Citation Nr: 22014669 Decision Date: 03/14/22 Archive Date: 03/14/22 DOCKET NO. 17-14 014 DATE: March 14, 2022 ORDER Entitlement to a disability rating in excess of 50 percent for post-traumatic stress disorder (PTSD) prior to July 10, 2021, and in excess of 70 percent thereafter, is denied. REMANDED Entitlement to a total disability evaluation based on individual unemployability (TDIU) due to service-connected disabilities prior to July 10, 2021, on an extraschedular basis is remanded. FINDINGS OF FACT 1. Prior to July 10, 2021, the Veteran's PTSD manifested in symptoms of depressed mood, chronic sleep impairment, circumstantial, circumlocutory, or stereotyped speech, difficulty in establishing and maintaining effective work and social relationships, recurrent intrusive dreams and memories, avoidant behavior, anhedonia, irritability, hypervigilance, exaggerated startle response, problems with concentration, and occasional flashbacks, approximating occupational and social impairment with reduced reliability and productivity. 2. Since July 10, 2021, the Veteran's PTSD manifested in symptoms of depressed mood, anxiety; suspiciousness, panic attacks occurring weekly or less often, chronic sleep impairment, suicidal ideation, agoraphobia, social anxiety, obsessional rituals, avoidant behavior, anhedonia, irritability, hypervigilance, exaggerated startle response, problems with concentration and difficulty adapting to stressful circumstances, approximating occupational and social impairment with deficiencies in most areas. CONCLUSIONS OF LAW 1. Prior to July 10, 2021, the criteria for a rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 2. Since July 10, 2021, the criteria for a rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1968 to December 1969. These matters come to the Board of Veterans' Appeals (Board) on appeal from a December 2016 rating decision issued by the VA Regional Office (RO). By way of background, the Veteran was previously granted a 50 percent disability rating for his PTSD in a March 2011 rating decision, effective from June 26, 2007; the Veteran did not timely appeal the RO's March 2011 decision and it has become final. See Dolan v. Brown, 9 Vet. App. 358, 361 (1996). The Veteran subsequently filed claims for an increased rating for PTSD and for a TDIU in September 2016. These matters were previously before the Board in June 2021, when the Board remanded the Veteran's claims to obtain any outstanding VA treatment records and to afford him a new VA examination for his PTSD. The Board finds that there has been substantial compliance with the prior remand, and the matter is ready for adjudication. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran testified before the undersigned Veterans Law Judge at a virtual Board hearing in April 2021. A transcript is of record. The Board notes that an October 2021 RO decision granted the Veteran entitlement to a TDIU and an increased evaluation of 70 percent for PTSD, both effective from July 10, 2021. Nevertheless, the benefits granted in the October 2021 RO decision represent only a partial grant of the possible benefits to which the Veteran may be entitled for the period on appeal and, therefore, the issues remain on appeal here and have been recharacterized above. See AB v. Brown, 6 Vet. App. 35 (1993) (a claim for an original or for an increased rating remains in controversy when less than the maximum available benefit is awarded); Harper v. Wilkie, 30 Vet. App. 356 (2018) (the Board has jurisdiction of the TDIU for the rest of the appeal period even if the RO grants TDIU for part of it). The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). 1. Entitlement to a disability rating in excess of 50 percent for post-traumatic stress disorder (PTSD) prior to July 10, 2021, and in excess of 70 percent thereafter, is denied. The Veteran seeks a disability rating in excess of 50 percent for his service-connected PTSD for the period prior to July 10, 2021, and a rating in excess of 70 percent from that date onward. He contends that his symptoms during both periods produced occupational and social impairment in excess of the impairment contemplated by the ratings assigned, up to and including the total occupational and social impairment contemplated by a disability rating of 100 percent. Disability ratings are based on a schedule of reductions in earning capacity from specific injuries or combinations of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Even if a rating is increased during the pendency of an appeal, a veteran is presumed to be seeking the highest possible rating, unless he expressly indicates otherwise. AB, 6 Vet. App. at 39. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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." See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD is rated under the provisions at 38 C.F.R. § 4.130 (Diagnostic Code 9411). A 50 percent rating is assigned when a Veteran exhibits 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; or difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is assigned when a Veteran exhibits 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; 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 an inability to establish and maintain effective relationships. A 100 percent rating is assigned when a Veteran exhibits 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; or memory loss for names of close relatives, own occupation, or own name. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall 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. See 38 C.F.R. § 4.126 (a). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126 (b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. The symptoms associated with the psychiatric rating criteria are not intended to constitute exhaustive lists, but rather 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, 443 (2002). Thus, the Board will consider whether "the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code," and, if so, the "equivalent rating will be assigned." Id. In Vazquez-Claudio v. Shinseki, the Federal Circuit held that a Veteran may only qualify for a given disability rating "by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration." 713 F.3d 112, 117 (Fed. Cir. 2013) ("[r]eading [38 C.F.R. §§ 4.126 and 4.130] together, it is evident that the 'frequency, severity, and duration' of a Veteran's symptoms must play an important role in determining his disability level"). Descriptive words such as "mild," "moderate," and "severe" are not expressly defined by regulation. According to Merriam-Webster's Collegiate Dictionary (11th Ed. 2007), "mild" means "not severe"; "moderate" means "limited in scope or effect"; "severe" means very "painful or harmful", or "of a great degree." Although a medical examiner's use of descriptive terminology such as "mild" is an element of evidence to be considered by the Board, it is not dispositive of an issue. The Board must evaluate all evidence in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. The Board finds that the Veteran's service-connected PTSD is appropriately compensated by the disability ratings currently assigned, and that there is therefore no present basis on which to disturb them. Turning to the relevant evidence of record, in multiple VA psychology notes between November 2015 and September 2016, the Veteran's PTSD was repeatedly described as mild, and the Veteran exhibited a bright affect, reality-based thinking without apparent psychosis, paranoia, or delusion, and no suicidal or homicidal ideation. The Veteran generally reported stable mental health symptoms, without signs of significant depression, and with some negative thinking and anxiety related to his work and his relationship with his wife. In VA psychology notes in December 2016 and January 2017, the Veteran was assessed as displaying an overall stable mood and affect, without indications of psychosis, paranoia, or delusions. The Veteran reported no suicidal or homicidal ideation. The Veteran began working as a funeral home attendant at services in December 2016; however, he reported in January 2017 that he had stopped this part-time work due to back strain from the required lifting of caskets. The Veteran was afforded a VA examination for his PTSD in February 2017, pursuant to his claim for an increased rating. The examiner confirmed the Veteran's PTSD diagnosis and stated that he exhibited occupational and social impairment with reduced reliability and productivity. The Veteran reported that his relationship with his wife was stable and supportive, and the examiner stated that he had positive relationships with his children and grandchildren, sometimes got coffee with a friend from high school, and had minimal social activity. The Veteran was able to complete all activities of daily living independently. The examiner noted that the Veteran experienced recurrent intrusive dreams and memories related to his PTSD, and exhibited avoidant behavior, diminished interest or participation in activities, feelings of detachment or estrangement, irritability, hypervigilance, an exaggerated startle response, and sleep disturbance. The examiner generally endorsed that the Veteran experienced depressed mood, chronic sleep impairment, circumstantial, circumlocutory, or stereotyped speech, and difficulty in establishing and maintaining effective work and social relationships. In describing the Veteran's behavior, the examiner stated that the Veteran was alert and fully oriented; exhibited spontaneous, coherent, and goal-directed speech, with some compulsive traits; was cooperative during the examination, displaying an appropriate affect; had no obsessive or ritualistic behavior; was able to remember both remote and recent events; and showed no hallucinations, delusions, or signs of a thought disorder. The examiner also stated that the Veteran did not have phobias or experience panic attacks, and that he felt on edge at times; that the Veteran credibly denied thoughts of self-harm or harm to others, with occasional but non-prominent low mood symptoms; and that he had no symptoms or episodes of manic behavior. The Veteran submitted a VA Form 9 Appeal in March 2017. The Veteran stated that his deteriorating mental health and increasing anxiety forced him to stop working, and that he made bad decisions and relied on his spouse to guide his judgment and thinking. He described his anger issues, irritability, and difficulty adapting to stressful circumstances as severe, and stated that he could not establish and maintain effective relationships. He stated that, as a realtor, his employment required working closely with others, but that his anxiety and irritability made others uncomfortable; he also stated that his PTSD caused poor memory, concentration, and judgment, which severely impeded his ability to work. In a September 2017 VA mental health diagnostic study note, the Veteran endorsed severe PTSD symptoms, including frequent intrusive memories and dreams; avoidant thoughts and behaviors; strong negative reactions, beliefs, and feelings related to his in-service stressor; loss of interest; trouble experiencing positive feelings; hypervigilance; and difficulty concentrating and with falling or staying asleep. The Veteran also reported that he experienced frequent trouble with sleep; reduced energy; problems with appetite; negative feelings; and difficulty concentrating. He denied any suicidal ideation or thoughts of self-harm. He reported that these problems made his work, self-care, or relationships very difficult. In subsequent VA mental health diagnostic study notes in September and October 2017, the Veteran again endorsed severe PTSD symptoms similar to those endorsed previously, but he denied experiencing reduced energy and reported less frequent problems with appetite, negative feelings, or concentration. He reported that these problems made his work, self-care, or relationships somewhat difficult. In an October 2017 VA psychology note, the Veteran exhibited congruent and stable mood and affect, with no signs of serious depression, psychosis, mania, or hypomania. In a December 2017 VA psychology note, the Veteran exhibited stable mood with a normal and congruent affect, no noticeable hypervigilance, and no indications of psychosis, paranoia, delusions, or suicidal or homicidal ideations. The Veteran exhibited a down mood and sad affect in a March 2018 VA psychology note, and reported increased stressors related to finances and his mother-in-law's health, with no reported changes to his other symptoms. In multiple VA psychology notes between April and December 2018, the Veteran generally exhibited stable PTSD symptoms with reduced depression or apparent anxiety, good affective range, and no indications of psychosis, paranoia, delusions, or suicidal or homicidal ideations. In a January 2019 VA psychology note, the Veteran reported increased depressive symptoms, and the VA psychologist noted issues with mood, apathy, anhedonia, negativism, and low energy. However, the VA psychologist also stated that the Veteran's affect showed good range, appropriateness, and spontaneity, and that the Veteran showed no signs of psychomotor retardation, extreme guilt, diurnal variation, suicidal or homicidal ideation, aggression, psychosis, paranoia, or delusions. In contemporaneous testing, the Veteran reported that his symptoms made his work, self-care, or relationships somewhat difficult, and also reported frequent sleep disturbance, avoidant thoughts and behaviors, hypervigilance, exaggerated startle response, and difficulty concentrating. In multiple VA psychology notes between March 2019 and July 2021, the Veteran was frequently described as alert and well oriented, with a stable mood, appropriate affect showing good range, and no suicidal ideation or intent, homicidal ideation or intent, aggressiveness, psychosis, paranoia, or delusions. In June 2019, the Veteran reported a transitory flashback experience related to his in-service stressor, although the examiner still described the Veteran as showing no indications of psychosis, paranoia, or delusional problems. The Veteran exhibited some hypervigilant behavior, as noted in September 2019, March 2020, and May 2021. In May 2021, the Veteran also reported an increase in his depressive symptoms; he exhibited a somewhat dejected affect, and reported general arousal symptoms as well as undefined passing suicidal thoughts, although he denied any active suicidal intention or plans. Later in May 2021, the Veteran reported improvement in his mood, without signs or symptoms of major depression, and no active suicidal intention or plans. In July 2021, the Veteran reported experiencing a flashback of watching a helicopter crash during the Vietnam War, as well as a general increase in his experience of hypervigilance and anxiety. In April 2021, the Veteran testified at a virtual Board hearing. With respect to his PTSD, the Veteran reported that his symptoms had caused him to crave isolation, endorsing both social and professional limitations. He reported that his symptoms had worsened since the February 2017 VA examination, although they had been "going down" prior to the COVID-19 pandemic. He stated that he had suicidal ideations that come and go, including sometimes thinking that suicide would be the "best and final" resolution. The Veteran was afforded a VA examination for his PTSD in July 2021. The examiner diagnosed the Veteran with other specified anxiety and depressive disorders, and with insomnia. The examiner stated that the Veteran exhibited occupational and social impairment with deficiencies in most areas, and noted symptoms of agoraphobia, social anxiety, panic, obsessive compulsion, sleep issues, fatigue, and suicidal feelings. The examiner noted that the Veteran experienced symptoms of recurrent intrusive dreams and memories, dissociative reactions, intense or prolonged psychological distress and physiological reactions upon exposure to internal or external triggers, avoidant thoughts and behavior, exaggerated negative beliefs, diminished interest or participation in activities, feelings of detachment or estrangement, inability to experience positive emotions, irritability, hypervigilance, an exaggerated startle response, problems with concentration, and sleep disturbance. The examiner generally endorsed that the Veteran experienced depressed mood, anxiety, suspiciousness, panic attacks occurring weekly or less often, chronic sleep impairment, and suicidal ideation. The examiner also remarked that the Veteran had minimal difficulties with self-care and moderate problems with interpersonal relationships and household responsibilities, including severe problems joining in community activities. The Veteran reported suicidal ideation, obsessional rituals, intermittent panic and depression, impaired impulse control, difficulty adapting to stressful circumstances, and a possible inability to establish and maintain effective relationships. In an August 2021 VA nursing note, the Veteran reported that over the preceding two weeks he had experienced little interest or pleasure in doing things for several days, had not felt down, depressed, or hopeless, and that over the past month he had neither wished he was dead nor thought of killing himself. In VA psychology notes from August and September 2021, the Veteran reported a general increase in symptoms, including reliving trauma and hypervigilance, and that while his mood varied from neutral to depressed it was improved overall relative to previous months, with no suicidal intention or plans. In an October 2021 VA psychology note, the Veteran exhibited moderate PTSD symptoms with some hypervigilance, and moderate depressive symptoms with apathy, depressed mood, problems with insomnia, mild to moderate fatigue, and mild issues with low self-esteem, as well as issues with focus and concentration. He also reported passive and passing non-specific feelings of going to sleep and not waking, but denied any suicidal intent or plan. The Veteran reported in a contemporaneous VA mental health diagnostic study note that he wished to die, but again denied any thoughts of killing himself. Prior to July 10, 2021 The Board finds that, for the period prior to July 10, 2021, the Veteran's disability picture most strongly resembles the criteria for a 50 percent disability rating. In several dozen VA treatment records during this period, the Veteran was repeatedly described as exhibiting mild PTSD symptoms, with consistent reality-based thinking and a stable, calm, or euthymic mood. Additionally, when the Veteran's symptoms worsened, those worsening symptoms did not tend to persist for prolonged periods; for example, the Veteran exhibited intermittent manifestations of hypervigilance in September 2019, March 2020, and May 2021, but no hypervigilance was noted in multiple treatment records between those dates. Throughout this period, the Veteran also maintained family relationships with his wife, children, and mother-in-law. The Board recognizes that the Veteran has endorsed, or exhibited, symptoms of flattened affect, depressed mood, anhedonia, impaired judgment, disturbances of motivation and mood, hypervigilance, sleep disturbance, intrusive memories and dreams, and occasional flashbacks. The Board also recognizes the functional impairment caused by the Veteran's symptoms. These symptoms, however, are already contemplated by the criteria associated with a 50 percent rating for PTSD. With respect to the rating criteria associated with a 70 percent rating, the Board notes that during this period the Veteran reported, or was observed to experience, symptoms of irritability and of undefined and passing thoughts of suicide. The Court of Appeals for Veterans Claims ("Court") has held that the presence of suicidal ideation alone can support a 70 percent rating. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017) ("the presence of suicidal ideation alone, that is, a veteran's thoughts of his or her own death or thoughts of engaging in suicide-related behavior, may cause occupational and social impairment with deficiencies in most areas."). The Board has considered the holding of Bankhead in light of the evidence, but finds that the Veteran's disability picture did not show suicide-related behavior causing occupational and social impairment with deficiencies in most areas prior to July 10, 2021. That is, although he stated in April 2021 that suicidal thoughts come and go, and described "undefined passive suicidal thoughts" in May 2021, he consistently and repeatedly denied any suicidal ideation or active intent or plans to commit suicide, on multiple occasions, to VA clinicians and examiners. The Veteran was regularly described as having no suicidal ideation and, following his mention of suicidal thoughts in May 2021, he denied any similar ideation later that same month. The evidence also does not support that the Veteran's passing suicidal ideation was productive of any material increase in his occupational or social impairment. There is also no evidence that the Veteran's reported irritability was ever associated with periods of violence. Moreover, the evidence does not demonstrate that the Veteran exhibited many other symptoms associated with the 70 percent criteria for PTSD. The Veteran did not report, nor was he described as exhibiting, illogical, obscure or irrelevant speech; obsessional rituals; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; neglect of his personal appearance and hygiene; or an inability to establish and maintain effective relationships. Indeed, the Veteran was consistently described as alert and oriented, without conversational difficulty, capable of managing his daily activities, and having some consistent relationship with several members of his family. In the aggregate, the Board finds that prior to July 10, 2021, the Veteran's PTSD manifested in symptoms of a frequency, severity, and duration so as to result in, at most, occupational and social impairment with reduced reliability and productivity. Accordingly, the Board finds that the evidence weighs persuasively against a finding that the Veteran is entitled to a rating in excess of 50 percent for service connected PTSD for that period. From to July 10, 2021 The Board also finds that, for the period from July 10, 2021 forward, the Veteran's disability picture most strongly resembles the criteria for a 70 percent disability rating. During this period, the Veteran exhibited symptoms of suicidal ideation; chronic sleep impairment; depressed mood and anxiety; panic attacks weekly or less often; obsessional rituals; agoraphobia; avoidant thoughts and behaviors; anhedonia; irritability; hypervigilance; suspiciousness; exaggerated startle response; and problems with concentration. The Veteran continued to maintain relationships with his wife and children, and although he endorsed thoughts of suicide, he repeatedly denied any intent, plan, or attempts to commit suicide. These symptoms, on the whole, are most analogous to occupational and social impairment with deficiencies in most areas. The Board distinguishes the Veteran's symptoms from those which might be expected to produce the total occupational and social impairment associated with an increased rating of 100 percent for PTSD. Notably, the Veteran has consistently shown no apparent psychotic, paranoid, or delusional thoughts or behavior, and continues to be described as behaving appropriately as well as maintaining his hygiene and personal appearance. He has, at most, only minimal to moderate problems with the activities of daily living, and has demonstrated no apparent disorientation to time or place, nor memory loss of his own name or those of close family. The evidence of record also does not show that the Veteran's difficulty in adapting to circumstances is so severe as to manifest as an inability to adapt to such circumstances. Accordingly, the Board finds that from July 10, 2021 forward, the Veteran's PTSD manifested in symptoms of a frequency, severity, and duration which resulted in, at most, occupational and social impairment with deficiencies in most areas. The Board thus finds that the evidence weighs persuasively against a finding that the Veteran is entitled to a rating in excess of 70 percent for service connected PTSD for that period. REASONS FOR REMAND Entitlement to a TDIU due to service-connected disabilities prior to July 10, 2021, on an extraschedular basis, is remanded. The Veteran was awarded TDIU effective July 10, 2021. He seeks a TDIU award prior to this date on the basis of his service-connected disabilities, and specifically asserts that he has been unable to obtain or maintain substantially gainful employment on the basis of his service-connected PTSD and service-connected persistent postural perceptual dizziness (PPPD), which is associated with his PTSD, since July 2016. Prior to July 10, 2021, however, the Veteran does not meet the threshold schedular criteria for TDIU. Where, as here, a claimant does not meet the threshold criteria for entitlement to TDIU, a total disability evaluation may still be assigned on a different basis. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16(b). The ratings boards are required to submit all cases of veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards, to the Director of Compensation Services (Director) for extraschedular consideration. Id. The Board does not have the authority to assign an extraschedular total disability rating for compensation purposes based on individual unemployability in the first instance. Bowling v. Principi, 15 Vet. App. 1 (2001). Rather the Board's sole inquiry is whether referral for extraschedular consideration is warranted in light of the evidence showing the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disability. In this case, the Board finds evidence suggesting that the Veteran's service-connected disabilities impacted his ability to obtain and maintain substantially gainful employment prior to July 10, 2021 and, therefore, the threshold for referral has been met. But see Ray v. Wilkie, 31 Vet. App. 58 (emphasizing that referral for extraschedular consideration to the Director is merely a quasi-factual finding and not binding on the Board). Here, the Veteran has reported that he stopped working in July 2016 due to his PTSD. The evidence indicates that the Veteran has a bachelor's degree and had worked as a realtor since at least 1989. The Veteran testified in April 2021 that he experienced sensory overload, had difficulty using computers, reading, and typing, and was unable to focus well on computers. Additionally, the Veteran described his PPPD episodes in January 2020 as rendering him "virtually housebound", and VA examiners in February 2020 and September 2021 reported that the Veteran's conditions would functionally impact his ability to work, including preventing him from performing sedentary work. Thus, the Board finds that referral is warranted for the issue of entitlement to a TDIU prior to July 10, 2021 on an extraschedular basis. The matter is REMANDED for the following actions: 1. Refer the Veteran's claim of entitlement to TDIU to the Director of Compensation Service for consideration of TDIU prior to July 10, 2021 on an extraschedular basis under 38 C.F.R. § 4.16(b). Include a full statement as to the Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue. A copy of the Director's decision must be associated with the claims file. (Continued on the next page) 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board David A. F. Litvak 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.