Citation Nr: 0814283 Decision Date: 04/30/08 Archive Date: 05/08/08 DOCKET NO. 03-09 837 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Reno, Nevada THE ISSUES 1. Evaluation of post-traumatic stress disorder (PTSD), rated as 50 percent disabling prior to November 18, 1997. 2. Entitlement to an effective date earlier than November 18, 1997 for the grant of a 70 percent evaluation for PTSD. 3. Entitlement to a total disability rating based upon individual unemployability due to service-connected disability prior to November 18, 1997. REPRESENTATION Appellant represented by: Jenny Y. Twyford, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Barone, Counsel INTRODUCTION The veteran served on active duty from October 1986 to September 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating determinations of the Department of Veterans Affairs (VA) Regional Office (RO) in Reno, Nevada. In August 2004, the United States Court of Appeals for Veterans Claims (Court) vacated an April 2003 Board decision and remanded the case for further Board action. In an August 2004 Joint Motion for Remand, the parties agreed that the issues on appeal had been mischaracterized. The issues as clarified are stated above. In September 2004, the Secretary and the claimant entered into a stipulation to assign an effective date in September 1993 for the grant of service connection for PTSD. The RO effectuated this stipulation in September 2004. The appeal was remanded in February 2005 and has been returned for appellate consideration. FINDINGS OF FACT 1. The veteran had no more than considerable social and industrial impairment due to PTSD prior to November 18, 1997. 2. The veteran has 2 years of college education, and had education or training as a dental assistant and in colonic therapy, and had education or training in police training schools. Additionally, she has an associates of science in Criminal Justice, has education or training in massage therapy, and worked full time as late as July 1994. 3. The veteran's sole service-connected disability is PTSD which did not preclude all forms of substantially gainful employment from prior to November 18, 1997. 4. Total disability based upon individual unemployability due to service-connected disability was not shown prior to November 18, 1997. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for PTSD prior to November 18, 1997 have not been met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. § 4.130, Diagnostic Code 9411 (1996). 2. The criteria for an effective date prior to November 18, 1997 for the grant of a 70 percent evaluation for PTSD have not been met. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2007); 38 C.F.R. § 4.130, Diagnostic Code 9411 (1996); 38 C.F.R. §§ 3.157, 3.400, 4.130, Diagnostic Code 9411 (2007). 2. The criteria for an effective date prior to November 18, 1997 for a TDIU have not been met. 38 U.S.C.A. § 5110 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.157, 3.340, 3.341, 3.400, 4.16 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2007); 38 C.F.R. § 3.159(b) (2005); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in his possession that pertains to the claim, in accordance with 38 C.F.R. § 3.159(b)(1). VCAA notice should be provided to a claimant before the initial unfavorable RO decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The Board also notes that during the pendency of this appeal, on March 3, 2006, the Court issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. In the present case, the veteran's claims were received prior to the enactment of the VCAA. A January 2001 letter discussed the status of the veteran's claim. An April 2005 letter asked the veteran to identify or submit any evidence or information she thought would support her claim. The evidence necessary to support higher evaluations was discussed, and the veteran was told what specific types of evidence might support her claim. The evidence of record was listed, and the veteran was told how VA would assist her in obtaining additional evidence. The letter also discussed the evidence necessary to support an earlier effective date. Additionally, the Board has considered the adequacy of the VCAA notice in light of the recent Court decision in Vazquez- Flores v. Peake, No. 05-0355 (U.S. Vet. App. January 30, 2008). The April 2005 notice advised the veteran of specific types of evidence that would show an increase in severity of her PTSD. The letter did not advise the veteran whether the Diagnostic Codes pertinent to the disability contain criteria necessary for entitlement to a higher rating that would not be satisfied by the veteran's demonstration that there was a noticeable worsening or increase in severity of the disability and the effect of that worsening on the veteran's employment and daily life. However, the Board's review of the record demonstrates that the veteran had knowledge of what was necessary to substantiate her claim. In this regard, the Board notes that in the August 2004 Joint Motion for Remand, the veteran's attorney pointed to specific evidence in effort to demonstrate the severity of the veteran's PTSD symptoms. The Joint Motion also discussed the veteran's employment