Citation Nr: 21008785 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 17-59 508 DATE: February 18, 2021 ORDER Entitlement to an initial 50 percent evaluation, but no higher, for service-connected posttraumatic stress disorder (PTSD) prior to July 15, 2020 is granted. REMANDED Entitlement to a total disability evaluation based on individual unemployability due to service-connected disabilities (TDIU), to include on an extraschedular basis prior to July 15, 2020 is remanded. FINDING OF FACT Prior July 15, 2020 the severity, frequency, and duration of the Veteran’s symptoms more closely approximate occupational and social impairment with reduced reliability and productivity. CONCLUSION OF LAW The criteria for entitlement to a 50 percent evaluation, but no higher, for service- connected PTSD, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the U.S. Air Force from October 1966 to October 1970. The case comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2016 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). In October 2019, the Veteran presented testimony at a travel Board hearing before the undersigned Veterans Law Judge (VLJ). The issues were previously before the Board in February 2020, when it was remanded for further development, that development was completed, and the case has since been returned to the Board for appellate review. Duties to Notify and Assists 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). The Board finds that there has been substantial compliance with the prior February 2020 remand directives, in regard to PTSD. See Stegall v. West, 11 Vet. App. 268 (1998). Increased evaluation for PTSD was remanded for a current VA examination and opinion to attempt to ascertain which mental health symptoms are attributable solely to the Veteran’s service-connected PTSD. As such has been accomplished, the Board finds there has been substantial compliance with the February 2020 remand directives. Increased Evaluation - PTSD Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2019). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2019). 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 (2019). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2019). 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 (2019). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence 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. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating a claim for an increased initial evaluation, the relevant time period is from the date of the claim. Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), rev’d in irrelevant part, Moore v. Shinseki, 555 F.3d 1369 (2009). Here, that date is January 11, 2016. The Veteran’s service-connected PTSD is rated under 38 C.F.R. § 4.130, DC 9411. Under the General Rating Formula for Mental Disorders, a 30 percent evaluation is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent evaluation is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent evaluation is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent evaluation is assigned when symptoms such 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; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms; the length of remissions; and the veteran’s capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126 (a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126 (a). Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). The 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. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). “[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 (Fed. Cir. 2013). The symptoms shall have caused occupational and social impairment in most of the referenced areas. Vazquez-Claudio, 713 F.3d 112. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126. In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner’s assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126. The Veteran filed a January 2016 claim for increase evaluation. An August 2020 rating decision granted a 100 percent evaluation effective, July 15, 2020. This was a partial grant of the issue on appeal. The Veteran asserts he is entitled to an initial evaluation higher than 30 percent. Resolving all doubt in the Veteran’s favor, the Board finds, that prior to July 15, 2020, the severity, frequency, and duration of the Veteran’s symptoms more closely approximate occupational and social impairment with reduced reliability and productivity. The VA examinations, VA treatment records, and lay statement support a 50 percent evaluation prior to July 15, 2020. VA mental health treatment records from April 2011 – August 2016 show diagnoses and treatment for generalized anxiety disorder, panic disorder with agoraphobia, chronic alcoholism in remission, and insomnia. The records also noted the Veteran did not express or show symptoms of suicidal or homicidal ideation. In a February 2016 VA addiction psychiatry treatment record the Veteran endorsed general anxiety, while still feeling situational anxiety, and his sleep continues to be disrupted. The treatment provider noted the Veteran presented with chronic anxiety and insomnia. The treatment provider observed the Veteran was casually dressed, alert, orientated, cooperative, coherent speech, stable mood, no suicidal/homicidal ideation, thought reality based, and judgement intact. A March 2016 VA psychiatrist note documented diagnoses of generalized anxiety disorder, panic attacks, insomnia, chronic alcoholism in remission, panic disorder with agoraphobia. The psychiatrist observed the Veteran was dressed casual, alert, oriented, cooperative, coherent speech, mood stable. No suicidal or homicidal ideation. Thought reality based, and judgement intact. The Veteran received a VA examination in April 2016. The examiner indicated 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, selfcare and conversation. The examiner indicated the Veteran had no other mental disorder diagnosis. The examiner noted symptoms of depressed mood, panic attacks that occur weekly or less often, and chronic sleep impairment. The examiner observed some initial irritability, his affect during the interview was appropriate to content. His thought processes were logical, coherent, and there was no evidence of psychotic ideation, and his attitude during the interview was cooperative. His motor behavior and speech were both normal. The examiner noted his impulse control and judgement are good. When asked about obsessive thoughts, he said when he is working on a task, he must complete it. The Veteran stated he thinks obsessively about death and about his disabled daughter’s well-being. In terms of compulsive behavior, he checks the locks at home three or four times and checks to make sure tasks are done. He reported having nightmares about once a month. He stated he has never been violent and reported no suicidal history or current intent or plan. He has intrusive memories. He indicated he has been taking medication for panic attacks since 1995. The examiner stated the Veteran is overly alert and easily startled; he feels distant from others, is irritable, and has difficulty concentrating. Socially he reported living with his wife of thirty-eight years. He shared that he and his wife share meal preparation. He showers every day and enjoys golf, cars, fishing, and will do activities with friends. He shares a daughter with his wife, who has a developmental disability, but is able to live on her own. A May 2016 VA psychiatrist note showed a diagnosis of obsessive-compulsive disorder (OCD) and alcohol abuse in remission. The Veteran endorsed sleep impairment. He stated though he has some anxiety he is happy with life except for his problem with sleeping. The psychiatrist asked about rituals. The Veteran acknowledged he has many rituals. When it was suggested that he does not have a sleep problem, but instead is obsessed with sleep, the Veteran was relieved and agreed to shift the focus of treatment away from sleep and toward obsessive-compulsive disorder. The psychiatrist observed the Veteran was alert and oriented, casually dressed, pleasant and cooperative, speech regular rate and rhythm, and mood. His affect full range, appropriate to content. His thought process was logical and coherent. There was no evidence of thought disorder. He denied suicidal intent or plan. Socially the Veteran reported being married. He stated he gardens, cooks, reads, and goes out with friends. The Veteran began VA group therapy in February 2016 in addition to his individual therapy. He endorsed experiencing panic attacks. Throughout the sessions the Veteran did not express or show symptoms of suicidal or homicidal ideation. It was noted he joined the group to learn about PTSD and gain skills for coping with symptoms without returning to substances. VA treatment records document the Veteran attended outpatient psychotherapy sessions from April 2016 – July 2016 for treatment of alcohol use disorder moderate-severe, in remission and panic disorder. In a May 2016 VA outpatient psychotherapy session record documents, the Veteran reported panic attacks increasing. The treatment provider observed the Veteran was appropriately groomed, relaxed demeanor, mood happy, affect normal, speech loud, memory good, and thought process logical. There was no suicidal or homicidal ideation noted. The treatment providers noted diagnoses of alcohol use disorder, moderate-severe, in remission and panic disorder. It was noted that his panic attacks require the use oxygen, followed quickly by palpitations and fear of heart attack, including sweating and chest pains. The treatment provider recommended breathing exercises to help with panic attacks. The Veteran reported comforting self by wrapping self in a particular blanket on the couch. In a June 2016 VA outpatient psychotherapy session record the Veteran reported when his panic attacks start, he needs oxygen which is complicated by his COPD, followed quickly by palpitations and fear of heart attack; including sweating and chest pains. The treatment provider observed the Veteran had a relaxed demeanor, mood happy, affect normal, speech loud, memory good, thought process logical. No suicidal or homicidal ideation. The treatment provider diagnosed alcohol use disorder, moderate-severe, in remission and panic disorder. In a subsequent June 2016 VA outpatient psychotherapy session record documents, the Veteran reported he stopped taking his medication because he believed that it weak to take medication and he could manage his symptoms on his own. The treatment provider noted a diagnosis of PTSD, obsessive compulsive disorder (OCD), and alcohol abuse in remission. The Veteran reported having episodes of panic once or twice a nearly every day. The Veteran reported he has difficulty sleeping because he is woken every night by nightmares that cause him distress that he has to curl up in the living room with his “security blanket and comfort himself in for one – two hours after which he is sometimes able to return to sleep for another hour. The treatment provider observed the Veteran was alert and oriented. He was cheerful, good eye contact and was eventually willing to let his guard down somewhat. He was casually dressed, pleasant and cooperative, speech regular rate and rhythm, mood euthymic. His affect labile, tearful when talking about his fear of death and needing to care for his daughter, thought process and content logical and coherent. There was no evidence of thought disorder. He denied suicidal intent or plan. The treatment provider encouraged the Veteran to resume medication, but particularly the medication used to treat his nightmares. In a July 2016 VA psychology note documents the Veteran was seen for a psychotherapy session. The treatment provider noted remission from substance abuse. The treatment provider observed the Veteran was engaged, mood serious, affect normal, speech loud, memory good, thought process logical. The Veteran was fully oriented. The treatment provider noted a diagnosis alcohol use disorder -moderate-severe, in remission and panic disorder. The Veteran reported trying to go without psych medication, but his panic attacks increased. He described having a big panic attack in June; therefore, he agreed to re-start his medication. There was no suicidal or homicidal ideation noted. August 2016 VA records indicated the Veteran’s panic attacks had increased. The treatment provider observed loud speech, good memory, logical thought process, no suicidal ideation, no homicidal ideation, his attitude was engaged, and his mood was serious. The Veteran was fully oriented. There was fair insight and good judgment. He was active with energy to garden, cook, read, and go out with friends. The treatment provider noted diagnoses of alcohol use disorder, moderate-severe, in remission and generalized anxiety. The Veteran reported he had been fired from a job. The Veteran was continued on medication. In February, May, June and July 2017 VA records, the Veteran was fully oriented, appropriately groomed and dressed, with intact memory, and appropriate speech. The Veteran had linear, logical, and goal-directed thought process and no evidence of hallucinations. The Veteran denied suicidal intent or plan and there was good insight and judgment. In August 2017 VA records, the Veteran was alert and oriented, with logical and coherent thought process and content. There was no evidence of a thought disorder, suicidal intent or plan. Insight and judgment were good. The Veteran’s memory was intact. There was no evidence of auditory or visual hallucinations. The Veteran received an October 2017 VA PTSD examination. The VA examiner indicated occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational task only during periods of significant stress, or symptoms controlled by medication. The Veteran reported he can be on his feet and busy working on his classic automobile for as long as seven hours per day. He also works 10 hours per week gardening for one of his friends. The Veteran reported a college degree in psychology. He worked for various public agencies serving trouble youth and working as a contract manager. Then, he owned his own general contracting business until he retired three or four years prior. The examiner noted symptoms of anxiety, panic attacks more than one a week, suspiciousness and chronic sleep impairment. The examiner observed the Veteran was appropriately dressed, groomed, and cooperative. During the interview he willingly shared troubling memories but indicated there were other things he was not ready to talk about. He reported he is generally a happy person and has a sense of humor. The treatment provider noted the Veteran seemed to be naturally sensitive to human suffering, which made him vulnerable to PTSD in response to the stress of combat. The examiner noted the Veteran had other symptoms attributable to PTSD. During the diagnostic interview the Veteran was tearful several times. He reports considerable negative feelings about the suffering and death he saw in Vietnam. He is sensitive in odors that remind him of dead bodies and nightmares that cause disturbances to his wife. He has alcoholism that started in the military. Also, he stated he is disturbed when he hears helicopters, which he associates with military activity in Vietnam. Further, he feels guilty about his violent verbal treatment of his wife over the years. Also, he has an irrational fear of bats and avoids going outside at night. Socially he reported he has been married for 40 years and the marriage is better than ever, though they have had their ups and downs. They share a daughter. He stated he is worried that his exposure to agent orange caused his daughter’s developmental disabilities. He reported some social anxiety but sees family members occasionally and has two friends for social support. In November 2017 VA records, the Veteran was alert, oriented, and casually dressed. He was extremely anxious and uncharacteristically demanding. The Veteran’s speech was normal, and he as irritable. His thought processes an content were logical and coherent. No evidence of a thought disorder, suicidal intent or plan. There was fair insight and judgment. In December 2017 VA records, the Veteran was fully oriented with an anxious mood. He was adequately groomed and appropriately dressed. The Veteran’s speech was appropriate and he had intact memory, linear, logical, and coherent thought process with evidence of delusions or hallucinations. The Veteran denied homicidal and suicidal ideations. The Veteran reported panic attacks which he stated prevented him from leaving the house. And being normal. In various 2018 VA treatment records, the Veteran was alert and oriented. The Veteran had logical and coherent thought process and content. There was no evidence of a thought disorder, suicidal intent or plant. There was improving insight and fair judgment and intact memory. The Veteran reported panic attacks and anxiety and denied homicidal suicidal ideations. In 2019 VA records, the Veteran was alert with an appropriate appearance. The Veteran’s mood was anxious. He had clear speech, intact memory, normal attention, coherent thought content. The Veteran denied suicidal and homicidal ideations. Impulse control was within normal limits, and there was rational judgment and good insight. In a March 2019 VA record, the Veteran was frustrated that he has not been able to get a job, but has been telling prospective employers that he has panic attacks. An October 2019 private treatment record documents the Veteran underwent counseling. He reported heavy marijuana use. The clinician explained to the Veteran that most of his symptoms are due to his marijuana use and excessive medications. The clinician observed the Veteran’s behavior incongruent with chronological age, mood anxious, inability to concentrate, thought content suspicious, and thought process disorganized. There were no reports of suicidal ideation. The clinician indicated the Veteran would not benefit from psychotherapy unless his marijuana use is discontinued. He recognized the harm it is doing; however, he struggles with the idea that he may become emotionally uncomfortable. At the October 2019 Board hearing the Veteran described symptoms of panic attacks that require him to stay home, difficulty leaving the house, inability to develop relationships, hypervigilance, and trouble with his memory. Also, he described having night sweats, shakes, not eating, and confusion. Additionally, he described an instance when he went to the emergency room because he thought he was having a heart attack, but it was an anxiety attack. A November 2019 private treatment counseling record documents that the Veteran reported he stopped smoking after his last appointment. He reported feeling painful levels of anxiety because of his BIA appeal. The clinician observed the Veteran affect was irritable, mood anxious, anxious thoughts, blaming others, preoccupation, and thought process circular. During the counseling session the Veteran went from being visibly shaky and trembling to being soft and focused by the end of the session. The clinician stated the Veteran may have some rebound anxiety from discontinuing smoking marijuana. The clinician also stated he responded extremely well to coherence training. There were no reports of suicidal ideation. A March 2020 private treatment record documents a diagnosis of PTSD and cannibis use disorder, severe. The clinician observed the Veteran was oriented to time, place, person, and situation. The Veteran reported that although he has stopped using marijuana, he struggles with anxiety and negative, fearful thinking. The clinician offered him suggestions for stress relief. A subsequent March 2020 private treatment record documents a diagnosis of PTSD and cannibis use disorder, severe. The Veteran discussed how angry he is over people dying of COVID-19, which has led to outrage about God and his blaming God for every bad thing that happens in the world. The clinician observed the Veteran was oriented to time, place, person, and situation. There was no suicidal or homicidal ideation present. An April 2020 private treatment record documents a diagnosis of PTSD and cannibis use disorder, severe. The Veteran reported he was frustrated with the state of the world. He described that he was feeling disconnected and is doing very little. The clinician observed the Veteran was oriented to time, place, person, and situation. His speech was within normal limits, affect appropriate to situation. There was no suicidal or homicidal ideation present. In a subsequent April 2020 private treatment record documents, a diagnosis of PTSD and cannibis use disorder, severe. He reported that he, his wife, and daughter are becoming closer and have bonded since social distancing policies have gone into place. He reported he was not feeling the guilt he once felt about his daughter’s disability. The clinician observed orientation to time, place, person, and situation. His speech was within normal limits, affect appropriate to situation, mood frustrated at times. There was no suicidal or homicidal ideation present. Most recently the Veteran received a July 2020 VA examination. The examiner indicated total occupational and social impairment. The examiner noted the following symptoms: 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, circumstantial, circumlocutory or stereotyped speech, speech intermittently illogical, obscure, or irrelevant, difficulty 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 in adapting to stressful circumstances, including work or a work like setting, inability to establish and maintain effective relationships, obsessional rituals which interfere with routine activities, intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene, and disorientation to time or place. The examiner observed the Veteran was clean and casually dressed. He was anxious to answer all questions but frequently got out of breath talking rapidly and when that happened seemed to not be able to talk as fast as he wanted, seemed to be having racing thoughts, would lose train of thought, and wife would rephrase or prompt him, and he waited for him to regain his composure. The examiner noted the overriding affect was one of extreme anxiety. The examiner noted the Veteran’s condition had clearly worsened his last VA examination in October 2017. The examiner stated the Veteran’s mental status is comprised by slow mental processing. The examiner explained he became tangential in responses as he seemed to be struggling to find words he wanted. At times, the Veteran seemed agitated. The examiner explained, a review of the stressor event caused the Veteran to become agitated, hyperventilated, resulting in stopping the session for him to recover. The examiner stated the panic reaction is considered part and parcel of the PTSD symptom array, not a separate condition from other causes. When panic decreases, he is rational and better able to respond appropriately. The examiner opined that the Veteran’s panic reactions and anxiety are totally based in the PTSD symptoms caused by stressor event. They have increased in both severity and frequency since his last VA examination in 2017. The examiner indicated all the other suggested diagnoses are part of his PTSD symptom array – panic attacks, alcohol use for a while, and generalized anxiety reactions. The OCD behaviors noted by others are more likely than not his way of dealing with (defense mechanisms) the anxiety and he has found some of the therapies (meditation & EMDR especially) helpful but it is clearly evident that the PTSD group sessions was anti-therapeutic because it only increased his anxiety, hypervigilance, intrusive memories, and panic reactions—in short worsening functioning and symptom intrusion. Lastly, the examiner stated that the additional (beyond PTSD) diagnoses were given by providers who in all likelihood did not have access to full C-file and are bound by their role(treatment) to base diagnosis on presentation only, not full record review- which would not be accessible to non-VA providers anyway. Socially the Veteran is still married to the same woman. He has a service dog and it helps greatly in anxiety reduction. The Board finds that prior to July 15, 2020, the Veteran’s PTSD symptoms more closely approximate occupational and social impairment with reduced reliability and productivity. The Veteran’s VA treatment records and private treatment records show symptoms of anxiety, chronic sleep impairment, panic attacks more than once a week, disturbances in mood and motivation, impaired judgment and difficulty in establishing and maintaining effective social relationships. First, notably VA treatment records regularly noted anxiety, sleep disturbances, and severe panic attacks. Next, the April 2016 VA examination showed irritableness, nightmares, and difficulty concentrating. Second, May 2016 and June 2016 VA treatment records noted the Veteran’s panic attacks are so severe that he requires the use of oxygen. His panic attacks are followed by palpitations, sweating, and chest pains. The clinician observed the Veteran affect was irritable, mood anxious, anxious thoughts, blaming others, preoccupation, and thought process circular. Next, the October 2017 VA examination notes the Veteran reported violent verbal treatment of his wife throughout their marriage. Lastly, at the October 2019 Board hearing the Veteran described symptoms of panic attacks that require him to stay home, difficulty leaving the house, inability to develop relationships, hypervigilance, and trouble with his memory. Also, he described having night sweats, shakes, not eating, and confusion. Additionally, he described an instance when he went to the emergency room because he thought he was having a heart attack, but it was an anxiety attack. An October 2019 private treatment record documents the clinician observed the Veteran’s behavior incongruent with chronological age, mood anxious, inability to concentrate, thought content suspicious, and thought process disorganized. Thus, and resolving all doubt in favor of the Veteran, the record indicated occupational and social impairment with reduced reliability and productivity. The Board also finds, however, that a 70 percent evaluation is not warranted. First, there is not deficiencies in judgment or thinking. Treatment records consistently indicate normal thinking and fair judgment. Second, the evidence does not show an inability to establish and maintain effective relationships. Although there are struggles in his family relationships, he remains married and has a good relationship with his daughter. Third, the other symptoms are not of similar severity, frequency, and duration of the 70 percent evaluation. His speech was normal throughout the appeal period. He was also noted to be fully oriented and adequately groomed and dressed. The Veteran consistently denied suicidal ideations. The reported obsessional rituals did not appear to interfere with routine activities and he was able to function independently, appropriately, and effectively. Accordingly, a 70 percent evaluation is not warranted. REASONS FOR REMAND 1. Entitlement to TDIU, to include on an extraschedular basis prior to July 15, 2020, is remanded. The Veteran’s service-connected disabilities do not meet the schedular requirements for TDIU under 38 C.F.R. § 4.16(a) prior to July 15, 2020. However, in an April 2020 statement the Veteran he quit working as a contractor because of the overwhelming responsibility. He stated he was unable to keep things straight and could not think because of his anxiety. The Veteran’s claim for TDIU is being remanded and referred to VA’s Director of Compensation Service for extraschedular consideration. The matters are REMANDED for the following action: After reviewing the record and conducting any additional development deemed necessary, in accordance with 38 C.F.R. § 4.16 (b), refer the issue of entitlement to extraschedular TDIU to VA's Director of Compensation Service. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Braxton, 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.