Citation Nr: 1313303 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 10-31 672A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUES 1. Entitlement to an initial evaluation greater than 50 percent for posttraumatic stress disorder (PTSD) with major depressive disorder. 2. Entitlement to a total disability evaluation for compensation based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD M. Katz, Counsel INTRODUCTION The Veteran served on active duty from August 1969 to August 1971. These matters are before the Board of Veterans' Appeals (Board) on appeal from May 2009 and December 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office in Hartford, Connecticut (RO). FINDINGS OF FACT 1. Since the initial grant of service connection, the Veteran's PTSD has been manifested by sleep disturbance, loss of energy, suicidal ideation, homicidal ideation, paranoia, depression, anger outbursts, crying spells, intrusive thoughts, flashbacks, irritability and road rage, hypervigilance, anxiety, nightmares, anhedonia, amotivation, social isolation, survivor guilt, avoidance of trauma-related stimuli, panic attacks, avoidance of crowds, and possible visual hallucinations productive of functional impairment comparable to no worse than occupational and social impairment with reduced reliability and productivity. 2. Service connection is in effect for PTSD, and the Veteran's currently assigned evaluation is 50 percent. 3. The most probative competent and credible evidence of record does not show that the Veteran is precluded from securing or following substantially gainful employment, consistent with his education and occupational experience, as a result of his single service-connected disability (PTSD). CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 50 percent for service-connected PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a total disability rating for compensation purposes based on individual unemployability (TDIU) have not been met. 38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has certain notice and assistance requirements. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Upon receipt of a substantially complete application for benefits, VA must notify the Veteran of what information or evidence is needed in order to substantiate the claim, and it must assist the Veteran by making reasonable efforts to obtain the evidence needed. 38 U.S.C.A. §§ 5103(a), 5103A; 38 C.F.R. § 3.159(b); see Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). Duty to Notify Here, the Veteran is appealing the initial rating assignment for PTSD. In this regard, because the May 2009 rating decision granted the Veteran's claim of entitlement to service connection for PTSD, said claim is now substantiated. The Veteran's filing of a Notice of Disagreement as to the initial rating assigned does not trigger additional notice obligations under 38 U.S.C.A. § 5103(a). 38 C.F.R. § 3.159(b)(3) (2012). Rather, the Veteran's appeal as to the initial rating assigned triggers VA's statutory duties under 38 U.S.C.A. § 5104 and 38 U.S.C.A. § 7105 (West 2002), as well as regulatory duties under 38 C.F.R. § 3.103 (2012). Under the heading "Pertinent Laws; Regulations; Rating Schedule Provisions," the July 2010 statement of the case set forth the relevant diagnostic codes for rating the disability at issue and included a description of the rating formulas for the current evaluation and for all other higher evaluations. The Veteran was thus informed of what was needed not only to achieve the next higher schedular rating, but also to obtain all schedular ratings above that assigned. Therefore, the Board finds that the Veteran has been informed of what was necessary to achieve a higher rating for the service-connected disability at issue. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996). With regard to the claim for a TDIU, VA issued a VCAA notice letter in October 2009, prior to the initial adjudication of the TDIU claim in December 2009, which satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. 183, 187 (2002); Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 491 (2006); Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008), vacated and remanded, Vazquez-Flores v. Shinseki, No. 2008-7150 (Fed. Cir. Sept. 4, 2009). Further, the purpose behind the notice requirements has been satisfied because the Veteran has been afforded a meaningful opportunity to participate effectively in the processing of his claims, to include the opportunity to present pertinent evidence. Simmons v. Nicholson, 487 F.3d. 892, 896 (Fed. Cir. 2007); Sanders v. Nicholson, 487 F.3d. 881, 887 (Fed. Cir. 2007), rev'd on other grounds, Sanders v. Shinseki, 556 U.S. 396 (2009). Duty to Assist The duty to assist the Veteran has also been satisfied in this case. The Veteran's service treatment records, VA medical treatment records, and Social Security Administration (SSA) records have been obtained. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In addition, the Veteran was provided with two VA examinations with regard to his claims. The Veteran has not indicated that he found any of the examinations to be inadequate. The Board finds that the VA examinations provided in this case are adequate, as they provide sufficient detail to determine the severity of and rate the Veteran's PTSD, to determine whether the Veteran is employable as a result of service-connected disabilities, and to issue a fully informed decision on the Veteran's claims. 38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion regarding the issue on appeal has been met. 38 C.F.R. § 3.159(c)(4). Finally, there is no indication in the record that additional evidence relevant to the issues being decided herein is available and not part of the record. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). I. PTSD with Major Depressive Disorder The Veteran is currently assigned an initial evaluation of 50 percent for his PTSD, effective from February 18, 2009. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where, as here, a veteran appeals the initial rating assigned for a disability when a claim for service connection for that disability has been granted, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence 'used to decide whether an initial rating on appeal was erroneous . . . .' Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Id. The Veteran is currently assigned an initial disability rating of 50 percent for PTSD with major depressive disorder under Diagnostic Code 9411. A 50 percent disability rating is contemplated for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereo-typed 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, Diagnostic Code 9411. A 70 percent disability rating is contemplated 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 worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent disability rating is contemplated 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. Id. GAF scores are a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), p. 32). GAF scores ranging between 81 and 90 reflect absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members). GAF scores ranging between 71 and 80 reflect that if symptoms are present they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument; no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). GAF scores ranging between 61 and 70 reflect some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect more 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). Scores ranging from 41 to 50 reflect 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). Scores ranging from 31 to 40 reflect some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school). A score from 21 to 30 is indicative of behavior which is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. A score of 11 to 20 denotes some danger of hurting one's self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g., smears feces) or gross impairment in communication (e.g., largely incoherent or mute). A GAF score of 1 to 10 is assigned when the person is in persistent danger of severely hurting self or others (recurrent violence) or there is persistent inability to maintain minimal personal hygiene or serious suicidal acts with clear expectation of death. See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV, for rating purposes). The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to an initial rating in excess of 50 percent at any time during the rating period on appeal. The Board finds that the evidence of record does not demonstrate functional impairmentdue to manifestations of the disability at issue which more nearly approximate the criteria for a 70 percent or 100 percent rating at any point during his appeal. A February 2009 intake form from the Vet Center notes that the Veteran was unemployed due to his employer downsizing, and indicates that he was looking for work. Mental status examination revealed the Veteran to be neat, friendly and cooperative, and average in intelligence. He had appropriate speech, and was alert and fully oriented. Memory function was normal, and affect was appropriate. Motor activity was relaxed and at ease. Judgment was good. There was no evidence of delusions, disorganized thinking, or hallucinations. There was evidence of sleep disturbance and loss of energy. The Veteran indicated that he divorced two years ago in a mutually agreed upon divorce. He explained that he had been married for 30 years, and that they divorced because they had not been emotionally close for the last 10 years of their marriage. He reported suicidal ideation several times per month with no suicide attempts. He could not say whether or not he would ever act on those impulses. He denied homicidal thought. He complained of sudden feelings of impending doom for no apparent reason. He described a substantial history of alcohol abuse. The Veteran indicated that he had two children, and that his oldest son possibly had Asperger's Syndrome, and lived with him. He noted that he saw his daughter once per month. With regard to his current symptoms, the Veteran reported bouts of paranoia, an overall sense of dread, and bouts of depression. He stated that he had a girlfriend, who he saw for a week at a time, once per month, as she lived in Montreal. The diagnoses were PTSD; recurrent, severe major depressive disorder; alcohol dependence; and adjustment disorder with depressed mood. In an April 2009 statement, the Veteran reported that he had symptoms including depression, paranoia, short fuse, difficulty holding a job, crying spells, sleep disturbance, fear, and intrusive thoughts. He also reported that he had anger outbursts and lashed out at people. In May 2009, the Veteran underwent a VA PTSD examination. The Veteran reported that he had a temporary job collecting census data. Prior to that job, he worked as a salesman for seven years. He indicated that his last job lasted for 20 months before he was let go for sub-optimal performance. The Veteran reported symptoms including difficulty sleeping, nightmares, flashbacks triggered by loud noise, demanding personality, irritability, and road rage while driving. He reported that he had intrusive thoughts of Vietnam, depression on a daily basis, a pervasive feeling of pessimism about the future, and a sense of paranoia. The Veteran reported that he had friends, and that he enjoyed seeing them at gatherings, but that since they are married, he did not want to burden them with his company. The examiner noted that, cognitively, the Veteran had no significant short- or long-term memory difficulty, and his attention and concentration were intact. He noted normal energy and sex drive, but poor appetite. He reported that he was divorced after having been married for 30 years. He stated that he had two children, and that his son lived with him on a part-time basis and was impaired in cognitive and motor functioning. He indicated that he maintained a friendly relationship with his ex-wife, but stated that they did not really talk. The Veteran noted that he held a variety of sales positions in the past with the longest sustained term of employment lasting for five years. He reported that he bought and sold antiques in his leisure time, but indicated that he had not pursued that interest in over two years. Mental status examination revealed the Veteran to be dressed casually and well-groomed. He was able to maintain adequate eye contact and his speech was within normal limits for rate and rhythm. His mood was somewhat flat, and he became tearful during the interview. His affect was mildly anxious. Cognitively, his long-term and short-term memory were intact, as were attention and concentration. There was no evidence of psychosis, paranoia, or mania. The Veteran was not suicidal or homicidal, but he reported that he experienced occasional, passive suicidal ideation. The diagnoses were PTSD; moderate to severe recurrent major depression; and alcohol dependence. A GAF score of 55 was assigned. A June 2009 VA treatment record reveals that the Veteran was not working at that time, but had a temporary job collecting census data. Prior to his temporary job, he worked in sales. The Veteran complained of intrusive thoughts, recurring nightmares, trouble sleeping, flashbacks triggered by loud noises, irritability, road rage, depression, pessimism, and paranoia. On mental status examination, the Veteran was casually dressed and well-groomed. He was pleasant and cooperative with good eye contact. Speech was normal. Mood was constricted or flat and affect was calm. Thought process was organized and goal-directed. There were no memory, concentration, or attention deficits. Insight was good and there was no evidence of psychosis, mania, or paranoia. There was no suicidal or homicidal ideation. The Veteran reported that he had a reasonably close relationship with his siblings and that he maintains a friendly relationship with his ex-wife but that they do not really talk. The diagnoses were PTSD, moderate to severe recurrent major depression, and alcohol dependence. A GAF score of 55 was assigned. Another June 2009 treatment record reflects that the Veteran complained of irritability, frequent road rages, nightmares, poor sleep, and hypervigilance to loud noises, surprises, and closed spaces. He stated that he last worked as a salesperson, but was fired due to mood irritability. He also endorsed anger outbursts at his children, intrusive thoughts, depressed mood, poor appetite, and poor motivation. He denied changes in his libido, energy, memory, or concentration. He acknowledged feeling helpless and pessimistic. He noted passive suicidal ideation but no previous attempts, current intention, or access to weapons. He denied mania or psychosis. Mental status examination showed the Veteran to be casually dressed with fair eye contact. His speech was normal. Mood was depressed and affect was constricted, dysphoric, and tearful. Thought process was linear and logical. The Veteran denied suicidal ideation, homicidal ideation, and hallucinations, paranoia, and delusions. Insight and judgment were fair. The physician indicated that the Veteran's symptoms led to significant impairment in functioning, including divorce, strained relationships with his children, and being fired from work. In July 2009, the Veteran presented reporting limited job prospects. He noted that his son was living with him, and that his son worked part-time and had developmental disabilities. The Veteran acknowledged feeling hopeless and depressed about his future. He noted passive suicidal ideations, but stated that he would not engage in suicidal behavior due to concern for his son. He complained of feeling anxious and restless. Mental status examination showed the Veteran to be dressed casually with fair eye contact. He was pleasant and cooperative. Speech was normal and mood was good. Affect was constricted, dysphoric, and tearful. Thought process was linear and logical. The Veteran denied homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. The physician noted that the Veteran's PTSD and depressive symptoms were "significant." An August 2009 record indicates that the Veteran reported ongoing financial difficulties and unemployment stress. He reported irritability during interview and frustration over lack of success finding work. He admitted to using a lot of alcohol. He also indicated that his ex-wife was suing him for alimony and that he continued to support his son who had developmental delay. Mental status examination revealed the Veteran to be casually dressed with fair eye contact. Speech was normal. Mood was described as "good and bad days." Affect was constricted, dysphoric, and tearful, and mood was congruent. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, paranoia, and delusions. Insight and judgment were fair. The physician indicated that the Veteran struggled with significant PTSD and depressive symptoms as well as financial difficulties and unemployment, and noted that his symptoms were complicated by ongoing alcohol use. A September 2009 treatment record reveals that the Veteran continued to drink significant amounts of alcohol on a daily basis. PTSD symptoms were unchanged, with nightmares and intrusive memories. The Veteran noted passive suicidal ideation without plan or intent. Sleep, appetite, and energy were poor. The Veteran reported that he was planning to work part-time on a short-term basis with the census bureau, and indicated that the job was "low stress." He endorsed feeling little interest or pleasure in doing things; feeling down, depressed, or hopeless; difficulty sleeping; feeling tired; feeling bad about himself; and feeling that he would be better off dead. On mental status examination, the Veteran was casually dressed and well-groomed. He was cooperative and able to maintain good eye contact. Mood was sad and tearful, but affect was calm. Speech was normal and thought process was organized and goal-directed. There was no memory, concentration, or attention deficit. Insight was good and there was no evidence of psychosis, mania, or paranoia. The Veteran denied suicidal and homicidal ideation. A GAF score of 55 was assigned. An October 2009 VA treatment record notes that the Veteran had significant PTSD and depressive symptoms. He endorsed depression, poor motivation, sleep disturbance, anhedonia, and feeling hopeless. He also noted anxiety and a sense of doom. He denied suicidal ideation but reported sleep disturbance. He indicated that he continued to use alcohol to help with anxiety and sleep. Mental status examination revealed the Veteran to be casually dressed with fair eye contact. Speech was normal. Mood was described as "doom" and affect was constricted and dysphoric. Thought process was linear and logical. Thought content was normal, and the Veteran denied suicidal ideation, homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. His symptoms were easily worsened by stress, and the VA physician noted that his symptoms "all impair his ability to work at this point." In an October 2009 letter, the Veteran's VA physician, J. Amatruda, Psy.D., MPH stated that, given the co-existence of the Veteran's chronic psychiatric conditions of PTSD, major depression, and alcohol dependence, the Veteran was "unable to sustain employment at this time, and in my opinion, it is unlikely that he will ever be able to resume work of any kind." A November 2009 VA treatment record reveals that the Veteran's PTSD symptoms were active and that he used alcohol to control his anxiety, numb himself emotionally, and promote sleep. He reported poor sleep. Mental status examination showed the Veteran to be dressed casually and well-groomed. He was cooperative and able to maintain good eye contact. Mood was sad and tearful and affect was fatigued. Speech was normal. Thought process was organized and goal-directed. There was no memory, concentration, or attention deficit. Insight was good and there was no evidence of psychosis, mania, or paranoia. The Veteran denied suicidal and homicidal ideation. A GAF score of 52 was assigned. Another November 2009 record reflects that the Veteran endorsed symptoms including poor sleep, anhedonia, amotivation, feelings of loss, frustration, poor energy, and poor appetite. He also noted nightmares and restlessness. Mental status examination showed the Veteran to be dressed casually with fair eye contact. He was pleasant and cooperative and his speech was normal. Mood was "still pretty stressed" and affect was constricted and dysphoric. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation as well as hallucinations, paranoia, and delusions. Insight and judgment were fair. The physician concluded that the Veteran had significant PTSD and depressive symptoms. A January 2010 VA treatment record reflects complaints of paranoid ideation and poor sleep. The Veteran denied suicidal ideation and suggested more homicidal ideation, but reported that he did not believe that he would do it. He indicated that he spent his days alone watching television, and noted that he terminated counseling at the Vet Center. Mental status examination showed the Veteran to be casually dressed and well-groomed. He was cooperative and able to maintain good eye contact. Mood was sad and tearful, and affect was fatigued. Speech was normal. Thought process was organized and goal-directed. There was no memory, concentration, or attention deficit. Insight was good and there was no evidence of psychosis, mania, or paranoia. A GAF score of 55 was assigned. Another January 2010 record reflects that the Veteran noted increased anxiety related to his divorce proceedings. He stated that his wife was seeking alimony from his SSA disability benefits, and reported that he would be unable to care for his developmentally disabled son with the reduced income, and that his son would have to live with his ex-wife. Mental status examination showed the Veteran to be dressed casually with fair eye contact. Speech was normal and mood was described as "less depressed but still worried." Affect was constricted and slightly dysphoric. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. The physician indicated that the Veteran had significant PTSD and depressive symptoms. In March 2010, the Veteran reported that he structured his time with chores and taking care of the house. Mental status examination showed the Veteran to be casually dressed with fair eye contact. He was pleasant and cooperative. Speech was normal, but mood was fearful. Affect was constricted and euthymic. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. The physician indicated that the Veteran had PTSD with major depressive disorder with improved mood stability but hypervigilance at night. A June 2010 VA treatment record notes that the Veteran complained of depressive mood. He noted that he was ordered to pay alimony to his ex-wife, which would cause significant financial burden. He reported feeling dazed but not sleepy. He complained of intermittent nightmares. Mental status examination showed the Veteran to be casually dressed with fair eye contact. Speech was normal. Affect was constricted, dysphoric, and tearful, and mood was congruent. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. The physician indicated that the Veteran had PTSD and major depressive disorder with chronic stressors stemming from divorce proceedings. Mood was significantly depressed complicated by alcohol use and PTSD symptoms. A July 2010 record indicates that there was minimal change from the Veteran's last visit except for less tearfulness. The Veteran admitted to anger at his ex-wife and drinking too much. Mental status examination showed the Veteran to be casually dressed with fair eye contact. Speech was normal. Mood was unchanged and affect was constricted and slightly dysphoric. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. An August 2010 treatment record reflects that the Veteran felt frustrated and "financially strapped." He noted that he spent most of his time at home and on the computer. He complained of poor sleep but noted that his mood was less depressed. Mental status examination showed the Veteran to be casually dressed with fair eye contact. Speech was normal and mood was described as "alright." Affect was constricted and slightly dysphoric. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. A September 2010 record indicates that the Veteran was unemployed. He reported no change in his psychosocial stress, mood, and use of alcohol. He complained that his financial situation had worsened since he was ordered to pay alimony. He complained of nightmares and poor appetite. Mental status examination revealed the Veteran to be casually dressed and well-groomed. He was cooperative and able to maintain good eye contact. Mood was flat and affect was calm and fatigued. Speech was normal and thought process was organized and goal-directed. There was no memory, concentration, or attention deficit. Insight was good and there was no evidence of psychosis, mania, paranoia, or suicidal or homicidal ideation. A GAF score of 55 was assigned. An October 2010 record reveals that the Veteran reported that he was going out more at night to nighttime auctions of antiques several times a week. He noted that he felt more energetic and hopeful but continued to have disrupted sleep with frequent nightmares. Mental status examination showed the Veteran to be dressed casually with fair eye contact. His speech was normal and mood was described as "better." Affect was constricted and euthymic. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. The physician noted that there was an improvement in the Veteran's level of alcohol use and degree of socialization with a more optimistic mood but continued sleep problems. In December 2010, the Veteran reported that his mood was slightly better which he attributed to stopping using alcohol. He reported ongoing sleep disturbance with frequent awakenings. He stated that, since stopping alcohol, he had difficulty coping with past memories of trauma. He noted intermittent flashbacks and nightmares. He indicated that he started to date again. Mental status examination revealed the Veteran to be casually dressed with fair eye contact. Speech was normal and mood was described as "a bit better." Affect was constricted and euthymic. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. Another December 2010 record reveals that the Veteran reported that he met a woman and that he was trying to drink less. He complained that sleep was poor, but appetite was good. Mental status examination revealed the Veteran to be casually dressed and well-groomed. He was cooperative and maintained good eye contact. Mood was flat and affect was calm or fatigued. Speech was normal. Thought process was organized and goal-directed. There were no memory, concentration, or attention deficits. Insight was good and there was no evidence of psychosis, mania, or paranoia. The Veteran denied suicidal and homicidal ideation. A GAF score of 63 was assigned. In January 2011, the Veteran stated that he significantly reduced his alcohol use over the past four weeks. On mental status examination, the Veteran was casually dressed and well-groomed. He was cooperative and had good eye contact. Mood was stable and affect was calm or fatigued. Speech was normal. Thought process was organized and goal-directed. There were no memory, concentration, or attention deficits. Insight was good. There was no evidence of psychosis, mania, or paranoia. The Veteran denied suicidal and homicidal ideation. A GAF score of 55 was assigned. Another January 2011 record reflects that the Veteran reported gradual reduction in alcohol intake. His mood was mostly anhedonic and his sleep was poor. Mental status examination showed the Veteran to be casually dressed with fair eye contact. Speech was normal. Affect was constricted and enuthymic and mood was congruent. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. A March 2011 VA record notes no significant changes since his last appointment. He noted that he spent most of his time at home by himself or using the computer. His mood was anhedonic and he was angry that he had to pay alimony each month. He indicated that he was still struggling financially. Mental status examination showed the Veteran to be dressed casually with fair eye contact. Speech was normal and mood was unchanged. Affect was constricted and euthymic. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. Another March 2011 record reflects that the Veteran was still using alcohol, but drinking less than he had in the past. He denied suicidal thoughts, but endorsed homicidal ideation toward people who have hurt him in the past. Sleep and energy level were poor. Appetite was good. Mental status examination showed the Veteran to be dressed casually and well-groomed. He was cooperative and able to maintain good eye contact. Mood was stable and affect was calm or fatigued. Speech was normal. Thought process was organized and goal-directed. There was no memory, concentration, or attention deficit. Insight was good. There was no evidence of psychosis, mania, or paranoia. A GAF score of 55 was assigned. During a March 2011 hearing before the RO, the Veteran testified that he had not worked for the prior few years. He indicated that he used to work in sales but had trouble interacting with others. He endorsed symptoms, including lashing out at people, irritability, social isolation, difficulty sleeping, nightmares, and depression. In a March 2011 letter, J. Amatruda, Psy.D, MPH stated that the Veteran carried diagnoses of PTSD, major depression, and alcohol dependence. Dr. Amatruda reported that there was minimal improvement in the Veteran's clinical presentation, although he was using alcohol less. Dr. Amatruda noted that the Veteran's symptoms included disrupted sleep pattern, intrusive thoughts and nightmares, feeling chronically overwhelmed and hopeless, social isolation, and distrust of people. Dr. Amatruda concluded that, "[g]iven the magnitude of his ongoing psychiatric symptoms, in my opinion, it is unlikely that he will ever be able to resume work of any kind." In April 2011, the Veteran underwent another VA psychiatric examination. The examiner noted that the Veteran contends that he is unemployable due to his service-connected PTSD. The examiner noted that the Veteran was divorced and lived alone, although his son lived with him on a part-time basis. The Veteran reported that he worked periodically since his last VA examination, and that his employment consisted of a temporary job for the census bureau collecting data on households. He explained that, previously, he worked as a salesman for a package company that that he was terminated due to difficulty getting along with management and colleagues. The Veteran complained of a mild decline in occupational functioning since his last examination, and explained that he did not think that he was employable due to his difficulty interacting with other people. He described himself as not suffering the mistakes of others well and often becoming argumentative or angry with individuals who were not completing tasks on time. The Veteran reported limited social engagements restricted to periodic interactions with seasonal visitors and occasional visits (six times per year) with a high school friend. He noted a good relationship with his son who lived with him part-time. He did not describe activities or hobbies, but reported that he liked to take walks. He noted that, when he engaged with other individuals, he becomes more anxious, but acknowledged that he becomes more depressed when he isolates himself and does not seek out social contact. The Veteran endorsed symptoms including frequent nightmares, intrusive recollections, survivor guilt, avoidance of trauma-related stimuli, social isolation, disrupted sleep, and irritability. He also reported guilt, sadness, self-loathing, self-criticalness, and passive suicidal ideation. He noted that he periodically thought of killing himself and described a poorly formed plan of walking out into the ocean. The Veteran indicated that his responsibility for his son kept him from acting on those thoughts. He also reported significant fatigue, poor energy, and irritability. Additionally, the Veteran noted doom, fearfulness, fear of losing control, and feeling ner+-vous. Mental status examination revealed the Veteran to be neatly dressed and appropriately groomed. He was alert and fully oriented. Eye contact was intermittent but improved as the session continued. Speech was normal but somewhat low in volume. Mood was generally dysphoric and affect was flat. The Veteran teared up on more than one occasion, but generally manage to maintain his composure. His thought processes were logical, coherent, goal-directed without loose associations. He did not display significant paranoid ideation. There was no evidence of hallucinations, although the Veteran did report that he periodically saw fully formed individuals whom he did not know. He did not describe significant anxiety concerning those events. The Veteran denied active suicidal ideation. Insight and judgment were grossly intact. The diagnoses were chronic PTSD, moderate recurrent major depressive disorder, and alcohol dependence in partial remission. A GAF score of 55 was assigned. The examiner explained that the Veteran's symptoms included nightmares, recurrent intrusive recollections, intense psychological distress upon exposure to thoughts or feelings or cues that remind him of the trauma, avoidance of trauma-related stimuli, restricted range of affect, social isolation and withdrawal, disrupted sleep and irritability, depressed mood, fatigue, feelings of worthlessness, excessive guilt, recurrent thoughts of death, and anxiety symptoms. The examiner concluded that the Veteran's PTSD and depressive symptoms resulted in deficiencies in most areas, including family relations, work, and mood, as well as reduced productivity and work efficiency which decrease his ability to socialize and function in social environments including the work world. After reviewing the Veteran's claims file, performing an interview of the Veteran, and conducting a mental status examination, the VA examiner concluded that, although the Veteran's PTSD and depression have an impact on his ability to maintain steady employment and his ability to maintain close interpersonal relationships, his PTSD with depression does not render him completely unemployable. The examiner explained that, while the Veteran has difficulty obtaining employment in positions that require him to interact effectively with individuals, he was able to successfully complete a job with the census bureau. Thus, the examiner found that the Veteran would be able to perform in a position where he was not required to interact frequently with work colleagues or the general public. A June 2011 treatment record reflects that the Veteran reported an increase in anxiety and rumination due to changes in his living situation, as he was recently informed that he had to move to another apartment. He noted worsening sleep but significantly reduced alcohol intake since the prior year. He also stated that he was no longer feeling particularly depressed and that he spent most of his days relaxing by the beach. Mental status examination revealed the Veteran to be dressed casually with fair eye contact. Speech was normal but mood was reported as "stressed." Affect was constricted and euthymic. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. Another June 2011 treatment note reveals that the Veteran was only drinking heavily one day a week. He reported transient suicidal ideation and paranoia with a sense of "impending doom," but denied suicidal ideation and paranoid ideation at that time. He reported that he tried to go to the beach daily. Sleep and energy level were poor, but appetite was good. Mental status examination revealed the Veteran to be dressed casually and well-groomed. He maintained good eye contact. Mood was stable and affect was calm and fatigues. Speech was normal. Thought process was organized and goal-directed. There was no memory, concentration, or attention deficit. Insight was good and there was no evidence of psychosis, mania, or paranoia. Insight and judgment were good. A GAF score of 53 was assigned. A July 2011 record notes the Veteran's reports of transient homicidal ideation without intent or plan. The Veteran also noted paranoia and a sense of "impending doom." He indicated that he enjoyed going to the beach when weather permitted. Sleep was and energy level were poor, but appetite was good. Mental status examination showed that the Veteran was casually dressed and well-groomed. He had good eye contact. Mood was stable but affect was calm and fatigued. Speech was normal. Thought process was organized and goal-directed. There was no memory, concentration, or attention deficit. Insight was good and there was no evidence of psychosis, mania, or paranoia. The Veteran denied suicidal and homicidal ideation. A GAF score of 53 was assigned. Another July 2011 record reveals that the Veteran's mood was positive and he had reduced alcohol use. Mental status examination showed the Veteran to be casually dressed with fair eye contact. Speech was normal and mood was "stressed." Affect was constricted and euthymic. Thought process was linear and logical. The Veteran denied suicidal and homicidal ideation, hallucinations, paranoia, and delusions. Insight and judgment were fair. SSA records reflect that the Veteran was found to be disabled based on his anxiety disorder and alcohol abuse in August 2009, effective October 13, 2008. The records note that he previously worked as a salesman and a census taker. A June 2009 record indicates that the Veteran had symptoms including difficulty dealing with people, nightmares, trouble sleeping, social isolation, poor memory, poor concentration, difficulty getting along with others, paranoia, depression, and tearful outbursts. The Veteran indicated that he was unable to hold a job due to stress, lashing out, and depression. There were no problems with personal care, grooming, taking medication, preparing meals, performing household chores, going grocery shopping, or managing money. The Veteran indicated that he enjoyed watching sports, but stayed home alone to watch them. A June 2009 letter from the Veteran's VA physician, J. Amatruda, Psy.D., MPH notes the diagnoses of PTSD and moderate recurrent major depressive disorder, and indicates that the Veteran's symptoms included nightmares, flashbacks, intrusive thoughts, depression, and mood instability. He self-medicated with alcohol for years. Dr. Amatruda reported that the Veteran's orientation, memory, attention, and concentration were normal, that he was well-groomed, and that his speech was normal. His thought content was normal and there was no evidence of hallucinations, delusions, or obsessions. The Veteran's mood was constricted and flat and his affect was calm. Insight and judgment were good. The Veteran was socially avoidant, irritable, and had a low tolerance for frustration. Dr. Amatruda noted that the Veteran was unemployed. During a January 2013 hearing before the Board, the Veteran testified that he had symptoms, including suicidal ideation, panic attacks a couple of times per week, and flashbacks. He noted that he spent most of his days watching television in his house, but that he occasionally took a walk. He described poor social interaction and avoidance of crowds. He indicated that he had a few friends, and that he sat around to talk with them. He noted that he angered easily and yelled at people. He stated that he did not see his siblings much and that he was divorced after having been married for 29 years. He reported that he was intolerant of people and reluctant to be in an environment with others. He also indicated that he last worked in October 2008. He stated that he cooked for himself, but prepared simple meals. He reported sleep disturbance, nightmares, and hypervigilance. He also stated that he did not believe that he was able to work with others due to his inability to interact with others and depression. He noted that he was receiving SSA disability benefits for his psychiatric disorder, and was found unemployable by the SSA. The Veteran's current 50 percent evaluation contemplates 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; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. As noted above, GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Carpenter, 8 Vet. App. at 242. The Veteran's GAF scores of 52, 53, and 55 show moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Veteran's GAF score of 63 indicates some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, and has some meaningful interpersonal relationships. The GAF scores do not suggest serious symptoms, serious impairment in social, occupational or school functioning, or major impairment in several areas, such as work, school, family relations, judgment, thinking or mood. Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. See Carpenter, 8 Vet. App. at 242. Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is considered but is not determinative of the percentage VA disability rating assigned; the percentage evaluation is based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2012); VAOPGCPREC 10-95, 60 Fed. Reg. 43186 (1995). Based on the evidence of record, the Board finds that the evidence does not demonstrate functional impairment which more nearly approximate the schedular criteria required for a higher disability evaluation. The Veteran's symptoms include sleep disturbance, loss of energy, suicidal ideation, homicidal ideation, feelings of impending doom, alcohol abuse, paranoia, depression, anger outbursts, crying spells, intrusive thoughts, and flashbacks. There is also evidence of irritability, road rage, hypervigilance, anxiety, nightmares, anhedonia, amotivation, social isolation, survivor guilt, sadness, avoidance of trauma-related stimuli, panic attacks, avoidance of crowds, and possible visual hallucinations. The Veteran had flat, constricted, good, sad, tearful, stressed, fearful, depressed, and stable moods, as well as anxious, calm, constricted, dysphoric, tearful, fatigued, and euthymic affect. The Veteran reported that he was divorced after having been married for nearly 30 years and indicated that he did not have a close relationship with his daughter. The evidence also shows that the Veteran's PTSD and major depressive disorder impact his ability to work in employment requiring interaction with people or other co-workers. The evidence also reflects that the Veteran regularly had normal speech; no delusions; no audio hallucinations; normal short- and long-term memory; intact attention and concentration; good, fair, or adequate eye contact; no psychosis or mania; linear, logical, organized, and goal-directed thought process; and good or fair insight and judgment. On several occasions he reported that he was dating or had a girlfriend, and he regularly noted that he had a few friends that he saw at gatherings or several times per year. He indicated that he had a good relationship with his son and a reasonably close relationship with his siblings. He reported that he performed his own household chores, including cooking, laundry, and taking care of his house. In October 2010, he indicated that he was going out at night to antique auctions. Although there is evidence that the Veteran was regularly and consistently depressed, the evidence does not demonstrate that his depression affected his ability to function independently, appropriately, and effectively. While the Veteran noted irritability, anger outbursts, and road rage, there was no evidence of impaired impulse control such as unprovoked irritability with periods of violence. Moreover, although the Veteran demonstrated difficulty establishing and maintaining effective relationships, the evidence does not show that he was unable to do so. In fact, as noted above, the Veteran periodically reported that he was dating, noted that he had a few friends including one from high school whom he saw about six times per year, had a reasonably close relationship with his siblings, and had a good relationship with his son. Although he was divorced after 30 years of marriage and does not appear to get along with his daughter, the evidence does not show an inability to establish and maintain effective relationships. The Board acknowledges that there is evidence of occupational and social impairment with deficiencies in many areas, including work, family relations, and mood; however, the Veteran's symptoms do not rise to the level of functioning suggested by the symptoms described in a 70 percent or 100 percent evaluation. Accordingly, the Veteran's symptoms do not meet the criteria for a higher initial evaluation for PTSD. 38 C.F.R. § 4.130, Diagnostic Code 9411. The Board has also considered the Veteran's symptoms which are not specifically contemplated by the Rating Schedule, such as sleep disturbance, avoidance of trauma-related stimuli, social isolation, nightmares, hypervigilance, loss of energy, loss of interest, loss of motivation, paranoia, crying spells, flashbacks, anxiety, survivor guilt, and avoidance of crowds. While those symptoms certainly contribute to the impairment caused by the Veteran's PTSD, they do not show occupational and social impairment sufficient to warrant a 70 percent evaluation, as they do not result in occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Mauerhan, 16 Vet. App. 436. Generally, evaluating a disability using either the corresponding or analogous diagnostic codes contained in the Rating Schedule is sufficient. See 38 C.F.R. §§ 4.20, 4.27 (2012). However, because the ratings are averages, it follows that an assigned rating may not completely account for each individual veteran's circumstance, but nevertheless would still be adequate to address the average impairment in earning capacity caused by disability. In exceptional cases where the rating is inadequate, it may be appropriate to assign an extraschedular rating. 38 C.F.R. § 3.321(b) (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate, a task performed either by the RO or the Board. Id.; see Thun v. Peake, 22 Vet. App. 111, 115 (2008); see also Fisher v. Principi, 4 Vet. App. 57, 60 (1993) ("[R]ating [S]chedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical"). Therefore, initially, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability with the established criteria found in the Rating Schedule for that disability. Thun, 22 Vet. App. at 115. If the criteria reasonably describe the Veteran's disability level and symptomatology, then the Veteran's disability picture is contemplated by the Rating Schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. The Board finds that the Veteran's PTSD is not so unusual exceptional in nature as to render the rating for this disorder inadequate. The demonstrated manifestations of the disability at issue are contemplated in the schedular criteria which provide guidance in rating the Veteran's PTSD. Id. As demonstrated by the evidence of record, since the initial grant of service connection, the Veteran's PTSD has been manifested by sleep disturbance, loss of energy, suicidal ideation, homicidal ideation, paranoia, depression, anger outbursts, crying spells, intrusive thoughts, flashbacks, irritability and road rage, hypervigilance, anxiety, nightmares, anhedonia, amotivation, social isolation, survivor guilt, avoidance of trauma-related stimuli, panic attacks, avoidance of crowds, and possible visual hallucinations. The evidence also shows that the Veteran had good or fair eye contact; normal speech; good or fair insight and judgment; goal-directed and logical thought processes; no inability to perform the activities of daily living; and no short- or long-term memory loss. When comparing this with the symptoms contemplated in the Rating Schedule, the Board finds that the schedular evaluation regarding the Veteran's PTSD is not inadequate. As the schedular criteria are adequate, no referral is required. After review of the evidence of record, there is no evidence of record that would warrant a rating in excess of 50 percent for the Veteran's service-connected PTSD with major depressive disorder at any time during the period pertinent to this appeal. 38 U.S.C.A. 5110 (West 2002); see also Fenderson, 12 Vet. App. at 126. While there have been day-to-day fluctuations in the manifestations of the Veteran's service-connected PTSD with major depressive disorder, the evidence shows no distinct periods of time since service connection became effective, during which the Veteran's PTSD with major depressive disorder has varied to such an extent that a rating greater or less than 50 percent would be warranted. Cf. 38 C.F.R. § 3.344 (2012) (VA will handle cases affected by change of medical findings or diagnosis, so as to produce the greatest degree of stability of disability evaluations). II. TDIU The Veteran contends that he is unable to work as a result of his service-connected PTSD. As noted above, the Veteran alleges that his PTSD renders him unable to interact with others. Total disability is considered to exist when there is any impairment which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a)(1). A total disability rating for compensation purposes may be assigned on the basis of individual unemployability: that is, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). In such an instance, if there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more, and sufficient additional disability must bring the combined rating to 70 percent or more. Id. Individual unemployability must be determined without regard to any nonservice-connected disabilities or the veteran's advancing age. 38 C.F.R. §§ 3.341(a), 4.19 (2012); Van Hoose v. Brown, 4 Vet. App. 361 (1993). Service connection is in effect for PTSD with major depressive disorder, currently rated as 50 percent disabling. As the Veteran's single service-connected disorder is not rated as 60 percent or greater, the schedular percentage criteria for TDIU are not met. 38 C.F.R. § 4.16(a). Nonetheless, the Board must consider whether the evidence of record establishes that the veteran is unable to secure or follow a substantially gainful occupation by reason of service-connected disabilities so as to warrant referral to the Director of Compensation and Pension Service for consideration of entitlement to a total rating for compensation purposes based upon individual unemployability on an extraschedular basis under the provisions of 38 C.F.R. § 4.16(b). 38 C.F.R. § 4.16(b); see also Fanning v. Brown, 4 Vet. App. 225 (1993). During a May 2009 VA examination, the Veteran reported that he had a temporary job collecting census data. Prior to that, he worked as a salesman for seven years and his last job ended for sub-optimal performance. In June 2009, the Veteran stated that he was not working at the time, but had a temporary job collecting census data. He noted that he previously worked as a salesperson, but was fired due to mood irritability. In July 2009, the Veteran noted limited job prospects and reported that he expressed irritability during an interview and frustration over lack of success finding work. In September 2009, the Veteran stated that he was planning to work part-time on a short-term basis with the census bureau, and indicated that the job was "low stress." In August 2009, the SSA determined that the Veteran was disabled and unemployable based on his anxiety disorder and alcohol abuse, effective October 13, 2008. In October 2009, a VA physician reported that the Veteran's PTSD symptoms "all impair his ability to work at this point." In an October 2009 letter, Dr. Amatruda reported that, given the co-existence of the Veteran's chronic psychiatric conditions, the Veteran was "unable to sustain employment at this time, and in my opinion, it is unlikely that he will ever be able to resume work of any kind." In a March 2011 letter, Dr. Amatruda reiterated that, "[g]iven the magnitude of his ongoing symptoms, in my opinion, it is unlikely that he will ever be able to resume work of any kind." During a March 2011 hearing before the RO, the Veteran testified that he had not worked for the prior few years, and indicated that he used to work in sales, but had trouble interacting with others. During an April 2011 VA examination, the Veteran reported that he was unemployable due to his PTSD because he had difficulty interacting with other people. However, he reported that he worked periodically since his last VA examination, and that his employment consisted of a temporary job for the census bureau collecting data on households. He explained that he previously worked as a salesman for a package company and that he was terminated due to difficulty getting along with management and colleagues. After reviewing the Veteran's claims file, conducting an interview of the Veteran, and performing a mental status examination, the VA examiner concluded that, although the Veteran's PTSD had an impact on his ability to maintain steady employment, it did not render him completely unemployable. The examiner explained that, while the Veteran had difficulty obtaining employment in positions that require him to interact effectively with individuals, he was able to successfully complete a job with the census bureau. Thus, the examiner concluded that the Veteran would be able to perform in a position where he was not required to interact frequently with work colleagues or the general public, and was not unemployable due to his PTSD. During a January 2013 hearing before the Board, the Veteran reported that he did not think that he was able to work with others due to his inability to interact with others and depression. He noted that he was receiving SSA disability benefits for his psychiatric disorder, and was found unemployable by the SSA. After thorough consideration of the evidence of record, the Board concludes that the probative medical evidence of record does not show that the Veteran is precluded from employment consistent with his education and occupational experience solely as a result of his service-connected PTSD. Although an October 2009 VA treatment record indicates that the Veteran's PTSD symptoms impaired his ability to work, it does not state that the Veteran is unemployable solely as a result of his service-connected PTSD. Additionally, while Dr. Amatruda reported that the Veteran was unable to sustain any employment and it was unlikely that he would ever be able to resume work of any kind as a result of his PTSD symptoms in October 2009 and March 2011 letters, Dr. Amatruda did not address the evidence of record which suggests that the Veteran was, in fact, periodically working on a part-time basis for the census bureau. As Dr. Amatruda did not address all of the pertinent evidence of record in his opinion, the Board does not afford the opinions by Dr. Amatruda significant probative value. In contrast, the Board affords significant probative value to the April 2011 opinion by the VA examiner. As noted above, after reviewing the Veteran's entire claims file, conducting an interview of the Veteran, and performing a mental status examination, the VA examiner concluded that, although the Veteran's PTSD impacted his ability to work, it did not render him unemployable, as he was able to successfully complete a job with the census bureau and would be able to perform in a position where he was not required to interact frequently with work colleagues or the general public. The VA examiner provided supporting rationale for the conclusion reached, and addressed all pertinent facts of record. Therefore, the Board affords the opinion provided by the April 2011 VA examiner significant probative value. Thus, the probative medical evidence of record does not show that the Veteran's service-connected PTSD with major depressive disorder prevents him from securing or following a substantially gainful occupation. The Board acknowledges the Veteran's argument that he should be found to be unemployable by VA because the SSA determined that he was unemployable and entitled to SSA disability benefits. However, the U.S. Court of Appeals for Veterans Claims has emphasized that VA is not bound by the findings of disability and/or unemployability made by other agencies, including SSA. See Collier v. Derwinski, 1 Vet. App. 413, 417 (1991) (indicating the SSA's favorable determination, while probative evidence to be considered in the claim with VA, is not dispositive or altogether binding on VA since the agencies have different disability determination requirements). Accordingly, while the SSA records relating to the Veteran's employability are pertinent to the Veteran's claim, the SSA's determination does not support a finding that the Veteran is unemployable as a result of his service-connected PTSD under VA regulations. A total rating for compensation purposes based upon individual unemployability is granted only when it is established that the service-connected disability is so severe, standing alone, as to prevent the retention of substantially gainful employment. 38 C.F.R. § 4.16(a). 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. See Van Hoose, 4 Vet. App. at 363. While the Veteran's service-connected disability may have a negative effect on employability, the sole fact that the Veteran is unemployed or has difficulty obtaining employment is not enough. The evidence of record does not demonstrate that the Veteran's service-connected PTSD with major depressive disorder precludes him from securing or following any type of substantially gainful occupation. The Veteran does not meet the percentage criteria under 38 C.F.R. § 4.16(a) and the evidence does not otherwise demonstrate an inability to secure or follow a substantially gainful occupation due to his service-connected disability. Thus, the Board finds that the issue should not be referred to the Director of Compensation and Pension Service for extraschedular consideration of a total rating for compensation purposes based upon individual unemployability. For the forgoing reasons, a total rating for compensation purposes based upon individual unemployability is not warranted. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, as the preponderance of the evidence is against the Veteran's claim for TDIU, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). ORDER Entitlement to an initial rating greater than 50 percent for PTSD with major depressive disorder is denied. Entitlement to a TDIU is denied. ____________________________________________ U. R. POWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs