Citation Nr: 21003328 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 15-14 438 DATE: January 21, 2021 ORDER Entitlement to a rating in excess of 50 percent, prior to May 31, 2016, for posttraumatic stress disorder (PTSD) is denied. Entitlement to a rating of 100 percent, as of May 31, 2016, for posttraumatic stress disorder (PTSD) is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a total disability evaluation based on individual unemployability (TDIU), as of November 7, 2014, is granted, subject to the law and regulations governing the payment of monetary benefits. REMANDED Entitlement to a TDIU, from October 3, 2012 to November 7, 2014, is remanded. FINDINGS OF FACT 1. Prior to May 31, 2016, the Veteran's PTSD has been manifested by 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. 2. As of May 31, 2016, the Veteran's PTSD has been manifested by total occupational and social impairment. 3. The Veteran's service-connected disabilities have rendered him unable to secure or follow a substantially gainful occupation since, at least, when he met the schedular criteria for TDIU in November 7, 2014. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 50 percent, prior to May 31, 2016, for posttraumatic stress disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 2. The criteria for entitlement to a 100 percent rating, as of May 31, 2016, for posttraumatic stress disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.130, Diagnostic Code 9411. 3. From November 7, 2014, the criteria for TDIU have been met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1970 to September 1971. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Board previously remanded this claim in July 2018 for further development. Increased Evaluations - PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10 (2017). The percentage ratings in the Rating Schedule represent the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. The percentage ratings are generally adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the disability. Diagnostic Codes (DCs) are assigned by the rating officials to individual disabilities. DCs provide rating criteria specific to a particular disability. If two DCs are applicable to the same disability, the DC that allows for the higher disability rating applies. 38 C.F.R. § 4.7 (2017). When a question arises as to which of two ratings apply under a particular DC, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of a veteran. 38 C.F.R. § 4.3. In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the veteran’s claim, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims). Under 38 C.F.R. § 4.130, Diagnostic Code 9411, a 50 percent evaluation is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty 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; the Veteran's difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating requires 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 work-like setting); or inability to establish and maintain effective relationships. Id. A 100 percent disability rating requires 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 as to time or place; or demonstrated memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. The use of such terminology permits consideration of items listed and other symptoms and contemplates the effect of those symptoms on the Veteran's social and work situation. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board acknowledges that symptoms recited in the criteria in the rating schedule for evaluating mental disorders 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." Id., at 442. In adjudicating a claim for a higher rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id., at 443. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to a rating in excess of 50 percent prior to November 21, 2019, and in excess of 70 percent thereafter for posttraumatic stress disorder (PTSD) 2. Entitlement to an effective date earlier than November 21, 2019, for the assignment of a 70 percent rating for posttraumatic stress disorder (PTSD) The Veteran seeks an increased rating for his PTSD, which is currently rated 50 percent disabling prior to November 21, 2019, and 70 percent disabling thereafter under 38 C.F.R. § 4.130, Diagnostic Code 9411. The Veteran was afforded a VA examination for his PTSD symptoms in November 2013. The examiner opined that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity. During the examination, the Veteran explained difficulties he’s had with his family and has not been employed since 2010, when he was a taxi driver. The examiner noted that the Veteran has recurrent, involuntary, and intrusive distressing memories of his traumatic events in service; recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event; and intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. The examiner also noted that the Veteran is in a persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) and has feelings of detachment or estrangement from others; efforts to avoid thoughts, feelings or conversations associated with the trauma; and efforts to avoid activities, places or people that arouse recollections of the trauma. The examiner explained that there are marked alterations in arousal and reactivity associated with the traumatic events, beginning or worsening after they occurred, as evidenced by irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; hypervigilance; and sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). The examiner confirmed that Veteran had symptoms such as depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. The Veteran was afforded another VA examination for his PTSD symptoms in November 2019. The examiner diagnosed the Veteran with PTSD and claustrophobia, while also noting that it’s not possible to differentiate the symptoms, because both conditions have overlapping symptoms with comorbid effects. The examiner opined that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity. During the examination, the Veteran explained difficulties he’s had with his family, and he noted that he fears losing his wife. The examiner noted that the Veteran has recurrent, involuntary, and intrusive distressing memories of his traumatic events in service; recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event; dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic events were recurring; and intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. The examiner also noted that the Veteran is in a persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame) and has feelings of detachment or estrangement from others; and a markedly diminished interest or participation in significant activities. The examiner explained that there are marked alterations in arousal and reactivity associated with the traumatic events, beginning or worsening after they occurred, as evidenced by irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; hypervigilance; an exaggerated startle response; problems concentrating; and a sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep). The examiner confirmed that Veteran had symptoms such as depressed mood; anxiety; suspiciousness; panic attacks more than once a week; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting and Inability to establish and maintain effective relationships. Based on this examination, the Veteran was rated at 70 percent, as of November 21, 2019. Additionally, during the period on appeal, the Veteran submitted a private PTSD evaluation dated May 2016. The physician diagnosed the Veteran with a dissociative type of PTSD with mood disorder features. The physician opined that the Veteran’s PTSD resulted in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and/or mood. During the evaluation, the Veteran explained difficulties he’s had with his family and has not been employed since 2010, due to his mental health difficulties. The examiner noted that the Veteran has recurrent, involuntary, and intrusive distressing memories of his traumatic events in service; recurrent distressing dreams in which the content and/or effect of the dream are related to the traumatic event; dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic events were recurring; intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event; and physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. The examiner also noted that the Veteran persistently avoids stimuli associated with his in-service trauma and has a numb general responsiveness manifesting as: efforts to avoid thoughts, feelings or conversations associated with the trauma; efforts to avoid activities, places or people that arouse recollections of the trauma; markedly diminished interest or participation in significant activities; feeling of detachment or estrangement from others; restricted range of affection; and sense of a foreshortened future. The physician explained that there are marked alterations in arousal and reactivity associated with the traumatic events, beginning or worsening after they occurred, as evidenced by difficulty falling or staying asleep; irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; difficulty concentration; hypervigilance; and exaggerated startle response. The physician confirmed that the Veteran has symptoms such as: depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; speech intermittently illogical, obscure, or irrelevant; difficulty in understanding complex commands; impaired judgement; impaired abstract thinking; gross impairment in thought processes or communication; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; impaired impulse control, such as unprovoked irritability with periods of violence; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The physician noted that, while the Veteran reported no current suicidal/homicidal ideation, he admitted that at times he has gotten angry enough to want to hurt people, including his wife and co-workers, but he has never wanted to kill anyone. The Board finds that the VA and private examinations in the record are probative and should be considered competent evidence of record. A. Prior to May 31, 2016 Based on all of the above medical evidence, the Board finds that the Veteran's PTSD disability picture remained relatively consistent with the assigned rating and does not warrant a higher than 50 percent rating prior to May 31, 2016. The Board has also considered the next higher ratings of 70 percent and 100 percent respectively. However, the Board finds that neither a 70 percent nor a 100 percent rating for the Veteran's PTSD disability is warranted throughout the period of appeal. Although he has noted social difficulties, including challenges in his marriage, however he has maintained a four-decade long marriage with his spouse. The Veteran also had difficulties in his occupational setting due to his PTSD symptoms. Further, during this time period, the Veteran's record is silent for any reports of hallucinations, delusions, and grossly inappropriate behavior. The evidence of record does not show that the Veteran was unable to perform activities of daily living, was disoriented to time or place, or experienced memory loss causing him to forget the names of close relatives, his own occupation, or his own name. In addition, the Board notes that the medical professionals who evaluated the Veteran throughout the time frame on appeal did not find his symptoms deficient in most areas or were severe enough to constitute total occupational and social impairment. In sum, after a review of the record, the Board finds that the Veteran's disability remained consistent during the period of the appeal and as such, an increased rating in excess of 50 percent for his PTSD is not currently warranted prior to May 31, 2016. B. As of May 31, 2016 The Board finds that, as of May 31, 2016, the Veteran’s PTSD has been characterized by depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; speech intermittently illogical, obscure, or irrelevant; difficulty in understanding complex commands; impaired judgement; impaired abstract thinking; gross impairment in thought processes or communication; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; impaired impulse control, such as unprovoked irritability with periods of violence; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. Despite the May 2016 private physician’s opinion that the Veteran’s PTSD results in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgement, thinking and/or mood and the November 2019 VA examination opinion that the Veteran’s PTSD resulted in occupational and social impairment with reduced reliability and productivity, the Board finds that the Veteran’s symptoms, chiefly his inability to establish and maintain effective relationships; impaired impulse control, such as unprovoked irritability with periods of violence; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; neglect of personal appearance and hygiene; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene, are suggestive of total occupational and social impairment with deficiencies in most areas. After resolving any doubt in the Veteran’s favor, the Board finds that his PTSD resulted in total occupational and social impairment with deficiencies in most areas. Accordingly, from May 31, 2016, to the present, a 100 percent rating for PTSD is warranted. Total Disability Evaluation Based on Individual Unemployability (TDIU) Generally, total disability will be considered to exist when there is present any impairment of mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings are authorized for any disability or combination of disabilities for which the Schedule for Rating Disabilities prescribes a 100 percent disability evaluation, or, with less disability, if certain criteria are met. Id. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is considered to be unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). An award of TDIU "does not require proving 100 percent unemployability." Roberson v. Principi, 251 F.3d 1378, 1385 (Fed. Cir. 2001). Rather, an award of TDIU requires that the claimant show an inability "to secure and follow a substantially gainful occupation by reason of service-connected disabilities." 38 C.F.R. § 4.16(b). When making this determination, "the central inquiry is whether the veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Pederson v. McDonald, 27 Vet. App. 276, 286 (2015). The Board also "must take into account the individual veteran's education, training, and work history" but "may not consider nonservice-connected disabilities or advancing age." Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). In cases where these percentages are not met, but the disabled person is unable to secure and follow a substantially gainful occupation by reason of service-connected disability or disabilities, the case should be submitted to the Director, Compensation and Pension Service, for consideration of extra-schedular TDIU. 38 C.F.R. § 4.16(b). 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). Additionally, in determining whether unemployability exists for TDIU, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to his age or to any impairment caused by any nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. In order for a veteran to prevail on a claim for a TDIU, the record must reflect some factor that takes his case outside of the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Neither the effect of nonservice-connected disabilities nor of the veteran's age may be considering in determining whether TDIU is warranted. Id. 3. Entitlement to a total disability evaluation based on individual unemployability (TDIU) The Veteran has filed a claim of entitlement to total disability rating due to TDIU in August 2013. When entitlement to a TDIU is raised during the adjudicatory process of the underlying disability, it is part of the claim for benefits for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447 (2009). In the Veteran’s filed VA Form 21-8940, the Veteran reports that he left his job as a nursing assistant in 2003 because his PTSD symptoms made his last few years difficult and stressful, with sudden outbursts of anger and panic attacks. In the November 2013 VA examination, the Veteran noted that after retiring as a nursing assistant, he worked as a taxi driver until 2010. In light of Rice and the Veteran's statements, the Board will infer a claim for TDIU as part of the Veteran's PTSD increased rating claim that was filed on October 3, 2012. From November 7, 2014, the Veteran’s service-connected disabilities are PTSD (assigned a 50 percent rating, until May 31, 2016, when it was increased to a 100 percent rating) and obstructive sleep apnea (assigned a 50 percent rating). The Veteran's combine rating is greater than 70 percent. The tenets of 4.16(a) thereby apply. The Veteran completed a VA Form 21-8940 dated August 2013 in which he reported that he last worked full time in 2003 as a nursing assistant. He indicated he left the job as a result of his disabilities and has been unable to obtain employment since that time. He further reported he had four years of high school education with no additional education or training. However, the Board notes that, based on the evidence of record, the Veteran also worked as a taxi driver until 2010. After weighing all the evidence of record, reported earlier in this decision, and resolving all doubt in the Veteran's favor, the Board finds that the Veteran's service-connected disabilities, primarily his PTSD, render him unable to secure and follow a substantially gainful occupation. The Veteran has very little formal education and has not received any other education or training beyond his prior work experience. Furthermore, the evidence shows that the Veteran's service-connected PTSD has an impact on his ability to maintain a daily routine which is necessary for any employment. In addition, he has difficulty adapting to stressful circumstances, including work or a work like setting and an inability to establish and maintain effective social relationships. Therefore, social interactions in a work environment, such as a nursing assistant or a taxi driver, would be very challenging for the Veteran. Therefore, the Board resolves all reasonable doubt in favor of the Veteran and finds that his service-connected disabilities prevent him from obtaining and maintaining substantially gainful employment, effective from the original date of his claim for PTSD of November 7, 2014. Accordingly, the Board finds that entitlement to TDIU is warranted, effective from November 7, 2014. 38 C.F.R. §§ 3.341(a), 4.16, 4.18, 4.19. REASONS FOR REMAND Entitlement to a total disability evaluation based on individual unemployability (TDIU), from October 3, 2012 to November 7, 2014, is remanded. A total disability rating may also be assigned on an extraschedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in § 4.16(a). Marginal employment shall not be considered as constituting substantially gainful employment. 38 C.F.R. § 4.16(a). VA policy is to grant TDIU, regardless of the percentages, when service-connected disability actually renders a veteran unemployable. 38 C.F.R. § 4.16 (b). Where there is evidence that a veteran is unemployable by reason of service-connected disability, but does not meet the percentage requirements, the Board is required to remand the claim, so that it can be referred to VA's Director of Compensation Service for adjudication in accordance with 38 C.F.R. § 4.16 (b). Once a referral for an extraschedular TDIU rating under § 4.16(b) is made by the Board, the Director of Compensation Service then determines whether an extraschedular TDIU evaluation under § 4.16(b) is warranted. At that juncture, only then does the Board have jurisdiction to decide the TDIU claim on the merits when it returns. The Veteran's only service-connected disability, prior to November 7, 2014, is PTSD which is rated as 50 percent disabling as of October 1, 2012. Thus, the Veteran did not meet the percentage standards set forth in § 4.16(a) prior to November 2014. However, there is plausible evidence of record that suggests the Veteran may have been unable to secure or follow a substantially gainful occupation as a result of his service-connected PTSD prior to November 2014, such that referral to the Director of Compensation Service for a possible extraschedular evaluation for TDIU for this period under 38 C.F.R. § 4.16(b) is warranted. The November 2013 VA examiner concluded that the Veteran has difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances, including work or a worklike setting. Since there is probative evidence of record that the Veteran may have been unable to secure and follow a substantially gainful occupation prior to November 2014 due to his service-connected PTSD, the Board therefore concludes that consideration of this TDIU claim for extra-schedular consideration for this period is appropriate under 38 C.F.R. § 4.16(b). Consequently, the Board finds that the issue of entitlement to TDIU benefits under 38 C.F.R. § 4.16(b), prior to November 2014, should be remanded for referral to the Director of Compensation and Pension Service for extraschedular consideration. The matters are REMANDED for the following action: (Continued on the next page)   1. Refer the case to the Director of Compensation and Pension Service for an opinion regarding whether the Veteran's service-connected PTSD prior to November 2014 rendered him unemployable and therefore entitled to TDIU on an extraschedular basis prior to November 2014 under 38 C.F.R. § 4.16(b). 2. Thereafter, readjudicate the claim for TDIU for the period prior to November 2014 on an extraschedular basis. If the benefit sought is not granted, issue the Veteran and his representative a supplement statement of the case (SSOC) and return the matter to the Board for further review. SCOTT W. DALE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. R. Montalvo, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.