Citation Nr: 1313341 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 09-22 455 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to a disability rating for posttraumatic stress disorder (PTSD), in excess of 50 percent prior to June 24, 2008; in excess of 70 percent from September 1, 2008 to January 9, 2011; and in excess of 70 percent since April 1, 2011. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to September 1, 2008. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J.R. Bryant, Counsel INTRODUCTION The Veteran had active military service from June 1966 to April 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 2008 rating decision in which the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio denied entitlement to a rating in excess of 50 percent for service-connected PTSD and entitlement to a TDIU. In a September 2008 rating decision, the RO granted a temporary 100 percent evaluation effective June 24, 2008 for the Veteran's service-connected PTSD due to his being hospitalized over 21 days. The 50 percent evaluation was continued effective September 1, 2008, following the Veteran's discharge from the hospital in August 2008. This case was then remanded by the Board in March 2011. After completing the development requested therein, the Appeals Management Center (AMC) in Washington, D.C., by a June 2012 rating action, awarded a 70 percent rating for the Veteran's PTSD from September 1, 2008. [As a second temporary total rating under the provisions of 38 C.F.R. § 4.29 for the period of hospitalization that began on January 10, 2011, the 70 percent rating was continued from April 1, 2011.] Despite the grants of increased disability ratings for the Veteran's PTSD, he has not been awarded the highest possible evaluation available. As a result, he is presumed to be seeking the maximum possible evaluation and the claim remains in appellate status. AB v. Brown, 6 Vet. App. 35 (1993). Also in the June 2012 decision, the AMC granted a TDIU. Although the agency of original (AOJ) jurisdiction awarded a TDIU from September 1, 2008 (the effective date of the 70 percent rating for PTSD), the Veteran's claim for a TDIU is also essentially a component of the claim for a disability rating in excess of 50 percent for PTSD, prior to September 1, 2008. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Inasmuch as a TDIU may be available prior to September 1, 2008, and the Veteran is presumed to seek the maximum available benefit for a disability, the Board finds that the TDIU issue is part of the pending appeal. Hence, his claim for a TDIU prior to this date remains on appeal. FINDINGS OF FACT 1. For the period prior to June 24, 2008, the Veteran's PTSD was primarily manifested primarily by symptoms of impaired sleep, irritability, distressing recollections, hypervigilance, and an exaggerated startle response; Global Assessment of Functioning (GAF) scores of 55 and 60; and difficulty in establishing and maintaining effective work and social relationships, rather than an inability to do so. These symptoms demonstrate no more than occupational and social impairment with reduced reliability and productivity. 2. At no time during the period from September 1, 2008 and January 9, 2011, was the Veteran's PTSD productive of total occupational and social impairment. He did not display 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), or disorientation to time or place. 3. Since April 1, 2011, the Veteran's PTSD has not been productive of total occupational and social impairment. He does not display 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), or disorientation to time or place. 4. For the period prior to September 1, 2008, the Veteran did not meet the minimum threshold requirements for a TDIU on a schedular basis; for this period his service-connected disabilities did not preclude him from obtaining and maintaining all forms of substantially gainful employment. CONCLUSIONS OF LAW 1. During the period prior to June 24, 2008, the criteria for a disability rating in excess of 50 percent for PTSD were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.126, 4.130, Diagnostic Code (DC) 9411 (2012). 2. For the period from September 1, 2008 and January 9, 2011, the criteria for a disability rating in excess of 70 percent for PTSD were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.126, 4.130, DC 9411 (2012). 3. Since April 1, 2011, the criteria for a disability rating in excess of 70 percent for PTSD were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.126, 4.130, DC 9411 (2012). 4. For the period prior to September 1, 2008, the criteria for a TDIU were not met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist Before addressing the merits of the issues on appeal, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the AOJ of any information and any medical or lay 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). These notice requirements apply to all five elements of a service-connection claim (veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in February 2008 of VA's duty to assist him in substantiating his claims under the VCAA, and the effect of this duty upon his claims. This letter also informed him of how disability ratings and effective dates are assigned. See Dingess, 19 Vet. App. at 484. A subsequent letter in September 2008 notified the Veteran of the types of evidence that may reflect a worsening of his service-connected PTSD, including the nature and symptoms of the condition; the severity and duration of the symptoms; and the impact of the condition and symptoms on employment and daily life. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). The timing defect of this second correspondence was cured by the AMC's subsequent readjudication of the claim and issuance of a Supplemental Statement of the Case, most recently in May 2012. Together, these letters addressed all notice elements. Nothing more was required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009). Also, VA has satisfied its duty to assist the Veteran in the development of his PTSD claim. In-service and pertinent post-service treatment reports, including those from the Social Security Administration (SSA), are of record. He has not indicated that any additional pertinent evidence exists, and there is no indication that any such evidence exists. VA examinations were obtained in February 2008 and June 2011. There is no objective evidence reflecting a material change in the severity of his service-connected PTSD since he was last examined. 38 C.F.R. § 3.327(a) (2012). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations are more than adequate, as they reflect a full review of all medical evidence of record, are supported by sufficient detail, and refer to specific documents and medical history to support the conclusions reached. They also provide sufficient detail to rate the Veteran's service-connected PTSD, including a thorough discussion of the effect of his symptoms on his functioning. 38 C.F.R. § 4.2 (2012); Abernathy v. Principi, 3 Vet.App. 461, 464 (1992) (citing Green v. Derwinski, 1 Vet. App. 121, 124 (1991) (holding that if the examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate). Thus, there is no basis to find that the VA examinations are inadequate, or that a remand for a new examination is required. Accordingly, the Board finds that VA has satisfied its duty to assist the Veteran in apprising him of the evidence needed, and in obtaining evidence pertinent to his claims under the Veterans Claims Assistance Act of 2000. No useful purpose would be served in remanding this matter for yet more development. A remand would result in unnecessarily imposing additional burdens on VA, with no additional benefit to the Veteran. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); & Quartuccio v. Principi, supra. II. Law and Analysis - PTSD In the current appeal, the Veteran contends that his service-connected PTSD is more disabling than is reflected in the current disability ratings. Disability evaluations are determined by comparing a veteran's present symptoms with the criteria set forth in the VA Schedule for Rating Disabilities, which is based upon average impairment in earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1995). Although a review of the recorded history of a disability is necessary in order to make an accurate evaluation [38 C.F.R. §§ 4.2, 4.41], the regulations do not give past medical reports precedence over current findings where such current findings are adequate and relevant to the rating issue. Francisco v. Brown, 7 Vet. App. 55 (1994); Powell v. West, 13 Vet. App. 31 (1999). However, where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of "staged rating" is required. Fenderson v. West, 12 Vet. App. 119 (1999). The United States Court of Appeals for Veterans Claims (Court) has also held that staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. In this case, service connection for PTSD was established by an April 2006 rating decision, which assigned a 50 percent disability rating under DC 9411, effective November 22, 2005. The Veteran filed his claim for increase in January 2008. In a September 2008 rating decision, the RO granted a temporary 100 percent evaluation effective June 24, 2008 for the Veteran's service-connected PTSD due to his being hospitalized over 21 days. The 50 percent evaluation was continued effective September 1, 2008, following the Veteran's discharge from the hospital in August 2008. In June 2012, the disability rating was increased to 70 percent, from September 1, 2008. The RO then assigned a second temporary total rating under the provisions of 38 C.F.R.§ 4.29 for the period beginning on January 10, 2011. A 70 percent evaluation was assigned effective on April 1, 2011, following the Veteran's discharge from the hospital in March 2011. Under the General Rating Formula for Mental Disorders, 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. 38 C.F.R. § 4.130, DC 9411 (2012). A 70 percent evaluation requires 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 work-like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted if there is 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. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. Evidence relevant to the severity of the Veteran's service-connected PTSD includes, in addition to his assertions of increased psychiatric symptomatology, private outpatient treatment notes, VA clinical records, and VA examination reports. Also of record is a SSA Disability Determination and Transmittal Form. It was found that the Veteran had been disabled since June 2008, according to SSA criteria. The primary diagnosis was discogenic/degenerative disorders of the back and the secondary disorder was anxiety-related disorders. Medical records accompany the disability determination, consisting of reports from VA and non-VA medical sources. A. In excess of 50 percent prior to June 24, 2008 The relevant temporal focus for adjudicating the level of disability of an increased rating claim begins one year before the claim was filed. 38 C.F.R. § 3.400(o). As the instant claim for increase was received in January 2008, the period for consideration should include the period from January 2007, one year prior to the date the RO received the Veteran's claim for increase. In this case, there are no medical records dated between January 2008 and January 2007. Thus, there are no clinical findings demonstrating an increased severity of PTSD symptoms, especially of such a degree to implicate a disability rating in excess of 50 percent. However in connection with his claim for increase, the Veteran was afforded a VA examination in February 2008. At that time, the examiner reviewed the claims file as well as records from the CPRS (Computerized Patient Record System). It was noted that, while the Veteran had no history of inpatient psychiatric care, he was being considered for an inpatient PTSD program. He had not been seen by a psychiatrist, but did participate in group and individual therapy, which he felt had some benefit. Regarding remission from his psychiatric symptoms, the Veteran indicated that some days were better than others. His primary complaints were problems sleeping and nightmares. He described himself as "typically nonviolent" with the exception of a conflict with his manager, but has not had any violent episodes or assaultive behavior. He denied any suicide attempts. It was noted that the Veteran had been able to maintain some degree of exposure to the reminders of Vietnam based on the fact that he displayed several articles of clothing and decorations which would remind one of such or communicate that he had been in Vietnam or the assumption that he been in Vietnam. The Veteran also attended yearly reunions. In terms of his relationships with others, the Veteran had been married for 39 years to the same woman and was employed in sales working 25-30 hours per week. When asked if he experienced any loss of work over the last year, he reported that he had missed a year's worth of work between 2006 and 2007 after he walked off his job. He had been at his current job for about a year, but reported that it involved a lot of walking and was becoming difficult due to hip pain. He indicated that he had few friends, but for enjoyment he reads and rides his motorcycle. On examination the Veteran was casually dressed and oriented to person, place, and time. His eye contact was good and he was animated and spontaneous. His speech was of normal cadence and volume. He did not endorse psychotic features or display inappropriate behavior and there was no psychological distress or physiological reactivity. The Veteran's thoughts were goal directed. He indicated brief periods of depression, but did not endorse symptoms consistent with major depression. He indicated trouble falling and staying asleep, nightmares, distressing recollections, irritability, hypervigilance, exaggerated startle response, and described his concentration as being somewhat "scattered." He did not endorse specific panic attacks, delusions, hallucinations, suicidal or homicidal ideation, obsessive thinking, ritualistic behavior, or impaired impulse control. He was able to maintain his own activities of daily living. The diagnosis was PTSD, and a GAF of 55 was assigned. The examiner concluded that, in comparison to the psychiatric examination which occurred for compensation and pension purposes in March 2006, there was no significant change. [At that time, the Veteran had reported more frequent recollections versus the current examination.] The remaining records during this timeframe show the Veteran participated in a 7 week inpatient residential program for PTSD from June 24, 2008 to August 8, 2008. The discharge summary shows that despite his initial severe symptoms and mistrust taking medications, he completed the program and his symptoms improved significantly. It was noted at admission, the Veteran's BDI-II score was 47, suggesting a severe level of symptoms associated with depression. However his BDI-II score at discharge had improved to 15, suggesting a mild level of depression. His diagnosis at discharge was PTSD in remission and a GAF score of 60 was given. By applying the Veteran's psychiatric symptomatology to the rating criteria noted above, it is apparent that his PTSD does not more nearly approximate the criteria for a 70 percent or higher rating. The record during this time frame shows the Veteran exhibited classic PTSD symptoms, including sleeplessness, irritability, distressing recollections, hypervigilance and an exaggerated startle response that are productive of no more than occupational and social impairment with reduced reliability and productivity. The evidence does not otherwise show significant disturbance of affect or mood, speech suggestive of disorders of thought or perception, difficulty understanding commands, or impairment of memory, judgment, or abstract thinking. During this period, it was found that the Veteran was not suicidal or homicidal and, up to that point, had required no inpatient psychiatric treatment. While the Veteran's irritability made social interactions complicated, he did have the ability to establish and maintain effective relationships as shown by his long-term marriage to his wife and his relationships with his children and grandchildren, albeit with strain. The Board finds it probative that despite his PTSD symptoms, the Veteran was able to maintain his work relationships sufficiently to remain relatively stable in his employment. Although his problem with irritability/anger is obviously a relevant consideration in evaluating the extent of psychiatric disability, according to the February 2008 VA examination report it appears that he had been able to refrain from actual physical assault. The Veteran also reported meaningful leisure pursuits including reading, motorcycling, and attending his various reunion events. Other symptoms of the type required for a higher 70 evaluation are neither complained of nor observed by medical health care providers, including suicidal ideation, obsessional rituals, illogical, obscure, or irrelevant speech, or impaired impulse control. The Veteran has not been shown to have symptoms equivalent in nature or severity to the criteria required for a higher rating. There is also no evidence of psychotic symptoms or cognitive deficits. In general, the Veteran was adequately groomed and able to take care of himself physically. The evidence also does not show spatial disorientation - the substantial weight of the evidence shows that he was alert and oriented in all spheres. Such findings are consistent with the rating criteria required for a 50 percent evaluation, and do not approximate the criteria required for assignment of a 70 percent or higher evaluation. While the clinical findings of record describe experiences, thoughts, and emotions due to PTSD that have had some impact on the Veteran's interpersonal relationships, particularly those within his immediate family, the evidence overall shows that he was able to function fairly well. In other words, the Veteran's walking off the job following a conflict with his manager suggests some difficulty in establishing and maintain effective work and social relationships with reduced reliability and productivity, but not occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, and mood, as is required for the next higher evaluation of 70 percent. Bowling v. Principi, 15 Vet. App. 1, 11 (2001); Vazquez-Claudio v. Shinseki, 2012-7114, (Fed. Cir. Apr. 8, 2013) (holding that a 70 percent disability rating requires sufficient symptoms of the kind listed in the 70 percent requirements, or others of similar severity, frequency or duration, that cause occupational and social impairment with deficiencies in most areas such as those enumerated in the regulation). The Board has also taken into account that the VA examiners who have examined the Veteran on both an inpatient and outpatient basis for treatment purposes or have evaluated him to assess the nature, extent and severity of his service-connected PTSD, have estimated GAF scores of 60 and 55 which, according to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV), denote moderate symptoms (e.g., flat effect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peer or co-workers). Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); Richard v. Brown, 9 Vet. App. 266, 267 (1996). These GAF scores are consistent with the symptomatology noted and do not provide a basis for a higher rating for the Veteran's PTSD in excess of 50 percent for the period prior to June 24, 2008. Accordingly, the Board finds that the Veteran's impairment due to PTSD for the period prior to June 24, 2008 is more consistent with a 50 percent rating and that the level of disability contemplated in DC 9411 to support the assignment of a 70 percent or rating or higher is absent. B. In excess of 70 percent for the periods from September 1, 2008 To January 9, 2011 and from April 1, 2011 The Board notes that, during the periods in question, in contrast to the one that preceded it, the severity of the Veteran's PTSD seemed to have increased beyond what a 50 percent disability rating contemplates. As discussed previously the Veteran was awarded a temporary total disability evaluation for hospitalization from June 24, 2005, to August 31, 2008. A 70 percent evaluation was assigned effective September 1, 2008, following the Veteran's discharge from the hospital. The discharge summary shows that despite his initial severe symptoms and mistrust taking medications, the Veteran completed the program and his symptoms had improved significantly. It was noted that at admission, the Veteran's score on the Beck Depression Inventory II (BDI-II ) was 47, suggesting a severe level of symptoms associated with depression. His BDI-II score at discharge had improved to 15, suggesting a mild level of depression. His diagnosis at discharge was PTSD in remission and a GAF score of 60 was given. However, subsequently dated VA clinical treatment records dated from August 2008 to March 2009 show that in the following weeks the Veteran reported worsening symptoms of depressed mood, problems sleeping, and nightmares. These records show that the Veteran presented to the emergency room on August 26, 2008 for depression and exacerbation of his PTSD symptoms. He expressed feelings that the program was not good for combat veterans, but denied mood swings, anger, irritability, anxiety, suicidal thoughts, or hallucinations. See VA Discharge Summary dated in August 2008. The evidence of record also shows that the Veteran was briefly hospitalized again in December 2008 at the insistence of his wife and daughter for worsening irritability and isolative behavior. The Veteran's wife noted that he had not been the same since his release from the inpatient stay and that he had become increasingly verbally abusive, but had not been physically abusive. The Veteran admitted that he had been more isolative spending most of the day alone in his room working on projects on the internet, watching television, and spending time with his grandsons. He reported depress mood, irritability, poor sleep, decreased energy, flashbacks, avoidance, nightmares, and hypervigilance. The Veteran cited to anniversaries related to the month of December as the possible reason for his current symptoms, giving some vague reference to his involvement in the Tet Offensive. In addition he complained that cold weather during the winter prevented him from most of his recreational activities which were generally conducted outdoors. The Veteran acknowledged that there was much marital strife in the home, noting that he had quit working in June 2008 when he entered the PTSD program and now spends all of his time at home. See VA Discharge Summary dated in December 2008 and supporting inpatient clinical records. VA treatment records following these hospitalizations are primarily comprised of records of therapy sessions; medications prescribed; and a record of behavior observed by medical staff. PTSD symptoms consistently shown in these records include irritability, sleep disturbance, nightmares, hypervigilance, and social isolation. A review of the counseling notes indicates that the Veteran actively participated during those sessions, and was cooperative and focused in spite of his stressors. He was described as engaged, attentive, and expressed understanding of concepts presented. However considerable discord remained with his wife. Mental status examination shows the Veteran was casually dressed and groomed, with normal speech and direct eye contact. His mood was irritable and his affect constricted to angry. He denied suicidal or homicidal ideation or hallucinations. His thought process was goal directed and insight was good. His judgment and concentration were both intact. At his next visit two weeks later the Veteran seemed to be doing better and was less agitated than at the previous visit. Also of record are several GAF scores, which range from 35 to 50. More recent records show the Veteran was admitted to a Residential Rehabilitation Treatment Program (RRTP) in January 2011. He was awarded a temporary total disability evaluation for hospitalization from January 10, 2011, to March 31, 2011. The 70 percent evaluation was continued effective April 1, 2011. The discharge summary shows that on admission the Veteran completed the PTSD Symptom Scale Interview (PSSI) scoring a 40, which fell in the severe range. However at discharge he scored a 29, which fell in the moderately severe range. Also at discharge, the Veteran indicated that, while he still had nightmares, the program helped him deal with distressing memories. He was able to make some gains with decreasing the frequency and intensity of the re-experiencing cluster. He continued to struggle with interrupted sleep, anxiety, and nightmares, but was able to make some gains with increased socialization, decreased emotional avoidance. The Veteran reported that he was feeling better and was able to manage his anger better. The Veteran also felt a little more interest in activities, had an increased ability to tolerate crowds, and had mildly improved concentration. He reported improvements in his relationships with his children and grandchildren, but acknowledged that he had more work to do related to his marriage. The Veteran was most recently evaluated for his PTSD in June 2011 as a consequence of the Board's March 2011 remand. His medical/psychiatric history since his last exam shows he has consistently participated in multimodal mental health care since his last examination. He had been regularly involved with PTSD group and individual therapy and consistently followed up with psychiatry for medication management. It was noted that the Veteran had been psychiatrically hospitalized on three occasions and had participated in two residential PTSD programs. Currently, he was being treated with multiple medications which he felt helped lower his irritability and improved his sleep somewhat. It was noted that the Veteran had moderate PTSD and depressive symptoms on a daily basis and that his symptoms had been persistent despite intensive treatment efforts over the last several years with no significant periods of remission. He reported continuing symptoms of pervasive depression, irritability, poor sleep, nightmares, and a tendency to isolate. It was also noted that the Veteran was frustrated by his new physical limitations imposed by his decreased cardiac function. The Veteran's psychosocial adjustment since the last examination was largely unchanged. Despite frequent marital discord, he remained married to his wife of 42 years and described "decent" relationships with his adult son and daughter. He had no close friends, but reported enjoying gardening, caring for his dog, and gun collecting. The Veteran has not worked regularly since 2008, but reported that in his past employment as a car salesman he was well-respected and financially successfully. He had occasional conflicts with coworkers and bosses, including one physical altercation, but never with customers. Mental status examination revealed the Veteran was appropriately groomed and cooperative. He was alert and oriented in all spheres with normal psychomotor activity. His affect was broad, non-labile, and appropriate. His speech was normal in tone, rate, and volume and his memory was grossly intact. His concentration, abstract thinking, insight, and judgment were all described as good. His thought process was coherent, linear, and goal-directed. He denied obsessions, suicidal/homicidal ideation, or psychotic symptoms. The clinical impression was chronic PTSD with GAF score of 55 for moderate symptoms. The examiner noted that it was not possible to separate the effects of PTSD and the Veteran's co-occurring depressive disorder as both conditions had some similarly symptom clusters and had likely co-existed for years. Moreover, the prognosis for improvement was considered poor based on many years of treatment resistance and the chronic nature of the Veteran's symptoms. In an addendum it was noted that the Veteran could perform his basic activities of daily living without assistance. Again applying the Veteran's psychiatric symptomatology to the rating criteria noted above, the Board concludes the Veteran's impairment cannot be described as "total," and the record does not show the type of cognitive and behavioral impairment reserved for a 100 percent evaluation for either time period. The symptoms required for such an evaluation are neither complained of nor observed by medical health care providers, including 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. Although the evidence clearly demonstrates that the Veteran has significant social and occupational impairment attributable to PTSD, his overall symptomatology is not consistent with the criteria for a 100 percent disability rating under DC 9411. In reaching this determination, the Board notes that various medical personnel, who have examined the Veteran on both an inpatient and outpatient basis for treatment purposes or have evaluated him to assess the nature, extent and severity of his service-connected PTSD, have estimated GAF scores primarily between 40 and 50. Such denote moderate to serious symptoms (e.g., flat affect, and circumstantial speech, occasional panic attacks, suicidal ideation, severe obsessional rituals, frequent shoplifting) to moderate to serious impairment in social, occupational, or school functioning (e.g., few or no friends, conflicts with peers or co-workers, unable to keep a job) symptoms social and occupational functioning. Carpenter supra; Richard supra. The Board finds that these GAF scores are commensurate with the assigned 70 percent disability rating. The Board acknowledges that the Veteran's GAF score, during his period of hospitalization in December 2008, was assessed as 35, which represents 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). While such a GAF score suggests a greater level of impairment than is contemplated by the current 70 percent rating, as noted previously the Veteran has manifested none of the symptoms typically considered indicative of that level of impairment, including for example severe obsessional rituals, and gross impairment in thought processes or grossly inappropriate behavior. In addition, subsequent scores of 55 were recorded by VA treatment providers. See VA discharge summary dated in January 2011 and VA examination report dated June 2011. Simply stated, when considered in light of the actual symptoms shown, this GAF score is inconsistent with the symptoms noted and does not provide a basis, alone, for assignment of a 100 percent rating for the Veteran's PTSD. Accordingly, with respect to the time periods here in question (September 1, 2008 to January 9, 2011 and from April 1, 2011), the Board finds that the Veteran's impairment due to PTSD is more consistent with 70 percent ratings and that the level of disability contemplated in DC 9411 to support the assignment of a 100 percent rating is absent during these time periods. C. Extraschedular Consideration and Conclusion The Board has carefully considered the Veteran's contentions in making this decision. However, inasmuch as the objective evidence does not otherwise substantiate the subjective complaints, his assertions do not suffice to assign higher disability ratings for his service-connected PTSD. The level of disability shown is encompassed by the ratings assigned and, with due consideration to the provisions of 38 C.F.R. § 4.7, higher evaluations are not warranted for this disability for any portion of the time period under consideration. See Hart, supra. It is also noted that the Veteran was found to have significant symptoms associated with depressive disorder in addition to symptoms of PTSD. This disorder is not service-connected, but, according to the evidence, causes some level of additional social and occupational impairment. As discussed above, the 2011 VA examiner could not differentiate between service-connected PTSD and nonservice-connected depressive disorder indicating that both conditions had some similar symptom clusters and had likely co-existed for years. As a result the Board has considered all of his psychiatric symptomatology in evaluating the severity of the service-connected PTSD. See Mittleider v. Brown, 11 Vet. App. 181 (1998) (which stipulates that the Board is precluded from differentiating between symptomatology attributed to a service-connected disability and another service-connected disability in the absence of medical evidence which does so). Yet, for the reasons discussed herein, the evidence of record does not warrant ratings higher than the currently-assigned 50 percent evaluation prior to June 24, 2008, or the 70 percent evaluations for the periods from September 1, 2008 to January 9, 2011 and from April 2, 2011 for the service-connected PTSD. The Board has considered the provisions of 38 C.F.R. § 3.321(b)(1), which provide for consideration of an extraschedular rating is in order when there exists such an exceptional or unusual disability picture so as to render impractical the application of the regular schedular standards. Therefore, 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 v. Peake, 22 Vet. App. 111 (2008). In this case, the schedular evaluations in this case are not inadequate. The Veteran has not identified any factors which may be considered to be exceptional or unusual so as to render impractical the application of the regular schedular standards, and the Board has been similarly unsuccessful. As discussed above, there are higher ratings available for the Veteran's service-connected PTSD, but the required manifestations have not been shown in this case. The Board notes that, during the course of the appeal, the Veteran has been hospitalized on four occasions between 2008 and 2011. However VA has adequately compensated the Veteran for his stay at residential treatment facilities in June 2008 and January 2011 by the assignment of temporary total evaluations (100 percent) under the provisions of § 4.29. With the exception of two other brief periods of hospitalization (in August 2008 for three days and in December 2008 for six days), the Veteran's evaluation and treatment has been primarily on an outpatient basis, not as an inpatient. Moreover the VA examinations of record are void of any finding of exceptional symptomatology beyond that contemplated by the schedule of ratings. Although the Board has no reason to doubt that the Veteran's psychiatric symptomatology adversely impacts his employability, this is specifically contemplated by the 50 percent and 70 percent schedular ratings currently assigned. Accordingly, the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). III. Law and Analysis - TDIU The Veteran contends that his service-connected PTSD renders him unemployable and that he is therefore entitled to a TDIU. In this regard, the Board notes that, generally, total disability will be considered to exist when there is present any impairment of mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Total disability ratings are authorized for any disability or combination of disabilities for which the Schedule for Rating Disabilities prescribes a 100 percent disability evaluation, or, with less disability, if certain criteria are met. Id. Where the schedular rating is less than total, a total disability rating for compensation purposes may be assigned when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In exceptional circumstances, where a veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b). In reaching such a determination, 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). Consideration may not be given to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. By way of relevant history, prior to September 1, 2008, the effective date of the TDIU, the Veteran was receiving a 50 percent award for PTSD, effective November 22, 2005. Service connection was also in effect for tinnitus (rated as 10 percent disabling) and for bilateral hearing loss (rated as noncompensably disabling), effective March 29, 2007. The combined service-connected disability rating was 60 percent. Thus, the Veteran did not meet the minimum percentage requirements for consideration of a TDIU under 38 C.F.R. § 4.16(a) at that time. While he did have more than one service-connected disability and had one disability rated at 40 percent or more, he did not have a combined disability rating of 70 percent. For the Veteran to prevail in a claim for TDIU, prior to September 1, 2008, the record must reflect circumstances, apart from nonservice-connected conditions, that place him in a different position than other veterans who meet the basic schedular criteria. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high 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 or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In this case, it cannot necessarily be concluded that prior to September 1, 2008, the Veteran was unemployable given the manifestations of his service-connected disabilities at that time. While it is clear that the Veteran's PTSD affected him in an occupational setting, the Board will not repeat, in its entirety, the discussion of the Veteran's psychiatric symptoms especially given that the above analysis details the level of such impairment and the appropriate disability ratings to account for such impairment. However, of some significance are contemporaneous treatment records which reflect that, by his own admission, the Veteran was employed in sales working 25-30 hours per week when he filed his TDIU claim in January 2008. He also indicated that his job involved a lot of walking and was becoming more difficult due to hip pain. See VA examination report dated in February 2008. The evidentiary record also includes a Social SSA Disability Determination and Transmittal Form. It was found that the Veteran had been disabled since June 2008, according to SSA criteria. The primary diagnosis was discogenic/degenerative disorders of the back, and the secondary diagnosis was anxiety-related disorders. However, SSA, unlike VA regulations, takes into account the Veteran's advancing age and was based on all of his current disabilities, not just his service-connected PTSD. Thus, SSA's decision that the veteran is unable to work is not, in and of itself, determinative of the issue before the Board. See Masors v. Derwinski, 2 Vet. App. 181, 188 (1992). The competent evidence persuasively suggests that, although he may have been unemployable prior to September 1, 2008, it was not solely as the result of his service-connected disabilities (in this case, PTSD, tinnitus, and hearing loss). The Veteran did not report, and the February 2008 VA examiner did not indicate, that he was unemployable solely as a result of his service-connected PTSD. Rather, the Veteran himself reported that his job as a salesman was becoming more difficult due to hip pain. The Board observes in this regard that service connection is not in effect for any hip disability and that such nonservice-connected disabilities may not be considered in support of the TDIU claim. Moreover, the Veteran has submitted no documentary evidence showing that his service-connected PTDS had resulted in unemployability prior to September 1, 2008. The evidence clearly reflects that the Veteran's PTSD was productive of the greatest degree of disability, as indicated by the 50 percent rating. However, the Board also finds no indication in the record that his other service-connected disabilities (tinnitus and hearing loss) had been cited as affecting his employability during the period at issue. His tinnitus has not been shown to affect his ability to obtain or maintain employment, and the same is true of his bilateral hearing loss. The Veteran has not identified or submitted any competent evidence, to include a medical nexus, which demonstrates that his service-connected disabilities, alone or in combination, precluded him from securing and maintaining substantially gainful employment and entitles him to a TDIU prior to September 1, 2008. For all the foregoing reasons, the Board finds that the claim for entitlement to a TDIU, prior to September 1, 2008 is not warranted. 38 C.F.R. § 4.16(b). In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER A disability rating for PTSD in excess of 50 percent prior to June 24, 2008; in excess of 70 percent from September 1, 2008 to January 9, 2011; and in excess of 70 percent since April 1, 2011 is denied. Entitlement to a TDIU prior to September 1, 2008 is denied. ____________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs