Citation Nr: 1317682 Decision Date: 05/30/13 Archive Date: 06/06/13 DOCKET NO. 06-34 321 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to a disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) for the period prior to March 18, 2011, and in excess of 70 percent from March 18, 2011. 2. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Kordich, Senior Counsel INTRODUCTION The Veteran served on active duty from August 1966 to March 1969. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma which denied the benefits sought on appeal. The Veteran testified at Board hearings at the RO in Muskogee, Oklahoma in June 2009 and October 2012. These transcripts have been associated with the file. This case was previously remanded by the Board in January 2011, July 2012 and December 2012, at which time the claims were remanded to the Agency of Original Jurisdiction (AOJ) to further assist the Veteran with the development of his appeal. After the December 2012 Board remand and while the case was in remand status, the RO granted an increased rating for the Veteran's PTSD to 70 percent disabling effective March 18, 2011. Thereafter, the case was again returned to the Board for further appellate action. In June 2009, a Travel Board hearing was held before an Acting Veterans Law Judge at the Muskogee, Oklahoma, RO. A transcript of this proceeding has been associated with the claims folder. In a June 2012 letter, the Veteran was advised that he was entitled to an additional Board hearing as the individual who had conducted the June 2009 hearing was no longer employed by the Board. See 38 U.S.C.A. § 7102 (West 2002); 38 C.F.R. § 20.707 (2012). On June 19, 2012, the Veteran submitted a statement to the RO indicating that he wished to appear at a hearing before a Veterans Law Judge of the Board. That hearing was held in October 2012. Although the RO assigned staged ratings of 50 and 70 percent for PTSD, the Veteran has continued his appeal for higher ratings. Applicable law mandates that when a veteran seeks an increased evaluation, it will generally be presumed that the maximum benefit allowed by law and regulation is sought, and it follows that such a claim remains in controversy where less than the maximum benefit available is awarded. See AB v. Brown, 6 Vet. App. 35 (1993). A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. For the period prior to March 18, 2011, the Veteran's PTSD was not manifested by occupational and social impairment with deficiencies in most areas, or by total occupational and social impairment. 2. For the period from March 18, 2011, the Veteran's PTSD is not manifested by total occupational and social impairment. 3. The Veteran's service-connected disability meets the percentage requirements for the award of a schedular TDIU, and his service-connected PTSD prevents him from obtaining and retaining substantially gainful employment. CONCLUSIONS OF LAW 1. For the period prior to March 18, 2011, the criteria for an evaluation in excess of 50 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. For the period from March 18, 2011, the criteria for entitlement to an evaluation in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 3. Resolving all reasonable doubt in the Veteran's favor, the criteria for a TDIU are met. 38 U.S.C.A. §§ 1155, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, as regards the claims herein decided on appeal. The Veteran must not assume that the Board has overlooked any pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. The Veterans Claims Assistance Act (VCAA) The VCAA, codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations were created, codified at 38 C.F.R. § 3.159 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012). VA's notice requirement applies to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The United States Court of Appeals for Veterans Claims (Court) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2002), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was provided VCAA-compliant notice except in one respect, described below, collectively in December 2004 and March 2006 correspondences. The VCAA letters indicated the types of information and evidence necessary to substantiate the claims for entitlement to an increased evaluation for PTSD and entitlement to a TDIU, and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. During the pendency of the appeal, the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice must include notice that a disability rating and an effective date for the award of benefits will be assigned, if service connection is awarded. Dingess/Hartman supra. The December 2004 and March 2006 letters did not provide adequate notice consistent with Dingess/Hartman. Notably, however, the Veteran received additional notice in June 2009 pertaining to the downstream disability rating and effective date elements of his claims. Despite initially inadequate notice, the Board finds no prejudice to the appellant in proceeding with the issuance of the final decision. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993). In this regard, the claim for entitlement to increased ratings are being denied, and thus any questions as to the appropriate rating and effective dates to be assigned are rendered moot. As to the TDIU claim, the Board is granting that claim, and trusts that the RO will provide any appropriate due process notice to the Veteran. Accordingly, the Board finds that no prejudice to the Veteran will result from the adjudication of his claims in this Board decision. Rather, remanding this case back to the RO for further VCAA development would be an essentially redundant exercise and would result only in additional delay with no benefit to the Veteran. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. The evidence of record includes private medical records, VA outpatient treatment reports, adequate VA examinations and statements and testimony from the Veteran and his representative. The Board notes that the January 2005, July 2005, April 2006, February 2010, and April 2011 VA examination reports on file, and the April 2006 VA examination addendum report dated in April 2006 reflect that the examiners reviewed the Veteran's past medical history, documented his current medical condition, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record, and with supporting rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App 295 (2008). Consequently, the Board concludes that the medical examinations and addendum are adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The Veteran has not indicated that he has any further evidence to submit to VA, or which VA needs to obtain. There is no indication that there exists any additional evidence that has a bearing on this case that has not been obtained. The Veteran and his representative have been accorded ample opportunity to present evidence and argument in support of his appeal. Thus, the Board finds that VA has obtained, or made reasonable efforts to obtain, all evidence that might be relevant to the issues on appeal, and that VA has satisfied the duty to assist. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103 (2012). PTSD Pertinent Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1 (2012). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. See 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When, as here, the Veteran is requesting an increased rating for an established service-connected disability, the present disability level is the primary concern and past medical reports do not take precedence over current findings. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, the most recent examination is not necessarily and always controlling; rather, consideration is given not only to the evidence as a whole but to both the recency and adequacy of examinations. See Powell v. West, 13 Vet. App. 31, 35 (1999). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different "staged" ratings may be warranted for different time periods. Ratings shall be based, as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust the schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in 38 C.F.R. § 3.321 an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extra-schedular rating. Thun v. Shinseki, 573 F.3d 1366 (Fed. Cir. 2009). By a rating decision dated in April 2002, the Veteran was granted service connection for PTSD and assigned a 30 percent disability rating effective January 10, 2002. In a September 2005 rating decision the Veteran's PTSD was increased to 50 percent disabling effective November 24, 2005, the date of claim within the appeal period. In a March 2013 rating decision, the Veteran's PTSD was increased to 70 percent disabling effective March 18, 2011, the date of the treatment report from the Christian Counseling Associates indicating the Veteran's condition had increased in severity. The rating for the Veteran's PTSD has been assigned pursuant to Diagnostic Code 9411. However, the actual criteria for rating the Veteran's disability are set forth in a General Rating Formula for evaluating psychiatric disabilities other than eating disorders. See 38 C.F.R. § 4.130. Under the formula, a 50 percent rating is assigned when there is 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. A 70 percent rating is assigned for occupational and social impairment with deficiencies in most areas, such as work, school, family relationships, 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 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. A rating of 100 percent is assignable for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The symptoms recited in the criteria in the rating schedule for evaluating mental disorders 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, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. When addressing entitlement to a 70 percent evaluation for psychiatric impairment, while symptomatology is the primary consideration, also required is an ultimate factual conclusion as to the existing level of impairment in areas such as work, school, family relations, judgment, thinking or mood. See Vazquez-Claudio v. Shinseki, No. 2012-7114 (Fed. Cir. Apr. 8, 2013). Psychiatric examinations frequently include the assignment of a Global Assessment of Functioning (GAF) score. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the global assessment of functioning is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the global assessment of functioning score and interpretations of the score are important considerations in rating a psychiatric disability. See e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). The global assessment of functioning score assigned in a case, however, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue. Instead, the global assessment of functioning score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). Background The report of a mental evaluation by W.D.R., Ph.D., of Christian Counseling Associates dated in November 2004 noted the Veteran presented for an initial interview for an evaluation of PTSD in October 2004. The Veteran described combat and being wounded. It was noted that the Veteran had intrusive, distressing memories of the events, which could come without any apparent stimulus. When he could not fall asleep, he experienced recurring recollections, and when there were other stressors present, the memories recur constantly. He also reported recurrent dreams, averaging two to three nightmares a week. The Veteran described unintentionally kicking his ex-wife out of bed several times and grabbing and kicking his girlfriend by her nightshirt when he awoke. The examiner indicated that the Veteran used avoidance as a coping mechanism and did not watch TV, especially programs concerning war, and avoids places where there are crowds. The Veteran also reported becoming anxious and sweating profusely if there are many people in a room. He indicated he lost interest in things he once enjoyed and had difficulty expressing emotions and reported that he did not feel emotions. The Veteran reported that he had experienced these symptoms to a greater or lesser degree since his return from service. Dr. W.D.R. noted that the Veteran's anxiety and depressed moods contributed to his irritability, and had adversely affected his ability to perform at work. His hand would shake and he could not perform simple tasks. This would trigger his anger, which would be expressed toward others or inanimate objects. He performed best when he did not have to be around people and his behavior antagonizes others. He also found it difficult to stay on task, mentally. The Veteran was assessed a Global Assessment of Functioning (GAF) score of 48. At a January 2005 VA examination, the Veteran reported that his psychiatric symptoms began 35 years prior. He had trouble sleeping for 35 years and indicated that he woke up kicking and fighting and in cold sweats. The current symptoms included depression, anxiety, nightmares, insomnia, social anxiety, isolation, hypervigilance, intrusive thoughts, increased startle response and avoidance of conflict. The symptoms described occurred constantly. The ability to perform daily functions during remission/partial remission was fairly good, and he had worked full-time in the past and was presently involved in starting a construction business. He did experience mild anxiety fairly consistently with bouts of more severe anxiety with tremulousness. The examiner noted that the Veteran would likely benefit from continuous treatment to control his psychiatric condition, but that the Veteran was not presently engaged in pharmacologic or psychotherapeutic treatment. The Veteran was concerned about medication side effects and was not inclined toward psychotherapy, and had not received psychotherapy for his mental condition within the past year. He had not been hospitalized for psychiatric treatment and had not required any emergency room visits for his psychiatric problem. The Veteran noted that since he developed his mental condition there had been major changes to his daily activities such as difficulty with being around others. Episodically, he struggled with depression, nightmares and intrusive thoughts which caused further difficulty within social and occupational settings. He developed a tremor and significant social anxiety. Typically this occurred approximately once a month. There had been some major social function changes such as social withdrawal and difficulty sustaining relationships. He stated that currently he was not working and had not worked for 2 years. He last worked as a cattle rancher for 16 years. He sold his cattle ranch in 2002 and was now attempting to start a construction company. He reported using alcohol that he started 35 years ago because of the sedating effect and still continued with this habit. Orientation was within normal limits. Appearance and hygiene were appropriate. His behavior was appropriate and affect and mood were normal. Communication and speech were within normal limits. Panic attacks were present and occurred as often as once a month; each episode lasting for 30 minutes. The attacks include nervousness, shaking, and desire to isolate. There was no delusion history present, and no delusions where observed at the examination. There was no hallucination history present and at the time of the examination there were no hallucinations observed. Obsessional rituals were absent and thought processes were appropriate. Judgment was not impaired. Abstract thinking was normal and memory was within normal limits. Suicidal and homicidal ideation were absent. The Veteran was assessed with a GAF score of 62. A mental status evaluation from Dr. W.D.R. dated in May 2005 noted the Veteran's complaints of personality decompensation, social withdrawal, disordered affect, and erratic, assaultive, hostile, irritable behavior. The examiner noted a blunted affect. The Veteran's hands shook during the interview and he reported he needed to use both hands to hold a cup of coffee. It was noted that the Veteran owned and operated machinery, and when working in close quarters he had to hire an operator as the stress of operating in close quarters caused his hands to tremble and he feared losing control. When feeling stressed or anxious the Veteran perspired profusely and his heart raced. Dr. W.D.R. noted that the Veteran also endorsed a number of symptoms that suggested he was experiencing a depressed mood such as feeling guilty and unworthy. He felt regretful and unhappy about life and experiences anxiety when he thought about the future. He felt hopeless at times, especially when things do not go right. Sometimes in these moments he is aggressive. He finds it difficult to settle down and sees the world as a threatening place. The examiner noted that disturbed relationships were also characteristic of the Veteran; he was introverted, fearful, and suspicious of others. He could be quite negative in social interactions and was unable to develop loving relationships as evidenced by a failed marriage and other failed relationships. He was emotionally distant and was quite uneasy, rigid, and over controlled in social situations. He had a cynical view about life and believed relationships with others to be threatening or harmful. He was visibly uneasy around others and disliked engaging in group activities. The Veteran was unable to concentrate or keep focused on tasks, especially when in the presence of others; he would begin to perspire profusely and reach a level of anxiety requiring him to leave. He was more productive when he was able to work alone. Dr. W.D.R. assessed a GAF score of 45. At a July 2005 VA examination, the Veteran described trouble sleeping and indicated that he woke up in a cold sweat, kicking and fighting with nightmares very often. His symptoms were noted as depression, paranoia, nervous sweating, and trembling hands. The symptoms described occurred often with each occurrence lasting one day. The ability to perform daily functions during remission/partial remission resulted in his inability to concentrate, irritability, violence, and inability to stay focused. The examiner noted that the Veteran was not receiving any treatment for his psychiatric condition. Over the past year he had received psychotherapy for his mental condition as often as once a month and the response had been minimal improvement. He had not been admitted to a hospital for psychiatric reasons and had not required any emergency room visits for his psychiatric problem. Orientation was within normal limits. His appearance, hygiene, and behavior were appropriate. Affect and mood were abnormal with impaired impulse control and some unprovoked irritability and periods of violence. Communication and speech were within normal limits. Panic attacks were absent and there was no delusion history present. At the time of the examination, there was no delusion or hallucination history and none observed on examination. Obsessional rituals were absent and thought processes were appropriate. Judgment was not impaired and abstract thinking was normal. Memory was within normal limits and suicidal ideation was absent. Homicidal ideation was present but with no target and no intent. It was also noted that the Veteran had flashbacks, reliving experiences, nightmares, increase startle response, survivor guilt, and problems with anger. The examiner estimated the Veteran's GAF score as 45. The examiner noted that the Veteran was mentally capable of managing benefit payments in his own best interest. Mentally, he occasionally had some interference in performing activities of daily living because of tremor, anxiety, social discomfort, hypervigilance, startle response, and difficulty managing stress. He had difficulty establishing and maintaining effective work and social relationships and worked best when alone. He had no difficulty understanding commands and appeared to pose no threat of persistent danger or injury to self or others. At an April 2006 VA examination, it was noted that the Veteran was not receiving any treatment for his psychiatric condition and had not received psychotherapy for his mental condition within the past year. He had not been admitted to a hospital for psychiatric reasons and had not required any emergency room visits for his psychiatric problem. The Veteran indicated that after leaving service he had worked in construction for 17 years, with poor relationships with his supervisor and co-workers. During his employment he had difficulty with anxiety and anger control. He ran a cattle ranch for 17 years and the relationship with his supervisor was good, but the relationship with his co-workers was poor. He reported that he was not currently working and had not been working for the past 6 months. The last job he had was running his own business for two years, but he went bankrupt. The Veteran indicated that his mental problems began 38 years ago and has had trouble sleeping since that time. He had difficulty getting to sleep without alcohol or sleeping pills. He reported restless sleep with yelling and kicking, nightmares, night sweats, and hypervigilance to sounds. The Veteran's symptoms included social anxiety, conflict and avoidance, intrusive thoughts and flashbacks; hypervigilance and startle responses; insomnia, nightmares and restless sleep; survivor's guilt, irritability and frequent fights and alcohol dependence; anxiety with shaking and depression. The Veteran indicated that these symptoms occurred constantly. The Veteran reported that the effect these symptoms had on his daily functioning was to cause him to sweat and his arms to shake when he tried to write or do business with people; he could not get along with coworkers and supervisors and could not tolerate crowds or maintain interpersonal relationships and could not achieve or maintain sleep. He reported recurring flashbacks, nightmares, and startle responses. The Veteran reported that after leaving the military service, he had engaged in multiple bar fights in 1969 to the present, indicating resultant jail time until bailed out; and domestic violence in 2001 which resulted in a deferred sentence. The examination showed the Veteran was oriented within normal limits, and that his appearance and hygiene were appropriate. His behavior was appropriate. Affect and mood were abnormal with depressed mood which occurred near-continuously and did not affect the ability to function independently. Communication and speech were within normal limits. Panic attacks were present and occurred less than once a week. The attacks included hyperventilation, shaking, and excessive sweating. There were signs of suspiciousness. There was no delusion or hallucination history present and at the time of the examination no delusions or hallucinations were observed. Obsessional rituals were present which were severe enough to interfere with routine activities as he would get out of bed at night to check out noises. Thought processes were appropriate and judgment was not impaired. Abstract thinking was normal and memory was within normal limits. Suicidal and homicidal ideation was absent. There were behavioral, cognitive, social, affective or somatic symptoms attributed to PTSD and were described as social anxiety, conflict and avoidance; flashbacks, intrusive thoughts and startle responses; nightmares, night sweats, insomnia, restless sleep with kicking and yelling; chronic anxiety with panic attacks, chronic depression with frequent fights, survivor's guilt with alcohol dependence. The Veteran was assessed a GAF score of 45. The examiner noted that the Veteran was mentally capable of managing benefit payments in his own best interest. Mentally, he did not have difficulty performing activities of daily living. He had difficulty establishing and maintaining effective work/school and social relationships. He had difficulty maintaining effective family role functioning. He was unable to perform recreation or leisurely pursuits. The examiner noted that the Veteran did not appear to pose a threat of persistent danger or injury to self or others. The Veteran's prognosis was guarded because of the chronic and progressive nature of his disorder for which he had not sought any treatment. In an addendum to the April 2006 VA examination, the RO asked the examiner if the examination report warranted an Axis I diagnosis for an alcohol abuse disability. The addendum noted that the Veteran continued to use alcohol to get to sleep because it worked better than other things he had tried. He reported he had drank more heavily in the past and had cut back his consumption appreciably as such, he has had an alcohol abuse disability in the past and has a present alcohol dependence but he did not report enough alcohol volume at the present time to be considered abusive. The addendum noted that if any Axis I diagnosis was present it would be alcohol dependence, mild to moderate. At a June 2009 Travel Board hearing, the Veteran testified that in stressful situations he shakes and sweats profusely. He stated that he was trying to start a disabled veterans' construction company. The Veteran testified that the previous week he had three nights running of nightmares and once or twice a week he would wake up with his pillow wet. He testified that he did not sleep well and had two or three drinks every night before sleeping. The Veteran stated he did not see a counselor on a regular basis. He saw one in the late 1970s on his own which was not affiliated with the VA. He saw the therapist approximately five times and she put him on a pill of some kind which he discontinued. He has been prescribed Xanax and Amitriptyline. The Veteran stated that he was in a constant state of panic and depression. During the hearing the Veteran noted that he had been asked by examiners if he was suicidal and he testified in the hearing that he just did not give a damn, and it did not make any difference. A February 2010 VA examination showed the Veteran's hygiene was appropriate and he was competent to handle his own funds. He remained oriented to time, person, and place. The examiner noted the Veteran's attitude was cooperative with a normal affect. His mood was described as anxious, hopeless, and depressed, but there was no impairment in thought content, or any delusions or hallucinations. There were rambling-like thoughts noted along with impairment in memory. The Veteran's judgment and intelligence were normal and he reported aggressive behavior once a month in the form of pushing people for which he felt remorse later. He denied panic attacks, homicidal/suicidal thoughts or persistent hallucinations. There were reports of sleep impairment and obsessive behavior, i.e., repeatedly counting his cattle. The Veteran reported that he was able to socialize in the casinos and bars and he talked to his son once or twice a week and would occasionally shoot pool. The examiner noted that the Veteran's drinking reduced his ability to inhibit aggressive tendencies that were caused by combat PTSD. The examiner also noted that the combination of PTSD and drinking made it unlikely that the Veteran could maintain gainful employment and it may or may not be possible if he stopped drinking. The Veteran was assessed a GAF score of 53. A mental health assessment from Dr. W.D.R. dated in March 2011 noted that the Veteran was initially seen in October 2004 and was diagnosed with PTSD and a GAF score of 48 was assessed. He was re-assessed in April 2005 with a GAF score of 45 with a diagnosis of PTSD chronic, severe. It was noted that the Veteran was agitated as he described the report he received from the VA concerning inaccuracies. One area was concerning panic attacks which he experienced several times a week and the other as to his drinking. It was noted that the Veteran's panic attacks were frequent and were often triggered if he felt any stress. They also included profuse sweating of the head and face. He also stated when these attacks occurred he was unable to speak clearly and his thinking became foggy. This has affected him socially and vocationally. The few friends he had were in a veterans' organization. He had left jobs or had not advanced due to his behavior. He sold his cattle ranch eight years ago and now occasionally helped in his son's business. Another means of coping has been the use of alcohol. The Veteran stated he was prescribed Xanax for his anxiety, but still had half of the bottle because he did not like the side effects of drowsiness. He felt that two beers were more helpful than the prescribed medication. An alcohol assessment was taken and the Veteran stated he used alcohol in which a typical week would consist of 10 to 15 mixed drinks or beers. This was not every week and there would be weeks he did not drink at all or times he would drink for several days in a row. The Veteran reported that he never missed work due to alcohol or been arrested, and he denied alcohol abuse. He agreed that he did use alcohol but not more than one or two beers/drinks at a time and did not get drunk. The examiner noted that since the Veteran's last assessment in 2005, his symptoms have increased in intensity and frequency, especially the panic attacks. It was noted that the Veteran had gone through a divorce and his medical condition had deteriorated. He reported pain in his lower back, and the physical pain more likely than not contributed to the increase in PTSD symptoms. Both worked against him socially, vocationally, and relationally. His impulse control was reduced and irritability was increased. Memory coordination (shaking hands) loss was greater. Small stressors in the past were exacerbated and this had reduced the Veteran's ability to function in all areas. These symptoms do not remain consistent, they fluctuate and the GAF score would depend on the day. Therefore, the examiner gave the range for the Veteran's GAF score as 40-45. The Veteran was oriented to time and place, and did not have suicidal ideation nor was he homicidal. His ability to maintain employment was severely limited due to his inability to deal with stress and lack of impulse control. In a March 2011 statement, the Veteran stated that there were inaccuracies with the VA examination reports. The Veteran stated that he did not deny panic attacks and indicated he had them very frequently. An examiner stated he had a cattle business in which the Veteran noted that he had not owned cattle in over 8 years. An examiner stated that the Veteran filed for bankruptcy, in which the Veteran denied. Lastly, an examiner noted that the Veteran socialized in bars, and the Veteran denied stating this, indicating he did not say he socialized anywhere. At an April 2011 VA examination, it was noted that the Veteran was depressed, dysphoric, sad, angry, had sleep impairment, had panic attacks, but had no problems with activities of daily living. The Veteran was deemed competent to manage his VA affairs. The diagnoses were PTSD and dysthymia. The GAF score was assessed as 55. The examiner noted that the Veteran's PTSD alone did not preclude him from some level of employment and the combination of PTSD and dysthymia did not preclude him from some level of employment. The examiner opined that the Veteran's drinking was by choice and not caused by PTSD. The alcohol use/abuse was a separate diagnosis independent of PTSD or dysthymia. At an October 2012 Travel Board hearing, the Veteran testified that he had marital violence and also engaged in bar room fights. He also testified to periods of violence in the workplace. The Veteran stated that for years he travelled construction for short duration jobs living in a travel trailer. After that he worked in an office for three or four years. He lived out on a cattle ranch for seventeen years and went into town once in a while. He stated that since his divorce he sold the cattle ranch and did sporadic work. The Veteran testified that sometimes he would work a month and sometimes for six, seven days a week. Sometimes he had a two day job, but it varied. The Veteran noted obsessive rituals of checking his door at night and making sure the stove was off. He stated he had panic attacks one to two times a day depending on if he slept well. The Veteran indicated that it was twenty five years ago that he was last employed fulltime other than self employed. The Veteran believed he received Social Security Administration (SSA) benefits for about a year or a year and a half. The Board remanded the claim in December 2012 for further development to include obtaining SSA records. A response from SSA in February 2013 indicated that the Veteran was not in receipt of SSA benefits. Analysis Period From November 24, 2004 to March 17, 2011 The Board initially notes that the Veteran has not at any point in the record exhibited impairment in judgment or thinking. To the contrary, his examiners have consistently noted that he has normal judgment and thought processes. The Veteran's primary symptom associated with his PTSD is his anxiety and associated tremulousness and sweating. The Veteran contends that the tremulousness affects the area of his capacity to work by causing him difficulty in handling machinery. Notably, however, the Veteran himself describes the tremulousness as occurring infrequently, namely about once a month. As for the anxiety itself and the sweating, it apparently varies in frequency from episodic to constant. The record shows, however, that the panic attacks associated with the PTSD do not occur with the same frequency, and that his examiners have indicated that his activities of daily living largely are not impacted by the anxiety. Only the July 2005 examiner noted some interference with the activities of daily living, although the examiners also assigned a GAF score indicative of no more than moderate impairment of PTSD on functioning. The record shows the Veteran's speech consistently is within normal limits, and despite the anxiety and claimed focus problems, his examiners have noted that he is able to follow commands. Moreover, while the Veteran does experience some isolation associated with the anxiety, he admittedly does have several friends, and at his February 2010 VA examination explained that he goes to casinos and bars, where he socializes. The Board notes that the Veteran recently has denied reporting to his examiners that he socializes. He also denies that he reported several other situations to his examiners. The common theme of the referenced "inaccuracies" in the examination reports is that the "inaccuracies" tend to militate against the claim. Given that the Veteran first raised the allegation of inaccuracies in the examination reports only after he learned how they impacted his claim, and as the Veteran has not explained (nor can the Board fathom) why the examiners would fabricate such specific reports by the Veteran, the Board finds the Veteran's allegations of inaccuracies to be unsupported, and further finds that the examination reports are accurate in the information contained within the reports. The Veteran has reported experiencing flashbacks and intrusive recollections, but notably the frequency of these symptoms has varied. In January 2005 he reported their occurrence as episodic. In April 2006 he reported the frequency as constant, but on later examinations did not report such a frequent occurrence. In any event, he consistently was oriented on examination, and denied any hallucinations or delusions. Nor was his behavior abnormal during any examination. The record does not suggest that any intrusive thoughts or flashbacks have interfered in any area of his life, and the symptoms certainly are not of the frequency or severity contemplated by the criteria for a 70 percent evaluation. Nor, given the absence of any disorientation or hallucinations or delusions, do the Veteran's symptoms even remotely approximate the criteria for a 100 percent rating. Although the Veteran reports a history of violence, and has been determined to have some loss of impulse control, his reported violence history is inconsistent, and his behavior on examination has been appropriate in every instance. The Veteran initially reported in November 2004 that he would strike his ex-wife and girlfriend, but only in an unintentional manner (when asleep, or when waking). He did not at that time express any broader violent tendencies. Dr. W.D.R. in January 2005 noted the Veteran's report of erratic and assaultive behavior, although no examples were provided. The July 2005 examiner, based on Veteran's report of periods of violence, identified the Veteran as having impaired impulse control. At the April 2006 examination, the Veteran described a history of getting into fights, but in February 2010 explained that once per month he would shove a person. At his 2012 hearing, he not only began describing a history of bar fights, but described a previously unmentioned history of violence in the workplace. The Board notes that from the above, the severity of the Veteran's impulse control is unclear, as his description of his history of violence appears to have evolved. In any event, the Board finds that the lack of impulse control is not of the frequency or severity as to be consistent with the criteria for a 70 percent rating. The only mention of frequency by the Veteran is a once per month pattern of shoving a person. Notably, however, the Veteran has denied any homicidal ideation on examination, except during the July 2005 evaluation. Even at that time, he denied any intent or plan. His report of trouble with law enforcement is remote, as he reported in April 2006, which tends to suggest his violent episodes are not as severe or frequent as he contends, and certainly not since 2004. Moreover, his examiners have consistently found that he is not a threat to others. For the above reasons, the Board finds that while the Veteran does manifest some impulse control, it is neither frequent nor particularly severe in nature. It does not approximate the criteria for either a 70 percent or a 100 percent evaluation. The Veteran reports depression and lack of emotion, which ranges in frequency from episodic to constant. The April 2006 examiner noted that the Veteran's depressed mood was near continuous, but did not affect his ability to function independently. Moreover, the Veteran consistently denied any suicidal ideation on examination. Although at his June 2009 hearing he alluded to thoughts of suicide, he did not report such symptoms to any of the multitude of examiners. In addition, his examiners have consistently indicated that he poses no danger to himself. The Veteran has consistently presented with appropriate hygiene on each examination. The Board notes that the Veteran has reported experiencing obsessional rituals, manifested by checking his house at night and, in the past, by counting his cattle. Notably, however, those tendencies now are limited to the evening hours and are not otherwise shown to actually interfere with work, family relations or other areas. The Veteran does not allege that his remote history of obsessively counting his cattle now manifests in other ways. The April 2006 examiner, in describing how the symptoms interfered with routine activities, indicated only that he would have to get out of bed. The Veteran has been unemployed for several years. The Board notes, however, that he does not have a history of frequent job changes. To the contrary, before his recent failed venture in construction, he held a job (or owned the business) for more than a decade. While the Veteran's PTSD clearly results in occupational impairment, none of his examiners has indicated that it results in total occupational and social impairment. Dr. W.D.R. indicated only that it adversely affected the ability to work. The January 2005 examiner did not directly address employability, but did assign a GAF score inconsistent with substantial impact on employment. The July 2005 examiner suggested that he could work if he worked alone. The February 2010 examiner indicated it was unlikely that the Veteran could maintain gainful employment, but this was not based on the PTSD alone. Thus, while the Veteran's PTSD clearly affects the area of employment, it does not render him totally impaired. The Board notes that in the period prior to March 18, 2011, the Veteran's GAF score has ranged widely from 45 to 62, in no particular pattern of decline or improvement. Dr. W.D.R. assessed a GAF score of 48 in November 2004. Two months later in January 2005, a VA examiner assessed a GAF score of 62. In May 2005 and July 2005, respectively, DR. W.D.R. and a VA examiner assigned a GAF score of 45, as did a VA examiner in April 2006. In February 2010, the VA examiner assigned a GAF score of 53. GAF scores ranging from 41 to 50 are indicative of serious symptoms, such as suicidal ideation, severe obsessional rituals, frequent shoplifting; or any serious impairment in social, occupational or school functioning, such as no friends, or unable to keep a job. GAF scores ranging from 51 to 60 reflect moderate symptoms, such as flat affect and circumstantial speech or occasional panic attacks; or moderate difficulty in social, occupational or school functioning such as few friends, or conflicts with peers or co-workers. GAF scores ranging from 61 to 70 are indicative of some mild symptoms or some difficulty in social, occupational or school functioning. See DSM-IV at 44-47. In reviewing the record, although the majority of the examiners assigned a GAF score falling within the range of 41 to 50, the Board finds that the Veteran's actual clinical presentation on those examinations is more consistent with a GAF score ranging from 51 to 60. The Veteran does not have symptoms such as suicidal ideations or severe obsessional rituals, and does have a social life. His inability to keep a job is not related solely to his PTSD. In contrast, his actual presentation appears to coincide with the examples listed in the GAF score range of 51 to 60, such as occasional panic attacks, few friends, and conflicts with co-workers. The Board is not implying that the few examples listed in the DSM-IV are dispositive in determining which GAF scores most accurately represent the Veteran's disability picture. Rather, the Board finds that the Veteran's symptoms appear more consonant with the types of symptoms contemplated by the GAF score range of 51 to 60. The Board also finds, given the fluctuation in the assigned GAF scores in no particular pattern, that the Veteran is not entitled to a further staged rating based on the lower GAF scores, but rather that despite some variations, the overall clinical picture for the Veteran is represented in the GAF score range of 51 to 60. In short, the Board finds that the Veteran's symptoms do not result in occupational and social impairment with deficiencies in most areas. In the areas of judgment and thinking, he has exhibited no impairment at all. He has occasionally exhibited deficiencies in mood, but as explained, he has consistently denied suicidal ideation, consistently shown adequate personal hygiene, and while at one point his depression was near continuous, it did not affect his ability to function. His symptoms probably have impacted the area of family relations, as noted by one examiner, in that he is divorced and has some general problems in forming relationships, but he notably keeps in contact with his child, and is able to attract girlfriends. As for work, the PTSD symptoms clearly do result in some occupational impairment, but as already discussed, the PTSD alone is not responsible for his unemployability. The Veteran's last reported occupation was as a business owner attempting his own construction business. He described that venture as failing to bankruptcy, but he has not described any involvement of his psychiatric symptoms in that failed venture. Given the above, the Board finds that neither the frequency nor the severity of the Veteran's PTSD approximate those contemplated by the criteria for a 70 percent rating. The symptoms do not cause deficiencies in many areas listed in the criteria, and in the remaining areas (including any not enumerated in the rating criteria) the symptoms do not cause the substantial level of impairment warranting a 70 percent evaluation. Nor do the symptoms approximate the criteria for 100 percent rating in frequency or severity. The evidence does not show disorientation, hallucinations, delusions, impairment of thought processes or communication, inappropriate behavior, intermittent ability to perform activities of daily living, severe memory problems, or any other like symptoms. Overall, the evidence does not support an evaluation in excess of 50 percent for PTSD for the period prior to March 18, 2011, and the claim for that benefit must be denied. 38 C.F.R. §§ 4.3, 4.7. After considering the totality of the evidence of record, the Board finds that the criteria for an evaluation in excess of 50 percent prior to March 18, 2011 have not been met. The pertinent medical evidence collectively reflects that the Veteran's PTSD during this period was primarily characterized by depression, trouble sleeping, memory problems, poor concentration, panic attacks of at least once a week, trouble socializing, and difficulty in adapting to stressful circumstances. The Board finds that these symptoms more nearly approximate occupational and social impairment with reduced reliability and productivity. The only medical evidence to directly address the level of impairment supports this conclusion. From March 18, 2011 The RO increased the Veteran's PTSD rating from 50 percent to 70 percent based on a March 18, 2011 mental health assessment from Dr. W.D.R. The examiner noted that since the Veteran's last assessment in 2005, his symptoms had increased in intensity and frequency, especially the panic attacks. His impulse control was reduced and irritability was increased. Memory coordination (shaking hands) loss was greater. In addition, small stressors in the past were exacerbated and this had reduced the Veteran's ability to function in all areas. The examiner noted that these symptoms did not remain consistent and fluctuated, the GAF score would depend on the day. Therefore the Veteran was assessed a GAF score of 40-45. As already discussed, the evidence prior to March 18, 2011 does not support assignment of a 100 percent rating. As to the evidence since that time, the evidence of does not reflect symptomatology of PTSD that would meet the criteria for a rating in excess of 70 percent. There was no evidence of 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; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. The March 2011 examination found the Veteran oriented to time and place, and he did not have suicidal or homicidal ideation. It was noted that the Veteran had gone through a divorce and had not maintained a relationship with a significant other or friends outside of a few veterans. His panic attacks and fear of them had significantly reduced his social involvement, and when stressed his thoughts and speech were disjointed, but his speech was not described as grossly impaired, and in any event any impairment is stress-related and not described as present persistently. Although he is withdrawn, he still has contact with his son and grandchildren, and clearly is not totally impaired socially. The Board finds that these symptoms more nearly approximate occupational and social impairment with deficiencies in most areas. The only medical evidence to directly address the level of impairment supports this conclusion. The Veteran has not demonstrated symptoms of the type, frequency, or severity to support assignment of a 100 percent scheduler rating for PTSD. As such, a higher rating of 100 percent is not warranted. Overall, the evidence does not support an evaluation in excess of 70 percent for PTSD, for the period since March 18, 2011 and the claim for that benefit must be denied. 38 C.F.R. §§ 4.3, 4.7. Extra-schedular Consideration The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. If the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. However, in the second step of the inquiry, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. § 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). Thun v. Shinseki, F.3d 1366 (Fed. Cir. 2009). The Board notes that the rating criteria for PTSD specifically contemplates the impact of any symptoms on industrial capacity. Moreover, the rating criteria do not limit the evaluation of the disorder to any particular manifestations. Consequently, the symptoms associated with the Veteran's PTSD are clearly contemplated by the rating criteria, and extraschedular consideration thus is not warranted. Id. TDIU Under the applicable criteria, total disability ratings for compensation based upon individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In this case, the Veteran meets the objective, minimum percentage requirements, set forth in 38 C.F.R. § 4.16(a), for award of a schedular TDIU, as service connection is in effect for PTSD (rated as 70 percent disabling); accordingly, there is a single service-connected disability ratable at 60 percent or more. Thus, the remaining question is whether the Veteran's service-connected disability, in fact, renders him unemployable. See 38 C.F.R. §§ 3.340, 3.341, 4.16. The central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's education, special training, and previous work experience, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). 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, however, is whether a veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, supra. The Board also points out that, in adjudicating a claim for VA benefit, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See generally 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection is currently in effect for PTSD, rated as 70 percent disabling; for gunshot wound, right medial upper thigh, rated as 10 percent disabling; tinnitus, rated as 10 percent disabling; and bilateral hearing loss, rated as 10 percent disabling. Effective March 18, 2011, the combined disability rating is 80 percent. The Veteran meets the threshold percentage requirements for consideration of TDIU from March 18, 2011. The remaining question, then, is whether the Veteran's service-connected disabilities render him unemployable. The sole fact that a Veteran 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, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose, 4 Vet. App. at 363 A March 18, 2011 mental health assessment from Dr. W.D.R. noted that the Veteran's PTSD symptoms had increased since his last assessment in 2005. The examiner indicated that the Veteran's ability to maintain employment was severely limited due to his inability to deal with stress and lack of impulse control. On the other hand, at an April 2011 VA examination, the examiner opined that the Veteran's PTSD alone did not preclude him from some level of employment. Thus, the record appears to reflect conflicting opinions on the issue of whether the Veteran is, in fact, unemployable due to his service-connected PTSD alone. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted solely because the examiner did not review the claims folder. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board finds the opinion of Dr. W.D.R. in March 2011 to be at least as probative as that of the VA examiner in April 2011. In so finding, the Board notes that it appears that, like the VA examiner, the private examiner has had the opportunity to interview and evaluate the Veteran as well as review his medical history. In addition, Dr. W.D.R. has seen and examined the Veteran since 2004. Although Dr. W.D.R. indicated that the Veteran's back pain more likely than not contributed to the increase in the Veteran's PTSD symptoms, the examiner did not otherwise indicate that conditions other than PTSD impact his ability to work. The Board notes that while the back pain might exacerbate the PTSD symptoms, the relevant inquiry is whether the PTSD symptoms render him unemployable, and not the origin of the increased psychiatric symptoms. As for the April 2011 VA examiner, it is unclear why he indicated that the Veteran's PTSD alone did not preclude him from some level of employment. A finding that TDIU is warranted must be based on the individual veteran's situation. Here, the competent medical evidence of record supports that the Veteran is precluded from engaging in substantially gainful employment as a result of his service-connected PTSD. The Veteran's PTSD is rated as 70 percent disabling, which is indicative of significant impairment. The term "unemployability," as used in VA regulations governing total disability ratings, is synonymous with an inability to secure and follow a substantially gainful occupation. See VAOPGCPREC 75-91. The critical issue is whether the Veteran's service-connected disability or 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"). See Moore v. Derwinski, 1 Vet. App. 356 (1991). In this case, the evidence reflects that the Veteran's PTSD presents significant obstacles with respect to the Veteran's employability, essentially rendering him unemployable as defined for VA purposes. As such, the Board finds that the competent opinion evidence on the question of whether the Veteran's service-connected PTSD, alone, precludes him from obtaining and maintaining gainful employment is, at least, in relative equipoise. Where, as here, after consideration of all evidence and material of record in a case for VA benefits, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. See 38 U.S.C.A. § 5107(b). See also 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Given the evidence noted above, and resolving all reasonable doubt in the Veteran's favor, the Board concludes that the criteria for a TDIU are met. ORDER Entitlement to a disability rating in excess of 50 percent for PTSD prior to March 18, 2011 is denied. Entitlement to a disability rating in excess of 70 percent for PTSD from March 18, 2011 is denied. A TDIU is granted, subject to the laws and regulations governing the payment of VA compensation. ____________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs