Citation Nr: 22016345 Decision Date: 03/22/22 Archive Date: 03/21/22 DOCKET NO. 15-41 867 DATE: March 22, 2022 ORDER An initial rating in excess of 10 percent for right knee chondromalacia is denied. An initial rating of 70 percent, but no greater, for bipolar disorder is granted, subject to the laws and regulations governing payment of monetary benefits. A total disability rating based on individual unemployability (TDIU) is granted. REMANDED An initial rating in excess of 10 percent for vertigo is remanded. FINDINGS OF FACT 1. The Veteran's right knee chondromalacia has been shown to exhibit painful motion, however, her knee extension has not been functionally limited to 15 degrees or less and flexion has not been limited to 45 degrees or less at any time over the period on appeal. She has been diagnosed with a meniscal condition, which manifests with symptoms of joint pain. She underwent arthroscopic surgery in 2009. The Veteran has not been found to have muscle atrophy, ankylosis, recurrent subluxation, lateral instability, recurrent patellar dislocation, shin splints, stress fractures, or any other tibial or fibular impairment. 2. Over the entire period on appeal, the Veteran's bipolar disorder has manifested with symptoms that create occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. However, at no time over the appeal period has the Veteran's bipolar disorder symptoms caused total occupational and social impairment. 3. The Veteran's service-connected bipolar disorder precludes her from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for right knee chondromalacia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5257-5263. 2. The criteria for an initial rating of 70 percent, but no greater, for bipolar disorder have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.130, DC 9432. 3. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Air Force from January 1988 to April 1990. She also had periods of active duty for training (ACDUTRA) in the Army National Guard, to include from March 2008 to April 2008 and from May 2009 to June 2009. The matter is on appeal before the Board from December 2014 rating decision. The Board previously remanded the appeal for further development in March 2019 and March 2021. 1. Initial Rating Right Knee Chondromalacia Procedurally, in a May 2013 rating decision, the Veteran was granted service connection for a right knee condition (chondromalacia) with an initial 10 percent rating effective April 22, 2010. Following a May 2013 VA examination, the Veteran was denied an initial rating in excess of 10 percent for her right knee condition in a February 2014 rating decision. She submitted a claim in July 2014 requesting an increased rating. In a December 2014 rating decision, the Veteran was again denied an initial rating in excess of 10 percent for her right knee condition. She appealed the denial to the Board, and in both March 2019 and March 2021, the issue was remanded for further development. Development has been completed and the issue has returned to the Board for further adjudication. Applicable Law The Veteran's right knee condition is rated under DC 5261 for limitation of extension. The normal range of motion (ROM) for the knee is from 140 to 0 degrees for extension, and from 0 to 140 for flexion. 38 C.F.R. § 4.71a, Plate II. DC 5260 evaluates the limitation of flexion for the knee. A noncompensable rating is assigned for flexion limited to 60 degrees, a 10 percent rating is assigned for flexion limited to 45 degrees, a 20 percent rating is assigned for flexion limited to 30 degrees, and a 30 percent rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. DC 5261 evaluates the limitation of extension for the knee. A noncompensable rating is assigned for extension limited to 5 degrees, a 10 percent rating is assigned for extension limited to 10 degrees, a 20 percent rating is assigned for extension limited to 15 degrees, a 30 percent rating is assigned to extension limited to 20 degrees, a 40 percent rating is assigned for extension limited to 30 degrees, and a 50 percent rating is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Of note, separate compensable ratings may be assigned for limitation of flexion and for limitation of extension, without violating the rule against pyramiding. See 38 C.F.R. § 4.14. DCs 5258 and 5259 evaluate impairment of the semilunar cartilage (synonymous with the meniscus). A 10 percent rating is assigned for removal of the meniscus that is symptomatic. A 20 percent rating is assigned for dislocated meniscus with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a, DCs 5258, 5259. DC 5256 evaluates ankylosis of the knee, DC 5257 evaluates recurrent subluxation or lateral instability of the knee, DC 5262 evaluates impairment of the tibia and fibula, and DC 5263 evaluates genu recurvatum. The medical record does not document any of these conditions in the Veteran's right knee, and therefore these DCs are not applicable with the Veteran's right knee evaluations and will not be further discussed. Effective February 7, 2021, the DCs pertaining to the knee were amended, specifically regarding subluxation and instability. However, as previously noted, the Veteran's record does not document either subluxation or instability, and therefore the changes in the rating criteria are not applicable to the evaluation of the Veteran's right knee condition. Analysis Over the course of the period on appeal, the Veteran has undergone five VA examinations pertaining to her right knee condition. At its worst, at the August 2021 VA examination, the Veteran's initial range of motion was limited to 100 degrees of flexion and had full extension to 0 degrees. The examiner noted that the Veteran exhibited pain with both flexion and extension. There was objective evidence of crepitus and localized tenderness on palpation of the joint. There was no additional loss of function or range of motion following repetitive use testing. The VA examiner estimated the Veteran's flexion to be limited to 90 degrees and her extension to be to be limited to 0 degrees during both flare-ups and repeated use over time. The examiner indicated that pain, fatigability, weakness, and lack of endurance limited the Veteran's functional ability during both flare-ups and repeated use over time. None of the previous VA examinations found either the Veteran's flexion or extension to be limited to a lesser degree than in the August 2021 VA examination, to include due to pain, or during flare-ups or with repeated use over time. The Veteran has not been shown in any VA examination to have muscle atrophy, ankylosis, recurrent subluxation, lateral instability, recurrent patellar dislocation, shin splints, stress fractures, or any other tibial or fibular impairment. Imaging studies show the Veteran to have arthritis in her right knee. The Veteran has not reported the utilization of any assistive devices in conjunction with her right knee. It was noted in the August 2021 VA examination, that the Veteran has been diagnosed with a meniscal condition with frequent episodes of joint pain. She underwent arthroscopic surgery in 2009. A review of the Veteran's VA and private treatment records does not show any findings of any greater significance than those relayed above. In general, they reflect complaints pertaining to worsening knee pain, however, they do not show any decreases in range of motion. Based upon the foregoing, an initial rating in excess of 10 percent for the Veteran's right knee condition in relation to limitation of extension is not warranted. At no time during the period on appeal has the Veteran's extension been limited to 15 degrees or more, so as to support a rating in excess of 10 percent. At all five VA examinations, the Veteran demonstrated full extension to 0 degrees, which is noncompensable. As such, an initial rating in excess of 10 percent for right knee limitation of extension is not warranted. In addition, a separate rating for limitation of flexion is not warranted. At no time over the entire period on appeal has the Veteran's flexion been shown to be limited to a compensable degree. The Veteran's flexion at its worst, was evaluated at the August 2021 VA examination to be at 90 degrees with both flare-ups and repeated use over time, which is noncompensable. As the Veteran's pain and arthritis are taken into account in her rating for limitation of motion with extension throughout the period on appeal, an additional rating based upon limitation of motion for flexion is not warranted. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain, weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and § 4.45 for the Veteran's right knee condition. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Nevertheless, even when the background factors listed in § 4.40 or § 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or § 4.45 is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). It is the Veteran's painful motion with functional loss which provides the Veteran with her initial 10 percent rating for her right knee condition in relation to limitation of extension. As outlined above, even when factoring limitations from pain, fatigability, weakness, lack of endurance, repetitive motion, flare-ups, and repeated use over time, the Veteran's motion was limited at most to 0 degrees of extension. As such, it has not been shown that functional limitation limited range of motion to an extent as to warrant an increased rating. The Board has also considered whether a separate evaluation is warranted for a meniscal condition. Generally, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. In pertinent part, § 4.14 instructs to avoid "evaluation of the same manifestation under different diagnoses." Id. The critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261 (1994). The United States Court of Appeals for Veterans Claims has held that evaluation of a knee disability under DC 5261 does not, as a matter of law, preclude a separate evaluation of a meniscal disability of the same knee under DCs 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). Entitlement to a separate evaluation depends on whether the manifestations of disability for which a separate evaluation is being sought have already been compensated by an assigned evaluation under a different DC. While the Veteran's record does show that she has been diagnosed with a meniscal condition with frequent episodes of joint pain, and that she has undergone arthroscopic surgery in 2009, a separate rating for a meniscal condition is not warranted. The condition has only been shown to manifest with joint pain, and pain is the sole basis for her 10 percent evaluation. Thus, the manifestation of her meniscal condition, pain, is not a distinct symptom and is already being compensated under DC 5261. As such, a separate rating for a meniscal condition would constitute pyramiding and is to be avoided. Accordingly, an initial rating in excess of 10 percent for right knee chondromalacia is denied. 2. Initial Rating Bipolar Disorder Procedurally, in a December 2014 rating decision, the Veteran was granted service connection for bipolar disorder with an initial 50 percent rating effective July 21, 2014. She appealed the initial 50 percent evaluation to the Board. In both March 2019 and March 2021, the Board remanded the issue for further development. During the pendency of the appeal, in a September 2021 rating decision, the Veteran was granted an increase from 50 percent to 70 percent for her bipolar disorder effective July 20, 2021. This decision represents a partial grant of the benefits sought on appeal, pertaining to this issue, as the Veteran was not awarded the maximum benefit provided by the rating schedule, nor was she granted the amount for the entire period on appeal. Thus, the issue remains before the Board. See AB v. Brown, 6 Vet. App. 35, 39 (1993). Applicable Law The Veteran's bipolar disorder is rated under DC 9432, which is evaluated under the General Rating Formula for Mental Disorders. The portions pertinent to the evaluation of the Veteran's service-connected bipolar disorder are provided below. 100 percent: 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. 70 percent: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 50 percent: 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. 38 C.F.R. § 4.130, DC 9432. Analysis Over the course of the appeal, the Veteran underwent two VA examinations pertaining to her bipolar disorder. She first underwent an examination in December 2014, at which the examiner found her bipolar disorder to result in occupational and social impairment with reduced reliability and productivity. Pertaining to relevant social and family history, the examiner noted that the Veteran had been married four times, two of the marriages were to the same person. The Veteran reported that she did not leave her home much, and that while at home she generally stayed in her pajamas and did not do more than play with her dogs and cat. She indicated that she often feels overwhelmed when she attempts to do housework, and therefore does not get anything done. She does not participate in any clubs or organizations, and she reported that she does not have any friends. She goes shopping only when she is accompanied by her husband, and they typically go out to eat twice a week. She indicated that she becomes nervous when driving a vehicle, and that she had been in four accidents during the previous 30 days. Pertaining to relevant occupational history, the Veteran noted that she had not worked since she was in the Florida National Guard. When she had worked in a nursing pool agency, she indicated that she would often make up a reason to leave work for the day and then not return. She reported having difficulties with occupational functioning due to her depression, which included easily becoming irritable with others, difficulty with concentration, and absenteeism. Pertaining to relevant mental health history, the Veteran reported a psychiatric admission in 1992, and another admission in the late 1990s, both for suicidal ideation. She attempted suicide in 2012. She was noted to have a current diagnosis of bipolar disorder and to be on medication. It was also noted that she had undergone ECT. Under behavioral observations, the examiner noted that the Veteran was adequately groomed and appropriately dressed. She had facial reconstruction due to a gunshot wound. Her psychomotor activity, mannerisms, and behaviors were unremarkable. She was alert and fully oriented. Her speech was spontaneous, coherent, and goal directed. She was cooperative, and her affect was appropriate. In relation to anxiety, the Veteran reported that she feels on edge much of the time, with excessive worry, trouble relaxing, and restlessness. She denied panic attacks and phobias. With depression, she credibly denied suicidal and homicidal ideations, however, she was noted to have a history of suicide attempts. Her low moods often last a week and then are followed by excessive energy that lasts for about three to five days. Her weight has been variable. Her sleep has improved due to her medications. She has low self-esteem and negative expectations of both herself and others. Pertaining to manic episodes, she reported that expansive moods last three to five days with increased energy, decreased sleep, racing thoughts, agitation, and excessive spending. She indicated that she had spent up to $7000 in a day, and that about three weeks prior she had spent $1200 in one day. She also reported excessive speeding, which is sometimes just to see if the police will catch up with her. She did not have any obsessive or ritualistic behaviors. With attention, she noted difficulty with concentration and that she forgets appointments. She was able to recall both remote and recent events during the interview. She denied hallucinations and delusions, and there were no signs of a thought disorder. The examiner indicated the Veteran's bipolar disorder actively manifested with symptoms to include depressed mood, anxiety, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, impaired judgment, disturbance of motivation and mood, and difficulty establishing and maintaining effective work and social relationships. Additionally, the examiner noted that the Veteran had not had any significant periods of remission from her mental health symptoms since she was first diagnosed with a mood disorder in 1989. The Veteran underwent a VA telehealth examination in July 2021, at which the examiner found her bipolar disorder to manifest with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Pertaining to relevant social and family history, the Veteran reported that she lived with her husband and emotional support animal. No significant issues in the marriage were noted. Socially, she relayed that she does not have a social support network. She described herself as being too out of control to establish and maintain friendships. She speaks with her son on the phone about every four weeks. She indicated that her relationship with her son had changed after her attempted suicide in 2012, which required multiple facial reconstructive surgeries. She does not communicate with her siblings. She indicated that she is unable to manage her emotions in social settings, and that her husband is unable to help moderate her mood while in public. She relies on her emotional support dog. Pertaining to relevant occupational history, the Veteran stated that she becomes easily angered and will yell and become physically aggressive. She reported a long-standing difficulty maintaining emotional regulation. She indicated that she had been unable to work for longer than 10 to 14 days at a time due to emotional swings. Pertaining to relevant mental health history, the examiner noted that the Veteran was undergoing ECT with limited success. She had been hospitalized on multiple occasions in 2019. She reported non-suicidal morbid ideation, but denied any plan or intent. She reported memory difficulty related to learning and recalling previously learned information. She has difficulty with tracking conversations and activities, and trouble with names and phone numbers. Her motivation to initiate and complete tasks is decreased, such as with maintaining cleaning protocols in the home. She stated that she becomes easily overwhelmed with simple tasks and will internalize and isolate. The Veteran reported and her records supported that she struggles to track medical appointments, for which she feels remorse. The examiner noted her medications, and the Veteran stated that her medications are not helpful and that due to changes in her mood she does not sleep or nap. Pertaining to behavioral issues, the Veteran reported that she becomes irrationally angry and irritated, with low frustration tolerance. Her typical response is verbal or physical posturing. She relayed that she will impulsively spend money and take out loans, drive at excessive speeds, and drive while intoxicated. Her sleep quality and quantity is poor due to difficulty falling and remaining asleep, with racing and ruminating thoughts. Due to her persistent lack of sleep, she is emotionally and cognitively exhausted. Her medications have been inconsistent, and she averages only two to three hours of sleep when she is able to sleep. Under behavioral observations, the examiner noted that the Veteran was alert and oriented, as well as well-groomed and appropriately dressed. She displayed expected eye contact, and demonstrated appropriate receptive and expressive language. She was friendly and cooperative with adequate insight expressed and her mood was congruent with affect. There was no psychomotor agitation. The Veteran denied suicidal and homicidal ideations, delusions, and hallucinations. The examiner indicated the Veteran's bipolar disorder actively manifested with symptoms to include depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; and impaired impulse control, such as unprovoked irritability with periods of violence. In addition to the VA examinations, the Veteran submitted a private examination dated May 24, 2017, in which the psychologist found the Veteran's bipolar disorder to manifest with occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Pertaining to relevant social and family history, the Veteran was noted to be married to her fourth husband of four years, and to have two adult children (one deceased). She lives with her husband and one grandson. She is socially isolated and withdrawn, keeping her struggles to herself as she does not want to burden others. Pertaining to relevant occupational history, the Veteran was a nurse in the military for ten years until 2012. Since 2015 she has received social security disability income for her mental health difficulties. The Veteran detailed great ongoing difficulty with her symptom pattern, and remarked that she can no longer enjoy the simplest of activities. Upon mental status examination, the Veteran's attention was normal, and her concentration appeared variable. She complained of increased trouble with short-term memory. She struggled with remembering basic information. Her speech flow was normal, although she was brief with information offered. Thought content was appropriate for the circumstances of the day. Her thought organization was goal directed. She denied any overt hallucinations. Her fund of knowledge appeared average, as well as her intellectual abilities. Her capacity for abstraction and her ability to interpret proverbs were below average. Her mood was anxious and nervous, and affect was restricted. She reported feeling both anxious and depressed. The examiner indicated that on that day she endorsed symptomatology of bipolar disorder as she was vague with responses, suspicious, and seemed rather paranoid when speaking with the examiner. She seemed cautious of the importance of the interaction. The examiner indicated the Veteran's bipolar disorder actively manifested with symptoms to include depressed mood, anxiety, suspiciousness, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty adapting to stressful circumstances, including work or a work like setting; inability to establish and maintain effective relationships; suicidal ideation; neglect of personal appearance and hygiene; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. A review of the Veteran's VA and private treatment records does not provide findings of any greater significance than those relayed above. In relation to the Veteran's symptoms, they show similarities to the symptoms as reported by the Veteran in the above two VA examinations, as well as the private examination. The Board notes, that while it would not rise to the level of persistent or constant, the Veteran has reported at a relatively consistent frequency throughout the appeal period, suicidal ideations, albeit without plan or intent. In addition, while it occurred two years before the appeal period began, the Veteran did attempt suicide in 2012. Based upon the foregoing, a rating of 70 percent, but no greater, is warranted for the Veteran's bipolar disorder for the entirety of the period on appeal. Both the 2017 private VA examination and the 2021 VA examination found the Veteran to have occupational and social impairment with deficiencies in most areas, and while the 2014 VA examination found the Veteran to have occupational and social impairment with reduced reliability and productivity, the Veteran's symptoms as she has reported them at each of the three examinations and throughout the appeal period have remained relatively consistent. As such, the Board finds that a 70 percent evaluation is warranted for the entirety of the appeal period. However, at no time over the appeal period is a rating in excess of 70 percent warranted, as the Veteran has not been shown at any time to exhibit total occupational and social impairment. To that end she has maintained family relationships with her husband and son. This is not to say that the relationships are perfect or that she has normal social functioning; quite the opposite. However, a 70 percent rating contemplates the inability to establish and maintain effective relationships. As such, total social impairment has not been shown. Accordingly, a rating of 70 percent, but no greater, for bipolar disorder is granted. 3. TDIU Previously, in the March 2019 Board decision, a claim for TDIU was found to be raised by the record in connection with the Veteran's appeal pertaining to an initial increased rating for her bipolar disorder. Rice v. Shinseki, 22 Vet. App. 447 (2009). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, the disability shall be ratable at 60 percent or more, and that, if there are two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be 70 percent or more. 38 C.F.R. § 4.16(a). Being unable to maintain substantially gainful employment is not the same as being 100 percent disabled. "While the term 'substantially gainful occupation' may not set a clear numerical standard for determining a TDIU, it does indicate an amount less than 100 percent." Roberson v. Principi, 251 F.3d 1378 (Fed Cir. 2001). Assignment of a TDIU evaluation requires that the record reflect some factor that "takes the claimant's case outside the norm" of any other Veteran rated at the same level. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A disability rating in itself is recognition that the impairment makes it difficult to obtain or keep employment, but the ultimate question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Id. The Veteran is considered unemployable if found that his or her service-connected disabilities result in being unable to secure or follow a substantially gainful occupation. 38 C.F.R. § 4.16. In Ray v. Wilkie, 31 Vet. App. 58, 73 (2019), the Court interpreted the phrase "unable to secure and follow a substantially gainful occupation" to have two components: one economic and one noneconomic. The economic component means an occupation earning more than marginal income (outside of a protected environment) as determined by the U.S. Department of Commerce as the poverty threshold for one person, and the noneconomic component requires more than determining the presence or absence of employment producing income exceeding any particular threshold. The ultimate inquiry on the Veteran's ability to secure or follow that type of employment. The Court also provided that to determine whether a Veteran can secure and follow a substantially gainful occupation, attention must be given to the Veteran's history, education, skill, and training; whether the Veteran has the physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the Veteran's limitations of lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations. Also, for consideration is whether the Veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the Veteran's limitations concerning memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. While not a checklist, these are potentially relevant factors for consideration if raised by the evidence. With the above grant of a 70 percent evaluation for the Veteran's bipolar disorder, the Veteran meets the schedular criteria for a TDIU for the entirety of the appeal period. In the Veteran's application for a TDIU submitted in December 2019, she indicated that she had last worked full-time as a Nurse with the Army National Guard in November 2010. She noted that all of her service-connected disabilities prevented her from securing or following a substantially gainful occupation. The Veteran submitted a private medical assessment pertaining to employability dated May 24, 2017, in which a psychologist opined that the Veteran's bipolar disorder prevents her from maintaining substantially gainful employment. The psychologist's opinion was based primarily off the Veteran's troubles sleeping causing daily fatigue that could lead to safety issues in the workplace, the Veteran's difficulties with her memory and concentration, her difficulties with maintaining a steady mood, and her anxiety and depression that could lead to both safety hazards and inappropriate work interactions. The psychologist provided a thorough and rationalized opinion, in which specific medical records were noted, as well as lay statements, and citations from medical journals were provided to support the conclusion. In a July 2021 VA examination, the examiner stated that it was unclear what type of positions would be suitable for the Veteran, either physical or sedentary, because her mood would be the limiting factor in her success. The ideal situation with a very understanding boss who would tolerate her temper and changing motivation may be impossible to find. The examiner explained that the Veteran has a long-standing difficulty with emotional regulation and social functioning impairment that was evident during basic training. The Veteran also described memory impairments, which are confirmed by her husband, that negatively impacts her ability to complete tasks and regulate her emotions. The Veteran was noted to experience difficulty in public with her response to simple situations, which are at times excess for the situation. The Veteran also reported impulsive behaviors when manic or angry that would impair her judgment in a work setting. Based upon the foregoing, a TDIU is warranted. The private psychologist's rationalization is consistent with the Veteran's record. In addition, based upon the July 2021 VA examiner's opinion, even if there is a physical or sedentary job that the Veteran is capable of doing, it is unlikely, and perhaps even impossible, that she will find a boss that will be able to be understanding and tolerate her temper and changing motivation. As such, a TDIU is warranted. Accordingly, a TDIU is granted. REASONS FOR REMAND 1. Initial Rating Vertigo During the pendency of the appeal, in a September 2021 rating decision, the Veteran was granted an increased rating for her vertigo from 10 percent to 30 percent effective August 18, 2021. It was noted in the rating decision that the 30 percent evaluation is the highest schedular rating allowed under the law for peripheral vestibular disorder. As such, the grant was considered to be a full and final determination in relation to the appeal for an initial rating in excess of 10 percent for vertigo. While a 30 percent rating under DC 6204 is the highest schedular rating provided, the Veteran was not provided the 30 percent evaluation for the entire period on appeal. Thus, the grant of a 30 percent evaluation for the Veteran's service-connected vertigo only represents a partial grant, and the issue of an initial rating in excess of 10 percent for vertigo remains on appeal. See AB v. Brown, 6 Vet. App. 35, 39 (1993). As the 30 percent evaluation had been deemed a full grant of the benefits sought, a Supplemental Statement of the Case (SSOC) was not rendered pertaining to an initial rating in excess of 10 percent for the Veteran's vertigo prior to August 18, 2021. As such, a remand is warranted to provide the Veteran with a SSOC pertaining to the issue of an initial rating in excess of 10 percent for vertigo. See Manlincon v. West, 12 Vet. App. 238 (1999). The matters are REMANDED for the following action: Issue an SSOC addressing the issue of an initial rating in excess of 10 percent for vertigo prior to August 18, 2021. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Lutgens-Staley, 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.