status for the period in question. The veteran has submitted statements concerning the severity of her symptoms. In essence, the veteran has demonstrated through her statements and those of her attorney that she was aware of the evidence necessary to substantiate her claims. Moreover, she has been advised of the criteria for evaluation of his PTSD. The Board therefore finds that the fundamental fairness of the adjudication process is not compromised in this case. With respect to the timing of VCAA notice, the Board finds that any defect was harmless error. Although the notices were provided to the veteran and after the initial adjudication, the veteran has not been prejudiced thereby. The content of the notice provided to the veteran fully complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) regarding VA's duty to notify. Not only has the veteran been provided with every opportunity to submit evidence and argument in support of her claim and to respond to VA notices, but the actions taken by VA have essentially cured the error in the timing of notice. Further, the Board finds that the purpose behind the notice requirement has been satisfied because the veteran has been afforded a meaningful opportunity to participate effectively in the processing of her claim. As the Federal Circuit Court has stated, it is not required "that VCAA notification must always be contained in a single communication from the VA." Mayfield, supra, 444 F.3d at 1333. With respect to VA's duty to assist, identified treatment records have been obtained and associated with the record. VA has sought information from identified employers. Neither the veteran nor her representative has identified any additional evidence or information which could be obtained to substantiate the claim. The Board is also unaware of any such outstanding evidence or information. Therefore, the Board is also satisfied that the RO has complied with the duty to assist requirements of the VCAA and the implementing regulations. For the foregoing reasons, it is not prejudicial to the appellant for the Board to proceed to a final decision in this appeal. Factual Background A Vet Center report which appears to have been made sometime between October 1993 and July 1994 (see a November 2001 Vet Center letter which indicates that this is the time period during which the therapist who made it treated the veteran) indicates that the veteran was expressing feelings of grief and anger concerning her military career, that she had a poor opinion of herself, and that she had angry outbursts toward her husband and felt hopeless and frequently tearful and angry. She reported that she had difficulty sleeping and could only sleep if she drank alcohol. The examiner indicated that the veteran was not functioning occupationally, emotionally, socially, psychologically, or sexually as she was prior to her experiences in the military. The diagnosis was PTSD. A global assessment of functioning (GAF) of 55 was reported. A December 1993 VA psychiatric examination report indicates that the veteran reported difficulty falling asleep and with concentration. It also indicates that she felt anxious and sensitive, and that she reported crying easily. She reported helplessness but denied suicidal and homicidal ideations and feelings of hopelessness. She reported that she had been collecting unemployment and had been unable to concentrate and focus and that she could not even think about getting a job due to the way she felt. Clinically, her speech was spontaneous and slightly increased but not pressured. Her mood was anxious but her affect was full with some lability. She denied hallucinations, ideas of influence, and ideas of reference, and her thoughts seemed goal directed. There was no other evidence of a thought disorder. She also denied suicidal and homicidal ideation or thoughts of harming herself. Her cognition was completely intact and her insight and judgment seemed adequate. The diagnosis was alcohol abuse, moderate. According to her December 1998 VA Form 21-8940, the veteran ended dental assistance training in March 1994. She worked as a cook from March to May 1994, earning slightly less than $2700 per month. Then she worked as a food preparer from May to July 1994, earning slightly less than $1500 per month. From February 1995 to July 1995, she received training in massage therapy. An April 1994 VA outpatient treatment record indicates that the veteran complained of being unable to get a job since being in Florida for seven months, and that she got into a panic by knowing that unemployment would run out by the end of that month. In June 1994 VA the veteran reported increased depression. She indicated that she was experiencing a problem at work and was afraid the owner might let her go although she was trying to perform her job. An October 1994 VA outpatient treatment record notes the veteran's report of being fired from a job in June, working in another health food store for about 5 days the next month, and being fired from that store and becoming more depressed. Then, she worked for another health store for one month. She presently was not working, was discouraged, and had fear of rejection. She had no suicidal or homicidal thoughts and no psychosis. On VA outpatient treatment in January 1995, the veteran reported emotional ups and downs, getting angry at herself, and not being in control. She denied ever having suicidal thoughts and stated that she was going to start massage school in February 1995. On VA evaluation in March 1995, the veteran was alert and oriented times three, her speech rate was coherent with some flight of ideas, and she had no vegetative signs of major depression. She also had no suicidal, homicidal, or psychotic thoughts and no delusions or hallucinations. Her insight and judgment were adequate. A May 1995 VA psychology report indicates that the veteran was attending massage school on the GI bill and that she reported doing quite poorly in school. She responded to questions appropriately. On the Beck scale, she endorsed symptoms consistent with moderate depression and mild to moderate anxiety. It was stated that given her age, average range IQ score, and mood, it was not surprising that school was difficult for her. A short term memory test pattern suggested motivation and concentration difficulties. The examiner stated that he veteran's test scores indicated that she was not yet emotionally stable despite being in counseling at the Vet Center. He noted that the neuropsychiatric data was consistent with problems secondary to emotional rather than organic factors. A later dated May 1995 VA outpatient treatment record indicates that the veteran reported that she enjoyed school and had three months to go. A June 1995 VA outpatient treatment record indicates that the veteran was in no acute distress and that she was alert and oriented times three. A September 1995 psychology screening report indicates that the veteran presented as anxious and agitated and angry. She reported that her current relationship was distressful, especially due to the dynamics between her, her husband, and her husband's mother. She wanted to move out of Florida. She was aware of resources and was no danger to herself or others. A December 1995 Vet Center report indicates that the veteran had been a client since October 1993 and had been followed by the author since November 1994. The author noted that the veteran had completed massage therapist school and was awaiting licensure, but that she continued to struggle with negative self-image, relationship problems, and difficulty concentrating. She indicated that despite counseling and support groups, the impact of the veteran's traumatic experiences had adversely affected the veteran's ability to return to a previous level of functioning. She noted that due to the veteran's sexual trauma history, she was unable to seek or maintain employment in settings that did not allow a significant amount of autonomy. The report of a December 1995 VA evaluation resulted in an impression of PTSD. The provider indicated that the veteran presented with paranoid features and that it was unclear whether they were premorbid or the result of trauma. On VA examination in February 1997, the veteran reported that she had done nothing since discharge. She stated that she could not work because she kept getting fired. She stated that she had held three jobs and that she was fired due to discrimination. She endorsed feelings of uselessness and worthlessness. She also complained of difficulty with concentration and trouble sleeping. On mental status examination, the veteran exhibited some detachment of emotions when describing her past difficulties. She described difficulties in her interpersonal relationships. The examiner noted that the veteran seemed to have aloof types of relationships in which she viewed herself as the victim, which had also repeated in three attempts at work. No psychotic deviations were elicited. Cognitive function appeared to be well-preserved. Insight and judgment were fair. The diagnosis was adjustment disorder with mixed emotional features. The examiner assigned a GAF score of 55. A March 1997 letter from the veteran's Vet Center therapist noted that the author saw the veteran for individual therapy. The author indicated that despite strong efforts by the veteran, she had been unable to attain the degree of functioning that she had prior to her military trauma. She stated that although the veteran had completed massage therapy school and obtained a professional license, her occupational functioning remained severely impaired. She noted that the veteran's judgment, thinking, and mood all continued to be affected by anything that triggered by memories of the traumatic events and hampered her ability to maintain effective business as well as social relationships. An April 1997 letter from a Vet Center social worker indicates that the author provided marital counseling services to the veteran and her husband. He noted that during the course of treatment, the veteran had consistently reported or exhibited intrusive and distressing recollections of trauma, avoidance of thoughts and feelings associated with the trauma, efforts to avoid people or activities that arouse recollections of the trauma, diminished interest in significant activities, sleep disturbances, irritability, angry outbursts, and difficulty concentrating. He indicated that such symptoms continued to substantially impair the veteran's capacity for effective occupational and social functioning. A July 1997 letter from the veteran's Vet Center therapist indicates the author's conclusion that the veteran's PTSD symptoms required long-term care and that the prognosis for complete recovery was poor. A November 1997 ED Form 1172 completed by the veteran's Vet Center therapist indicates that due the traumatic experiences during military service, the veteran had been unable to maintain stable employment since her discharge. Analysis VA law and regulation provide that unless otherwise provided, the effective date of an award of increased evaluation shall be fixed in accordance with the facts found, but shall not be earlier than the date of receipt of the application therefor. 38 U.S.C.A. § 5110(a); 38 C.F.R. § 3.400(o)(1). The Board notes that the effective date of an award of increased compensation may, however, be established at the earliest date as of which it is factually ascertainable that an increase in disability had occurred, if the application for an increased evaluation is received within one year from that date. 38 U.S.C.A. § 5110(b)(2); 38 C.F.R. § 3.400(o)(2). In addition, the Court of Appeals for Veterans Claims (Court) has indicated that it is axiomatic that the fact that must be found in order for entitlement to an increase in disability compensation to arise, in other words, that the service- connected disability must have increased in severity to a degree warranting an increase in compensation. See Hazan v. Gober, 10 Vet. App. 511, 519 (1992) (noting that, under section 5110(b)(2) which provides that the effective date of an award of increased compensation shall be the earliest date of which it is ascertainable that an increase in disability had occurred, "the only cognizable 'increase' for this purpose is one to the next disability level" provided by law for the particular disability). Thus, determining whether an effective date assigned for an increased rating is correct or proper under the law requires (1) a determination of the date of the receipt of the claim for the increased rating as well as (2) a review of all the evidence of record to determine when an increase in disability was "ascertainable." Id. at 521. Also, with regard to the terms "application" or "claim", the Board notes that once a formal claim for compensation has been allowed, receipt of a VA hospitalization report, a record of VA treatment or hospitalization will be accepted as an informal claim for increased benefits, and the date of such record will be accepted as the date of receipt of a claim. 38 C.F.R. § 3.157(b)(1); 38 C.F.R. § 3.155(a). 38 C.F.R. § 3.155(c) provides that when a claim has been filed which meets the requirements of 38 C.F.R. § 3.151 or 38 C.F.R. § 3.152, an informal request for increase or reopening will be accepted as a claim. 38 C.F.R. § 3.157 provides that once a formal claim for compensation has been allowed, the date of outpatient or hospital examination will be accepted as a claim when such reports relate to examination or treatment for which service connection has previously been established or when a claim specifying the benefit sought is received within one year. Evaluation of PTSD prior to November 18, 1997 The principle of the possibility of staged ratings during this time period, discussed in Fenderson v. West, 12 Vet. App. 199 (1999), has been considered for this time period. However, the Board finds that the disability did not significantly change during the time period in question, and a uniform rating is appropriate. Disability evaluations are determined by comparing the symptomatology with the criteria set forth in the Schedule For Rating Disabilities. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4 (1994). The Board notes that effective November 7, 1996, VA revised the criteria for diagnosing and evaluating psychiatric disabilities. 61 Fed. Reg. 52695 (1996). On and after that date, all diagnoses of mental disorders for VA purposes must conform to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 61 Fed. Reg. 52700 (1996) (codified at 38 C.F.R. § 4.125). Under the criteria effective prior to November 7, 1996, a 50 percent rating is warranted when the ability to establish or maintain effective or favorable relationships with people is considerably impaired; and where, by reason of psychoneurotic symptoms, the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. A 70 percent rating is warranted when the ability to establish and maintain effective or favorable relationships with people is severely impaired. In such cases, the psychoneurotic symptoms are of such severity and persistence that there is severe impairment in the ability to obtain or retain employment. A 100 percent schedular evaluation is warranted when the attitudes of all contacts, except the most intimate, are so adversely affected as to result in virtual isolation in the community; there are totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities such as fantasy, confusion, panic, and explosions of aggressive energy resulting in a profound retreat from mature behavior; or there is a demonstrable inability to obtain or retain employment. 38 C.F.R. § 4.132 (1996). The Board notes that each of the three criteria for a 100 percent rating under Diagnostic Code 9411 is an independent basis for granting a 100 percent rating. See Johnson v. Brown, 7 Vet. App. 95 (1994). Under the criteria effective November 7, 1996, a 50 percent evaluation is warranted for 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 for 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. A 100 percent evaluation is warranted for 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. In assessing the evidence of record, it is important to note that the GAF score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet.App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). A score of 41- 50 is assigned where there are "Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job)." Id. A score of 51-60 is assigned where there are "Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers)." Id. Having carefully reviewed the evidence for the applicable period, the Board has determined that the evidence shows no more than considerable social and industrial impairment during the period prior to November 18, 1997. During this period, the veteran took care of her husband's son, worked, attended school, lived with her husband and his son, and coped with relationships involved. When evaluated, she was always cooperative, she denied homicidal or suicidal ideation as well as hallucinations and ideas of influence or reference, and she was alert and oriented times three. Her speech was spontaneous and only slightly pressured at times. Her thoughts were goal directed and there was no evidence of a thought disorder. Additionally, her insight and judgment were adequate on VA evaluation in March 1995, and a May 1995 Beck scale test was consistent with no more than moderate depression and mild to moderate anxiety. The evidence also establishes that there was an absence of gross repudiation of reality with disturbed thought processes. Additionally, while an November 1997 ED Form 1172 indicates that the veteran became unable to work in September 1993, and being unemployable is part of the criteria for a 100 percent rating under the former Diagnostic Code 9411, the evidence more contemporaneous to the period in question is more persuasive, to the effect that no more than considerable social and industrial impairment was present. This includes the GAF scores of 55 which were reported in the undated Vet Center report as well as the February 1997 VA examination report. Such a score signifies moderate symptoms or moderate difficulty in social, occupational, or school functioning. The evidence supports such a score. The evidence demonstrates that the veteran's ability to establish and maintain effective or favorable relationships was severely impaired, or that her psychoneurotic symptoms were of such severity and persistence that there was severe impairment in her ability to obtain or retain employment. Notably, while the veteran reported in May 1995 that she was not doing well in massage school, she reported later that same month that she enjoyed school and had three months to go. A December 1995 Vet Center report indicates that the veteran was unable to seek or maintain employment in settings that did not allow a significant amount of autonomy. While the Board has considered this report, it notes that such report does not indicate that gainful employment was precluded by the veteran's PTSD. In fact, the February 1997 VA examiner noted the veteran's report that she was fired from three jobs due to discrimination rather than due to her PTSD symptoms. The Board acknowledges the veteran's reports of difficulty sleeping, trouble concentrating, anxiety, and anger. The objective evidence indicates anxious mood with full affect, no thought disorder, no psychotic symptoms, intact cognition, and adequate insight and judgement. The veteran has consistently denied suicidal and homicidal ideation. However, the Board concludes that such symptoms and findings are adequately addressed by the criteria for a 50 percent evaluation. In summary, the preponderance of the evidence supports an evaluation of 50 percent for the period prior to November 18, 1997. Moreover, the specific employment and activity information contained in December 1993 VA examination report, the August 1994 VA examination report, the March 1995 VA evaluation report, the May, June and September 1995 VA reports, and the December 1995 Vet Center report, and the veteran's December 1998 VA Form 21-8940. The evidence shows that there was no more than considerable social and industrial impairment. While the representative argued in December 2002 that the RO's decision to deny a rating in excess of 50 percent during this time period was flawed because there is some evidence in favor of a higher rating during this time period and all evidence must be taken into account, the preponderance of the evidence shows that no more than considerable social and industrial impairment was present and that as such, no more than a 50 percent rating is warranted. With respect to the veteran's claim for an effective date earlier than November 18, 1997 for the grant of a 70 percent evaluation for her PTSD, the Board has determined above that an evaluation exceeding 50 percent for PTSD is not warranted for this period. It is axiomatic, therefore, that the grant of an effective date earlier than November 18, 1997 for the grant of a 70 percent evaluation is also not warranted, as the Board determined above that the veteran's PTSD did not warrant an evaluation exceeding 50 percent prior to that date. TDIU Prior to November 18, 1997 A total rating based on unemployability due to service- connected disabilities may be granted if the service- connected disabilities preclude the veteran from obtaining or maintaining substantially gainful employment consistent with his education and occupational experience. 38 C.F.R. §§ 3.340, 3.341, 4.16. If there is only one such disability, it must be rated at 60 percent or more, and if there are two or more disabilities, there shall be at least one disability rated at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent. 38 C.F.R. § 4.16(a). For those veterans who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a), total disability ratings for compensation may nevertheless be assigned when it is found that the service-connected disabilities are sufficient to produce unemployability; such cases should be referred to the Director, Compensation and Pension Service, for extra- schedular consideration. 38 C.F.R. § 4.16(b). The central inquiry is, "whether the veteran's service- connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet.App. 524, 529 (1993). Neither nonservice-connected disabilities nor advancing age may be considered in the determination. 38 C.F.R. §§ 3.341, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). The Board observes that a claim for TDIU is, in essence, a claim for an increased rating. Norris v. West, 12 Vet. App. 413, 420-21 (1999). A TDIU claim is an alternate way to obtain a total disability rating without recourse to a 100 percent evaluation under the rating schedule. In reviewing claims for assignment of earlier effective dates for TDIU awards, the applicable law is the same as that governing assignment of earlier effective dates for increased rating claims. The Board concluded above that an evaluation in excess of 50 percent for PTSD was not warranted prior to November 18, 1997. As such, 38 C.F.R. § 4.16(a) is not for application during the period in question. Moreover, the Board does not find that consideration of an extraschedular rating under the provisions of 38 C.F.R. §§ 3.321(b)(1), 4.16 (2007) is in order. The evidence in this case fails to show that the veteran's PTSD caused marked interference with her employment during the period prior to November 18, 1997, or that the disability required frequent periods of hospitalization rendering impractical the use of the regular schedular standards. Id. Rather, the Board notes that the veteran worked and performed other activities, such as going to school and watching after her husband's son. Review of the evidence demonstrates that she was not precluded from obtaining and retaining all forms of substantially gainful employment due to her PTSD. Furthermore, her December 1998 VA Form 21-8940 discloses that the veteran has 2 years of college education, and had education or training as a dental assistant and therapy, and had education or training in police training schools. Additionally, it indicates that she has an associates of science in Criminal Justice, has education or training in massage therapy, and had worked full time as late as July 1994. The Board acknowledges that there is evidence reflecting the difficulty the veteran experienced with employment during the period prior to November 18, 1997. However, while Vet Center providers have stated that she had been unable to return to a previous level of functioning and that she was unable to seek or maintain employment in settings that did not allow a significant amount of autonomy, such findings do not serve to establish that her PTSD alone was of sufficient severity to produce unemployability. In fact, the evidence indicates that the veteran held jobs during the period in question, and that she asserted that she was fired due to discrimination. In summary, the evidence demonstrates that the veteran's service-connected PTSD did not preclude employment during the period prior to November 18, 1997. Moreover, the evidence fails to show that she has in the past or presently requires frequent periods of hospitalization due to PTSD which renders impractical the use of the regular schedular standards. The record does not establish unemployability due to service- connected disability. 38 C.F.R. § 4.16(b). Accordingly, the Board finds that a total rating based on unemployability due to service-connected disability is not warranted. The preponderance of the evidence is against the claim and there is no doubt to be resolved. 38 U.S.C.A. § 5107; Gilbert. ORDER Entitlement to an evaluation in excess of 50 percent for PTSD during the period prior to November 18, 1997 is denied. Entitlement to an earlier effective date for a 70 percent evaluation for PTSD is denied. Entitlement to TDIU for the period prior to November 18, 1997 is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs