Citation Nr: 1827335 Decision Date: 05/04/18 Archive Date: 05/14/18 DOCKET NO. 12-32 834 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an initial rating in excess of 50 percent prior to May 14, 2009 and 70 percent thereafter for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD C. Jones, Counsel INTRODUCTION The Veteran served on active duty from July 2006 to May 2007. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2008 and February 2010 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. Jurisdiction has been transferred to the RO in New York, New York. In the December 2008 rating decision, the RO, in pertinent part, granted service connection for PTSD and assigned a 50 percent rating, effective May 3, 2007. In the February 2010 rating decision, the RO continued the 50 percent rating for PTSD and denied entitlement to a TDIU. This appeal was before the Board in October 2016 at which time it was remanded for additional evidentiary development. A review of the record shows that the RO has complied with the remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). The Board observes that the issue of entitlement to service connection for Meniere's disease was also remanded by the Board in the October 2016 decision. While the matter was in remand status, in a May 2017 rating decision, the RO granted service connection for Meniere's disease and assigned an initial 100 percent rating, effective May 14, 2009. She was also awarded special monthly compensation at the housebound rate, effective May 14, 2009. See 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). The grant of service connection constitutes a full award of the benefit sought on appeal with respect to this claim. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). The record currently available to the Board contains no indication that the Veteran has initiated an appeal with any downstream element, such as effective date assigned. Grantham, 114 F. 3d at 1158 (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). Thus, the issue is not currently in appellate status. The issue of entitlement to a TDIU prior to May 14, 2009 is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Prior to May 14, 2009, the Veteran's PTSD was manifested by symptoms that caused occupational and social impairment with reduced reliability and productivity in most areas; the symptoms did not cause occupational and social impairment with deficiencies in most areas or total occupational and social impairment. 2. As of May 14, 2009, the Veteran's PTSD has been manifested by symptoms which cause occupational and social impairment with deficiencies in most areas; the symptoms have not caused total occupational and social impairment. 3. From May 14, 2009, the Veteran's combined disability rating is 100 percent, with special monthly compensation under 38 U.S.C. § 1114(s). CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 50 percent prior to May 14, 2009 and 70 percent thereafter for posttraumatic stress disorder (PTSD) have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2017). 2. From May 14, 2009, the claim for entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disabilities is moot. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) Neither the Veteran nor her 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). Entitlement to an Initial Increased Rating for PTSD Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10 (2017). Where a claimant appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence "used to decide whether an [initial] rating on appeal was erroneous . . ." Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time based on facts found. Id. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture 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 is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). The Veteran's PTSD has been rated under the criteria contained in the General Rating Formula for Mental Disorders. Under those criteria, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect, circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-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 effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating is assigned when there is objective evidence demonstrating 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, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships. 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 and place, memory loss for names of close relatives, own occupation, or own name. Id. In Mauerhan v. Principi, 16 Vet. App. 436 (2002), the U.S. Court of Appeals for Veterans Claims (Court) held that use of the term "such as" in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are 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. Accordingly, the evidence considered in determining the level of impairment under section 4.130 is not restricted to the symptoms provided in the diagnostic code. Rather, VA must consider all symptoms of a claimant's condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. More recently, the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that "a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116 (Fed.Cir 2013). The Federal Circuit explained that in the context of a 70 percent rating, section 4.130 "requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment in most of the referenced areas." Id. at 118. The Federal Circuit indicated that "[a]lthough the veteran's symptomatology is the primary consideration, the regulation also requires an ultimate factual conclusion as to the veteran's level of impairment in 'most areas.'" Id. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, a GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266 (1996) (citing the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders 32 (4th ed. 1994) (DSM-IV)). The Board notes that an interim final rule was issued on August 4, 2014, that replaced the DSM-IV with the DSM-5. GAF scores have been removed from DSM-5. The provisions of this interim final rule, however, do not apply to the instant case, as these provisions only apply to applications for benefits that are received by VA or that are pending before the RO on or after August 4, 2014. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule, effective March 19, 2015. 80 Fed. Reg. 53, 14,308 (March 19, 2015). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Factual Background The Veteran was provided a VA examination in February 2008. The examiner noted that she was cooperative during the examination and she showed no signs of a psychotic condition or a communication problem. She was determined to be a reliable informant. Occupationally, the Veteran reported that she had been in a supervisory position for a major supermarket. She resigned from her position due to her difficulty with interpersonal relationships. With regard to the activities of daily living, the Veteran reported that she spent most of her time at home. She does shopping when the stores have few people in them. She carries out all the required household chores and is still acting as a mother to a teenage son. Her older child is in the Marine Corps. The Veteran reported that she found herself quite rigid about her housekeeping and tended to keep everything in very exact order in a compulsive manner. She indicated that her spouse handled most of their financial affairs since, at times, she would become distracted and overlook bills. She reported that she felt uncomfortable away from home and, at times, had frequent panic attacks not only when driving but in other locations, to include at home and at work. The Veteran reported no significant difficulty with hygiene. The Veteran's PTSD symptoms included numbing of emotion and general responsiveness, difficulties with anger and irritability, being easily startled, panic attacks, difficulty sleeping, and avoidance. On mental status examination, it was noted that the Veteran was quite animated and cooperative. She made good eye contact and appeared sincere. She showed full range of affect and her orientation was good in all spheres. The Veteran showed no signs of a significant acquired cognitive deficit such as gross memory gaps or nonlinear thinking. There was no inappropriate behavior. The Veteran revealed no signs of a psychotic process such as hallucinations, elusions, inappropriate affect, or loosened associations. She had a fair degree of insight into her problems, which she had apparently gained in the process of treatment. She offered no homicidal or suicidal thoughts, contents, plans, or intentions. She seemed to understand her financial realties adequately and seemed to be dealing with these reasonably although she had turned over some of the responsibilities to her husband. A GAF score of 50 was assigned. With regard to the impact of PTSD, the examiner determined that the Veteran showed greatly diminished reliability and productivity, even to the point of having to give up a significant job because of psychological symptoms. She has suffered, at least until very recently, panic attacks more than once a week and sometimes multiple attacks in one day. She has disturbances of motivation and much difficulty dealing with stressful circumstances. She has developed, in contrast, to her former function, distinct difficulties in establishing and maintaining effective work relationships. Thus, she shows very significant impairment of her industrial capacity. Her social life has become quite restricted also so that there is impact in that sphere additionally. The examiner noted that the Veteran is somewhat guarded, but is very intelligent, is developing insight, and has been cooperating with treatment. VA clinical records from January 2008 to November 2008 note treatment for PTSD symptoms, which include nightmares, sleep disturbances, anxiety, irritability, and depression. The Veteran was provided an additional VA examination in November 2008. At that time, the Veteran reported that upon returning from deployment, she returned to her job. However, she had significant problems dealing with people. She eventually resigned due to issues surrounding anger, irritability, and anxiety. Socially, it was noted that the Veteran is married and has 2 children. She is also helping take care of her nephew who is staying at her house. With regard to subjective complaints, cognitively, the Veteran endorsed problems with reading/comprehending and forgetfulness. She stated that she is forgetful of "everything" and it "drives her husband crazy." In order to compensate for her forgetfulness, she writes things down on a white board, journals, uses a digital voice recorder, and repeats things aloud to herself. Emotionally, the Veteran reported anxiety, irritability, and variable mood. In regard to mood, she stated that she does not get overly depressed, but gets more upset by "loss of abilities." She also mentioned that she used to manage 155 employees and now has to stay home all day. In regard to irritability and anger, she stated "I get mad, whoever is around me I get angry at." She is also less tolerant of her teenaged son and nephew. She endorsed improved sleep due to medication and a new yoga regimen. On behavioral observation, the Veteran was casually dressed and neatly groomed. Her speech was within normal limits in terms of prosody, articulation, and volume. No word finding abnormalities were detected. The Veteran displayed adequate comprehension for test instructions and conversation. She was goal-directed and cooperative throughout the session. Her mood was stable. She was friendly and polite; however, she expressed irritability that a medical doctor was not seeing her for any appointments on the day of the examination. She was oriented to all spheres. The Veteran denied any current thoughts of suicidality or homicidality. Hallucinations and delusions were denied and no delusional/hallucinatory behavior was observed during testing. A GAF score of 60 was assigned. Subsequent records note continued treatment for PTSD symptoms, noting a GAF score of 58. The Veteran underwent a VA examination in July 2009. Regarding psychological issues, the Veteran reported ongoing depression and anxiety. She last worked in May 2006. The Veteran indicated increasing marital distress with her husband who had been recently deployed in Kuwait. They had been together for 19 years, although that had been functionally separate for approximately 3 years due to her husband's deployment and moves. To the degree that they are experiencing increasing relationship issues, these appear to be largely attributable to both distance factors, and what the Veteran described as insensitivity on her husband's part regarding her medical concerns, as well as the fact that she was involved in an active combat zone where he never was. She also has two children, ages 18 and 21. The 18 year old is living at home and the 21 year old is an active duty Marine. She stated that one of her son's friends is also living at her home. Nevertheless, she indicated that his is generally a stressful situation and reported that neither of the individuals living with her provided adequate assistance around the house, thereby increasing her stress burden. The Veteran also reported limited leisure recreational pursuits, although she does enjoy listening to an iPod and sitting outside enjoying the outdoors. She denied any violence or assaults. She also denied any history of suicidal thoughts or suicide attempts. The examiner indicated that it is not clear that the Veteran is functioning significantly worse in some domains - e.g., her work situation has not changed (she in unemployed), and her social situation has not significantly changed since her last rating examination. She does present with some general deficits in social and interpersonal relationships, including impulsivity, and anger outbursts, as well as general deficiencies in recreation and less leisure pursuits. The Veteran reported that she had more recently become involved in the Mormon Church, although she often found herself avoiding going to church and/or avoiding people there because she has to repeat the same things over and over again and she does not like to feel dependent. On mental status examination, there was no clear evidence of impairment of communication nor was there report of delusions or hallucinations. The Veteran did indicate some impaired thought processes, particularly ongoing difficulties with forgetfulness. She denied suicidal or homicidal ideation. Eye contact was within normal limits. The Veteran was oriented to person, place, and time. She reported a history of obsessive type routines, particularly focused on cleanliness. She also reported a significant decrease in the intensity of these since being prescribed medication. Additionally, the Veteran reported experiencing variable panic attacks, ranging in frequency from several a week to none for a period of a month or more. She also reported significant depressed mood. There was also some evidence of impaired impulse control, although this is infrequent and generally out of character. The Veteran indicated that she does have some difficulty maintaining aspects of personal hygiene; for example, she stated that she recently went a week without a shower and required prompting by her son in order to do so. The examiner opined that the Veteran continued to present with a range of symptoms consistent with PTSD, including having strong physical and emotional reactions to reminders of stressful military experience, significant avoidance thinking about and avoiding activities or situations which remind her of her traumatic experiences, general anhedonia and emotional numbness, and finally, in regard to hyperarousal, angry outbursts, difficulty concentrating, exaggerated startle response, and hypervigilance. She also indicated a history of difficulty falling or staying asleep. A GAF score of 55 was assigned. VA clinical records following the examination show continued psychiatric care. The Veteran was hospitalized in October 2009 for 5 days for psychiatric care. At admission, the Veteran complained of problems at home and worsening symptoms. Due to marital problems, she started having worsening dreams and began to isolate herself. A GAF score of 30 was provided on admission. However, a GAF score was not provided at discharge. Subsequent records reveal continued psychiatric care. The Veteran was again hospitalized for 8 days in June 2011. A GAF score of 20 was assigned at admission. Medical records following discharge show continued PTSD treatment. In a July 2011 record, the Veteran reported that she was making an effort to socialize more, baked muffins for her neighbors, and attended a birthday party thrown for her by her family. In a November 2012 social work telephone encounter note, the Veteran stated that she was vising her sister for the Thanksgiving holiday. GAF scores ranged from 45 to 58. The Veteran underwent a final VA examination in January 2017. The examiner opined that the Veteran's level of occupational and social impairment was best summarized as occupational and social impairment with reduced reliability and productivity. Socially, it was noted that the Veteran married her current husband twice and they have been together since she was 24 years old. They have been married for the second time for 11 years. The marriage had been strained historically and the Veteran describes her husband as emotionally abusive. They have separated many times, but have lived together continually for 4 years. She reported that they live together peacefully now most of the time. However, she indicated that they are not a romantic couple. They have 2 adult sons. Her relationship with her younger son is strained, but good with her older son. Occupationally, she stated that she returned to her civilian job after her deployment in May 2007, but quit after 2 shifts due to her anxiety and has not attempted to work since that time. However, she has volunteered for the Humane Society for a year. She works in the office 2 days a week for about 4 to 6 hours a week and fosters animals at her home. With regard to symptoms, the Veteran reported panic attacks and problems being intimate or close with anyone. Additionally, she does not like to shower because she does not feel safe. She won't shower unless her husband is in the house. She reported that she stays away from people so that she won't get angry or lose control. She doesn't feel confident and she experiences intrusive thoughts several times a week. She reported that she used to move out and separate from her husband after conflicts, but for the last 2 years, she instead leaves and goes for drives or visits family. Panic attacks, nightmares, and depressed mood were also reported. She complained of decreased energy, concentration, and interests. She did not experience suicidal ideation. The Veteran is independent in her activities of daily living. She enjoys spending time with and caring for her animals. Her husband works full-time and she does all of the cooking, cleaning, and shopping. With regard to leisure pursuits, in addition to volunteering, the Veteran plays games on her tablet 5 to 7 hours per day. She watches television a few hours a day. She does not have any friends. She goes out for breakfast with her husband on Sundays. Last summer, she attended half of her husband's softball games. For VA rating purposes, the examiner reported that the Veteran's PTSD symptoms included depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, difficulty understanding complex commands, disturbance of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. On behavioral observation, the examiner noted that the Veteran was alert and oriented. She was cognitively intact. She was cooperative and rapport was established. Mood was anxious and affect was full. There were no suicidal or homicidal ideations. Analysis Applying the criteria set forth above to the facts in this case, the Board finds that the preponderance of the evidence is against assignment of an initial rating in excess of 50 prior to May 14, 2009 and 70 percent thereafter for PTSD. Prior to May 14, 2009 As summarized above, the Veteran's PTSD symptoms prior to May 14, 2009 were shown to include sleep disturbances, anxiety, irritability, depression, numbing of emotion and general responsiveness, difficulties with anger, being easily startled, panic attacks, difficulty sleeping, and avoidance. Such symptoms are contemplated by the current 50 percent evaluation and have been determined to cause occupational and social impairment with reduced reliability and productivity. See 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board finds, however, that the preponderance of the evidence is against the assignment of a rating in excess of 50 percent. In this case, the evidence does not show that the Veteran's overall disability picture is more consistent with nor does it more nearly approximate the criteria required for 70 percent evaluation during this period of the appeal. In this regard, the Veteran's psychiatric symptoms have not caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Mauerhan, supra, Vazquez-Claudio, supra. Specifically, as set forth in more detail above, the evidence shows that the Veteran did not exhibit illogical or irrelevant speech; near continuous panic attacks; spatial delusions; impaired impulse control; spatial disorientation; or an inability to establish and maintain effective relationships. Further, there was no indication of neglect of personal appearance and hygiene, obsessive rituals or suicidal ideation. Socially, the Veteran reported that she is married and has 2 children. She is also helping take care of her nephew who is staying at her house. In view of the record in its entirety, the Board finds that the Veteran's PTSD symptoms do not indicate a disability picture commensurate with the next-higher 70 percent rating. The Board also notes that throughout this period on appeal, GAF scores have ranged from 50 to 60, indicative so moderate to some severe PTSD symptoms. In this case, the GAF scores assigned are but one factor for consideration in a rating. Overall, the GAF scores assigned are generally consistent with moderate to serious symptomatology. Nevertheless, while considering the GAF scores of record as part of the overall social and occupational functioning picture, the Board finds the narratives contained in the lay statements, treatment records, and examination reports to be the most probative evidence of the Veteran's psychiatric symptomatology. In summary, the Board has considered the Veteran's PTSD symptoms that affect her level of occupational and social impairment. After so doing, the Board concludes that the preponderance of the evidence is against the assignment of an initial rating in excess of 50 percent prior to May 14, 2009. From May 14, 2009 During this period of the appeal, the Veteran's symptoms were shown to include depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, mild memory loss, difficulty understanding complex commands, disturbance of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. Such symptoms have been determined to cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, thus warranting the current 70 percent rating. See 38 C.F.R. § 4.130, Diagnostic Code 9411. However, the record does not demonstrate that the Veteran's overall disability picture during this period is consistent with a 100 percent evaluation. The Veteran has not demonstrated a level of impairment consistent with the 100 percent criteria, nor have her symptoms been shown to cause total occupational and social functioning, to include in areas referenced by the 100 percent criteria. Mauerhan, supra, Vazquez-Claudio, supra. As set forth in more detail above, the evidence shows that the Veteran did not exhibit gross impairment in thought processes or communication; grossly inappropriate behavior; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place, memory loss for names of close relatives, own occupation, or own name. Additionally, there were no persistent delusions or hallucinations. In fact, the Veteran consistently denied such symptoms. Notably, the January 2017 VA examiner opined that the Veteran's level of occupational and social impairment was best summarized as occupational and social impairment with reduced reliability and productivity. Thus, in view of the record in its entirety, the Board finds that the symptoms during this stage of the appeal do not indicate a disability picture commensurate with the next-higher 100 percent rating. Moreover, the Board emphasizes that a 100 percent disability evaluation requires both total social and occupational impairment. See Melson v. Derwinski, 1 Vet. App. 334 (1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met); cf. Johnson v. Brown, 7 Vet. App. 95 (1994) (only one disjunctive "or" requirement must be met in order for an increased rating to be assigned). The Veteran in this case has not been found to be totally occupationally and socially impaired. Although the Veteran is unemployed, she is not totally socially impaired. During the in July 2009 VA examination, the Veteran reported that she started attending church. In subsequent VA clinical records, she reported that she began being more social, baking for her neighbors, and visiting her sister for the holidays. Further, during the January 2017 VA examination, the Veteran reported that she volunteered for the Humane Society and previously attended her husband's softball games. Thus, the evidence does not show that the Veteran has total occupational and social impairment due to her psychiatric disability. The Board also notes that throughout this rating period, GAF scores have ranged from 20 to 58, indicative of severe PTSD symptoms. In this case, the GAF scores assigned are but one factor for consideration in a rating. While considering the GAF scores of record as part of the overall social and occupational functioning picture, the Board finds the narratives contained in the lay statements, treatment records, and examination reports to be the most probative evidence of the Veteran's psychiatric symptomatology. In summary, the Board has considered the Veteran's PTSD symptoms that affect her level of occupational and social impairment. After so doing, the Board concludes that the preponderance of the evidence is against the assignment of an initial rating in excess of 70 percent for the period from May 14, 2009. Entitlement to a TDIU from May 14, 2009 VA disability ratings are based, as far as practicable, on the average impairment of earning capacity attributable to disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.10 (2017). Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Id. Where the schedular rating is less than total, a total disability rating may nonetheless be assigned when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disability; provided that, in pertinent part, if there is only one such disability, the disability shall be rated at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability rated 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(a), 4.16(a). It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. Thus, in any case where the Veteran is unemployable by reason of service-connected disabilities but has failed to meet the percentage standards discussed above, rating boards will submit the case to the Director, Compensation and Pension Service, for extra-schedular consideration under 38 C.F.R. § 4.16(b). Entitlement to a total rating must be based solely on the impact of service-connected disabilities on the ability to keep and maintain substantially gainful employment. See 38 C.F.R. §§ 3.340, 3.341, 4.16 (2017). 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). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the level of education, special training, and previous work experience in arriving at a conclusion. Individual unemployability, however, must be determined without regard to any nonservice-connected disabilities or advancing age. 38 C.F.R. §§ 3.341(a), 4.16, 4.19 (2017); Van Hoose v. Brown, 4 Vet. App. 361 (1993). A high rating in itself is recognition that the impairment makes it difficult to obtain or maintain employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363. The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (2012); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis As of May 14, 2009, service connection is in effect for Meniere's disease, rated as 100 percent disabling; PTSD, rated as 70 percent disabling; chronic headaches, rated as 30 percent disabling; radiculopathy of the upper right extremity, rated as 20 percent disabling; radiculopathy of the upper left extremity, rated as 20 percent disabling; tinnitus, rated as 10 percent disabling; cervical spine degenerative disc disease and degenerative joint disease, rated as 20 percent from May 14, 2009 and 10 percent from August 1, 2011; lumbar strain, rated as 20 percent from May 14, 2009 and 10 percent from August 1, 2011; and radiculopathy of the left lower extremity, rated as 10 percent disabling. Service connection is also in effect for plantar fasciitis of the bilateral feet and residuals of a left big toe injury for which noncompensable ratings are assigned. The Veteran has had a combined 100 percent rating, effective May 14, 2009. See 38 C.F.R. § 4.25 (2017). The United States Court of Appeals for Veterans Claims (Court) has recognized that a 100 percent rating under the Schedule for Rating Disabilities means that a Veteran is totally disabled. Holland v. Brown, 6 Vet. App. 443, 446 (1994), citing Swan v. Derwinski, 1 Vet. App. 20, 22 (1990). Thus, if VA has found a Veteran to be totally disabled as a result of a particular service-connected disability or combination of disabilities pursuant to the rating schedule, there is no need, and no authority, to otherwise rate that Veteran totally disabled on any other basis. See Herlehy v. Principi, 15 Vet. App. 33, 35 (2001) (finding a request for TDIU moot where 100 percent schedular rating was awarded for the same period). A grant of a 100 percent disability does not always render the issue of TDIU moot. VA's duty to maximize a claimant's benefits includes consideration of whether her disabilities establish entitlement to special monthly compensation (SMC) under 38 U.S.C.A. § 1114(s). See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011). Specifically, SMC may be warranted if the Veteran has a 100 percent disability rating for a single disability, and VA finds that TDIU is warranted based solely on the disabilities other than the disability that is rated at 100 percent. See Bradley v. Peake, 22 Vet. App. 280, 294 (2008) (analyzing 38 U.S.C. § 1114(s)). In pertinent part, special monthly compensation is payable under section 1114(s) (i.e. at the housebound rate) where a veteran has a single service-connected disability rated as 100 percent disabling and, in addition, has a service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability, and involving different anatomical segments or bodily systems. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). In this case, special monthly compensation based on housebound criteria being met was granted in the May 2017 rating decision, effective May 14, 2009. Accordingly, there is no question or controversy for consideration by the Board with regard to entitlement to a TDIU for the period since May 14, 2009. See Bradley v. Peake, 22 Vet. App. 280 (2008); Buie v. Shinseki, 24 Vet. App. 242 (2011). ORDER Entitlement to an initial rating in excess of 50 percent prior to May 14, 2009 and 70 percent thereafter for posttraumatic stress disorder (PTSD) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) from May 14, 2009 is dismissed. REMAND Prior to May 14, 2009, the Veteran did not meet the schedular criteria for a TDIU under 38 C.F.R. § 4.16(a). In this regard, the Veteran's combined disability rating prior to prior to May 14, 2009 was 60 percent and her service-connected disabilities did not result from a common etiology or affect a single body system. Accordingly, she did not meet the percentage threshold requirements set forth under 38 C.F.R. § 4.16(a). Notwithstanding, the Veteran asserts that she is unemployable due to her service-connected disabilities. While the Veteran fails to meet the criteria for a schedular a TDIU prior to May 14, 2009, she has argued that she has been unemployable due to her service-connected disabilities since April 2007. As such, referral of her TDIU claim to the Director of Compensation Service for extraschedular consideration is warranted. Accordingly, the case is REMANDED for the following action: 1. Refer the claim for a TDIU to the Director, Compensation Service for a determination under 38 C.F.R. § 4.16(b) and notify the Veteran of such action. 2. Thereafter, readjudicate the Veteran's claim of entitlement to a TDIU. If the benefit sought on appeal remains denied, the Veteran and her representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ____________________________________________ K. Conner Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs