a veteran's service-connected disability or disabilities do not prevent him from performing work that would produce sufficient income to be other than marginal. Friscia v. Brown, 7 Vet. App. 294 (1995) (citing Beaty v. Brown, 6 Vet. App. 532, 537 (1994)). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Court has held that the central inquiry in determining whether a Veteran is entitled to a TDIU is whether service-connected disabilities alone are of sufficient severity to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). In determining whether a Veteran is unemployable for VA purposes, consideration may be given to the Veteran's level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Hersey v. Derwinski, 2 Vet. App. 91, 94 (1992); Faust v. West, 13 Vet. App. 342 (2000). A Veteran need not show 100 percent unemployability in order to be entitled to a TDIU. Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). Analysis In the present case, the Veteran meets the percentage requirements for a schedular award of a TDIU prior to August 20, 2014. He is currently in receipt of a 70 percent rating for PTSD with agoraphobia from July 15, 2009 to prior to August 20, 2014, and a 100 percent rating thereafter; a 60 percent rating for bilateral hearing loss, as of April 1, 2010; a 10 percent rating for tinnitus, as of April 1, 2010; and a 100 percent rating for lung cancer, as of November 25, 2015. He was also awarded SMC based on housebound criteria under 38 U.S.C.A. § 1114(s), effective August 20, 2014. As of July 15, 2009 and prior to August 20, 2014, the threshold requirements for a schedular award of a TDIU have been met. From July 15, 2009 to prior to April 1, 2010, the Veteran had a single disability (i.e. PTSD with agoraphobia) rated at 70 percent. From April 1, 2010 to prior to August 20, 2014, he had a combined 80 percent rating with at least one disability ratable at 40 percent or more. As such, the remaining inquiry is whether the Veteran is unable to secure or follow substantially gainful occupation due solely to his service-connected disabilities. In an August 2009 VA psychiatry note, the psychologist noted that because of the Veteran was "afraid of traveling far away from home" and panic attacks, his "chances of getting a job was limited and that this overall functioning is grossly impaired." Symptoms of "anxiety attacks, evidenced by palpitation . . . and feelings of impending doom" were noted as result of such anxiety. The September 2009 VA examiner commented on the Veteran's inability to "travel beyond a half-mile from his home without a second veh[icle] in tow out of fear of being stranded alone." The examiner opined that work was impacted because the Veteran was limited to working in a grocery store near his house "secondary to inability to travel beyond." An October 2009 VA mental health note reflects that at times, the Veteran required two drivers to travel with him, such that one drove him while the other driver "follow[ed] in another car due to his fear of being stranded on the road" and that he "ma[de] extremely short drives, and that on his way back, he called his family to inform them that "he is on his way home so that someone can watch for him." In a November 2009 VA psychiatry note, the psychologist noted that the Veteran worked in a grocery store as a store clerk for 15 to 20 hours a week. Also noted was the Veteran's report that "job has been difficult lately" because "[he] can't hear anything." In a February 2010 Application for Increased Compensation based on Unemployability, the Veteran reported that his PTSD and hearing disabilities prevented from securing or following any substantially gainful occupation. He reported that he last worked at a grocery store as a clerk in December 2009. He reported that he earned a total income of $11,000 in the past 12 months. The Veteran indicated that he had three years of college education, but that he dropped out before graduating, and that he has no other education or training. In a July 2010 VA audiology examination report, the examiner opined that the Veteran's hearing loss and tinnitus had effect on occupation, noting his "difficulty understanding over the telephone" and his general "hearing difficulty." In various VA treatment notes, physicians noted problems communicating with the Veteran due to his hearing loss disabilities. See November 2009 VA treatment note; February 2010 VA treatment note; March 2010 VA treatment note; July 2010 VA treatment note. In a June 2011 VA audiology examination report, the examiner founds that the Veteran's hearing loss had no significant effects on his occupation or daily activities. The examiner opined that "hearing loss and tinnitus alone do not render a person unable to seek or maintain gainful employment." In a July 2011 VA examination report, the examiner noted that the Veteran's PTSD symptoms, to specifically include his fear of going to 'places outside [his] safe zone,' "significantly" limited his employment options. The examiner noted that the Veteran avoided driving long distances, which resulted in feelings of being "overwhelmed" and "being constantly on guard while driving surveying his environment." During the September 2012 hearing, the Veteran testified that he often felt "trapped" at work and that he had to "get outside" on daily basis. See September 2012 Hearing Transcript at 10. He reported that his anxiety prevented him from working in any store settings and that it was difficult for him to drive by himself because he was "home base." See id. at 11. Initially, the Board observes that although there is evidence that the Veteran's hearing loss and tinnitus affected his ability to work due to difficulty understanding conversation, again the June 2011 VA audiology examiner stated that "hearing loss and tinnitus alone do not render a person unable to seek or maintain gainful employment. As such, the evidence does not show that the Veteran's hearing loss and tinnitus alone rendered him unemployable. However, based on the foregoing, the Board finds that the evidence is in relative equipoise as to whether the Veteran's service-connected PTSD and agoraphobia render him unemployable. In this regard, the Veteran's PTSD and agoraphobia has resulted in "significant" limitation of employment opportunities due to his fear of being away from home. See June 2011 VA examination report. The June 2011 VA examiner opined that such fear and anxiety significantly limited the Veteran's job opportunities. The September 2009 VA examiner noted that the Veteran was unable to travel more than "half-mile" from his house due to anxiety and that he was limited to working at a grocery store near his house "secondary to inability to travel beyond," indicative of difficulty engaging in non-marginal, substantially gainful employment. Importantly, the record reflects that the Veteran earned a total annual income of $11,000 approximately from 2009 to 2010, barely exceeding the poverty threshold for one person as determined by the U.S. Bureau of the Census (i.e. $10,956 in 2009 and $11,139 in 2010) . See 38 C.F.R. § 4.16 (a)(providing that marginal employment may also be held to exist, on a factual basis, when earned annual income exceeds the poverty threshold). Further, the Veteran testified that he often felt "trapped" and anxious at work on daily basis, significantly affecting his ability to work. See September 2010 Hearing Transcript at 10-11. The final determination with respect to a Veteran's entitlement to a TDIU is an adjudicatory, and not a medical, function. Further, the Board notes that the Veteran's past work history consisted of working as a grocery store clerk during the pertinent appeal period and that he had no other relevant training or significant work experience. Therefore, in light of the totality of the record, and giving due consideration to the Veteran's description of the functional effects of his service-connected PTSD with agoraphobia as his disorder relates to his level of education and prior occupational experience, the Board finds that the Veteran is unable to secure and follow a substantially gainful occupation by reason of a single service-connected disability (i.e. PTSD with agoraphobia) from July 15, 2009 and prior to August 20, 2014. As such, from July 15, 2009 and prior to August 20, 2014, a TDIU is granted due to the Veteran's PTSD with agoraphobia. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Further, as noted in the Introduction, the Veteran is in receipt of a 100 percent disability rating from August 20, 2014, as well as SMC based on housebound criteria from August 20, 2014. As this award represents a full grant of the benefits sought with respect to the claim for a TDIU from August 20, 2014, the claim of entitlement to a TDIU as of August 20, 2014 is moot. Lastly, the Board has considered whether SMC at the housebound rate is warranted prior to August 20, 2014. Buie v. Shinseki, 24 Vet App 242 (2010) (finding that SMC is a potential element of increased rating claims without the need for a separate claim). While the Board has granted a TDIU based on a single disability (i.e. PTSD with agoraphobia) from July 15, 2009 and prior to April 1, 2010, thus satisfying the requirement for a single disability rated as total, see Bradley v. Peake, 22 Vet. App. 280 (2008), the Veteran had no additional service-connected disability rating independently ratable as 60 percent or more during that period. However, as of April 1, 2010, the Veteran has a TDIU rating based on a single disability (i.e. PTSD with agoraphobia). Further, the Veteran has an additional disability of hearing loss, which is distinct from his PTSD disability and independently rated as 60 percent disabling from April 1, 2010. Thus, from April 1, 2010, the schedular criteria for entitlement to SMC due to housebound status have been met. The Board notes that the issue of entitlement to SMC for aid and attendance has not been raised by the record and is not before the Board at this time, as the evidence of record does not indicate that the Veteran is rendered so helpless due to his service-connected disabilities so as to require regular aid and attendance of another person during this period. See Akles v. Derwinski, 1 Vet. App. 118 (1991) (the issue of entitlement to SMC is part and parcel of a claim for increased compensation and does not require submission of a separate claim). ORDER From July 15, 2009 and prior to August 20, 2014, an initial rating of 70 percent, but no higher, for PTSD with agoraphobia is granted, subject to the law and regulations governing the payment of VA compensation benefits. From July 15, 2009 and prior to August 20, 2014, a TDIU is granted, subject to the law and regulations governing the payment of VA compensation benefits. The claim of entitlement to a TDIU as of August 20, 2014 is dismissed. From April 1, 2010, entitlement to special monthly compensation at the housebound rate is granted, subject to the law and regulations governing the payment of VA compensation benefits. REMAND In a September 2016 substantive appeal (via VA Form 9) as to the service connection claim for a left foot disability, the Veteran requested a Board video-conference hearing. As the Veteran has not yet been afforded the requested hearing, the claim is remanded to provide one. Accordingly, the case is REMANDED for the following action: Schedule the Veteran for a video-conference hearing before a Veterans Law Judge as to the issue of entitlement to service connection for a left foot disability. The appellant 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). ______________________________________________ J. N. MOATS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs