Citation Nr: 1321272 Decision Date: 07/02/13 Archive Date: 07/12/13 DOCKET NO. 09-31 574 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and fiancée ATTORNEY FOR THE BOARD Timothy D. Rudy, Counsel INTRODUCTION The Veteran served on active duty from August 1967 to September 1969. This matter comes before the Board of Veterans' Appeals (Board) from a December 2008 rating decision that denied the benefits sought on appeal. In July 2011, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. Subsequently, the Board remanded this matter for additional development in decisions dated in October 2011 and January 2013. The Board has reviewed the claims file and the Virtual VA electronic claims file. FINDINGS OF FACT 1. The evidence of record does not show that the Veteran's PTSD results in occupational and social impairment with reduced reliability and productivity. 2. The Veteran is service-connected for cystic and chloracne of the face, neck and back, rated 60 percent; PTSD, rated 30 percent; moderately disfiguring scars of the face, residuals of acne, rated 10 percent disability; and a scar of the right hand, rated 0 percent. The Veteran's combined service-connected rating is 80 percent. 4. The evidence of record does not show that service-connected disabilities prevent the Veteran from securing or following a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 30 percent for PTSD are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.125-4.130, Diagnostic Code 9411 (2012). 2. The criteria for entitlement to a TDIU are not met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating claims for VA benefits. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Proper notice from VA must inform the claimant, prior to the initial unfavorable decision on a claim by the AOJ, of any information and any evidence not of record (1) that is necessary to substantiate the claim, (2) that VA will seek to provide, and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); 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). With respect to increased rating claims, general rather than specific information of the evidence needed to substantiate the claim must be provided to the claimant. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). That includes evidence demonstrating a worsening or increase in severity of the service-connected disability at issue and the effect that worsening has on employment. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Information on how effective dates are assigned also must be provided. Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Veteran has not alleged prejudice with respect to the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. The Veteran was notified by correspondence dated in September 2008 and March 2009 of the criteria for establishing an increased rating and TDIU, the evidence required, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings, which was noted to include consideration of the impact on employment, and effective dates. Those letters addressed all notice elements and predated the adjudication of these issues by the RO in a March 2013 supplemental statement of the case. Nothing more is required. Even if a defect with respect to notice content or timing existed, it is harmless because the Veteran has had a meaningful opportunity to participate in the processing of this appeal. That includes participation in a hearing before the Board. The essential fairness of adjudication has not been impacted. VA is required to aid a claimant in the procurement of pertinent records, whether or not the records are in Federal custody. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. §§ 3.159(c) (2012). VA also is required to provide a medical examination or obtain a medical opinion when necessary. 38 U.S.C.A. § 5103A(d) (West 2002); 38 C.F.R. §§ 3.159(c)(4) (2012). The Veteran's VA treatment records have been obtained through VA's efforts, to include those found on his Virtual VA electronic claims file. No private treatment records have been obtained by VA. However, no private facility has been identified by the Veteran as providing pertinent treatment. He also did not submit any pertinent private treatment records on his own behalf. The record contains a May 2009 memorandum of unavailability of records from the Social Security Administration (SSA) wherein it was indicated SSA has no medical records on file or they could not be located. A contemporaneous report of contact also indicates that the Veteran denied there are any SSA medical records. VA medical examinations were conducted in November 2008 and February 2012 and, in compliance with the Board's January 2013 remand, in February 2013. Each examiner reviewed the Veteran's claims file and medical records, interviewed him, and undertook an assessment of his PTSD, or in the case of one of the February 2012 examiners, the Veteran's other service-connected disabilities. Diagnoses were made by each, and the February 2013 PTSD examiner and one of the February 2012 VA examiners rendered employability opinions. All questions necessary to render a decision were answered with the exception of the February 2012 PTSD examination, which was found inadequate for rating purposes in the January 2013 remand. Otherwise, the examinations are adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Neither the Veteran nor his representative have identified any further development necessary for a fair adjudication of the claims that has not been completed. Therefore, 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). Therefore, appellate review may proceed without prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384 (1993). Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2012). The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Tor rate 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 (1991). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). 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. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in this decision is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. It is the responsibility of the rating specialist to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately compensate the elements of disability present. 38 C.F.R. § 4.2 (2012). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204 (1994). Ratings of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses are prohibited. 38 C.F.R. § 4.14 (2012). Lay statements are considered to be competent evidence when describing the features or symptoms of an injury or illness observable through the senses. Falzone v. Brown, 8 Vet. App. 398 (1995). As a layperson, the Veteran is only competent to report observable symptoms, but not the clinical findings which are applied to VA's Rating Schedule. Barr v. Nicholson, 21 Vet. App. 303 (2007); Bruce v. West, 11 Vet. App. 405 (1998). When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7 (2012). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. 38 C.F.R. § 4.3 (2012). Service connection for PTSD was granted in an August 2006 rating decision and a 30 percent disability rating was assigned, effective February 28, 2006, pursuant to the rating criteria of 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). Under Diagnostic Code 9411 and the General Rating Formula for Mental Disorders, ratings may be assigned ranging between 0 and 100 percent. A 30 percent disability rating is appropriate when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130 (2012). A 50 percent requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130 (2012). A 70 percent rating requires occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); and inability to establish and maintain effective relationships. 38 C.F.R. § 4.130 (2012). A 100 percent rating requires 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; and memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130 (2012). The symptoms recited in the criteria in the rating schedule for rating 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. 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. Mauerhan v. Principi, 16 Vet. App. 436 (2002). When rating a mental disorder, the rating must be based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2012). Further, when rating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). Reports of psychiatric examination and treatment frequently include a Global Assessment of Functioning (GAF) score. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), Fourth Edition, a GAF scale includes scores ranging between 0 and 100 which represent the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. Richard v. Brown, 9 Vet. App. 266 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, an assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). 38 C.F.R. § 4.126(a) (2012). A GAF score of 51 to 60 indicates moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF score of 61 to 70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy or theft within the household), but generally functioning pretty well with some meaningful interpersonal relationships. American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), Fourth Edition (1994). The RO interpreted the Veteran's written submission of September 2008 as a claim for a higher rating for service-connected PTSD. He essentially contends that his PTSD is more severe than his current 30 percent disability rating. VA treatment records dated from September 2007, a year before the Veteran filed his request for an increased rating, until January 2013 show medication reviews and occasional individual therapy. In addition to his fiancée's support, the record shows that the Veteran is dependent on psychoactive medications and therapy sessions with a VA treating provider to ameliorate his PTSD symptoms. A June 2008 VA psychiatric clinic record noted that the Veteran was last seen in June 2007. The Veteran presented with complaints of anger, irritability, and poor sleep. He minimized depressive symptoms, but his fiancée said he could become tearful with little provocation. He said he was willing to return to an antidepressant medication. He also complained of blackouts from intense pain lasting 10 seconds or so. It was noted that he spent most of the time venting frustrations about legal issues related to drunken driving charges and that not much time was spent discussing his PTSD traumas. He noted struggling with flashbacks, intrusive memories, and poor sleep which improved later, but resurfaced when a Vietnam buddy passed away. On mental status examination, the Veteran was alert and oriented. His affect and mood were constricted, he fought back tears, and appeared down. His memory and concentration were grossly intact. Diagnosis was PTSD and depression not otherwise specified. According to a July 2008 VA mental health clinic record, a social worker indicated that the Veteran reported his current medication was helping his depression and he was not having as many angry outbursts as prior to his medication change. He was also sleeping much better. It was noted his current symptoms developed when his handicapped wife died suddenly in 2002. He was currently working on his property to build a workshop for his woodworking and computer building hobbies. Correspondence dated in July 2008 from L.L., M.D., the Veteran's treating psychiatrist at a VA clinic, indicated that he had been evaluated at the clinic and diagnosed with PTSD and depression not otherwise specified. The physician stated that there was no evidence that the Veteran had been struggling with any substance abuse or dependency issues and that counseling had not been recommended at this time. A subsequent July 2008 VA medical record showed psychiatric follow-up. He said he had tolerated medication. He had no tearfulness or irritability and was more talkative and outgoing and slept better. On mental status examination, his affect and mood evidenced some fullness and was closer to euthymic. His memory and concentration were noted as grossly intact. Diagnosis was PTSD and depression with a GAF score of 58 assigned. A November 2008 VA medical record showed outpatient follow-up treatment for his psychiatric condition. He was undergoing physical therapy for recent hip surgery. The Veteran noted changes in himself and he was noted to evidence irritability, intolerance, and a quick temper, even when hospitalized with a hip replacement. A mental status examination showed memory and concentration were grossly intact and that his affect and mood showed some fullness and were closer to euthymic. The diagnosis was PTSD and depression with a GAF score of 55 assigned. At a November 2008 VA mental disorders examination, the Veteran complained of various symptoms weekly to daily since service, which were currently of a mild severity, including sleep difficulties, irritability, and difficulty concentrating. He conceded that he had few friends and that he flew off the handle if they or someone else did something he thought stupid. He confessed to a lack of patience and said that he had not seen his brothers or sisters since 1994. He was taking Celexa. The Veteran told the examiner that he no longer went fishing and had stopped hunting years ago. He said he did not do much of anything but "fiddle" on the computer (he used to build web sites) and was building a shop. On mental status examination, the Veteran's attention, memory, and judgment appeared to be within normal limits. He denied hallucinations, delusions, and suicidal or homicidal ideation. His mood appeared to be euthymic with full and congruent affect. Psychological testing results were noted and explained which appeared to suggest that the Veteran either had mild PTSD symptoms or was exaggerating his symptoms. Diagnosis was a prior history of chronic PTSD with a GAF score of 65 assigned. The examiner estimated that the level of occupational and social impairment was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to PTSD signs and symptoms, but with generally satisfactory functioning, or the standard for a 30 percent disability rating under the General Rating Formula. The examiner noted that the Veteran reported a depressed mood, anxiety, and chronic sleep impairment, all of which would likely cause occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks if he were currently employed. The VA examiner also noted a guarded prognosis due to the reported chronicity of symptoms. The examiner suggested another examination in 24 months as involvement in treatment was a positive sign. A February 2009 VA medical record noted a mental status evaluation showing memory and concentration were grossly intact while there was some fullness to his affect and his mood remained irritable. Diagnosis was PTSD and depression with a GAF score of 55 assigned. A May 2009 VA medical record noted the effect of medication changes on some of his symptoms. On mental status examination, memory and concentration were grossly intact, but constricted affect was noted and his mood remained irritable. Diagnosis was PTSD and depression with a GAF score of 55 assigned. According to VA medical records dated in July 2009, September 2011, January 2012, April 2012, July 2012, and September 2012, the Veteran was alert and oriented, his affect was appropriate, and his memory for remote and recent events was appropriate. In his August 2009 substantive appeal, the Veteran stated that the reason he did not have counseling from June 2007 to June 2008 was because the psychiatrist at the VA clinic was not seeing patients. He also said that the November 2008 VA examiner was wrong when he wrote that the Veteran was 56 years old and working. The Veteran maintained that he was then 58 years old and had not worked for approximate three years at that point. According to a September 2010 VA medical record, the Veteran complained of fitful sleep and said that the prior plan for emotional lability, irritability, tearfulness, intolerance, and quick temper had not been useful. Mental status evaluation showed memory and concentration were grossly intact with a constricted affect. His mood remained mostly irritable with some tearfulness. Diagnosis was PTSD and depression with a GAF score of 55 assigned. According to VA medical records dated in June 2010, September 2010, October 2010, January 2011 and March 2011, mental status evaluations showed memory and concentration grossly intact, thought process somewhat circumstantial, and a constricted affect. His mood remained mostly irritable with some tearfulness. Diagnosis was PTSD and depression with a GAF score of 55 assigned. According to a May 2011 VA medical record, the Veteran remained very tearful, emotional, depressed, with poor sleep and nightmares, although his fiancée said his irritability and anger were somewhat improved by medication. On mental status examination, affect was constricted, his mood remained mostly irritable with some tearfulness, thought process was somewhat circumstantial, and memory and concentration were grossly intact. Diagnosis was PTSD and depression with a GAF score of 55 assigned. During his Board hearing in July 2011, the Veteran testified that he had been married and divorced five times, probably due to his irritability and anger. He said that although he never physically abused his wives, he was mentally or verbally abusive. Since April 2005, he has lived with his fiancée, who also attended the hearing and testified on the Veteran's behalf. The Veteran said that he had two children of his own and conceded that he had been a stern parent. He rarely spoke with his own children, but noted that he had conversed with his daughter online the night before for the first time in five years. He said that he believed he got along pretty well with his stepchildren who were all female. The Veteran also testified that he had only one or two friends, but his fiancée said she was his only friend. However, the Veteran worked with homeless veterans. The couple denied any social life. While the Veteran used to fish, he still did carpentry, restoring and building furniture. But his fiancée noted that her kitchen was only half done because the Veteran started a project and then lost interest and took a long time to get things done. Under questioning the Veteran conceded that he had thought about suicide, perhaps three years before, but that he had never come close to acting on those thoughts. He also admitted that he was easily provoked but that his violence was confined to arguing. The Veteran also said that he got all his PTSD treatment through VA. According to a July 2011 VA medical record, the Veteran had a dysthymic mood. He told the examiner that he was helping set up a veterans' stand down for homeless vets and was active in the VFW. He continued occasional teariness. On mental status evaluation, affect was teary and concentration was intact. PTSD was stable with medication and supportive therapy. A GAF score of 55 was assigned. According to an October 2011 VA mental health record, the Veteran telephoned to renew his medications. It was noted that he did not know what he was taking and that he had been out of medications for a long while. He reported that they did help when he took them. Four medications were refilled. According to a February 2012 VA medical record, the Veteran presented as dysthymic and said he needed a medication switch. On mental status evaluation, mood was dysthymic, affect was constricted, concentration was intact, and memory was noted as grossly intact though not formally tested. His PTSD was stable with medication and supportive therapy. A GAF score of 57 was assigned. The Veteran underwent a VA mental disorders examination in February 2012. He complained of two recent drunken driving arrests. He also explained that very recently he got drunk on a Saturday night and used up his VA compensation check. He said that was the first time he had done that in about a year. He was taking Abilify, Wellbutrin, Effexor, and Xanax. The VA examiner failed to check, or noted there were no, PTSD symptoms. On mental status examination, the Veteran was alert and fully oriented. His speech was normal. Thought content and process were unremarkable. Mood was mildly depressed with generally somewhat restricted effect. There was no observable responsiveness to internal stimuli. He denied hallucinations, delusions, and suicidal or homicidal ideation. The examiner also noted no observable impairment in attention, concentration, or memory. Diagnosis was PTSD with a GAF score ranging from 55 to 60 assigned. The examiner noted that the level of occupational and social impairment showed that a mental condition had been formally diagnosed, but the symptoms were reportedly not severe enough to interfere with occupational functioning while the social impairment was mild, or the rating criteria for a noncompensable rating under the General Rating Formula. In part because the same VA psychologist had examined the Veteran in both November 2008 and February 2012 and failed to explain why he assigned a lower GAF score in the latter examination, the Board found the February 2012 examination inadequate for rating purposes and remanded for a new VA mental examination. In an April 2012 signed statement the Veteran asserted that he constantly had flashbacks when he lost track of time up to two hours. According to a May 2012 VA medical record the Veteran reported residual mood swings. He found himself often crying and sleep, appetite, energy and motivation were often compromised. Concentration was poor. He denied any preoccupation with suicidal or homicidal thoughts. On mental status evaluation, his mood was dysphoric, affect was quite full range, no thought disorder was noted, short and long term memory were intact, and concentration was noted as normal. Diagnosis was PTSD with a GAF score of 60 assigned. The Veteran underwent a VA mental disorders examination in February 2013. He complained of inconsistent treatment due to doctors leaving. He said that he was seen about three times at the clinic in the past year and that his medication did not seem to be helping. He was currently taking Bupropion, Venlafaxine, Xanax, and Aripiprazole. His PTSD symptoms included chronic sleep impairment, which the Veteran thought had worsened over the past year; mild memory loss, such as forgetting names, directions, or recent events; some flashbacks; "up and down" emotions; excessive worry; avoidance of other people; and a feeling that he lost track of time. He denied ever contemplating suicide or homicide. He told the examiner that he remained with his fiancée of eight years in a rural subdivision and that after five marriages he was not in a hurry. While they used to fish, they had not done so in two years and he said they did not do much of anything now. He attended monthly meetings of the VFW, watched television, and took care of pets and chickens. He split housework with his fiancée's daughter and did the cooking and yard work. A four-year-old grandson also lived with them. In her review of the Veteran's record, the February 2013 VA examiner highlighted psychological testing administered during the November 2008 VA examination wherein one set of scores suggested mild PTSD symptoms while the other suggested any subjective report of symptoms was questionable and exaggerated. The VA examiner also noted the testimony of the Veteran and his fiancée during his Board hearing which suggested his overall mental health symptoms had worsened. The examiner noted that the Veteran's PTSD signs and symptoms were in the mild category. Social impairment was mild as the Veteran preferred interacting with a small number of people, but he was able to function well within that group and appeared to have a good relationship with the people in his home. As for occupational impairment, the VA examiner noted that the Veteran chose not to work outside the home but that his PTSD in and of itself would not prevent him from finding and maintaining gainful employment if he so desired. Diagnosis was chronic PTSD with a GAF score of 63 assigned. The February 2013 VA examiner suggested that the Veteran's level of occupational and social impairment was due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by medication, or the rating criteria for a 10 percent disability rating under the General Rating Formula. The Board finds that the Veteran's PTSD, for the period of this appeal, is manifested by no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as irritability, sleep impairment, and a depressed mood. The evidence of record does not show that the Veteran's PTSD symptoms more nearly approximated the criteria for the next higher rating of 50 percent, which requires occupational and social impairment with reduced reliability and productivity. While the Veteran exhibited some symptoms contained in the criteria for the assignment of a 50 percent rating, those symptoms were limited to some impairment of memory, such as forgetting to complete tasks, and disturbances in motivation and mood, according to the Veteran and his wife. The February 2013 VA examiner also noted the Veteran exhibited some mild memory loss, such as forgetting names, directions, or recent events, but that level or memory loss is indicative of a 30 percent rating. Otherwise, there was no objective evidence of symptoms analogous to those found in the General Rating Formula as suggestive of a 50 percent rating, such as difficulty in understanding complex commands; impaired judgment; stereotyped speech; flattened affect; panic attacks more than once a week; or difficulty in establishing and maintaining effective work and social relationships. In addition, information in the claims file shows that the Veteran lived at home with his fiancée, a stepdaughter and grandson, undertook volunteer activities for homeless veterans, and attended VFW meetings. The record also contains inconsistent evidence of suicidal ideation, which is associated with a higher 70 percent rating. During his July 2011 Board hearing the Veteran indicated that he had thought about suicide years before but never acted on it. All VA treatment records and examinations report the Veteran denied any suicidal ideation. In any case, the Board notes that during the period of this appeal, there was no objective evidence of the following symptoms or of any symptoms analogous to these criteria for a 70 percent rating: speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control and violence; spatial disorientation; and inability to establish and maintain effective relationships. The Board finds that the symptomatology described in the February 2013 VA examination, and in the VA medical records found in the claims file and the other VA mental examinations conducted during this appeal period, is more consistent with the rating criteria for a 30 percent rating than for any higher rating. The February 2013 VA examiner reported that the Veteran's PTSD symptoms were mild. The February 2013 VA examiner found that the Veteran's profile showed occupational and social impairment due to mild and transient symptoms which decrease work efficiency and the ability to perform occupational tasks only during periods of significant stress, or, symptoms controlled by continuous medication, which matches the language of the regulatory criteria for a 10 percent disability rating. However, the Board is only examined whether entitlement to a rating greater than 30 percent is warranted. The GAF score of 63 also reflected some mild symptoms. The examination report highlighted symptoms such as sleep impairment and irritability which do not support a rating greater than 30 percent. The Board also notes that the GAF scores assigned during the appeal period range from 55 to 65. Scores between 51 and 60 indicate moderate symptoms, and scores between 61 and 70 indicate only mild symptoms. For the most part, scores suggesting moderate symptoms were assigned during treatment while scores suggesting mild symptoms were assigned on formal examination. The Board is persuaded that the preponderance of the evidence supports the GAF scores that show the Veteran evidenced moderate to mild symptoms, which are indicative of his current 30 percent rating. The Board has considered the assertions of the Veteran and his fiancée that his PTSD disability warrants a higher rating. He is competent to report that his symptoms are worse. Layno v. Brown, 6 Vet. App. 465 (1994). However, in rating a claim for an increased schedular disability rating, VA must consider the factors enumerated in the rating criteria, which in part involves the examination of clinical data gathered by competent medical professionals. Massey v. Brown, 7 Vet. App. 204 (1994). While the Veteran and his fiancée are competent to report that his symptoms are worse, the training and experience of medical personnel makes the medical findings found in VA treatment notes and VA examinations more probative as to the extent of the disability. Cromley v. Brown, 7 Vet. App. 376 (1995). Consideration has been given to assigning a further staged rating for this claim. However, at no time during the time period on appeal have the Veteran's PTSD symptoms warranted the assignment of a rating higher than assigned. Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The Board finds that the preponderance of the evidence is against the assignment of a rating greater than 30 disability rating for PTSD during the period of this appeal. Finally, the Board finds that the Veteran's PTSD disability does not warrant referral for extraschedular consideration. In exceptional cases where schedular rating are found to be inadequate, consideration of an extraschedular rating is made. 38 C.F.R. § 3.321(b)(1) (2012). There is a three-step analysis for determining whether an extraschedular evaluation is appropriate. First, there must be a comparison between the level of severity and symptomatology of the Veteran's service-connected disability and the established criteria found in the rating schedule to determine whether the Veteran's disability picture is adequately contemplated by the rating schedule. If not, the second step is to determine whether the claimant's exceptional disability picture exhibits other related factors identified in the regulations as governing norms such as causing marked interference with employment or frequent periods of hospitalization. 38 C.F.R. § 3.321(b)(1) (2012). If those factors are found, the third step is to refer the case to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for a determination whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Thun v. Peake, 22 Vet. App. 111 (2008). The rating criteria are not inadequate in this case. The Veteran does not meet the schedular criteria for a 50 percent rating in the time period examined in this appeal. However, the Veteran has filed a separate claim for a TDIU claiming interference with employment, which is discussed below. TDIU All veterans who are shown to be unable to secure and follow a substantially gainful occupation by reason of service-connected disability shall be rated totally disabled. Total disability will be considered to exist when there is presented any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340 (2012). If the schedular rating is less than total, a total disability rating can be based on individual unemployability if the veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. 38 C.F.R. § 4.16 (2012). Where a veteran meets the schedular criteria for consideration of unemployability under 38 C.F.R. § 4.16(a), the only remaining question is whether the veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities. 38 C.F.R. § 4.17 (2012). If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides a rating of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341 (2012). In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability, and to the effects of combinations of disability. 38 C.F.R. § 4.15 (2012). The Veteran has applied for TDIU benefits due to his service-connected PTSD, but his representative insists in his May 2013 informal hearing presentation that TDIU should be awarded due to all of the Veteran's service-connected disabilities. The Veteran is currently service connected for cystic and chloracne of the face, neck, and back, rated 60 percent; PTSD, rated 30 percent; moderately disfiguring scars of the face, residuals of acne, rated 10 percent; and a scar of the right hand, status post laceration, rated 0 percent. His combined service-connected disability rating is 80 percent. Because the Veteran has one disability rated 60 percent, he meets the minimum schedular percentage standards for consideration of a TDIU are met. 38 C.F.R. § 4.16(a) (2012). The remaining question before the Board, therefore, is whether the Veteran is unable to secure or follow a substantially gainful occupation by reason of his service-connected disabilities alone, taking into consideration his educational and occupational background. The fact that a Veteran is unemployed is not enough. The question is whether his service-connected disabilities, without considering nonservice-connected disabilities or lack of work skills or advancing age, made him incapable of performing the acts required by employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). On the Veteran's Application for Increased Compensation Based on Unemployability received in August 2008, the Veteran reported that he had been unemployed since becoming disabled due to PTSD in January 2007. It was noted that he had worked full-time as a truck driver from 1998 to 2001 and then worked part-time in maintenance at a car wash from 2003 to 2007. Shelton Trucking reported that the Veteran had only worked 18 months and was terminated. The Veteran also indicated that he could not handle day-to-day contact with the public and fellow employees. He reported that he had completed high school, but did not report any post-secondary vocational schooling. The record shows that the Veteran is currently 63 years old. In addition to his service-connected disabilities, the record shows that the Veteran has several non-service connected disabilities, to include chronic prostatitis, benign hypertrophy of prostate without urinary obstruction, chronic kidney disease (Stage I), sleep apnea, folliculitis, low back pain, hypertension, osteoarthritis of the hip, hyperlipidemia, lumbar intervertebral disc disorder with myelopathy, displacement of cervical intervertebral disc without myelopathy, and chronic obstructive pulmonary disease (COPD). Information from VA's vocational rehabilitation office shows that the Veteran applied for benefits several times after discharge. His case was suspended with counseling in late 1980 after he sought assistance to become a truck driver. He said that he had completed auto mechanic school, but found that he could no longer bend over cars as a result of a back problem. He also noted that grease and grime aggravated his service-connected acne problem. He was counseled against truck driving out of concern for his back problems. The possibility of computer programming was discussed. In 1984, the Veteran again applied for benefits after the Missouri Division of Vocational Rehabilitation had trained him for over-the-road truck driving. However, he was not able to pass the physical and sought further training. VA found then that the Veteran was beyond his 12-year termination date for the program. Even though he had limitations that would contribute to an employment handicap, the counseling psychologist found that it could not be demonstrated through the Veteran's prior employment history that his back disorder constituted a serious handicap to employment. It was recommended that the state retrain him. In 1989, the Veteran was approved for job training under the Emergency Job Training Act of 1983 with a film developer. In 2009, the Veteran applied for VA vocational rehabilitation benefits but failed to appear for an appointment or contact the office for rescheduling. In his November 2008 VA mental examination, the VA examiner opined that the Veteran's individual unemployability was not caused by or a result of his service-connected PTSD. The VA psychologist noted that, based on his symptoms of PTSD exclusively, the Veteran appeared capable of being gainfully employed at a wide variety of occupations. In his February 2009 notice of disagreement the Veteran stated that he had left his last job at a car wash because of his inability to function normally with other personnel. He stated that he had worked at trucking companies before the car wash and that he had problems in those jobs dealing with people and that he had gone from job to job. He also said that he had tried to obtain other employment, but had not been successful. According to a February 2009 VA psychiatric clinic record, the Veteran reported that he was seeking a TDIU because it was difficult for him to deal with other people on any kind of level. He was easily angered and upset and said he could not get along due to his PTSD symptoms. He said that he had not worked in the past two years, but his last job was at a car wash where he basically picked up trash. A previous job as a truck driver was solitary, but he was unable to continue when he became too irritated by other drivers. He did not think it safe to continue to operate a large vehicle in that frame of mind. A September 2010 VA examination noted that the Veteran had a 2 centimeter by 0.1 centimeter scar on the right hand that was superficial but not tender. No functional limitation of motion was noted. During his Board hearing in July 2011, the Veteran testified that he last worked in approximately 2006 for a car wash. He said that he left on his own because he could not handle dealing with customers. Since discharge from service, he said that he had worked as an auto mechanic, a truck driver off and on for 30 years, a cook, a pipe fitter, and a welder. He said that he took the maintenance job at the car wash after he quit truck driving due to irritability. The Veteran testified that he was never fired from a job but that he quit jobs because he got fed up with what he had to deal with. Under questioning about working a full-time job for 40 hours, the Veteran testified that he had applied for and been turned down for work three times in the last four years, but that he thought he could maintain attendance. He was sure he could not interact with customers, but could interact with supervisors or co-workers. His fiancée, a certified nurse's aide at a VA facility, was dubious that the Veteran could engage in gainful employment because she said the Veteran could not concentrate long enough to finish projects. The Veteran underwent a VA employability examination in February 2012. It was noted that the Veteran had quit his last job in January 2007 in maintenance at a car wash. He told the examiner that he quit due to PTSD because he could not handle people and customers any longer. No functional limitations were noted for any of the service-connected disabilities. The February 2012 VA employability examiner also found that none of the service-connected disabilities prevented the Veteran from securing or following a substantially gainful occupation. The examiner stated that, based on his service-connected disabilities alone, the Veteran was capable of sedentary to moderate physical duty employment, if he so chose. In an April 2012 signed statement the Veteran asserted that problems with his short-term memory were difficult enough to prevent him from obtaining or holding a job. In his February 2013 VA mental examination, a VA psychiatrist opined that individual unemployability was less likely than not caused by or a result of the PTSD. She explained that from the perspective of his documented and subjectively reported PTSD symptoms exclusively, excluding age and physical health considerations, the Veteran did not appear to be unemployable according to VA criteria. Functional impairments which would mildly affect his ability to maintain gainful employment, either physical or sedentary, included sleep impairments and a preference to avoid other people. However, the examiner found that those considerations did not preclude the Veteran from working if he so desired. The report of examination noted that the Veteran had worked as a long haul truck driver off and on for 30 years until he stopped driving in 2000. He then worked in a car wash doing maintenance and cleaning for about five years but stopped that in 2005. He told the examiner that he was tired of putting up with the people who came in to wash their cars. As he was able to retire without financial worries, he did. In light of the foregoing, the Board finds that the preponderance of the evidence does not show that the Veteran is unable to secure and follow substantially gainful employment by reason of his service-connected disabilities. Although the Veteran contends that he could not work because of his service-connected PTSD, the Board finds no objective medical evidence that any of the Veteran's four service-connected disabilities currently render him unemployable, or that they do so in conjunction with each other. The February 2012 and February 2013 VA examiners opined that the Veteran's disabilities, including PTSD, did not currently prevent the Veteran from employment. The Board acknowledges that the Veteran undoubtedly has some limitations due to his service-connected disabilities, especially his mild memory loss and preference for isolation within the family. However, those factors have been contemplated by the disability rating assigned for his service-connected PTSD. The fact that a veteran is unemployed or has difficulty obtaining employment is not sufficient, in and of itself, to establish unemployability. The relevant question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether he can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). In recognition of the severity of his service-connected disabilities, the Veteran is currently rated as 80 percent disabled. However, the Board cannot conclude that the Veteran's service-connected disabilities alone produce unemployability, based on an analysis of the evidence. The Board finds that the record does not demonstrate that the Veteran's service-connected disabilities actually preclude him from engaging in substantially gainful employment and that he is not totally disabled due to his service-connected disabilities. The Board has considered the statements of the Veteran and his fiancée that he is unable to participate in gainful employment due to his service-connected mental disorder. However, the evidence overall does not support those subjective contentions. The medical evidence of record indicates that the Veteran has mild PTSD signs and symptoms that would not preclude any gainful employment, physical or sedentary. The Board may not consider nonservice-connected disorders. There is also no medical opinion of record to support the Veteran's assertions. Further, the Veteran testified that he could not interact with customers in a future job, but did not deny he could interact with supervisors or co-workers or maintain adequate attendance over the period of a year. He testified that he has applied for work and been rejected three times. While the Veteran contends that he was unable to work due solely to his service-connected disabilities, the Board finds that the preponderance of the evidence is against a finding that the Veteran is unable to secure or follow a substantially gainful occupation solely by reason of service-connected disability. The Board finds that VA examinations to be more persuasive than the contentions of the Veteran and his fiancée. Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's claim for TDIU and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to a rating in excess of 30 percent for PTSD is denied. Entitlement to a total disability rating based upon individual employability due to service-connected disabilities is denied. ____________________________________________ Harvey P. Roberts Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs