Citation Nr: 1315060 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 09-44 760 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to an increased disability rating in excess of 50 percent prior to May 11, 2012, for service-connected posttraumatic stress disorder (PTSD). 2. Entitlement to an increased disability rating in excess of 70 percent since May 11, 2012, for service-connected PTSD. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD H. Yoo, Counsel INTRODUCTION The Veteran had active service from November 1965 to November 1967. This appeal comes before the Board of Veterans' Appeals (Board) from a February 2007 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. Subsequently, this matter has been transferred to the RO in Pittsburgh, Pennsylvania. In May 2011, the Board denied entitlement to an increased rating for PTSD, rated at 50 percent disabling. The Veteran appealed the denial to the Court of Appeals for Veterans Claims (Court), which vacated the Board decision and remanded the claim for development pursuant to an October 2011 joint motion for remand (JMR). The Board complied with the JMR, remanding the claim for additional development in April 2012, namely to provide the Veteran with a contemporaneous VA examination. This development has been completed and this matter is returned to the Board for further consideration. See Stegall v. West, 11 Vet. App. 268 (1998). Subsequent to the April 2012 Board remand, the RO granted the Veteran's appeal for an increased rating for his service-connected PTSD in December 2012. The Veteran was assigned a 70 percent disability rating, effective May 11, 2012. However, a Veteran is generally presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35 (1993). Therefore, the claim for an increased disability rating for PTSD prior to and since May 11, 2012, remains on appeal before the Board. In addition, the Veteran has submitted evidence indicating that his service-connected acquired psychiatric disorder affects his ability to obtain and maintain gainful employment. In Rice v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) recently held that a TDIU claim cannot be considered separate and apart from an increased rating claim. Rice v. Shinseki, 22 Vet. App. 447 (2009). Instead, the Court held that a TDIU claim is an attempt to obtain an appropriate rating for a service-connected disability. The Court also found in Rice that, when entitlement to a TDIU is raised during the adjudicatory process of the underlying disability, it is part of the claim for benefits for the underlying disability. In light of Rice, a claim for TDIU has been added to this appeal. Finally, in addition to the claims file, there is a Virtual VA paperless claims file associated with the Veteran's claim. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are not relevant to the issues on appeal. The issue of entitlement to TDIU is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. Prior to May 11, 2012, the Veteran's acquired psychiatric disorder continued to more nearly approximate occupational and social impairment with reduced reliability and productivity. 2. From May 11, 2012, the Veteran's acquired psychiatric disorder continues to more nearly approximate occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; total occupational and social impairment has not been demonstrated. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for PTSD prior to May 11, 2012 have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a rating in excess of 70 percent for PTSD, effective May 11, 2012, have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. The Veterans Claims Assistance Act of 2000 (VCAA) The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the U.S. Court of Appeals for Veterans Claims held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the RO sent correspondence in November 2006 that informed the Veteran of what evidence was needed to establish the benefit sought, of what VA would do or had done, and of what evidence the Veteran should provide. In addition, the letter informed the Veteran of how effective dates are assigned. The Board finds that any defect with regard to the timing or content of the notice to the Veteran is harmless because of the thorough and informative notices provided throughout the adjudication and because the Veteran had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. There has been no prejudice to the Veteran, and any defect in the timing or content of the notices has not affected the fairness of the adjudication. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006) (specifically declining to address harmless error doctrine); see also Dingess v. Nicholson, 19 Vet. App. 473 (2006). Thus, VA has satisfied its duty to notify the Veteran. VA must also make reasonable efforts to assist the Veteran in obtaining evidence necessary to substantiate the claim for the benefit sought unless no reasonable possibility exists that such assistance would aid in substantiating the claim. This duty includes assisting with the procurement of relevant records, including pertinent treatment records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The VA has also done everything reasonably possible to assist the Veteran with respect to his claim for benefits, such as obtaining medical records (VA treatment and records from the Social Security Administration) and providing the Veteran with VA examinations in November 2006 and May 2012. The Board finds that the examination reports are adequate as the examiners had knowledge of the relevant facts of the Veteran's medical history, considered the contentions of the Veteran, and addressed the applicable rating criteria. Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claim. 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 Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). The Veteran has submitted argument and evidence in support of the appeal. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. Consequently, the duty to notify and assist has been satisfied as to the claim now being finally decided on appeal. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). The Board also finds that there was substantial compliance with the April 2012 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). II. Merits of the Claims Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § Part 4 (2012). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § Part 4 (2012). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Board notes that the Veteran's service-connected PTSD was evaluated under Diagnostic Code 9411. The regulations establish a general rating formula for mental disabilities. See 38 C.F.R. § 4.130 (2012). Ratings are assigned according to the manifestation of particular symptoms. However, the use of the term "such as" 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 the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under § 4.130 is not restricted to the symptoms provided in the diagnostic code. Instead, VA must consider all symptoms of a claimant's disability that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV). The criteria for a 50 percent rating are: 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. The criteria for a 70 percent rating are: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. And, the criteria for a 100 percent rating are: 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. See 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). The Global Assessment of Functioning is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. See Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing the Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). A GAF score ranging between 31 and 40 are assigned when there is 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). A GAF score of 41 to 50 is defined as denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). A score of 51 to 60 is defined as indicating 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). A score of 61 to 70 is defined as indicating some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning but generally functioning pretty well, has some meaningful interpersonal relationships. See Carpenter v. Brown, 8 Vet. App. 240, 242- 244 (1995). A GAF score is, of course, just one part of the medical evidence to be considered and is not dispositive. The Veteran is seeking entitlement to higher disability ratings for PTSD, evaluated as 50 percent disabling prior to May 11, 2012, and as 70 percent disabling since May 11, 2012. After a careful review of the record, and for reasons and bases expressed immediately below, the Board finds that increased ratings for the Veteran's acquired psychiatric disorder is not warranted. Evaluation prior to May 11, 2012 The Veteran was afforded a VA examination in December 2006, where his claim file was reviewed by the examiner. The Veteran reported he lived with a woman who had been his girlfriend for four years. He was unemployed and had not been gainfully employed on a part-time basis since 2003. He did volunteer work at the Altoona VA Medical Center approximately twice weekly for four hours at a time as an escort. He stated he was able to tend to his own personal needs and complete other routine activities of daily living, including being able to drive. He deferred to his girlfriend when grocery shopping and in other shopping activities, unless he absolutely needed to go himself due to extreme discomfort when being out in public. He stated he found the holiday season to be especially stressful. As to treatment, the Veteran had not had any psychiatric hospitalizations since his last rating examination and there had not been any significant substance abuse issues. It was noted that he had not engaged in any significant alcohol or other substance abuse for at least twenty years. He continued to see a VA clinical psychologist for individual psychotherapy and involvement in a PTSD group. He also saw a VA psychiatrist every three months to monitor his psychotropic medication regime. This treatment regime had "taken the edge off" by allowing him to remain calmer but, overall, he believed that his symptoms had not appreciably improved over time. In addition to the Veteran's previously noted difficulty interacting in the general public, his sleep also remained a problem because he often had a difficult time getting to sleep and remaining asleep. At best, he slept uninterrupted for three to four hours, before awakening and this occurred almost nightly. He stated that about every four to five months, when especially tired and needing to sleep, he might drink to the point of "passing out" but denied that this was a regular occurrence. He continued to have nightmares every month or so. To help him sleep and to avoid nightmares, the Veteran stated he avoided any documentaries on television about not only Vietnam but news coverage of the Iraq conflict. He had hypervigilance and an exaggerated startle response, especially to any loud and unexpected noise or persons who approached from behind. He also had flashbacks. Interpersonally, he was easily irritated, especially towards his girlfriend. The Veteran reported that about one year ago he had pushed to the ground an individual that had insulted his girlfriend. He denied any other occurrences of this type and denied having any legal difficulties. He also denied any other psychosocial stressors in his life of the magnitude that led to his initial PTSD. On mental status examination the Veteran was on time and was appropriately dressed. He was adequately groomed, alert, and oriented in all spheres. He was able to effectively relate and communicate by both responding to questions and engaging in spontaneous conversation. Overall, his eye contact was appropriate as was his general behavior and demeanor. His affect, while stable, did reflect at least a moderate decrease in range and intensity, consistent with his ongoing "down" mood. Although he denied any suicidal or homicidal ideations, he stated that he sometimes thought about death and had always wondered, since returning from Vietnam, whether or not he might be better off "just dead." His thought processes were logical, goal directed, and appropriate in speed. His thought content was free of any evidence of delusional ideations or hallucinatory perceptions. Matters that supported the diagnosis of PTSD were his ongoing sleeping difficulties, nightmares, flashbacks, irritability, avoidance of stimuli reminding him of wartime experiences, interpersonal conflict with his girlfriend and others, difficulty interacting which prevented close relationships, and continued difficulty showing affection to his girlfriend. No psychological testing was accomplished and none was deemed necessary. The examiner judged the Veteran's overall cognition as being appropriate with no particular problems with judgment or insight. The diagnosis was chronic PTSD. It was reported that the ongoing PTSD symptoms that especially impacted upon him were his difficulty sleeping at night, ability to function on a day-to-day basis due to extreme ongoing fatigue, periodic flashbacks, and exaggerated hypervigilance and startle response. He had also had a difficult time over the years with affection and interpersonal relatedness. His Global Assessment of Functioning was 45 which was within the central limits of what was qualitatively defined as "serious symptoms or any serious impairment in social, occupational, or school functioning." It was opined that the Veteran was capable of dealing with any and all benefit payments and financial decision making. Records of the Veteran's award of SSA disability benefits make reference to a Workman's Compensation release agreement of January 2002 stating that the Veteran was totally disabled and that he was unemployable. Private medical records reference only disability pertaining to the Veteran right upper extremity following an on-the-job injury, prior to which he had worked on a full-time basis. The VA treatment records show that in February 2007 the Veteran did not want to socialize more because he did not want to end up in a bar. He had been visiting his aunt and his girlfriend's daughters. He was not psychotic or a danger to himself or others. On mental status examination in May 2007 he was alert and fully oriented. He was not depressed or psychotic. He was not a danger to himself or others. On mental status examination in November 2007 the Veteran's mood and affect were fair. His dreams and certain other things that distressed him were discussed. He was not depressed or psychotic and did not pose a danger to himself or others. In April 2008 he was alert and fully oriented. His mood was depressed. He had had nightmares but was not a danger to himself or others. In February 2009 his mood was good and he was fully oriented. He was not depressed and did not pose a danger to himself or others. At the August 2009 RO hearing the Veteran testified that he was currently receiving SSA disability benefits and had last worked in 2004, at which time he had had only a part-time job. He was single but in a relationship. He stated that he would become moody, sometimes from just being around people. He had sudden mood swings for no reason. He was easily provoked. He was currently in counseling and saw a psychiatrist or psychologist about once every two months. This was with VA. He took medications which at first had seemed to help but he believed that he had now developed immunity to them. If he got four hours of uninterrupted sleep he considered himself to be doing well. Most of the time he got only three hours of uninterrupted sleep, and would then go back to sleep. He had short term memory loss. He continued to have anxiety and depression. He had not looked for employment because he was now receiving SSA disability benefits which he received due to right carpal tunnel syndrome, and he was right handed. He had worked as a civilian for the Department of the Army for about twenty three years, but had not retired from the employment. He had worked shift-work for about fifteen years and had then quit and after that he was able to "get the term positions" with the government he was not able to get reinstated under the Civil Service Retirement System. The Veteran testified that all of the jobs that he had held were mostly as a boiler plant operator and material handler which were laborer or blue-collar jobs that were all manual or physical labor. He was no longer able to do that work because of his right carpal tunnel syndrome, for which he had had surgery at the wrist and elbow. He had consistently received VA psychiatric outpatient treatment since 2004, about every two months. The evidence of record does not support an evaluation in excess of 50 percent for the Veteran's acquired psychiatric disorders. The level of occupational and social impairment due to a psychiatric disorder is the primary consideration in determining the severity of a psychiatric disorder for VA purposes and not all the symptoms listed in the rating criteria must be present in order for a rating to be warranted. See Mauerhan, 16 Vet. App. 436. Although the Veteran reports worsening of his symptoms, it would not constitute an increase in the rating of his acquired psychiatric disorders. Even at their most severe, the Board finds that the Veteran's symptoms have been no worse than the criteria contemplated by a 50 percent rating under DC 9411: 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. At no time during this appeal has the Veteran been found to display or symptoms similar to or impairment commensurate with 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; spatial disorientation; neglect of personal appearance and hygiene; or inability to establish and maintain effective relationships. The Veteran was not suicidal. While he reported, in essence, having had diminished social interaction with others, he continued to see family members and worked as a volunteer at a VA medical facility. Although the Veteran reported problems with his girlfriend, he maintained this relationship. Thus, the Veteran retained the ability to maintain effective relationships. The level of social impairment described by the Veteran is contemplated in the current rating. Further, there is no impairment in his speech or orientation, or any neglect of his hygiene or appearance. The Veteran testified that he had some short term memory loss. This was not corroborated on the most recent VA psychiatric examination nor is it corroborated by VA treatment records. Thus, the complained of memory loss is not shown to be of such severity as contemplated in a higher rating. Rather, the current rating accounts for some impairment in short term memory. The Board recognizes the clinical notation that the Veteran continues to have impaired sleep due to nightmares, flashback, hypervigilance, and irritability. These are symptoms contemplated in the current rating. The Veteran does have difficulty in adapting to stressful circumstances, including a work-like setting, but the majority of the Veteran's symptoms are commensurate with a 50 percent rating. Furthermore, the Veteran's GAF score was 45, denoting serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifter) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). Arguably, a GAF score of 45 can support a 50 percent or 70 percent rating. The GAF score only provides guidance and is not determinative of the proper evaluation to be assigned. Here, the totality of the evidence shows that the Veteran's symptoms more nearly approximate the currently assigned 50 percent rating. In reaching the above conclusion, the Board has not overlooked the Veteran's statements with regard to the severity of his service-connected PTSD. In this regard, the Veteran is competent to report on factual matters of which he has firsthand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence was provided by the Veteran during the course of his VA examinations and to his treatment providers at the VA medical center. The Veteran is competent to report his current symptomatology as it pertains to his acquired psychiatric disorder and the Veteran is credible in his belief that he is entitled to a higher rating. His competent and credible lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the mental impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of mental impairment. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) ("[t]he probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . the credibility and weight to be attached to these opinions [are] within the province of the adjudicator.") The Board has considered the Veteran's reports with respect to experiencing symptoms in evaluating his disability rating in this decision. Therefore, all things considered, the record as a whole does not show persistent symptoms equally or more nearly approximating the criteria for an evaluation higher than 50 percent at any time prior to May 11, 2012. The Board finds that the Veteran's symptoms have not worsened to the extent that a 70 percent disability rating is warranted. 38 C.F.R. § 4.130, DC 9411. As such, for the reasons and bases discussed, the preponderance of the evidence is against his claim, the benefit of the doubt rule does not apply. 38 C.F.R. § 4.3; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The benefit sought on appeal accordingly is denied. Evaluation since May 11, 2012 The Veteran was afforded another VA examination in May 2012. The VA examiner indicated that while it was possible to differentiate what symptoms are attributable to the PTSD diagnosis and what symptoms are attributable to the major depressive disorder diagnosis, it was not possible to differentiate what portion of the occupational and social impairment was caused by each mental disorder. When it is not possible to separate the effects of the service-connected condition and the nonservice-connected condition, VA regulations at 38 C.F.R. § 3.102, which require that reasonable doubt on any issue be resolved in the appellant's favor, dictate that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Accordingly, all signs and symptoms of the Veteran's mental disorders will be attributed to the service-connected PTSD. Here, the Veteran was diagnosed with PTSD and major depressive disorder. A GAF score of 35 was assigned. The examiner stated that while the symptoms of impaired concentration, anhedonia, impaired sleep, and restricted affect were attributable to both PTSD and major depressive disorder, the symptoms of daily sadness, suicidal ideation, lack of appetite, low energy, and excessive guilt were attributable to major depressive disorder. Furthermore, the Veteran's PTSD was observed in constant re-experiencing of his trauma, avoidance of thoughts related to his trauma or cues related to his trauma, and hyperarousal such as hypervigilence, exaggerated startle response and a constant feeling of being on edge. At the examination, the Veteran stated he maintained contact with his sister and was free from any specific conflict however, he did not maintain contact with his brother. He stated he was no longer with his girlfriend as the relationship became strained and physically violent. He terminated the relationship in 2010 and has not communicated with her since. He indicated a marked distrust in people after this experience. He denied having any particular friends and has chosen to socially isolate himself and withdraws from social settings. He denied having any regular activities outside his home and that he has not been motivated to do anything. The Veteran stated his last job was in 2003 while working as a part-time janitor before getting laid off. He then worked temporarily in 2009 as a census worker. While the job was not demanding, the Veteran was suspicious of his supervisor and experienced extreme irritation. He also reported a lack of mental and emotional fortitude and stability, stating that he just has not been able to overcome the irritability, lack of motivation, and general distrust of others. The Veteran's symptoms included depressed mood; anxiety; suspiciousness; panic attacks more than once a week; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; mild memory loss with impairment of short- and long-term memory; flattened effect; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships; suicidal ideation; and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner reported the Veteran was alert and oriented to person, place, time and situation. He was appropriately dressed and groomed, was cooperative and friendly, his speech was normal and responded appropriately, and his attitude was appropriate. The Veteran's psychomotor skills and intellectual functioning were within normal limits. The Veteran's thought process was logical and goal oriented and thought content was absent of hallucinations or apparent delusions. There was no evidence of psychotic thinking but his mood was depressed. His affect was flat and he became emotionally distressed during the evaluation. The Veteran admitted passive suicidal ideation without specific plans. He also reported homicidal ideation without any plans. The examiner concluded that "the [V]eteran is functionally impaired, occupationally, socially and he has shown significant deficiencies in his ability to think clearly through situations due to surges of anxiety and ongoing irritability, and he has demonstrated poor judgment on a number of occasions as a result of this." The Board observes that the evidence as a whole demonstrates that the Veteran's mental disorder is no more than 70 percent disabling for the period since May 11, 2012. Significantly, in the opinion of the examiner, the Veteran had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood in the opinion of the examiner. The examiner explicitly found that total occupational land social impairment was not present. The examiner's opinion is supported by the findings in the examination report. 38 C.F.R. § 4.2 (2012). The Board cannot conclude based on the psychiatric symptomatology that the Veteran's disability is of a severity to produce total occupational and social impairment as required for a 100 percent rating. The medical evidence cited, including the GAF score of 35, does not support a rating above 70 percent for the period since May 11, 2012. In reaching the above conclusion, the Board has not overlooked the Veteran's statements with regard to the severity of his service-connected PTSD. In this regard, the Veteran is competent to report on factual matters of which he had firsthand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Lay evidence was provided by the Veteran during the course of his VA examinations and to his treatment providers at the VA medical center. The Veteran is competent to report his current symptomatology as it pertains to his acquired psychiatric disorder and the Veteran is credible in his belief that he is entitled to a higher rating. His competent and credible lay evidence, however, is outweighed by competent and credible medical evidence that evaluates the true extent of the mental impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the VA examiner has the training and expertise necessary to administer the appropriate tests for a determination on the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings in regard to the type and degree of mental impairment. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) ("[t]he probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. . . the credibility and weight to be attached to these opinions [are] within the province of the adjudicator.") The Board has considered the Veteran's reports with respect to experiencing symptoms in evaluating his disability rating in this decision. Nevertheless, the weight of the evidence demonstrates that the Veteran's acquired psychiatric disorder is no more than 70 percent disabling under Diagnostic Code 9411 for the period since May 11, 2012. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Extraschedular Consideration Consideration has also been given to whether the schedular evaluations are inadequate, thus requiring that the RO refer a claim to the Under Secretary for Benefits or the Director, Compensation and Pension Service, for consideration of "an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities." 38 C.F.R. § 3.321(b)(1) (2009); Barringer v. Peake, 22 Vet. App. 242, 243-44 (2008) (noting that the issue of an extraschedular rating is a component of a claim for an increased rating and referral for consideration must be addressed either when raised by the veteran or reasonably raised by the record). In determining whether an extra-schedular evaluation is for consideration, the Board must first consider whether there is an exceptional or unusual disability picture, which occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a Veteran's service-connected disability. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must next consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 115-16. When those two elements are met, the appeal must be referred for consideration of the assignment of an extra-schedular rating. Otherwise, the schedular evaluation is adequate, and referral is not required. 38 C.F.R. § 3.321(b)(1)(2009); Thun, 22 Vet. App. at 116. The schedular evaluations in this case are not inadequate. An evaluation in excess of the assigned ratings is provided for certain manifestations of the mental disability but the evidence reflects that those manifestations are not present in this case. Additionally, the diagnostic criteria adequately describe the severity and symptomatology of the Veteran's disability, as the criteria assess the level of occupational and social impairment attributable to the Veteran's symptoms. The Veteran has not described any exceptional or unusual features associated with his mental disorder. As the Board finds that the Veteran's disability picture is contemplated by the rating schedule, the inquiry ends and the Board need not consider whether the disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Accordingly, referral for consideration of an extra-schedular rating is not warranted. ORDER Entitlement to an increased disability rating in excess of 50 percent prior to May 11, 2012, for service-connected PTSD is denied. Entitlement to an increased disability rating in excess of 70 percent since May 11, 2012, for service-connected PTSD is denied. REMAND It is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. VA has a duty to assist claimants in obtaining evidence needed to substantiate a claim. 38 U.S.C.A. §§ 5107(a) 5103A (West 2002); 38 C.F.R. § 3.159(c) (2012). With respect to the issue of entitlement to a TDIU, the Veteran contends that his service-connected disabilities render him unemployable. In the February 2013 Informal Hearing Presentation, it was noted that the Veteran is unable to work due to the combination of his service-connected PTSD and nonservice connected major depressive disorder. As noted above, all signs and symptoms of the Veteran's mental disorders will be attributed to the service-connected PTSD. See Mittleider, 11 Vet. App. at 182. The Veteran may be awarded a TDIU upon a showing that he is unable to secure or follow a substantially gainful occupation due solely to impairment resulting from his service-connected disability. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2012). Consideration may be given to his level of education, special training, and previous work experience in making this determination, but not to his age or the impairment caused by any disabilities that are not service-connected. See 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19 (2012). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, 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 provided that if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more such disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. For the purpose of one 60 percent or one 40 percent disability in combination, disabilities resulting from a common etiology or a single accident will be considered as one disability. 38 C.F.R. § 4.16(a). The essential issue is whether the Veteran's service-connected disabilities preclude him from engaging in substantially gainful employment (i.e. work which is more than marginal, that permits the individual to earn a "living wage"). 38 C.F.R. § 4.16(a); Moore v. Derwinski, 1 Vet. App. 356 (1991). The record must reflect that circumstances, apart from nonservice-connected conditions, place him in a different position than other veterans having the same compensation rating. 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. The ultimate question is whether the Veteran, in light of his service-connected disability, is capable of performing the physical and mental acts required by employment, not whether he could find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). According to the May 2012 VA examination report: The [V]eteran reported a history of having worked in jobs that required physical labor. His education is commensurate with that report; as such the [V]eteran's [PTSD] diagnosis does not in and of itself preclude the [V]eteran from working a job that required physical labor. His diagnosis of depression; however, may impair his unemployability in that regard as low motivation and inertia may impair his ability to get going. Overall, his level of employability is guarded, especially the [V]eteran is physical[ly] limited and must work in a job that requires in a way of concentration, in that regard the [V]eteran's current symptoms may interfere with his ability to be effectively employed, and addition to the symptoms associated with [PTSD], which impact the [V]eteran's ability to maintain focus on the task at hand. The Board is of the opinion that an addendum to the May 2012 examination is needed prior to further appellate review for purposes of obtaining a definitive opinion on whether the Veteran's mental disorders in fact render him unemployable. Finally, the RO/AMC should send the Veteran a VCAA notice letter for the TDIU issue. Accordingly, the case is REMANDED for the following action: 1. Send a VCAA notice letter to the Veteran and his representative regarding the claim for a TDIU. The letter should notify the Veteran of the information and evidence necessary to substantiate the claim for TDIU. The letter should also contain notice of the manner in which both disability ratings and effective dates are assigned for awards of disability benefits. 2. Return the May 2012 VA examination report along with the claims file and a copy of this remand to the examiner for an addendum opinion. In light of the examiner's finding that it was not possible to differentiate what portion of the occupational and social impairment was caused by each mental disorder, the examiner is asked whether it is at least as likely as not (i.e., a 50 percent probability or greater) that the Veteran's PTSD and major depressive disorder render him unable to secure or follow a substantially gainful occupation. Consideration may be given to the Veteran's level of education, special training, and previous work experience when arriving at this conclusion, but factors such as age or impairment caused by nonservice-connected disabilities other than major depressive disorder are not to be considered. If this examiner is not available, send the claims file and a copy of this remand to another appropriate examiner to address the above opinion request. 3. Thereafter, adjudicate the issue. If any benefit sought on appeal remains denied, the Veteran and his representative should be provided with a Supplemental Statement of the Case. An appropriate period of time should then be allowed for a response, before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs