Citation Nr: 21014164 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 15-40 061 DATE: March 11, 2021 ORDER Entitlement to a rating in excess of 10 percent for left foot disability prior to September 26, 2019 is denied. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to November 9, 2015 is denied. Entitlement to a 70 percent rating, but no higher, for posttraumatic stress disorder (PTSD), effective November 9, 2015 to February 5, 2016, is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to September 26, 2019, the preponderance of the evidence shows the Veteran’s left foot disability symptoms were most nearly approximated as a moderate foot injury. 2. Prior to November 9, 2015, the preponderance of the evidence shows that the Veteran’s service-connected PTSD was manifested by occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. 3. For the period from November 9, 2015 to February 5, 2016, the preponderance of the evidence shows that the Veteran’s service-connected PTSD was productive of functional impairment comparable to occupational and social impairment with deficiencies in most areas. 4. Prior to February 5, 2016, the preponderance of the evidence is against finding that the Veteran’s service-connected PTSD resulted in total occupational and social impairment. CONCLUSIONS OF LAW 1. Prior to September 26, 2019, the criteria for an initial rating in excess of 10 percent for a left foot disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.10, 4.40, 4.71a, Diagnostic Code (DC) 5284. 2. Prior to November 9, 2015, the criteria for entitlement to a rating in excess of 30 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.102, 4.7, 4.130, Diagnostic Code 9411. 3. From November 9, 2015 to February 5, 2016, the criteria for entitlement to a rating of 70 percent for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.102, 4.7, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 2008 to February 2012, including service in Afghanistan. This case is before the Board of Veterans’ Appeals (Board) on appeal from March 2014 and July 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO), which granted service connection for PTSD and a left foot disability. The RO assigned an initial rating of 30 percent for PTSD and an initial noncompensable rating for the left foot disability, both effective March 21, 2013. In a March 2016 rating decision, during the pendency of the present appeal, the RO increased the rating for PTSD from 30 percent to 100 percent, effective February 5, 2016. In an April 2020 rating decision, also during the pendency of the present appeal, the RO increased the rating for a left foot disability to 20 percent, effective September 26, 2019. Therefore, a rating of 100 percent for the Veteran’s PTSD from February 5, 2016 is considered a full grant of the benefit sought on appeal. Moreover, the Veteran, through her representative, notified VA that she does not seek a rating in excess of 20 percent for her left foot disability from September 26, 2019. See Appellate Brief, September 2020. Therefore, a rating in excess of 20 percent for the Veteran’s left foot disability from September 26, 2019 is considered a full grant of the benefit sought on appeal and will not be discussed further. In September 2018, the Board remanded the case for further development. In July 2020, the Board granted the Veteran an increased initial rating of 10 percent disabling prior to September 26, 2019 for her left foot disability and also remanded the case for further development to determine entitlement to increased ratings in excess of 30 percent for PTSD prior to February 5, 2016 and in excess of 10 percent for left foot disability prior to September 26, 2019. Because less than the maximum available benefit for schedular ratings were awarded during the current appeal and because such ratings were not awarded for the entirety of the claims period, the Veteran’s claims remain before the Board. See Fenderson v. West, 12 Vet. App. 119, 126(1999); AB v. Brown, 6 Vet. App. 35 (1993). The Board also notes the Veteran perfected her Appeals Modernization Act (AMA) appeal for earlier effective dates for her left foot disability, left and right lower extremity radiculopathy and special monthly compensation for housebound benefits, which are currently certified to the Board under the AMA system. As such, these claims will be addressed in a separate decision. See VA Form 10182 (AMA Notice of Disagreement (Direct Review)), June 2020. Moreover, Social Security Administration (SSA) disability determination records show that the Veteran was awarded disability benefits on May 15, 2015 due to her anxiety disorders. Thus, the Board finds that the record raises a claim for a TDIU. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, this issue has been added above as one of the issues on appeal. Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155: 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by a Diagnostic Code (DC). 38 C.F.R. § 4.27. When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate higher or lower compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as “staged” ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to 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. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2009). 1. Entitlement to an increase rating for left foot disability prior to September 26, 2019. The Veteran contends she is entitled to a rating in excess of 10 percent prior to September 26, 2019. For the period prior to September 26, 2019, the Veteran is in receipt of a 10 percent disability rating for her left foot disability under 38 C.F.R. § 4.71a, DC 5284, applicable to other foot injuries. Under DC 5284, a 10 percent rating is warranted for moderate impairment. A 20 percent rating is warranted for moderately severe impairment. A 30 percent rating is warranted for severe impairment. A Note under DC 5284 provides that a 40 percent rating is warranted for actual loss of use of the foot. Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as “moderate” “and “severe.” See Sellers v. Wilkie, 30 Vet. App. 157 (2018). It should also be noted that use of terminology such as “moderate” and “severe” by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. Rather than applying a mechanical formula, the Board must instead evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. In evaluating disabilities of the musculoskeletal system, painful motion is an important factor of disability. See 38 C.F.R. § 4.59. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. Id. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Id. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. Id.; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that section 4.59 applies to all forms of painful motion of joints, and not just to arthritis). Moreover, when evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. 38 C.F.R. § 4.40. Consideration must also be given to weakened movement, premature or excess fatigability and incoordination. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995) (holding that the criteria discussed in sections 4.40 and 4.45 are not subsumed by the Diagnostic Codes applicable to the affected joint). The Court of Appeals for Veterans Claims (Court) clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West,13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski,1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Turning to the evidence, an August 2010 service treatment record indicated that the Veteran sustained a fifth metatarsal base fracture in her left foot a year earlier. At that time the Veteran reported pain primarily associated with impact activity. She was diagnosed with peroneal tendonitis secondary to the fracture and prescribed rigid custom orthotics. A January 2011 service treatment record for follow up treatment of her left foot disability noted the Veteran was able to run without limitation and she reported orthotics were a great help, reducing pain to 0 out of 10 on the subjective pain scale. The Veteran next underwent a VA examination for her left foot disability in July 2015. The examiner stated the Veteran was diagnosed with peroneal tendonitis in her left foot in June 2015. The Veteran reported her symptoms as tingling in the left foot when using an elliptical, aching in rainy weather, and pain in the lateral forefoot with running. The Veteran further reported that she had not sought medical treatment for her left foot since leaving service and that the condition stayed the same since service. The Veteran described her foot pain as aching, stabbing, and stiff during the July 2015 VA examination. The Veteran additionally reported functional loss in the form of trouble with physical training and walking long distances. The examiner described the severity of the Veteran’s left foot disability as “mild” and reported the Veteran’s disability does not chronically compromise weight bearing or require arch supports, custom orthotic inserts, or shoe modifications. The examiner noted pain on examination and described contributing factors of disability as pain on weight bearing and disturbance of locomotion. The examiner described the functional impact of the condition as a mild limitation in walking. Tenderness was noted in different areas along the left fifth metatarsal. The examiner additionally noted the Veteran’s stance and gait were normal and there was no erythema or swelling. A detailed review of treatment records from Jacksonville, Fayetteville, Wilmington, Asheville and Albany VA Medical Center’s fail to disclose any additional complaints of, treatment for, or findings pertaining to the Veteran’s left foot disability prior to September 26, 2019. Based on a review of the evidence, both lay and medical, the Board finds the July 2015 VA examination, including the Veteran’s lay statements, to be the most probative evidence of record as to the severity of her left foot disability for the period prior to September 26, 2019. Specifically, the report notes the Veteran experienced intermittent mild to moderate symptoms of pain and tenderness while exercising and walking longer distances, resulting in some functional loss, such as mild limitation in walking. The Veteran’s left foot disability did not compromise weight bearing or require the use of orthotics. Moreover, the last treatment record from service reported the Veteran could run without limitation and the Veteran reported on the July 2015 VA examination that her symptoms had not changed since service. The Board finds the preponderance of the evidence shows the Veteran’s symptoms were consistent with having “moderate” symptoms of a disability, where the Veteran’s symptoms caused her intermittent functional impairment in that they mildly interfered with her ability to perform physical training and walk long distances. See 38 C.F.R. § 4.40. It is important for the Veteran to understand that her left foot pain is what forms the basis for the current finding of a 10 percent disability rating. There is no basis for a higher rating beyond the 10 percent for any time prior to September 26, 2019 because service and post-service treatment records lack the combination of manifestations sufficient to identify a “moderately severe” or “severe” left foot disability, as distinguished from merely isolated findings that show a “mild” or “moderate” level of severity that occur mainly during flare-ups with pain while exercising and walking longer distances. Finally, neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record with respect to her left foot disability. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In summary, the Board finds that the preponderance of the evidence shows an initial rating of 10 percent, but no higher, is warranted for the left foot disability during the period prior to September 26, 2019. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130. 2. Entitlement to a higher rating for PTSD prior to November 9, 2015. 3. Entitlement to a higher rating for PTSD from November 9, 2015 but prior to February 5, 2016. The Veteran contends that the medical evidence of record supports a higher rating for her PTSD prior to February 5, 2016. See Appellate Brief, September 2020. As the Court recently explained, evaluation under 38 C.F.R. § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. VazquezClaudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering “not only the presence of certain symptoms[,] but also that those symptoms have caused occupational and social impairment in most of the referenced areas” - i.e., “the regulation... requires an ultimate factual conclusion as to the Veteran’s level of impairment in ‘most areas.’” Vazquez-Claudio, 713 F.3d at 117-18; 38 C.F.R. § 4.130, Diagnostic Code 9411. Further, when evaluating a mental disorder, the Board must consider the “frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission,” and must also “assign an evaluation 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). Prior to February 5, 2016, the Veteran’s service-connected PTSD is rated as 30 percent disabling under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. The General Formula provides a 30 percent rating is warranted when the evidence shows occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted when the evidence shows occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted when there is 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 MDD 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); inability to establish and maintain effective relationships. A 100 percent rating is warranted when the evidence shows total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Turning to the merits of the claim, in a March 2013 VA mental health treatment record, the Veteran reported her marriage of nearly four years was “good,” and that she worked full-time with the Navy as an administrative employee. See Wilmington VAMC MH Progress Note, March 06, 2013. Moreover, she reported having good relationships with her family members and in-laws at this time. The Veteran reported having problems with feelings of distance from others, feelings of being emotionally numb, trouble falling asleep, irritability and angry outbursts, extreme difficulty in concentrating, being super alert or watchful and being easily startled. The Veteran answered “no” to all of the suicide risk screening questions and based on the examination results and considering the Veteran’s report of occupational and social history, the examiner opined that the complexity and level of impairment of the Veteran’s PTSD at this time was “mild/moderate.” The Veteran underwent a VA examination for her PTSD disability in July 2015. The examiner noted that the symptoms attributable to her PTSD were chronic sleep impairment, nightmares, anxiety, irritability, startle, hypervigilance, intrusive memories, avoidance, isolation, depression, mild memory loss and poor concentration. During the examination, the Veteran reported she attended college prior to joining the military, was married since 2009 and worked as a civilian administrative employee for the Department of the Navy since October 2012. As far as symptoms of her PTSD, the Veteran reported having trouble sleeping, which left her feeling tired during the day. The July 2015 examiner noted the Veteran was a bit withdrawn and distant and that she has depression, loss of energy and loss of interest. The examiner further reported that the Veteran had no suicidal thoughts, mania or psychosis, but she had some problems with her concentration. The examiner noted the Veteran did not experience panic attacks during this time period. In terms of occupational impairment, the July 2015 examiner reported that the Veteran was able to get along with the public, coworkers and supervisors and that she can learn new procedures and follow complex instructions. As far as social impairment, the examiner noted the Veteran was a bit isolated and did not like to go out and be around crowds or strangers. The examiner reported that the Veteran’s overall symptoms were most closely represented 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. Upon examination, the Veteran was neatly groomed and dressed, behaved normally, was pleasant, cooperative and polite, her speech was normal in rate and tone, with good grammar and vocabulary. She was spontaneous and logical, not inhibited or vague. No pressured speech, flight of ideas or loose associations. The Veteran was reported as being able to communicate well with others. The examiner also noted the Veteran had no hallucinations, delusions, paranoia or ideas of reference. She was not homicidal or suicidal. In terms of activities of daily living, the Veteran reported she can take care of her activities of daily living. The Veteran reported that she and her husband go out to eat or do things with friends in their free time. She also reported getting along with family and friends. Importantly, the July 2015 examiner opined that the Veteran is able to establish and maintain effective work and social relationships. In September 2015, the Veteran denied suicidal harm and suicidal ideation but admitted to intermittently depressed mood that had, up to that point, never been treated with medication. See Asheville VAMC Women’s Health Evaluation Note, September 09, 2015. The Veteran also reported feeling a racing heart and anxiety when in crowds with a history of panic attacks. However, the Veteran reported she had no panic attacks recently and could not recall when the last one occurred. In October 2015 and early November 2015, the Veteran endorsed mild levels of anxiety and depression, accompanied by symptoms of insomnia and aggression. See Asheville VAMC MH Progress Note, October 20, 2015; see also Asheville VAMC MH Progress Note, November 04, 2015. VA mental health treatment records show that in November 2015, the Veteran began reporting her anxiety and depression were getting worse at this time. See Asheville VAMC MH Progress Note, November 09, 2015. At this time, the Veteran reported that she and her husband recently moved to Asheville area for her husband’s schooling, but they were from New York and she did not have friends in the area, which caused isolation, exacerbating her mood symptoms. The Veteran was attending brewery school at this time and reported symptoms of hypervigilance, intrusive combat memories triggered by noises and smells, conversations, panic attacks, agoraphobia and social anxiety, initial insomnia and symptoms of sleep apnea, frequent nightmares, anergia, daytime fatigue, anhedonia, frequent tearfulness, poor concentration, emotional numbing, and low frustration tolerance with severe irritability. Importantly, the VA psychiatrist noted at this time the Veteran developed suicidal ideation, without any attempt, and which resolved. However, the Veteran reported she never wanted to end her life but over past several months she had periods of “feeling that being dead would be better.” Moreover, the Veteran reported obsessional anxiety about locks in her house, repeatedly checking them after leaving the home and stated that she had become “verbally abusive” recently to her husband. In December 2015 the Veteran was seen for treatment at VA mental health clinic where she reported she “no longer wakes up wanting to [commit] suicide”, is less frequently tearful and hopeless, and her anxiety was reduced since going on medication for the prior three weeks. See Asheville VAMC MH Progress Note, December 10, 2015. However, the Veteran also reported having severe marital difficulties at this time along with difficulty coping with stress due to an upcoming exam at her school because she was having difficulty concentrating and sleeping. In December 2015 the Veteran next reported for a regularly scheduled mental health appointment with her mother present and she reported she had been incredibly “stressed, angry, anxious” due to continuing marital issues and social isolation, having no friends or family in the area where she lived. See Asheville VAMC MH Progress Note, December 21, 2015. The Veteran’s mother expressed concern during the appointment for the Veteran’s safety because she had heard the Veteran make comments about suicide recently. The Veteran acknowledged thoughts of self-harm but denied any plan or intent to follow through. In January 2016 the Veteran was seen at VA mental health clinic and reported she was doing better since her last visit but admitted that she cut herself over the prior weekend because she was “feeling so much anger she needed to release it.” See Asheville VAMC MH Progress Note, January 6, 2016. According to the VA psychiatrist, the Veteran appeared less angry and hopeless at this visit, with the Veteran expressing hope for future and much more future oriented. The Veteran denied any suicidal ideation at this visit. The Veteran was seen at VA mental health clinic in January 2016 where she reported ongoing severe anxiety that “felt paralyzing.” See Asheville VAMC MH Note, January 29, 2016. The Veteran also reported that she had trouble leaving the house but made it clear that she had no suicidal or homicidal intent. The Veteran reported having panic attacks and agoraphobia that were overwhelming to her during this visit. The Board also notes that the SSA records obtained by VA since the most recent Board remand do not contain additional medical records for the period prior to February 2016. They contain a mental health evaluation record from October 2016 that documents the severity of the disability after February 2016 (the date for which the Veteran is rated 100 percent disabled from PTSD). See e.g., Appellate Brief, September 2020. Having reviewed the evidence of record, the Board finds that, prior to November 9, 2015, the Veteran’s primary psychiatric symptoms were consistent with a 30 percent disability rating under the diagnostic criteria. While it is true that the Veteran had marital problems and disturbances of motivation and mood during the period to November 9, 2015, such as chronic sleep impairment, anxiety, anger, difficulty concentrating and depression, the complete disability picture of the Veteran’s psychiatric condition, taking into account the frequency, duration and severity of her symptoms up to this point in time, most closely resemble the symptoms related to a 30 percent disability rating during this period. Specifically, the Veteran worked and/or went to school full-time, had close relationships with family and friends and had mild to moderate symptoms of depressed mood, anxiety, chronic sleep impairment, and mild memory loss and poor concentration. The Board finds the July 2015 VA examination report and chronological medical treatment reports of record provide competent, credible and highly probative evidence in this claim. The medical examiners agreed that the Veteran’s PTSD symptoms were mild to moderate in severity. See e.g., Wilmington VAMC MH Progress Note, March 06, 2013; VA Examination, July 2015. In some cases, the Veteran’s own statements provide evidence against a higher disability rating during this period. See e.g., Asheville VAMC Women’s Health Evaluation Notes from September 09, 2015 (Veteran reports she cannot recall the last panic attack she had), October 20, 2015 (Veteran endorsed mild levels of anxiety and depression). Importantly, a higher rating of 50 percent disabling is not warranted during this period because the evidence does not demonstrate or suggest occupational and social impairment with reduced reliability and productivity (so as to warrant a 50 percent schedular rating) 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; difficulty in establishing and maintaining effective work and social relationships. Likewise, a 70 percent rating, or higher, is not warranted for any time prior to November 9, 2015 because the Veteran’s symptoms did not show occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Specifically, the Veteran repeatedly denied suicidal ideation throughout this particular time period on appeal and did not show symptoms of obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or MDD 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. Taking into account the Veteran’s competent and credible lay reports of symptoms, the frequency, duration and severity of her symptoms, as well as the competent, credible and probative opinions made in the July 2015 VA examination and other VA mental health treatment records throughout the period, the Board finds the symptoms show by a preponderance of the evidence that the Veteran’s PTSD disability was most closely approximated by a 30 percent disability rating at all times prior to November 9, 2015. Accordingly, a rating in excess of 30 percent rating must be denied for all times prior to November 9, 2015 based on the best lay and medical evidence of record. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board next finds, effective November 9, 2015, that VA mental health treatment records show that the Veteran’s service-connected PTSD presented a disability picture more consistent with occupational and social impairment with deficiencies in most areas, as contemplated by the criteria for a 70 percent rating. Specifically, VA mental health treatment record from November 9, 2015 show that the Veteran first reported a worsening of her symptoms, which included, hypervigilance, intrusive combat memories triggered by noises and smells, conversations, panic attacks, agoraphobia and social anxiety, initial insomnia and symptoms of sleep apnea, frequent nightmares, anergia, daytime fatigue, anhedonia, frequent tearfulness, poor concentration, emotional numbing, and low frustration tolerance with severe irritability. See Asheville VAMC MH Progress Note, November 09, 2015. Moreover, the Veteran’s treating psychiatrist noted the Veteran developed suicidal ideation at this time (which is supported by lay statements from the Veteran and her mother, reported the following month, in December 2015), along with a more severe form of agoraphobia that became “paralyzing,” as well as certain obsessional rituals of checking and re-checking door locks in her home and cutting herself, which show, objectively, a worsening progression of her PTSD symptoms from November 9, 2015. Where any medical record shows improvement between November 9, 2015 and February 5, 2016, the Board notes the Veteran began taking medication for her psychiatric condition during this period for the first time in her life and has taken this fact into consideration in coming to the conclusion that her symptoms warrant a 70 percent disability rating for her PTSD during this period. However, the Board finds that total occupational and social impairment, which would warrant a 100 percent rating for the Veteran’s service-connected PTSD, is not warranted from November 9, 2015 to February 5, 2016. Notably, the Board finds there is no evidence showing the Veteran had 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; memory loss for names of close relatives, own occupation, or own name. Specifically, the Board notes the Veteran was working through her marital issues at this time, she kept in close contact with family members, she was attending brewery school to completion, was future-oriented and expressed an intermittent (rather than persistent) danger of hurting herself (but denied any plan or intent to follow through) throughout the period. Thus, taken together, the Board finds the Veteran’s level of functioning between November 9, 2015 and February 5, 2016 does not warrant a 100 percent disability rating for this time period and would be inconsistent with a finding of total occupational and social impairment. In summary, the Veteran’s symptoms reflect no more than moderately severe difficulty in social, occupational, or school functioning. As such, the Board finds that a 70 percent rating adequately compensates the Veteran for her symptomatology between November 9, 2015 and February 5, 2016. In other words, the Board finds that the criteria for a disability rating greater than 30 percent effective November 9, 2015 but prior to February 5, 2016 for PTSD have been met and a 70 percent disability rating, but no higher, for this period is warranted. REASONS FOR REMAND 1. Entitlement to TDIU The Veteran was deemed totally disabled under SSA regulations on May 15, 2015. See SSA Decision of June 12, 2017. Therefore, the record raises a claim for a TDIU. See Rice, supra. However, from the existing record, the Board is not able to ascertain a complete picture of the Veteran’s post-service employment history nor of her education and training history for the period on appeal. Further, the record does not show the Veteran has been provided notice of the laws and regulations governing a TDIU claim. In adjudicating a claim for a TDIU the Board must ascertain if the Veteran’s service-connected disability would prevent her from securing or following a “substantially gainful” occupation given her prior vocational history, work experience, education. The collective impact her service-connected disability would have in performing jobs that require sedentary and non-sedentary employment, including her past employment as an administrative employee with the Navy or post-graduation from brewery school, must be considered. Therefore, a remand to obtain a VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability, with the stated information is required. See 38 U.S.C.§ 5103A(b); 38 C.F.R. §§ 3.340, 4.16, 19.9; Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013) (holding that the determination of whether a Veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the regional office). Thus, the Board finds that a remand for further development of the Veteran’s TDIU claim is required. See 38 U.S.C. §§ 5103; 5103A(b); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The matters are REMANDED for the following actions: 1. Associate with the record any outstanding VA treatment records. 2. After obtaining all needed authorizations from the Veteran, associate with the claims file any outstanding private treatment records. If possible, the Veteran’s representative should submit any new pertinent evidence that the Board does not have. 3. Obtain and associate with the claims file a fully executed VA Form 21-8940. In this regard, the request should include a request for the Veteran to provide a detailed statement as to her employment history since service along with her duties at those places of employment, whether she continues to be unemployed, the approximate date she stopped working full or part time, and how her service-connected disability (i.e., PTSD) prevents her from obtaining and maintaining substantial gainful employment in both fields that are sedentary (i.e., administrative) and physically demanding (i.e., bartending). Any help from the Veteran and her representative in obtaining this information would be appreciated. The request should also notify the Veteran that her claim for a TDIU can be denied if she fails to cooperate with the prosecution of the claim by providing the VA with a Form 21-8940 (Application for Increased Compensation Based on Unemployability). John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Davidson 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.