Citation Nr: 18152767 Decision Date: 11/26/18 Archive Date: 11/26/18 DOCKET NO. 15-34 968 DATE: November 26, 2018 ORDER The propriety of the reduction of the disability rating for surgical scar of the left side of the neck from 30 percent to 10 percent, effective May 1, 2014, is dismissed. For the entirety of the appeal period, entitlement to a 70 percent evaluation, but no higher, for mood disorder/generalized anxiety disorder is granted. For the entirety of the appeal period, entitlement to a total disability rating based on individual unemployability (TDIU) is granted. REMANDED Entitlement to an increased disability rating in excess of 40 percent for status post resection of malignant lymph node resulting in severing of brachial plexus leading to brachial plexitis is remanded. FINDINGS OF FACT 1. In February 2017, prior to the promulgation of a decision in the appeal, the Veteran requested that his appeal of the issue of the propriety of the reduction of the disability rating for surgical scar of the left side of the neck from 30 percent to 10 percent, effective May 1, 2014, be withdrawn. 2. For the entirety of the appeal period, the Veteran's mood disorder/generalized anxiety disorder 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. 3. The Veteran meets the scheduler criteria for a TDIU, and his service-connected mood disorder/generalized anxiety disorder has rendered him unable to secure or follow a substantially gainful occupation for the entirety of the appeal period. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal of the issue of the propriety of the reduction of the disability rating for surgical scar of the left side of the neck from 30 percent to 10 percent, effective May 1, 2014, have been met. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 2. For the entirety of the appeal period, the criteria for a disability rating of 70 percent for mood disorder/generalized anxiety disorder have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1, 4.4, 4.7, 4.130, Diagnostic Code 9434. 3. The criteria for entitlement to a TDIU have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.59, 3.340, 3.341, 4.1, 4.3, 4.16, 4.18, 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Navy from April 2005 to June 2008. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated in April 2013 and February 2014. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in February 2017. A transcript from that proceeding is associated with the Veterans Benefits Management System (VBMS) folder. The Board notes that during the February 2017 Board hearing, the record was held open for 60 days. See February 2017 Board Hearing Transcript, page 2. In a subsequent April 2017 statement, the Veteran’s representative requested that the record be held open for an additional 60 days as he was in the process of procuring additional medical evidence. However, it appears from the record that the representative later submitted this additional medical evidence in May 2017. See May 2017 Psychological Evaluation. Thus, the extension request is considered moot. The Board also notes that the Veteran waived the Agency of Original Jurisdiction’s initial review of this additional evidence. I. Duties to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). II. Law and Analysis 1. The propriety of the reduction of the disability rating for surgical scar of the left side of the neck from 30 percent to 10 percent, effective May 1, 2014. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the veteran or by his authorized representative. Except for appeals withdrawn on the record at a hearing, appeal withdrawals must be in writing. 38 C.F.R. § 20.204. During the February 2017 hearing, the Veteran testified on the record that he wished to withdraw the issue of the propriety of the reduction of the disability rating for surgical scar of the left side of the neck from 30 percent to 10 percent, effective May 1, 2014. See February 2017 Board Hearing Transcript (Tr.), page 2. Given that there remain no allegations of errors of fact or law for appellate consideration, the Board does not have jurisdiction to review the appeal, and it is dismissed. 2. Entitlement to an increased disability rating in excess of 50 percent for mood disorder/generalized anxiety disorder. 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. § 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. § 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). When, as here, the Veteran is requesting a higher rating for already established service-connected disabilities, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, "staged" ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509 (2007) ("The relevant temporal focus for adjudicating an increased-rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim."). The Board notes that the Veteran's increased rating claims for mood disorder/generalized anxiety disorder and status post resection of malignant lymph node resulting in severing of brachial plexus leading to brachial plexitis was received on February 7, 2012. Therefore, the period for consideration on appeal began on February 7, 2011, one year prior to the date of receipt of his increased rating claim. 38 C.F.R. § 3.400(o)(2). The Veteran's service-connected mood disorder/generalized anxiety disorder has been evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9434; 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. The Veteran's psychiatric disability has been assigned a 50 percent disability rating for the entire period on appeal. A 50 percent rating is assigned 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 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. 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. The Board acknowledges that psychiatric examinations frequently include the assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5) has been officially released, and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, No. 16-1208, Slip opinion at 5 (Vet. App. Feb. 23, 2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. The Court added that it does not hold that the Board commits prejudicial error every time the Board references GAF scores in a decision. As this appeal was certified to the Board after August 2016, the DSM-5 criteria apply to this case. Consequently, the Board will not afford any probative value to the GAF scores that are documented in the record. In June 2011, a VA treatment record noted in the assessment that the Veteran had adjustment disorder with depressed mood. In relation to this diagnosis, the Veteran was assessed to have grief that was secondary to his brother's death from head injuries in a motorcycle accident. In March 2012, the Veteran underwent a VA examination related to his psychiatric disability. At the time of the examination, the Veteran was not receiving any mental health treatment. The examiner noted that the Veteran's symptoms included a depressed mood, anxiety, and disturbances in motivation and mood. The Veteran's symptoms of depression had increased since his last VA examination in 2008 due to the fact that the Veteran had witnessed the traumatic death of his brother in June 2011. The Veteran reported feeling sad as well as "left behind" from the financial stability and success of his peers due to his physical limitations. The Veteran further described loving his military career and the sadness he experienced after being discharged as a result of medical complaints. The Veteran also experienced a chronic sleep impairment, and mild memory loss, such as forgetting names, directions, or recent events. In addition, the Veteran had impaired impulse control such as unprovoked irritability with periods of violence. Regarding his social functioning, the examiner stated that the Veteran lived with his mother. Although he did not have any romantic relationships, he did engage in some socialization. His activities included watching television. The Veteran had not worked since his military discharge. The examiner observed that he continued to struggle with pain related to a "botched" surgical procedure in the military to remove a lymphoma. The Veteran indicated that his inability to work was related to physical pain rather than mental health complaints. Although the Veteran suffered from symptoms of depression, the examiner noted that they were not at the forefront of his inability to work. Consequently, the examiner opined that his mental health conditions did not render him unable to maintain employment. The examiner determined that the Veteran was capable of managing his financial affairs. The diagnosis was major depressive disorder. The examiner opined that the Veteran had an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. A subsequent December 2014 VA treatment record noted the Veteran's report that he was seeking help for his depression. He had tried to attend school, but he had some problems being around other people. The record noted that he had very poor sleep, occasional nightmares, and poor concentration. The assessment was depression with mild agoraphobia. The record stated that although the Veteran was not taking medication, it was evident that he needed help. A plan was made to start sertraline and trazodone. During the February 2017 Board hearing, the Veteran described his social functioning. The Veteran stated that he wanted to withdraw from people. The Veteran reported that he had a son who he was no longer able to see as a result of his mood. He also reported that his engagement to his son’s mother had ended two years ago due to problems with trust and anger. The Veteran indicated that he had been afraid that the anger would lead to physical violence. The Veteran cried during the hearing when attempting to describe how his mood affected him. In terms of family members, the Veteran stated that he could not be around them for too long. He did, however, indicate that he preferred to travel to visit his mother who lived two hours away. The Veteran also reported that he had been living with a friend for the past year who helped him with cooking and cleaning. In addition to his problems with social functioning, the Veteran described problems with sleeping. He slept for approximately two hours a night. The Veteran attributed these problems to sensitivity to noises and an apprehension that something would happen. He consequently felt tired most of the time. The Veteran additionally reported feeling depression and lacking a desire to be productive. He also acknowledged having suicidal thoughts, but noted that he had never acted on them. In addition, he described becoming easily angered, disliking crowded rooms, and constantly feeling on alert. The Veteran testified that he had a history of verbal and physical altercations, with two physical altercations occurring in the past year. Although verbal altercations were an infrequent occurrence, the Veteran also reported that he tried to minimize talking to people. The Veteran did not indicate that he had a problem maintaining his personal hygiene. In terms of treatment, he indicated that he was receiving recurring prescriptions for his psychiatric disability from VA. The Veteran reported having difficulty concentrating. He testified that he had attempted to attend school twice since his discharge from service, but both attempts were unsuccessful due to his problems concentrating as well as discomfort being around others. He also had problems concentrating in the context of private activities such as watching a movie. In addition, the Veteran reported that he last worked in 2014 for a cable company. The position lasted for a period of two months until the Veteran had an episode in a class. The Veteran stated that he had “exploded,” cursed at others, and flipped chairs in reaction to his inability to concentrate. The company called the police to escort the Veteran out of the building, and the Veteran was terminated on the day of the event. The Veteran reported that his difficulties with concentration and dealing with others prevented him from performing fulltime, competitive work. Following the hearing, VA received a January 2017 statement from the Veteran's mother and a February 2017 statement from the friend referenced by the Veteran during the hearing. The Veteran’s friend stated that as a result of the Veteran’s sleep difficulties and his fear that something would happen, she had to say up late with the Veteran to help him fall asleep. She also reported that when trying to wake the Veteran, she jumped backwards as the Veteran awakened feeling as though he was being attacked. She stated that she never knew when the Veteran would physically harm her when she tried to wake him up, and she noted that she was worried of the danger despite the fact that “hits” had been minimal. The friend also reported that the Veteran had moods swings with happy and sad days. In addition, she described feeling apprehensive that the Veteran would verbally attack her. The Veteran’s mother stated that the Veteran was unable to sleep at night, function during daily tasks, and she indicated that he no longer participated in previous social activities due to his pain and lack of sleep. In May 2017, a psychological evaluation was conducted by Dr. T., PhD. Dr. T. stated that the evaluation was conducted through the computer video program GoToMeeting, and the Veteran was in full view throughout the examination. During the evaluation, the Veteran spoke in a clear voice and used grammatically correct sentences. Dr. T. estimated that his intellectual functioning was within the average range. The Veteran a normal affect and a neutral mood. However, Dr. T. stated that the Veteran had been quite anxious and depressed since his discharge from the Navy as a result of the physical impairment he experienced after his brachial plexus was severed during service. The Veteran described experiencing daily symptoms of sadness, anhedonia, self-criticism, restlessness and agitation, indecisiveness, feelings of worthlessness, low energy, and loss of interest in sex. The Veteran’s symptoms also included difficulty concentrating, frequent irritability and episodes of anger with little provocation, intermittent inability to perform activities of daily living due to his severe depression, anxiety, irrational fears, social withdrawal, physical limitations, and deficiencies in family relationships. In a psychiatric/psychological impairment questionnaire associated with the psychological evaluation, Dr. T. also checked a box to indicate that the Veteran experienced neglect of personal appearance and hygiene. Regarding his social functioning, the Veteran reported that he often clashed with his siblings and could not deal with other people. Dr. T. stated that the Veteran had poor interpersonal communication skills, noting that he found it difficult to be tactful in his interpersonal interactions. The Veteran kept to himself and preferred as little interaction with people as possible. Dr. T. noted that the Veteran was living with his brother in his brother’s house. The Veteran also received some financial support from his brother and mother. The Veteran had a three year old son, and he had never been married. He also felt angry as a result of his physical impairment from the surgery in service. The Veteran had symptoms of hypervigilance and felt suspicious of the motivations of others. Dr. T. opined that the Veteran had an inability to establish and maintain effective social relationships. Dr. T. also stated that the Veteran’s daily and constant symptoms of anxiety and depression affected his ability ot function independently, appropriately, and effectively. The Veteran’s daily episodes of anxiety entailed feeling nervous, having a racing heart, and wanting to cry. The Veteran additionally described having a poor short-term memory that affected his ability to recall things he had planned to do. For example, the Veteran had left food cooking on the stove. In addition, the Veteran had recurrent nightmares regarding service. Dr. T. reported that the Veteran had persistent suicidal ideation, but he had never planned or attempted to harm himself. The evaluation was also negative for symptoms of a psychotic disorder, such as hallucinations or delusions. Dr. T. determined that the Veteran had occupational and social impairments with deficiencies in most domains of his functioning, including work, family relations, judgment, mood, and thinking. The diagnosis was major depressive disorder, recurrent episode, that was severe; and generalized anxiety disorder. In the evaluation report, Dr. noted that the Veteran had been unsuccessful in his attempt to work at the cable company after service. The Veteran had difficulty during interpersonal interactions that he attributed to his anger, depression, and anxiety that resulted from his surgery and subsequent functional impairment. The Veteran also experienced poor impulse control that was evidence by his firing from the cable company due to interpersonal conflicts. Dr. T. opined that the Veteran could not perform fulltime competitive work, and he was disabled secondary to his service-connected psychiatric disability. In support of this opinion, Dr. T. highlighted the Veteran’s symptoms of low stress tolerance, poor impulse control, poor interpersonal communication skills, and anger management problems. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to a 70 percent rating for mood disorder/generalized anxiety disorder for the entirety of the appeal period. Throughout the appeal period, the Veteran's disability picture, to include the severity, frequency, and duration of his symptoms, as well as the resulting impairment of social and occupational functioning, is more consistent with a 70 percent rating. A 70 percent rating is awarded 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. The evidence from this period demonstrates that the Veteran felt near-continuous panic or depression that affected his ability function independently, appropriately, and effectively. The Board notes the opinion from the March 2012 VA examiner that the Veteran was generally functioning satisfactorily with his symptoms of depression and anxiety. However, the subsequent statements from the Veteran, his family, and his mother reflect that his mood prevented him from functioning effectively or appropriately in public or private settings. Although the March 2012 VA examiner stated that the Veteran’s symptoms of increased depression had coincided with the death of his brother in June 2011, the other evidence of record indicates that the depression, anxiety, and associated difficulties in functioning had been present since he was discharged from active service due to medical impairments. Thus, it appears that he has experienced these symptoms since at least the beginning of the appeal period in February 2011. In addition, the March 2012 VA examination, the workplace incident in 2014, the February 2017 testimony regarding verbal and physical altercations, and the May 2017 psychological evaluation reflect that the Veteran has experienced impaired impulse control throughout the appeal period. The evidence from this period also supports that the Veteran had difficulty in adapting to stressful circumstances as a result of concentration problems. The Board finds that the Veteran's intermittent suicidal ideation also contributed to his overall level of social and occupational impairment. The Board notes that the Veteran’s representative has also asserted that the Veteran’s symptoms are most consistent with a 70 percent rating. See February 2017 Board Hearing Transcript, page 16. Although the Board has considered whether the next higher 100 percent rating is warranted, the Board finds that no rating higher than 70 percent should be awarded. First, the evidence throughout the period on appeal, without even considering occupational impairment, does not demonstrate total social impairment. While the Veteran was noted to be withdrawn from family members and others, he was living with his mother when the March 2012 VA examination was conducted, with a friend at the time of the February 2017 Board hearing; and with his brother at the time of the May 2017 psychological evaluation. In a February 2017 statement, the friend reported that she and the Veteran spoke to each other over the phone late into the night to help with his sleep difficulties. The Veteran’s February 2017 testimony also reflects that he maintained a relationship with his mother, and this testimony is consistent with a January 2017 statement from the Veteran’s mother in which she indicated that she would always support the Veteran. Dr. T.’s May 2017 report that the Veteran received of financial support from his mother and brother is further evidence that he maintained a relationship with these family members. As such, total social impairment has not been demonstrated. In addition, the Veteran did not display symptoms of the frequency, duration and severity contemplated by a 100 percent disability rating. Neither the March 2012 VA examiner nor Dr. T. reported that the Veteran suffered from delusions or hallucinations. Although memory loss has been reported during this period, it was described as short-term and there was no indication that the Veteran’s memory was impaired to the extent that he was unable to remember the names of close relatives, his own occupation, or his own name. In addition, there is no indication from the record that the Veteran was disoriented to time or place. Dr. T.’s finding that the Veteran had average intelligence and spoke in grammatically correct sentences is also not reflective of a gross impairment in thought processes or communication. Although the Veteran experienced thoughts of suicide, he has not indicated that he is in danger of acting on these thoughts. The record does not suggest that the Veteran has experienced homicidal ideation, and the evidence reflects that he was not in persistent danger of hurting others. Although the Veteran’s friend indicated that he had hit her while in the process of waking up, she also noted that hits had been minimal; and she did not report he engaged in similar behavior while fully awake. The Board also notes that the Veteran reported a history of physical altercations during the February 2017 Board hearing. However, it does not appear that these events were persistent as the Veteran only reported being involved in two such altercations over the year before the hearing. Although the Veteran reported feeling worried about his anger towards his fiancée leading to violence, he did not report that any violence ever occurred. Moreover, the Veteran’s February 2017 testimony reflects that he strived to avoid hurting others and deliberately removed himself from situations that could lead to physical violence. Consequently, the record does not show that he was in persistent danger of hurting himself or others. The record further fails to reflect that the Veteran exhibited behavior that was grossly inappropriate. Although the Veteran described isolated incidents of impaired impulse control, the record does not indicate that he had a pattern of grossly inappropriate behavior. Moreover, the March 2012 VA examination as well as the May 2017 psychological evaluation are negative for such a finding. In addition, the Board does not find that the Veteran was intermittently unable to perform activities of daily living, including maintenance of his personal hygiene. The March 2012 VA examiner did not report any deficiencies in his hygiene. During the February 2017 Board hearing, the Veteran indicated that he sometimes cut his hair infrequently, but noted that at a minimum, he washed himself. The Board acknowledges the Veteran’s report from the hearing that his friend helped him with cooking and cleaning. However, the activities of daily living referenced by the 100 percent rating criteria encompass basic self-care and are distinguishable from instrumental activities of daily living such as housework or meal preparation. See, e.g., 38 C.F.R. § 4.124a, Diagnostic Code 8045, Note (3). The Board also notes that in a psychiatric/psychological impairment questionnaire associated with the May 2017 psychological evaluation, Dr. T. checked a box to indicate that the Veteran experienced neglect of personal appearance and hygiene. However, Dr. T. did not include a description of any deficiencies that might have been observable in Veteran’s appearance during the May 2017 video interview. Apart from this one checked box, the May 2017 psychological evaluation also failed to include any specific details to support Dr. T.’s finding that the Veteran was intermittently unable to perform activities of daily living. Moreover, as noted above, the record does not establish that any difficulty in performing activities of daily living led to the total social impairment that is contemplated by a 100 percent rating. After considering the evidence of record, the Board finds that the Veteran's symptoms more closely approximate the criteria for a 70 percent disability rating. The record does not reflect that the Veteran has a level of impairment consistent with the total occupational and social functioning referenced by the 100 percent evaluation criteria. The criteria for the next higher rating of 100 percent have not been met or approximated during this period on appeal. See 38 C.F.R. § 4.130, Diagnostic Code 9434. 3. 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. § 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; Van Hoose v. Brown, 4 Vet. App. 361 (1993). Marginal employment shall not be considered substantially gainful employment. For purposes of 38 C.F.R. § 4.16, marginal employment generally shall be deemed to exist when a Veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce as the poverty threshold for one person. 38 C.F.R. § 4.16(a). Marginal employment may also be held to exist, on a facts found basis (includes but is not limited to employment in a protected environment such as a family business or sheltered workshop), when earned annual income exceeds the poverty threshold. Id. Consideration shall be given in all claims to the nature of the employment and the reason for termination. Id. 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 record reflects that the Veteran obtained a GED, and he reported completing one year of college in his February 2012 VA Form 21-8940, Veteran’s Application for Increased Compensation based on Individual Unemployability. The Veteran contends that his service-connected disabilities have prevented him from securing and maintaining a substantially gainful occupation. The Veteran’s TDIU claim was raised in the context of his increased rating claim for his psychiatric disability. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Thus, for the reasons explained above, the appeal period begins on February 7, 2011. During the appeal period, the Veteran has been in receipt of a 70 percent rating for mood disorder/generalized anxiety disorder, and a 40 percent rating for status post resection of malignant lymphoma node resulting in severing brachial plexus leading to brachial plexitis. The Veteran was also assigned a 30 percent rating for surgical scar, left side of the neck, prior to May 1, 2014, and a 10 percent rating thereafter. In light of the Veteran’s award of a 70 percent rating for mood disorder/generalized anxiety disorder for the entirety of the appeal period, the Veteran meets the minimum percentage requirements for consideration of a TDIU under 38 C.F.R. § 4.16(a). The Board also notes that it does not appear that the Veteran has engaged in substantially gainful employment during the appeal period. Although he reported working in 2014, he stated that he was only able to maintain this employment for a brief period of two months. Neither the Veteran nor the record has suggested that he held any other employment during the appeal period. Thus, the Board will consider whether entitlement to a TDIU is warranted at any point in the appeal period. In addition to the previously noted symptoms regarding the Veteran’s psychiatric disability, the record includes evidence regarding the functional effects of his brachial plexitis and left neck scar disabilities. In a March 2012 VA examination, the examiner noted that the Veteran reported that the symptoms associated with his brachial plexitis disability included swelling in his left hand, pulsation in the left upper arm, and upper shoulder pain that extended down to the middle fingers. The Veteran also experienced numbness under the left jaw, above the left shoulder area, and at the base of the left neck. The examiner noted that the Veteran would be able to perform work that required him to lift no greater than 15 pounds. The Veteran would be able to work as a sales clerk, teacher, salesman, or other positions that did not involve heavy lifting with the use of his left upper extremity. There was no lifting restriction with the right upper extremity or bilateral lower extremities. The Veteran was able to bend, kneel, squat, run, and walk without any limitations. During another March 2012 VA examination concerning the Veteran’s scar, the examiner indicated that the scar was not painful or unstable, and it measured 7 centimeters by 1 centimeter. The examiner stated that the Veteran’s left neck scar did not cause any functional limitation and would not affect his ability to work. In reviewing the evidence above, the Board attributes great probative value to the May 2017 opinion from Dr. T. that the Veteran was unable to secure or follow substantially gainful employment as a result of his psychiatric disability. Dr. T. indicated in the report that he was aware of the Veteran’s educational background, he arrived at the opinion after his clinical interview of the Veteran, and he used specific symptoms and examples from the Veteran’s medical and employment history to support the opinion. The Board acknowledges that there is an inconsistency between Dr. T.’s opinion and the Veteran’s report during the March 2012 VA examination that his ability to maintain employment was primarily affected by his left arm disability instead of any psychiatric complaints. However, the Veteran’s subsequent February 2017 testimony clarified that his lack of success in pursuing an education or employment after service have mainly been due to the concentration, impulse control, and interpersonal problems associated with his psychiatric disability. As the March 2012 VA examiner was only able to consider the Veteran’s prior statement before providing the negative opinion noted above, the Board finds that it is less probative than Dr. T.’s opinion. 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 mood disorder/generalized anxiety disorder has rendered him unable to secure or follow a substantially gainful occupation for the entire appeal period, and a TDIU is warranted. See 38 U.S.C. § 5107(b); Gilbert 1 Vet. App. at 53-56. In making this determination, the Board notes that, in the present case, the TDIU award is based on the effects of the Veteran's service-connected mood disorder/generalized anxiety disorder, as opposed to a combination of his multiple service-connected disabilities. See Guerra v. Shinseki, 642 F.3d 1046 (Fed. Cir. 2011); Buie v. Shinseki, 24 Vet. App. 242, 250-51 (2010); Bradley v. Peake, 22 Vet. App. 280, 293 (2008). Although the Board has considered the severity of the Veteran’s impairment associated with his left side of neck surgical scar and brachial plexitis disabilities, the evidence of record establishes that it is the Veteran's psychiatric disability, standing alone, which prevents him from working. REASONS FOR REMAND 1. Entitlement to an increased disability rating in excess of 40 percent for status post resection of malignant lymph node resulting in severing of brachial plexus leading to brachial plexitis is remanded. A VA examination related to the Veteran’s brachial plexitis disability was last conducted in March 2012. During the examination, the examiner stated that no muscle atrophy was present. A subsequent July 2013 VA treatment record noted that the Veteran had muscle atrophy in the left upper extremity and left hand ulnar aspect. As this record suggests that the severity of the Veteran’s disability has worsened since the last VA examination, the Board finds that a remand is necessary to obtain a contemporaneous VA examination. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). The matter 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 status post resection of malignant lymph node resulting in severing of brachial plexus leading to brachial plexitis. 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 Columbia VA Health Care System dated since December 2014. 2. The Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected status post resection of malignant lymph node resulting in severing of brachial plexus leading to brachial plexitis. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran's status post resection of malignant lymph node resulting in severing of brachial plexus leading to brachial plexitis under the rating criteria. In particular, he or she should identify each affected nerve or nerve group. For any nerve group identified, the examiner should indicate whether there is mild, moderate, or severe incomplete paralysis; or complete paralysis; and report any neurological complaints or findings attributable to that disorder. 3. Then readjudicate the claim. If this benefit is not granted, the Veteran must be furnished a supplemental statement of the case and given an appropriate opportunity to respond. The case should then be returned to the Board for further consideration. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.C. Spragins, Associate Counsel