Citation Nr: 18144784 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 11-25 750 DATE: October 25, 2018 ORDER For the initial rating period prior to July 3, 2010, a rating in excess of 10 percent for the lumbar spine disability is denied. For the rating period from July 3, 2010 to April 14, 2011, a 20 percent rating, but no higher, for the lumbar spine disability is granted. For the rating period from July 3, 2010 to February 26, 2018, a rating in excess of 20 percent for the lumbar spine disability is denied. For the rating period beginning February 27, 2018, a rating in excess of 40 percent for the lumbar spine disability is denied. An initial rating of 70 percent, but no higher, for posttraumatic stress disorder (PTSD) is granted. Entitlement to a total disability rating on the basis of individual unemployability due to service-connected disabilities (TDIU) from July 3, 2010 to May 4, 2018 is granted. FINDINGS OF FACT 1. For the rating period prior to July 3, 2010, the Veteran’s lumbar spine disability did not more nearly approximate forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 2. For the rating period from July 3, 2010 to April 14, 2011, the Veteran’s lumbar spine disability more nearly approximated forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. 3. For the rating period from July 3, 2010 to February 26, 2018, the Veteran’s lumbar spine disability did not more nearly approximate forward flexion of the thoracolumbar spine 30 degrees or less or unfavorable ankylosis of the entire thoracolumbar spine. 4. For the rating period beginning February 27, 2018, the Veteran’s lumbar spine disability does not more nearly approximate unfavorable ankylosis of the entire thoracolumbar spine. 5. There is no objective evidence of any neurological impairment due to the lumbar spine condition during the appeal period. 6. For the entire initial rating period on appeal, the evidence is in equipoise as to whether the Veteran’s PTSD was manifested by occupational and social impairment with deficiencies in most areas including family relations, judgment, thinking, and mood. 7. For the rating period from July 3, 2010 to May 4, 2018, the combined effect of the Veteran’s service-connected PTSD and lumbar spine disabilities prevented him from obtaining or maintaining a substantially gainful occupation. CONCLUSIONS OF LAW 1. For the rating period prior to July 3, 2010, the criteria for a rating in excess of 10 percent for the lumbar spine disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237, 5242 (2017). 2. For the rating period from July 3, 2010 to April 14, 2011, the criteria for a 20 percent rating, but no higher, for the lumbar spine disability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237, 5242 (2017). 3. For the rating period from July 3, 2010 to February 26, 2018, the criteria for a rating in excess of 20 percent for the lumbar spine disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237, 5242 (2017). 4. For the rating period beginning February 27, 2018, the criteria for a rating in excess of 40 percent for the lumbar spine disability are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5237, 5242 (2017). 5. For the entire initial rating period on appeal, the criteria for a rating of 70 percent, but no higher, for PTSD are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.130, Diagnostic Code 9411 (2017). 6. For the rating period from July 3, 2010 to May 4, 2018, the criteria for entitlement to a TDIU are met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2017). REFERRED ISSUE The Veteran has been awarded a TDIU beginning May 5, 2018 based on his service-connected disabilities. See September 2018 rating decision. The Veteran’s attorney filed a notice of disagreement with the effective date. As discussed in more detail below, the Board is granting TDIU from July 3, 2010 to May 4, 2018. Although the RO has not yet considered the notice of disagreement, this action is not prejudicial to the Veteran, as the Board is able to grant the benefit sought back to July 3, 2010. The Veteran did identify July 3, 2010, as the date he became too disabled to work in his formal TDIU claim, so it appears the Board is granting, in full, the benefit sought. However, it is not known whether this fully resolves the pending notice of disagreement, as the Veteran’s attorney did not request a specific date. Therefore, the RO should continue to process the pending notice of disagreement in the ordinary course of business. If the attorney and the Veteran are fully satisfied with the Board’s grant herein, then they should notify the RO the notice of disagreement is withdrawn. In October 2018, the RO certified for appeal a claim for service connection for a left ankle condition. However, the Board denied that claim in 2016. Therefore, no further action is needed. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2002 to February 2009. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from the September 2009 and December 2009 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO), in San Juan, Puerto Rico. The issues on appeal were previously remanded by the Board in February 2016 for further development.   Laws and Analysis for Lumbar Spine Disability By way of procedural background, the Veteran was initially granted service connection for a lumbar spine disability in the September 2009 rating decision. The Veteran was assigned a 10 percent rating effective February 13, 2009 (the day following service separation). Beginning April 15, 2011, the RO increased the Veteran’s lumbar spine disability rating to 20 percent. See September 2011 rating decision. In an April 2018 rating decision, the RO again increased the Veteran’s rating to 40 percent beginning February 27, 2018. Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). The Veteran’s lumbar spine disability has been rated under Diagnostic Code 5237 for lumbosacral strain and 5242 for degenerative arthritis of the spine. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) (for DCs 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula)). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The disabilities of the spine that are rated under the General Rating Formula include vertebral fracture or dislocation (DC 5235), sacroiliac injury and weakness (DC 5236), lumbosacral or cervical strain (DC 5237), spinal stenosis (DC 5238), unfavorable or segmental instability (DC 5239), ankylosing spondylitis (DC 5240), spinal fusion (DC 5241), and degenerative arthritis of the spine (DC 5242) (for degenerative arthritis of the spine, see also DC 5003). The General Rating Formula provides a 10 percent rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned forward flexion of the thoracolumbar spine 30 degrees or less; or, unfavorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. The Notes following the General Rating Formula provide further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note (2) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. DC 5243 provides that IVDS is to be rated either under the General Rating Formula or under the IVDS Formula, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The IVDS Formula provides a 10 percent rating for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) to DC 5243 provides that, for purposes of ratings under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) provides that, if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated on the basis of incapacitating episodes or under the General Rating Formula, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a. The evidence includes an August 2009 VA general medical examination. During the evaluation, the Veteran reported low back pain since 2002. He indicated that he had intermittent episodes of low back pain (approximately 3 times a month, lasting 3 days in duration). Flare-ups of pain were precipitated by prolonged sitting. Upon physical examination, the Veteran’s gait was normal. Range of motion testing of the thoracolumbar spine showed flexion limited to 90 degrees. Extension, bilateral lateral flexion, and bilateral lateral rotation were limited to 30 degrees. There was no additional pain or additional loss of motion on repetitive use testing. The examiner also noted that there were no abnormalities of the spinal muscles, such as guarding, spasm, or tenderness. The evidence also includes a December 2013 Social Security Administration Decision where it was noted that the Veteran was found to be disabled since July 3, 2010, due to a spine disability and psychiatric disability. Specifically, the decision noted that on July 3, 2010, the Veteran injured his back at work and complained of lumbar pain without radiation. The Veteran continued to receive treatment up to July 2011 and infiltrations were performed in June 2011. During an April 2011 VA spine examination, the Veteran reported having back pain since service that had progressively worsened over time. The Veteran also reported that his pain now radiated to the gluteal area. Flare-ups were noted to occur weekly and were precipitated by bending and lifting. Upon range of motion testing, flexion of the thoracolumbar spine was limited to 40 degrees, with no objective evidence of pain. Repetitive use testing did not additionally limit motion. The Veteran was afforded VA spine examinations in February 2018 and July 2018. During the evaluations, the Veteran reported severe low back pain that was controlled by medication. Due to the pain, the Veteran had difficulty bending, stooping, lifting, and standing for more than 20 minutes. Upon range of motion testing, flexion of the thoracolumbar spine was limited to 30 degrees during the February 2018 examination. In July 2018, flexion was limited to 25 degrees. Repetitive use testing did not additionally limit motion or function. The examiners also noted that the Veteran did not have ankylosis, IVDS, or radiculopathy. Upon review of all the evidence of record, lay and medical, the Board finds that the criteria for a rating in excess of 10 percent has not been met for the rating period prior to July 3, 2010. Specifically, forward flexion of the thoracolumbar spine prior to this date was limited to, at worst, 90 degrees and the combined range of motion of the thoracolumbar spine in the August 2009 VA examination discussed above was greater than 120 degrees. There was also no objective evidence of muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour or ankylosis. There is also no basis for the assignment of a higher rating due to pain, weakness, fatigability, weakness or incoordination. See 38 C.F.R. §§ 4. 40 and 4.45 and DeLuca, 8 Vet. App. at 206-7. The August 2009 VA examiner indicated that there was no pain was present during repetitive use testing, and there was no additional loss of motion. The Board finds that the limitation of motion and functional loss due to pain is contemplated in the 10 percent rating assigned prior to July 3, 2010. Based on the objective medical evidence of record, there is no basis for the assignment of a higher rating pursuant to 38 C.F.R. §§ 4.40 and 4.45. The Board further finds that a higher rating is not warranted under Diagnostic Code 5243 for incapacitating episodes associated with intervertebral disc syndrome for the rating period prior to July 3, 2010. There is no indication in the medical evidence prior to this date, that the Veteran had been prescribed bedrest by a physician. Thus, the Board finds that a disability evaluation in excess of 10 percent for the lumbar spine disability is not applicable under Diagnostic Code 5243. 38 C.F.R. § 4.71a, Diagnostic Code 5243. In summary, the Board finds that the preponderance of the evidence is against the assignment of a disability evaluation in excess of 10 percent for the lumbar spine disability for the rating period prior to July 3, 2010. Regarding the rating period from July 3, 2010 to April 14, 2011, the Board finds that a 20 percent rating was more nearly approximated for the Veteran’s lumbar spine disability, based on evidence of forward flexion limited to 30 degrees but not greater than 60 degrees. The Board is aware that forward flexion of the spine was limited to 40 degrees in the April 2011 VA examination; however, the Board finds it reasonable to assume that his spine disability (and resulting decrease in motion) began as a result of his work injury on July 3, 2010. As a result of this injury, the Veteran complained of lumbar pain without radiation and received treatment up to July 2011. It is also unlikely that the Veteran’s lumbar spine disability became worse on the very date of his April 2011 VA examination. For these reasons, and resolving reasonable doubt in the Veteran’s favor, the Board finds that a 20 percent rating is warranted for the rating period from July 3, 2010 to April 14, 2011. Next, the Board finds that from July 3, 2010 to February 26, 2018, a rating in excess of 20 percent is not warranted. As noted above, the April 2011 VA examiner indicated that flare-ups were noted to occur weekly and were precipitated by bending and lifting. Upon range of motion testing, flexion of the thoracolumbar spine was limited to 40 degrees, with no objective evidence of pain. Repetitive use testing did not additionally limit motion. The remaining evidence of record during this period does not show forward flexion of the thoracolumbar spine to 30 degrees or less or unfavorable ankylosis of the entire thoracolumbar spine. Further, there is no indication in the medical evidence during this time period, that the Veteran had been prescribed bedrest by a physician. For these reasons, the Board finds that a rating in excess of 20 percent is not warranted from July 3, 2010 to February 26, 2018. The Board further finds that a rating in excess of 40 percent is not warranted beginning February 27, 2018. At no point has the Veteran been found to have unfavorable ankylosis of the entire thoracolumbar spine. See February and July 2018 VA examination reports. Further, there is no indication in the medical evidence during this time period, that the Veteran had been prescribed bedrest by a physician. For these reasons, the Board finds that a rating in excess of 40 percent is not warranted beginning February 27, 2018. Finally, the Board also contemplated whether separate ratings are warranted for any neurological impairment resulting from the lumbar spine condition. Although the Veteran has at times complained of radiating pain, the VA examinations in 2011 and 2018 conclusively determined there was no evidence of radiculopathy, and sensory, reflex, and muscle strength evaluations were all normal. A neurological evaluation performed for the Social Security Administration in 2012 also showed sensory and reflex evaluations were all normal. Without objective evidence of any neurological impairment, separate ratings are not warranted. Laws and Analysis for PTSD Disability The Veteran is currently in receipt of a 30 percent evaluation for PTSD for the initial rating period from February 13, 2009 to January 12, 2010. Beginning January 13, 2010, he is in receipt of a 50 percent rating. He maintains higher ratings are warranted. The Veteran’s PTSD is rated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). Ratings are assigned according to the manifestation of particular symptoms. 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 a veteran’s occupational and social impairment. Vazquez-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; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). As noted above, the RO has assigned a 30 percent disability rating for PTSD under Diagnostic Code 9411 for the initial rating period prior to January 13, 2010. A 30 percent rating is assigned when a mood disorder causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment and mild memory loss. 38 C.F.R. § 4.130 (2017). Beginning January 13, 2010, the RO assigned a 50 percent rating for his PTSD disability. A 50 percent disability rating requires evidence of the following: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are: 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.). The criteria for a 100 percent rating are: 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, Diagnostic Code 9411. In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV or DSM 5). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. See Mauerhan, 16 Vet. App. 436. The relevant evidence of record includes an April 2009 VA initial psychiatric consult note. During the evaluation, the Veteran reported having episodes of irritability and bad humor with poor tolerance of people and noise. The Veteran stated that, at times, he was unable to be in places with multitudes due to “fear of a possible enemy attack.” Frequent sleep disturbances, nightmares, and recurrent thoughts of in-service stressors were also reported. The Veteran’s wife also stated that the Veteran was isolated at home and had poor interest in hobbies and had no close friends. The evidence also includes a July 2009 VA mental condition examination report. During the evaluation, the Veteran reported that he was married and had two children. Regarding symptoms, the Veteran stated that he did not like public places where many people were gathered. He also reported irritability, but denied any violent behavior. The Veteran did report being less tolerant and had feelings of sadness on occasion. Upon mental status examination, the Veteran’s mood was mildly anxious. The Veteran reported being employed at the time. During a November 2009 VA PTSD examination, the Veteran reported trouble sleeping, nightmares, anxiety, forgetfulness, avoidance behavior, and feelings of detachment. Following service separation, the Veteran indicated that his relationship with his wife and children was “different,” but he did report going on family outings and playing in the pool with his family. After performing a mental status examination, the examiner indicated that the Veteran had “moderate” impairment in performance in employment, social and interpersonal relationships, and recreational pursuits. In June 2011, the Veteran was afforded another VA PTSD examination. At that time, the Veteran reported that his wife would attend activities with the children and social activities without him as he had intolerance to noises and large groups of people. The Veteran was noted to be isolated at home and experienced episodes of irritability, and poor interest in hobbies and with no close friendships. The Veteran stated that he last worked in 2010 as a truck driver due to chronic low back pain. Upon mental status examination, the Veteran’s affect was constricted and his mood was anxious. The examiner indicated that the Veteran had “markedly” diminished interest or participation in significant activities. He also had difficulty falling and staying asleep and had irritability with outbursts of anger. The Veteran also reported symptoms of depression. VA treatment records include March 2011 and September 2011 VA psychiatric progress notes. During the evaluations, the Veteran reported sleep problems, nightmares, and recurrent thoughts of episodes from service. The Veteran was also noted to be “isolated at home unable to be in places with multitudes, including family or his daughter’s school activities.” The VA mental health professional noted that the Veteran had evidence of avoidance behavior, isolation, numbness of feelings and startle reaction. In November 2011, a private clinical counselor provided a detailed report of the Veteran’s mental health history, concluding, in part, that the veteran would be unable to sustain work as a direct result of his PTSD. In 2012 and 2014, he was hospitalized due to mental health symptoms. Most recently, the Veteran underwent VA PTSD examinations in February 2018 and July 2018. The February 2018 examiner noted that the evaluation covered the time period from June 2011 to the February 2018. Current symptoms were noted to include depressed mood, anxiety, chronic sleep impairment, impaired judgment, mild memory loss, difficulty in establishing and maintaining effective work and social relationships, and difficulty adapting to stressful circumstances. The July 2018 VA examiner further indicated that PTSD could cause difficulties completing a normal workday task, keeping a specific schedule, and integrating appropriately with peers/clients. Upon review of all the evidence of record, both lay and medical, the Board finds that, for the entire initial rating period on appeal, the evidence is at least in equipoise as to whether the criteria for a higher rating of 70 percent is warranted, as the Veteran’s PTSD disability symptoms more nearly approximate occupational and social impairment, with deficiencies in most areas, such as family relations, judgment, thinking, and mood. The Board finds that the Veteran’s symptoms have remained relatively consistent throughout the rating period on appeal. Further, and as discussed in detail above, the Veteran has experienced symptoms of sleep impairment, nightmares, irritability, mild memory loss, social isolation, recurrent memories, irritability with periods of anger, anxiety, depression, and avoidance of crowds. The Veteran was also found to have specific symptoms contemplated by the 70 percent rating criteria, including difficulty in adapting to stressful circumstances, and near-continuous anxiety and depression affecting his ability to socialize or be in large groups. Accordingly, and resolving reasonable doubt in the Veteran’s favor, the Board finds that a 70 percent disability evaluation for PTSD is warranted for the entire initial rating period on appeal. The Board further finds that, for the entire initial rating period on appeal, the Veteran’s PTSD does not more nearly approximate a 100 percent disability evaluation. The Board finds that weight of the lay and medical evidence shows that the Veteran’s PTSD symptoms do not demonstrate total 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. See 38 C.F.R. § 4.130. In reaching this conclusion regarding the degree of occupational and social impairment, the Board has considered all the Veteran’s psychiatric symptoms and impairment, whether or not the symptom is specifically listed in the rating criteria, considering such symptoms as “like or similar to” the symptoms in the rating criteria. See Mauerhan, 16 Vet. App. at 442 (stating that the symptoms listed in VA’s general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and that, without those examples, differentiating between rating evaluations would be extremely ambiguous); Vazquez-Claudio, 713 F.3d at 116-17 (the rating criteria under § 4.130 is “symptom-driven” and “a veteran may only qualify for a given disability rating under [this criteria] by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration”). With this in mind, the evidence shows that the Veteran’s overall PTSD picture is already adequately contemplated by the 70 percent rating, granted herein. The Veteran does experience disturbance of motivation and mood (depression and anxiety), and difficulty sleeping, but these symptoms are specifically contemplated in the 30, 50, and 70 percent rating criteria. The same is true with the Veteran’s near-continuous depression and anxiety, and difficulty in establishing and maintaining relationships, which are all symptoms contemplated under the 70 percent rating criteria. Further, the Veteran has remained married and, although somewhat limited in social activities, the Veteran has reported that he participates in some family excursions and plays at home with his children. He has also described his marriage as good and has indicated that his wife was very supportive. The Board finds that this does not more nearly approximate “total” social impairment as contemplated by a 100 percent PTSD rating. Accordingly, the Board finds that a 70 percent rating for PTSD, is warranted for the entire occurred rating period on appeal. TDIU from July 3, 2010 to May 4, 2018 A TDIU is warranted when the evidence shows that the Veteran is precluded, by reason of service-connected disabilities, from obtaining and maintaining any form of gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). TDIU benefits are granted only when it is established that the service-connected disabilities are so severe, standing alone, as to prevent the retaining of gainful employment. If there is only one such disability, it must be rated at least 60 percent disabling to qualify for TDIU benefits; if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16 (a). The Veteran has been awarded a TDIU beginning May 5, 2018 based on his service-connected disabilities. See September 2018 rating decision. The Veteran maintains that he became too disabled to work on July 3, 2010. See Veteran’s Application for TDIU dated in April 2018. That is also the date as of which the Social Security Administration deemed him disabled. As such, the Board will consider whether a TDIU is warranted for the appeal period from July 3, 2010 to May 4, 2018. Notably, the RO granted a TDIU effective May 5, 2018 as this was the date the Veteran filed his formal claim for a TDIU. However, the Board notes that a TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). As the Veteran’s attorney pointed in the notice of disagreement with the assigned effective date, the Veteran was found disabled by SSA in 2010, and the claim for TDIU can be inferred as a part of the pending appeal. Pursuant to the grant of a 70 percent rating for PTSD herein, the Veteran now meets the schedular criteria for the entire period from July 3, 2010 to May 4, 2018. Further, the evidence demonstrates that the Veteran is unemployable as a result of the combined effect of his service-connected physical and mental health disabilities during this period on appeal. The July 2018 VA examiner indicated that PTSD could cause difficulties completing a normal workday task, keeping a specific schedule, and integrating appropriately with peers/clients. The Board finds that this would impair the Veteran’s ability to perform sedentary employment. Further, a July 2018 VA spine examination report indicated that that the Veteran's lumbar spine disability would preclude gainful employment in the Veteran’s usual job as a truck driver. The evidence also includes a December 2013 Social Security Administration Decision where it was noted that the Veteran was found to be disabled since July 3, 2010, due to a spine disability and psychiatric disability, and an April 2018 private vocational assessment which reached the same conclusion.   For these reasons, and upon review of all the evidence of record, the Board finds that the weight of the probative evidence supports a finding that the Veteran has been unable to follow a substantially gainful occupation as a result of the combined effect of his service-connected disabilities throughout the rating period on appeal from July 3, 2010 to May 4, 2018. Accordingly, resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for a TDIU have been met from July 3, 2010 to May 4, 2018. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHELLE KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Casadei, Counsel