Citation Nr: 1315575 Decision Date: 05/10/13 Archive Date: 05/15/13 DOCKET NO. 04-16 279 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to an initial evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) for the period through June 26, 2012. 2. Entitlement to an initial evaluation in excess of 70 percent for PTSD for the period beginning June 27, 2012. 3. Entitlement to a total disability evaluation based on individual unemployability (TDIU) for the period through June 26, 2012. REPRESENTATION Veteran represented by: Virginia A. Girard-Brady, Attorney at Law ATTORNEY FOR THE BOARD S. Becker, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1970 to March 1975. He was awarded several decorations for this service, to include a Combat Action Ribbon. This matter comes before the Board of Veterans' Appeals (Board) from an April 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. It granted service connection and assigned an initial evaluation of 30 percent effective December 5, 2001, for PTSD. The Veteran appealed with respect to this evaluation. In a July 2005 rating decision, the RO increased his initial evaluation for PTSD to 50 percent effective December 5, 2001. The appeal continued, however, for consideration of an even higher initial evaluation. AB v. Brown, 6 Vet. App. 35 (1993). In a December 2006 decision, the Board denied an initial evaluation in excess of 50 percent. The Veteran, through his attorney, and VA's Office of General Counsel filed a Joint Motion for Remand (Joint Motion) of this decision with the United States Court of Appeals for Veterans Claims (Court) in April 2008. In May 2008, the Court issued an Order granting the Joint Motion. The decision thus was vacated. In September 2009, the Board remanded this matter for additional development to include development consistent with the Joint Motion. Adjudication may proceed because such development fully or at least substantially has been completed. Dyment v. West, 13 Vet. App. 141 (1999), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002); Stegall v. West, 11 Vet. App. 268 (1998). The RO, in a December 2012 rating decision, increased the Veteran's initial evaluation for PTSD to 70 percent effective June 27, 2012, as a result of some of this development. The appeal once again continued. AB, 6 Vet. App. at 35. For the sake of simplicity, at this time the Board recharacterizes it as indicated above. The aforementioned rating decision also granted a TDIU effective as of June 27, 2012. A TDIU for the period prior thereto has been added by the Board at this time. Indeed, a TDIU is not separate from a higher evaluation claim but rather is part of such a claim. Rice v. Shinseki, 22 Vet. App. 447 (2009). The following determinations on all issues comprising this appellate matter are made based on review of the Veteran's claims file and his Virtual VA "eFolder." FINDINGS OF FACT 1. The Veteran's PTSD caused occupational and social impairment with deficiencies in most areas but not total occupational and social impairment during the period through June 26, 2012. 2. For the period beginning June 27, 2012, the Veteran's PTSD has not caused total occupational and social impairment. 3. The Veteran's service-connected disability, which was evaluated at 70 percent, was of sufficient severity to render him unable to secure or follow a substantially gainful occupation for the period through June 26, 2012. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation of 70 percent, but no higher, for PTSD for the period through June 26, 2012, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for an initial evaluation in excess of 70 percent for PTSD for the period beginning June 27, 2012, have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.126, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for a TDIU have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.15, 4.16, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist Before addressing the merits, VA has a duty to notify and a duty to assist claimants. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. Discussion of these duties is not necessary with respect to a TDIU for the period through June 26, 2012, because this benefit is granted herein. It follows that any error committed regarding the aforementioned duties was harmless. Discussion of these duties is necessary with respect to higher initial evaluations for PTSD because only a partial grant is made herein with respect to the period through June 26, 2012, and a denial is made with respect to the period beginning June 27, 2012. VA must notify the claimant and his representative, if any, of any information and any evidence not of record that is necessary to substantiate the claim, that VA will seek to obtain, and 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). Notification that an evaluation and an effective date will be assigned if the benefit sought is granted also must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice must be provided prior to the initial decision by the agency of original jurisdiction (AOJ). Pelegrini, 18 Vet. App. at 112. However, there is no error in failing to provide prior notice if it was not required at the time. Subsequent VA process following notice instead must be provided. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (overturning Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007)). None is found. A March 2002 letter provided notification of the criteria for establishing service connection, the evidence required in this regard, the Veteran's and VA's respective duties for obtaining evidence. This was prior to the initial decision by the RO, which in this case also is the AOJ, in April 2002. Notification regarding an evaluation and effective date was not provided until two March 2006 letters. It was not required until then, however. Further, these two letters were unnecessary since the purpose of notice was fulfilled. Dingess, 19 Vet. App. at 473. An initial evaluation and effective date indeed were assigned in the April 2002 rating decision because service connection (the original benefit sought) was granted by the RO/AOJ. VA must assist the claimant in procuring relevant records, whether or not they are in Federal custody. 38 U.S.C.A. § 5103A(b-c); 38 C.F.R. §§ 3.159(c)(1-3). VA also must assist the claimant by providing a medical examination and/or obtaining a medical opinion when necessary. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Throughout the pendency of this matter, the Veteran has had opportunities to identify pertinent records. This includes responding to January and August 2010 letters sent to him in this regard in compliance with the Board's remand. VA has obtained his service treatment records, VA treatment records, and identified private treatment records. Social Security Administration records were not obtained by VA because neither the Veteran nor his representative indicated that there would be any and there is nothing to indicate otherwise. The Veteran submitted some private treatment records on his own behalf. He also submitted a private medical examination on his own behalf. Numerous VA medical examinations were performed, the latter ones as a result of the Board's remand. A recent VA social and industrial survey also was performed as a result of the remand. All the examiners reviewed the Veteran's claims file, with the exception of one in February 2004, and some reviewed additional evidence. The lack of claims file review is of no great import since the Veteran gave a reasonably accurate account of his medical history to this examiner. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); D'Aries v. Peake, 22 Vet. App. 97 (2008). He also did so to the other examiners. All of the examiners interviewed him regarding his symptomatology. All finally undertook a mental assessment of the Veteran. These actions have provided sufficient detail so that the determinations made herein are fully informed. As such, the examinations are adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Neither the Veteran nor his representative has identified any development necessary for fair adjudication that has not been completed. The record also does not indicate any such development. Accordingly, the Board finds that no further notice or assistance is required and that VA's duties to notify and to assist have been satisfied. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Appellate review therefore may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). II. Higher Evaluation A. Schedular Evaluations are assigned pursuant to VA's Schedule for Rating Disabilities. Separate Diagnostic Codes identify various disabilities and the criteria for a specific evaluation to be assigned for that disability. The evaluations represent as far as practicably can be determined the average impairment in earning capacity due to a disability. 38 U.S.C.A. § 1155. An evaluation is assigned by comparing the extent to which a claimant's disability impairs his ability to function under the ordinary conditions of daily life, as demonstrated by his symptoms, with the evaluation criteria. Id.; 38 C.F.R. § 4.10; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Examination reports must be interpreted, and if necessary reconciled, into a consistent picture so that evaluation of the disability is accurate. 38 C.F.R. § 4.2. If two evaluations are potentially applicable, the higher is assigned if the disability more nearly approximates the criteria required for it. Otherwise, the lower evaluation is assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant, however. 38 C.F.R. § 4.3. He thus prevails if the evidence supports a higher evaluation or is in relative equipoise but does not prevail when it is against a higher evaluation. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Consideration must be given to whether a staged evaluation is, or staged evaluations are, warranted when an initial evaluation is appealed. Fenderson v. West, 12 Vet. App. 119 (1999). In staged evaluations, two or evaluations are assigned because a disability meets the criteria for one evaluation during one period on appeal but meets the criteria for another evaluation or evaluations during another or other periods on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's PTSD is evaluated under 38 C.F.R. § 4.130, Diagnostic Code 9411. It calls for evaluation based on the General Rating Formula for Mental Disorders (Formula). A 50 percent evaluation is warranted thereunder 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, and difficulty in establishing and maintaining effective work and social relationships. An evaluation of 70 percent requires occupational and social impairment with deficiencies in most areas, including work, school, family relationships, judgment, thinking or mood, due to such symptoms as suicidal ideation, obsessional rituals which interfere with routine activities, intermittently illogical, obscure, or irrelevant speech, near-continuous panic or depression affecting 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), and inability to establish and maintain effective relationships. The maximum 100 percent evaluation is reserved for total occupational and social impairment due to such symptoms as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of closes relatives, own occupation, or own name. Global Assessment of Functioning (GAF) is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental health illness. Richard v. Brown, 9 Vet. App. 266 (1996) (citing Diagnostic and Statistical Manual of Mental Disorders (4th ed.1994)). GAF scores ranging from 51 to 60 are indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 to 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging from 31 to 40 indicate 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). An examiner's classification of the level of impairment, by GAF score or by words, is to be considered but is not determinative. 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (Mar. 31, 1995). The symptoms listed in Formula further 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." Mauerhan v. Principi, 16 Vet. App. 436 (2002). It is not required that "all, most, or even some of the enumerated symptoms" be found in order to assign a particular evaluation. Id.; 38 C.F.R. § 4.21. Rather, all manifested symptoms impacting occupational or social impairment must be considered. Id.; 38 C.F.R. § 4.126. If they demonstrate occupational and social impairment equivalent to what would be caused by the symptoms listed, then the equivalent evaluation is to be assigned. Id. The probative value of the evidence must be assessed. 38 C.F.R. § 4.6. In other words, the Board must account for evidence which it finds to be persuasive or unpersuasive and provide reasons for rejecting any evidence favorable to the Veteran. Gabrielson v. Brown, 7 Vet. App. 36 (1994), Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The competency and credibility of lay evidence therefore must be assessed. See Layno v. Brown, 6. Vet. App. 465 (1994) (noted that competency is "a legal concept determining whether testimony may be heard and considered" whereas credibility is "a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Only the most relevant evidence need be discussed, however, even though all the evidence must be and thus has been reviewed. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Upon private examination in November 2001, the Veteran complained of anxiety, thoughts of Vietnam, and nightmares of Vietnam at least twice a week. Depression was referenced by the examiner. The Veteran reported drinking alcohol every night and being the "black sheep" of his family because he had married unsuccessfully 4 times and had had approximately 20 jobs which he either quit or got fired from due to a poor attitude. He stated that he lived alone, had no friends other than a cousin, did his own household chores, enjoyed fishing, and no longer enjoys hunting. Assessment showed that he was casually dressed, oriented, pleasant, cooperative, and somewhat tense. He had no memory problems. His intellectual functioning, to include comprehension social judgment, was above average. The Veteran denied hallucinations and delusions. A GAF score of 50 was assigned. The Veteran complained of insomnia, startling easily, worrying that authorities were scheming against him, and flashbacks of Vietnam at the April 2002 VA examination. He reported binge drinking, usually as a result of a family problem, as well as blackouts and fighting while drunk. In addition to unsuccessful marriages and a terminated live-in relationship, he reported not being close with his daughter. The Veteran noted that he was not comfortable leaving his property, that dealing with the general public was a hassle, and that he had little social interaction except with his brother and occasional visits from a cousin and a friend. However, he was able to shop. He viewed the future as pretty good, and had a job as an evening bartender. He only had contact with servers and not customers in this position, and he spent his days fishing and caring for his guard dogs. He also enjoyed woodworking. Assessment showed that the Veteran was dressed appropriately but unshaven and oriented with normal speech. He rated his mood as a 3-4 out of 10. His affect was appropriate to thought content, and there was no indication of a psychotic thought disorder. He indeed denied suicidal, homicidal, and frank paranoid ideation as well as hallucinations. A GAF score of 50 was assigned. An April 2003 private treatment record documents that the Veteran reported being unemployed. His mood was normal and stable. His anxiety seemed to be under control. He did not appear to be showing signs of alcohol abuse. In an October 2003 statement, the Veteran stated that he had nightmares and depression and felt burned out. He indicated that he barely knew his daughter. The Veteran complained of insomnia and a deep sense of demoralization and apathy but no sense of a foreshortened future at the February 2004 VA examination. He reported binge drinking with friends to the point where he has blackouts and passes out approximately once a week. He indicated that he had been unemployed since summer 2003, when he was asked to leave his job, but hoped to set up a fishing guide business. Assessment showed that the Veteran was well dressed, was oriented, and had good eye contact and interaction. His speech was relevant, logical, and not obscure. His affect was full and spontaneous, and his mood was congruent. He rated his mood as a 6-7 out of 10. He had no memory loss other than due to alcohol. His flow of thought was goal-directed, with no bizarre ideation or communication. The Veteran did not suffer suicidal or homicidal ideation, delusions, hallucinations, panic attacks, impaired impulse control, or obsessive or ritualistic behavior. He was deemed able to maintain personal hygiene and other basic activities of daily living. GAF scores of 51 and 50 were assigned respectively for PTSD and alcohol dependency. The examiner opined that the Veteran had not changed significantly since his April 2002 VA examination. On his April 2004 substantive appeal form, the Veteran complained of depression, bad moods, rage, regular panic attacks, forgetfulness, and problems maintaining relationships. April 2004 private treatment records reflect the Veteran's complaints of bothersome dreams causing him to desire to stay at home, forgetfulness, poor memory, and decreased attention span. He noted that he last worked 2 years prior, was negligent in his child support, and was apathetic about his responsibilities. He also noted that his depression improves when he is busy, that he was sleeping, that his appetite was normal, and that he was close with his mother and siblings though they lived apart. Assessment showed that the Veteran was alert and oriented. His memory was somewhat impaired. He denied suicidal and homicidal ideation as well as hallucinations. A GAF score of 50 was assigned. The Veteran complained of fewer flashbacks and nightmares but greater depressed mood, avoidance, and hypervigilance at the June 2005 VA examination. He also complained of other sleep difficulties and panic symptoms to include difficulty concentrating. He reported sleeping with a gun nearby, drinking every evening, and failure to pay bills. The Veteran indicated that his relationship with his daughter remained distant and that he had a limited social network, though he occasionally talked with a neighbor. He further indicated limited leisure pursuits, as he had lost interest in and motivation for fishing and building cabins. He attributed his unemployment to an inability to relocate due to finances, "fear of unknown," and a desire to minimize social interaction. Upon assessment, he arranged his chair so that his back was not facing the door. His had poor personal hygiene and disheveled clothes but was oriented and cooperative with unremarkable speech. The Veteran's affect was flat, his mood was dysphoric, his attention was intact, his memory somewhat impaired, his judgment was partially impaired, his impulse control was fair, and his thought process was goal-directed, relevant, and coherent. His thought content was unremarkable. He did not have violent episodes, paranoid delusions, or hallucinations. He denied homicidal ideation. He admitted frequent suicidal ideation without serious intent. The Veteran acknowledged severe inappropriate behavior such as driving while intoxicated and "dumpster diving" as well as moderate obsessive/ritualistic behavior in the form of making repetitive sounds and patrolling his home while armed. Malingering was suspected, since testing suggested that he may have attempted to portray himself in an especially negative manner. A GAF score of 50 was assigned. The examiner opined that the Veteran has difficulty with activities of daily living and that his alcohol abuse appeared to be secondary to his PTSD. In April 2008 statements, the Veteran's mother and aunt indicated that his symptoms have been progressive. They specifically mentioned him having very little contact with his daughter and paranoia, role-playing by wearing military clothing, being unable to meet deadlines or remember, and taking money to include for bill payment from family members often. They noted that his personal hygiene is excellent except for his teeth and that he no longer drank alcohol. A November 2009 VA treatment record reveals the Veteran's complaints of increasing depression, poor mood with disturbances nearly every day, loss of interest in leisure activities, decreased motivation, difficulty concentrating, nightmares once per week, other sleep difficulties, chronic but fleeting thoughts of suicide, and recklessness. He reported drinking over 6 alcoholic beverages daily and being a river outfitter. Upon assessment, the Veteran had good hygiene, had fluent speech of normal rate and volume, and was alert, oriented, and responsive. His affect was flat while his mood was mildly depressed. He denied hallucinations, and there was no evidence of psychosis. A GAF score of 50 was assigned. Upon VA examination on June 27, 2012, a female who the Veteran described variously as his daughter and as his girlfriend accompanied him. He complained of intrusive memories of Vietnam 1-2 times per week, infrequent nightmares, a "hot temper," anxiety to leave his home, compulsive behavior including tapping his teeth and going to a specific gas pump, hypervigilance, paranoia, avoidance of anything that reminds him of Vietnam, forgetfulness, difficulty completing tasks, and being depressed "all the time." Mild memory loss, impaired judgment, difficulty in adapting to stressful circumstances, and neglect of personal appearance and hygiene were referenced by the examiner. The Veteran reported drinking alcohol heavily but not daily. He stated that his neighbors visit him and that he has close friends he does not get together with but also that he had been with his "crew." He noted that he stopped working around 2001 because he lost his driver's license. Assessment showed the Veteran to be somewhat disheveled though his speech was within normal limits and he was alert, oriented, pleasant, cooperative, and talkative. His mood was mildly dysphoric with congruent affect. His thoughts were logical yet somewhat tangential. He appeared to lose his train of thought frequently. There was no psychosis. A GAF score of 40 was assigned, and the examiner opined that the Veteran had occupational and social impairment with deficiencies in most areas. It further was opined that his symptoms are consistent with depression. Finally, it was opined that it cannot be stated that his substance abuse is due to his depression. This same examiner clarified in an August 2012 VA examination addendum that the change in diagnosis from PTSD to depression was a correction of a previously erroneous diagnosis. Then, the examiner opined that the Veteran's depression appears to be unrelated to his service. The Veteran complained of flashbacks, thoughts of Vietnam, sleep difficulties, poor eating habits, losing his train of thought, memory difficulties, avoidance, anxiety, tolerance for only limited social exposure, hypervigilance, inappropriate behaviors now including tapping his fingers and basing decisions on the outcome of games, declining interest in and motivation for activities to include sports and playing on the computer, transient weekly suicidal ideation without any intent, and engaging in dangerous behavior at a November 2012 VA examination. Impaired judgment, suspiciousness, and difficulty in adapting to stressful circumstances were referenced by the examiner. The Veteran reported improved depression due to having a girlfriend but everyone in his family considering him dysfunctional. He stated that he has dinner with his aunt and uncle weekly, is in touch with his brother weekly, and communicates with his mother daily. The Veteran reported drinking daily. He indicated that he hoards. Assessment showed him to be unshaven with poor hygiene and slurred speech, although he was oriented and cooperative. His affect was constricted, his mood was anxious, his impulse control was fair, his attention was intact, and his memory was mildly impaired. He lost his train of thought several times. His thought process was unremarkable. With respect to judgment and insight, he did not have comprehension. His was paranoid but did not have hallucinations. The Veteran denied homicidal ideation, and he did not have obsessive/ritualistic behavior. It was opined that the Veteran had difficulty with activities of daily living. The examiner also opined that the Veteran does have PTSD, though it is of mild severity and overshadowed by his substance abuse, and that this substance abuse is related to his PTSD. GAF scores of 50 and 40 were assigned respectively for PTSD and a combination of substance abuse disorders. It was opined that the Veteran had occupational and social impairment with deficiencies in most areas. At a VA social and industrial survey in July 2012, the Veteran indicated talking to his brother a few times per month and described his relationship with his mother as good. He further indicated having established a good relationship with his daughter, with monthly contact. The Veteran noted that he has 6 friends that come see him but that it is hard for him to leave his home. He stated that he no longer engages in hobbies of collecting coins and model cars or fishing. He finally reported being unable to work due to anxiety. The Veteran was dirty, disheveled, and unshaven. He also was attentive, was cooperative but anxious, appeared oriented, and maintained good eye contact and normal speech. He lost his train of thought a few times and became tearful discussing Vietnam. The Board acknowledges, at the outset, that differentiation between symptoms attributed to a non-service-connected disability and those attributed to a service-connected disability must be based on medical evidence. Mittleider v. West, 11 Vet. App. 181 (1998); Mitchem v. Brown, 9 Vet. App. 136 (1996). Here, the Board finds based on the preponderance of the medical evidence that all symptoms shall be considered. One examiner determined that the Veteran has depression unrelated to his service and thus should not be service-connected for it. Yet all other examiners either determined or did not question that he has service-connected PTSD. The same solitary examiner determined that the Veteran's substance abuse, primarily alcohol, is separate from his psychiatric diagnosis. Such abuse concededly was to varying levels, as it was not found on occasion. When it was found, all examiners except the aforementioned either determined or did not question that it was due to psychiatric diagnosis. The Board also notes at the outset that the Veteran, his mother, and his aunt are lay persons because there is no indication any of them possesses a medical background. The Veteran is competent to report his symptoms and life circumstances because he personally experiences them. His mother and aunt are competent because such generally is capable of observation. Competent lay evidence may be discounted "in the light of its own inherent characteristics and its relationship to other items of evidence." Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). Factors for credibility consideration therefore include interest, self-interest, bias, inconsistency, inconsistency with other evidence, facial implausibility, bad character, malingering, desire for monetary gain, and witness demeanor. Pond v. West, 12 Vet. App. 341 (1999); Macarubbo v. Gober, 10 Vet. App. 388 (1997); Caluza v. Brown, 7 Vet. App. 498 (1995); Cartright v. Derwinski, 2 Vet. App. 24 (1991). None of these factors is significant here. The Veteran is self-interested and stands to gain financially, but his reports are plausible as well as relatively consistent with each other, the lay evidence from his mother and aunt, and the medical evidence. Malingering was referenced only once, and he was only suspected of it as opposed to it being confirmed. The reports of his mother and aunt also are plausible as well as relatively consistent with each other, his lay evidence, and the medical evidence. In sum, there is no reason to doubt the Veteran, his mother, or his aunt. Their credibility therefore is conceded. Given the above, the Board finds that an initial evaluation in excess of 50 percent is warranted for PTSD for the period through June 26, 2012. The Board specifically finds that an initial evaluation of 70 percent, but no higher, is warranted. With respect to the period beginning June 27, 2012, the Board finds that an initial evaluation in excess of 70 percent is not warranted. The Veteran's symptoms consistently have caused occupational and social impairment with deficiencies in most areas but not total occupational and social impairment, in other words. No opinions on the degree of the Veteran's occupational and social impairment exist for the period through June 26, 2012. However, he was employed for a small portion of this period as an evening bartender and as a river outfitter. He drank alcohol, could not meet deadlines, and had anxiety, somewhat impaired judgment, problems with mood, and ultimately problems with memory and concentration. These symptoms clearly interfered substantially with his ability to work. The Veteran's avoidance of the public, suspiciousness, reluctance to leave his house, and ultimate poor hygiene and unkempt appearance also clearly interfered substantially with his ability to work. These symptoms, plus ultimate decreased motivation and interest, also substantially interfered with his ability to interact with others during the aforementioned period. Interaction between him and VA examiners, presumably strangers, was cordial. Yet his relationship with his daughter was distant, and he had only a limited social network. He was close with his mother and brother, but neither lived nearby. Friends were noted only once. Sometimes his cousin visited, and occasionally he talked to a neighbor. No romantic relationship was reported. In sum, the Veteran was quite impaired occupationally and socially. He was not totally impaired, however, as he was capable of some work and had at least some interaction with both family and others. It was twice opined during the period beginning June 27, 2012, that the Veteran has occupational impairment with deficiencies in most areas rather than total occupational impairment. He has not been employed during this period. He drinks alcohol and has had anxiety, impaired judgment, problems with mood as well as with memory and concentration, difficulty completing tasks, and difficulty adapting to stressful circumstances. Like above, these symptoms clearly interfere substantially with his ability to work. The same is true of the Veteran's avoidance of the public, paranoia, reluctance to leave his house, and ultimate poor hygiene and unkempt appearance. These symptoms, plus ultimate decreased motivation and interest, additionally substantially interfere with his ability to interact with others during the aforementioned period. However, interaction between him and VA examiners, presumably strangers, once again was cordial. He now has a good relationship with his daughter as well as his mother. He has contact with his brother, aunt, and uncle. His family nevertheless thinks he is dysfunctional. The Veteran has a number of friends, though they and neighbors go see him instead of vice versa. In sum, he has remained quite impaired occupationally and socially. He has not become totally impaired, however. The progression of his occupational impairment, in that he cannot work at all, indeed is offset by his lessened social impairment, in that he now has greater contact with both family and others. Of further import, GAF scores ranging from 40 to 51 have been assigned during the period through June 26, 2012, and beginning June 27, 2012. 50 was the score assigned most often. The scores collectively signify that the Veteran generally has had serious symptoms or serious impairment in occupational and social functioning with some moderate symptoms or moderate impairment and some major impairment in several areas such as work, family relations, judgment, thinking, or mood as well as with respect to reality. As such, they signify at most occupational and social impairment with deficiencies in most areas. It lastly is notable that none of the symptoms enumerated as being indicative of total occupational and social impairment has been manifested by the Veteran. There is no indication of a persistent danger of hurting others, persistent hallucinations, gross impairment in thought processes or communication, disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. While he has some suicidal ideation, the Veteran has not had a plan or intent. It thus cannot be said, despite his recklessness, that there is a persistent danger he will hurt himself. Some paranoia was found, though it never was characterized as a persistent delusion. Delusions indeed specifically were not found on numerous occasions. The Veteran has manifested inappropriate behavior, to include driving while intoxicated, dumpster diving, and hoarding. Yet this behavior was characterized as severe instead of grossly inappropriate. Dumpster diving and hoarding at least, while socially unacceptable, indeed are not inherently improper. Finally, it was determined that the Veteran has difficulty with activities with daily living. It was not determined that he has any inability, however transient, to perform these activities. The lack of these enumerated symptoms, in sum, is not dispositive but supports the Board's finding that of only occupational and social impairment with deficiencies in most areas. Consideration has been given to reasonable doubt in determining that an initial evaluation of 70 percent for PTSD should be granted for the period through June 26, 2012, and that an initial evaluation in excess of 70 percent for PTSD should be denied for the period beginning June 27, 2012. However, it does not apply because these determinations were based upon the preponderance of the evidence. Consideration also has been given to staged evaluations. None are warranted because the aforementioned determinations cover the entire period to which they apply. Indeed, the only stage that was in place has been eliminated by these determinations. B. Extraschedular The alternative to assigning an evaluation schedularly is to assign an evaluation on an extraschedular basis. 38 C.F.R. § 3.321(b). There are three steps to be taken regarding extraschedular evaluations. Thun v. Peake, 22 Vet. App. 111 (2008). A determination of whether the evidence presents such an exceptional disability picture that the applicable schedular evaluation criteria are inadequate because they do not contemplate the Veteran's level of disability and symptomatology first must be made. If these criteria are inadequate, it second must be determined whether the exceptional disability picture exhibits other related factors such as marked interference with employment or frequent periods of hospitalization. If such related factors are exhibited, then referral third must be made to the Under Secretary for Benefits or the Director of the Compensation and Pension (C&P) Service for consideration of an extraschedular evaluation. Consideration was given to an extraschedular initial evaluation in a December 2012 supplemental statement of the case, as required by the Board's remand. Yet there is no indication that the Veteran's PTSD cannot be contemplated adequately by the applicable schedular evaluation criteria discussed above. His symptoms specifically were accounted for by the criteria and associated statutes, regulations, and caselaw to include Mauerhan. Evaluation was based on these sources. A higher evaluation exists pursuant to them. As explained above, however, an initial evaluation of 70 percent for the period through June 26, 2012, and for the period beginning June 27, 2012, accurately describes the severity of the Veteran's PTSD. In other words, the effect his PTSD has on him is encompassed by the aforementioned evaluation. Since the applicable schedular evaluation criteria are adequate, the Board does not find an exceptional PTSD disability picture. Discussion of whether there are related factors such as marked interference with employment or frequent periods of hospitalization accordingly is unnecessary. Referral for consideration of the assignment of an initial extraschedular evaluation further is not warranted. Thun, 22 Vet. App. at 111; Bagwell v. Brown, 9 Vet. App. 337 (1996); Floyd v. Brown, 9 Vet. App. 88 (1996); Shipwash v. Brown, 8 Vet. App. 218 (1995). III. TDIU Total disability means that there is present any impairment of mind or body sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. A substantially gainful occupation is an occupation at which a livelihood is earned. VA Adjudication Procedure Manual, Part IV.ii.2.F.24.d. It thus is "an occupation that provides an annual income that exceeds the poverty threshold for one person, irrespective of the number of hours or days" actually worked. Faust v. West, 13 Vet. App. 342 (2000). It does not encompass positions of marginal employment where annual income does not exceed the poverty threshold for one person or where annual income exceeds this threshold because the employment is in a protected environment such as a family business or sheltered workshop. 38 C.F.R. § 4.16(a). In determining whether a claimant is unable to engage in a substantially gainful occupation., consideration may be given to level of education, special training, and previous work experience but not to age or impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361 (1993). A TDIU may be granted on a schedular or extraschedular basis. It is granted schedularly when a claimant is unable to secure or follow a substantially gainful occupation due to a service-connected disability or service-connected disabilities evaluated at less than 100 percent. 38 C.F.R. § 4.16(a). If the claimant has one service-connected disability, it must be evaluated at 60 percent or more. Id. A TDIU may be granted extraschedularly even where the claimant does not meet the percentage evaluation requirements if he is unemployable due to a service-connected disability or service-connected disabilities evaluated at less than 100 percent. 38 C.F.R. § 4.16(b). Referral to the Director of the C & P Service is required because VA, to include the Board, cannot assign an extraschedular TDIU in the first instance. Id.; Bagwell, 9 Vet. App. at 337; Floyd, 9 Vet. App. at 88; Shipwash, 8 Vet. App. at 218. Here, the Veteran's only service-connected disability is PTSD. It follows from the aforementioned that this disability was evaluated at 40 percent or more during the period through June 26, 2012. The percent evaluation requirement thus was met for during this period. A TDIU thus may be awarded on a schedular basis with respect to this period. The relevant inquiry is whether the Veteran's PTSD was of sufficient severity to render him unable to secure or follow a substantially gainful occupation therein. The Board must account for evidence which it finds to be persuasive or unpersuasive and provide reasons for rejecting any evidence favorable to the Veteran, like above. Gabrielson, 7 Vet. App. at 36, Masors, 2 Vet. App. at 18; Wilson, 2 Vet. App. at 614; Hatlestad, 1 Vet. App. at 164; Gilbert, 1 Vet. App. at 49. The competency and credibility of any lay evidence therefore once again must be assessed. See Layno, 6. Vet. App. at 465. Also like above, the benefit of the doubt is given to the Veteran when there is an approximate balance of positive and negative evidence. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 49. He thus prevails if the evidence supports a TDIU or is in relative equipoise but does not prevail when it is against a TDIU. Finally like above, only the most relevant evidence need be discussed even though all the evidence must be and thus has been reviewed. Gonzales, 218 F.3d at 1378. Much relevant information was set forth above. At the private examination, VA examinations, and VA social and industrial survey noted above, the Veteran additionally reported at least a high school education. He once reported attending college for a few years. He indicated jobs to include as a bartender and cook in restaurants and country clubs as well as a security guard, border agent, and river outfitter. He further indicated that he had worked at Wal-Mart and had sold men's clothes. Bartender was identified as his primary occupation. The Veteran noted that he had had no difficulty maintaining employment when he worked, despite his numerous positions and although his longest position was for only four or five years. The April 2008 statements from his mother and aunt included recounts that he would go from job to job, as he had no difficulty finding work but eventually would stop showing up. The Veteran, his mother, and his aunt are competent as well as credible for the same reasons specified above. Based on the above, the Board finds that the Veteran's PTSD generally rendered him unable to secure or follow a substantially gainful occupation during the period through June 26, 2012. It is uncertain precisely when he stopped working. He worked very little within the aforementioned period, however, and at least most of this work was toward the beginning of this period. It is not entirely clear whether or not his work constituted a substantially gainful occupation or marginal employment. However, marginal employment rather than a substantially gainful occupation is found. The poverty threshold for one person under 65 years of age as established by the United States Department of Commerce, Bureau of the Census, has exceeded $9,000 since 2001. Specifics were not provided on the annual amount made by the Veteran when he was working. Yet he did not work for long. He further never indicated that his employment was full-time. That his employment as a bartender and river outfitter during the aforementioned period respectively was in the evening and presumably at his discretion suggests it was part-time. The Veteran did not earn much, in other words. The Veteran was suited best for entry level or near entry level jobs given his education and lack of specialized training. He further was suited best for jobs in public that involve interaction with others given his previous work experience. Jobs that are entry level or near entry level and jobs would not have been problematic during the period through June 26, 2012, notwithstanding his PTSD. Yet jobs in public that involve interaction with others would have been extremely problematic during this period. The Veteran ultimately became reluctant to leave his house. Accommodations were made to limit his interactions with others prior to that when he was bartending. However, he could not keep even this job. Whether or not this is due to the poor interactions he had to have or otherwise is unknown. Similar accommodations in other positions, in any event, are unlikely. Positions such as those that can be undertaken from home with little to no interaction, for example computer jobs, were within the Veteran's capability. In other words, it is reiterated that he did not have total occupational impairment. Yet he did not have the background for these positions that he was capable of doing. The Veteran's PTSD, in sum, was an insurmountable impediment to him securing or following a substantially gainful occupation during the period through June 26, 2012. Such determination was made based on the preponderance of the evidence. Accordingly, a TDIU is granted without the necessity of invoking the benefit of the doubt. (CONTINUED ON NEXT PAGE) ORDER An initial evaluation of 70 percent for PTSD for the period through June 26, 2012, is granted, subject to the statutes and regulations governing monetary awards. An initial evaluation in excess of 70 percent for PTSD for the period beginning June 27, 2012, is denied. A TDIU for the period through June 26, 2012 is granted, subject to the statutes and regulations governing monetary awards. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs