Citation Nr: 1322528 Decision Date: 07/15/13 Archive Date: 07/24/13 DOCKET NO. 05-18 827 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) for the period prior to May 13, 2008. 2. Entitlement to a rating in excess of 70 percent for PTSD for the period beginning on May 13, 2008. 3. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD L. A. Rein, Counsel INTRODUCTION The Veteran served on active duty from August 1968 to November 1972. These matters on appeal before the Board of Veterans' Appeals (Board) arise from a June 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, that denied a rating in excess of 50 percent for the Veteran's service-connected PTSD. In November 2008, March 2011 and October 2012, the Board remanded these matters for additional development actions. In a January 2010 rating decision, the RO granted a higher 70 percent rating for PTSD, effective May 13, 2008. However, as higher ratings are available for both periods, the claim for an increased rating for PTSD remains on appeal. AB v. Brown, 6 Vet. App. 35 (1993). In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. The issue of entitlement to TDIU is raised by the record. Therefore, this issue is included on appeal, as noted on the title page. FINDINGS OF FACT 1. For the period prior to May 13, 2008, the evidence shows that the Veteran's PTSD symptoms are indicative of occasional occupational and social impairment with reduced reliability and productivity due to such symptoms as chronic sleep impairment, nightmares, intrusive thoughts, flashbacks, depression, exaggerated startle response, and some panic attacks. Occupational and social impairment with deficiencies in most areas and inability to establish and maintain effective relationships are not demonstrated. 2. For the period beginning on May 13, 2008, the evidence shows that the Veteran's PTSD symptoms are indicative of occupational and social impairment with deficiencies in most areas and inability to establish and maintain effective relationships due to such symptoms as chronic sleep disturbance, depressed mood, anxiety, intermittently having suicidal ideation, exaggerated startle response, flashbacks, panic attacks, nightmares, impulsive/reckless/aggressive behaviors, and impaired judgment and insight. Symptoms that are commingled with non service-connected psychiatric and pain symptoms, which are also considered in the 70 percent disability rating for PTSD include difficulty concentrating, disturbances of motivation and mood, and difficulties establishing and maintaining effective social and work relationships. Symptoms of total occupational and social impairment have not been demonstrated. 3. The Veteran has one service-connected disability, his PTSD, rated as 50 percent disabling, for the period prior to May 13, 2008. Hence, for this period, the Veteran's does not meet the minimum percentage requirements for an award of a TDIU and his service-connected PTSD disability is not shown to prevent him from obtaining or retaining substantially gainful employment. 4. For the period beginning on May 13, 2008, the Veteran service-connected PTSD disability is rated as 70 percent disabling, and, thus, meets the minimum percentage requirements for an award of a TDIU. However, the evidence does not support a finding that the Veteran's service-connected PTSD disability prevents him from obtaining or retaining any form of substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 50 percent for service-connected PTSD for the period prior to May 13, 2008, have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.159, 3.321, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for a disability rating in excess of 70 percent for service-connected PTSD for the period beginning on May 13, 2008, have not been met. 38 U.S.C.A. §§ 1155 , 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102 , 3.159, 3.321, 4.1, 4.3, 4.7, 4.130, Diagnostic Code 9411 (2012). 3. The criteria for entitlement to a TDIU have not been met during any period on appeal. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102 , 3.340, 3.341, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to notify and assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice 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 the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (2012); Pelegrini v. Principi, 18 Vet. App. 112 (2004). If VA does not provide adequate notice of any of element necessary to substantiate the claim, or there is any deficiency in the timing of the notice, the burden is on the claimant to show that prejudice resulted from a notice error, rather than on VA to rebut presumed prejudice. Shinseki v. Sanders, 129 S.Ct. 1696 (2009). The Board finds that any defect with regard to the timing or content of the notice to the appellant is harmless because of the thorough and informative notices provided throughout the adjudication and because the appellant had a meaningful opportunity to participate effectively in the processing of the claim with an adjudication of the claim by the RO subsequent to receipt of the required notice. The record does not show prejudice to the appellant, and the Board finds that any defect in the timing or content of the notices has not affected the fairness of the adjudication. Mayfield v. Nicholson, 19 Vet. App. 103 (2005); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Specifically, the Veteran was notified in letters dated in May 2004, October 2008, and in March 2011. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board considers it significant that the subsequent statements made by the Veteran and his representative suggest actual knowledge of the elements necessary to substantiate the claim. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (actual knowledge is established by statements or actions by the claimant or the claimant's representative that demonstrate an awareness of what is necessary to substantiate a claim). Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the most recent May 2013 supplemental statement of the case. Overton v. Nicholson, 20 Vet. App. 427 (2006) (Veteran afforded a meaningful opportunity to participate effectively in adjudication of claim, and therefore notice error was harmless). The Board also finds that the duty to assist requirements have been fulfilled. All relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. The Board notes that the RO requested records for VA inpatient hospitalization in November 2008 as identified by the Veteran; however, in an April 2011 response the Fayetteville VA medical center advised the RO that there were no records for the Veteran at that time. In July 2011, the RO issued a formal finding of unavailability. The Board also notes that in November 2012, in response to VA's request for records, the Social Security Administration advised that medical records requested do not exist as they had been destroyed. VA has also obtained several examinations with respect to the claims on appeal. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist him in development. 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). II. Increased ratings Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular Diagnostic Code (DC), the higher rating is assigned if the disability more closely approximates the criteria for the higher rating; otherwise, the lower rating applies. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is to be considered when assigning disability rating. 38 C.F.R. § 4.1 (2011); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (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, 509-510 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When rating a mental disorder, VA must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the claimant's capacity for adjustment during periods of remission. VA shall assign a rating 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). When rating the level of disability from a mental disorder, VA will consider the extent of social impairment, but shall not assign an rating solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2012). The Board reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all of the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claim file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Veteran's service-connected PTSD is currently assigned a 50 percent rating for the period prior to May 13, 2008, and 70 percent for the period beginning on May 13, 2008 pursuant to 38 C.F.R. § 4.130 , Diagnostic Code 9411. A General Rating formula for evaluating psychiatric impairment other than eating disorders contains the actual rating criteria for evaluating the Veteran's disability. Pursuant to the General Rating Formula for Mental Disorders, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for 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); inability to establish and maintain effective relationships. A rating of 100 percent is warranted 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. 38 C.F.R. § 4.130 , General Rating Formula for Mental Disorders (2012). Period prior to May 13, 2008 A May 2004 VA examination report reflects that the Veteran presented with fair grooming and poor personal hygiene. Interpersonally, he was alert and cooperative. Eye contact, mannerisms, facial expressions, and motor activity were all normal. Observed quality of mood was euthymic with full affect. The Veteran stated he was having more dreams, about three to four nights weekly. He had woken up with the sheets soaked three to four nights a week. The Veteran stated that he has no energy and is having decreased sleep. The Veteran indicated that he was not in therapy other than for medication management. Current medications are amitriptyline, sertraline, and gabapentin. There have been no hospitalizations since his last VA examination. Although the Veteran indicates that his symptoms have worsened, there has not been a coinciding medication increase per his report. The Veteran has not worked since September 2003 and per his report, he has been unable to work due to his arthritis in that he cannot use his arms and hands. The Veteran lives alone and moved to Fayetteville to be closer to his family who help get him to his doctor's appointment. He likes to play bingo and spend time with his father. He has grandchildren that he enjoys for a while, but has trouble with relationships because people get on his nerves very easily. The VA examiner reported that there was no impairment in thought, communication or speech processes. There were no attention or memory problems noted throughout the interview. The Veteran is doing his own cooking and cleaning. He manages his finances independently. During the period of a week, the Veteran stated that he was having two to three good days. The diagnosis was PTSD and a GAF score of 45 was assigned. A July 2004 VA medication evaluation report reflects that the Veteran had some sleeping problems, appetite fluctuated, and he felt depressed. At times, self-injurious thoughts crossed his mind, but he would not act on them because of his family. He currently denied any suicidal or homicidal ideation or hallucination. Mental status examination revealed that the Veteran was casually dress, cooperative and made fair eye contact. No obvious psychomotor agitation or retardation, no abnormal involuntary movement. Speech was normal in rate and volume. Mood was "depressed." Affect was congruent with mood. Thought processes were mostly goal directed, no FOI no LOA, no obvious delusion, currently denied auditory or visual hallucinations or suicidal or homicidal ideation or plan. He was oriented times three with fair insight. The impression was chronic PTSD with depressive features and nicotine dependence. A GAF score of 55 was assigned. It was recommended that the Veteran was to continue Sertraline and Neurontin. In his May 2005 substantive appeal (via a VA form 9), the Veteran asserted that he has panic attacks two to three times a week and wakes up sweating of bad dreams. He stated that he was unable to seek employment because no one is going to hire him with this problem. He also contended that he had problems with his long and short term memory, in that if he doesn't write things down, he forgets to do them. The Veteran stated that his medications had been increased because of his moods and relationships with his ex wife and friends. He tends to be a loaner and wants to avoid people. He feels that everyone is out to get him. VA mental health records include an April 2007 VA mental health consultation report reflects that the Veteran felt that people were talking about him and he did not like it. He accepts feeling depressed, slept irregularly, and has nightmares about stuff from Vietnam. He has flashbacks from Vietnam. He is startled by sound, is lonely and gets away from everything, is irritable, and gets angry easily. He has been married five times. He has his own home. On mental status examination, the Veteran's speech was slow, clam, and cooperative. He was apathetic and appropriate answered questions. His mood was depressed, affect was constricted, paranoid thought, with no evidence of hallucinations. He denied suicidal or homicidal ideations. He was oriented to person, place, time, and purpose and was alert. He had normal concentration, insight/judgment, and normal memory. The diagnosis was PTSD, chronic, and major depressive disorder with psychotic features. A GAF score of 45 was assigned. A May 2007 VA mental health clinic record reflects that the Veteran stated he had nightmares and flashbacks once in a while. He sleep four to five hours a night. He was alert and oriented times three. His mood was withdrawn and affect was constricted. He had no auditory or visual hallucinations. No thought disorder, paranoid, suicidal or homicidal ideations. He exhibited good impulse control and judgment and has insight. He was to continue with 20 milligrams of Prozac. With regard to the period prior to May 13, 2008, the Board finds that a 50 percent disability rating accurately reflects the impairment imposed upon by the Veteran by his service-connected PTSD. The Board finds that for the period prior to May 13, 2008, the Veteran's service-connected psychiatric disability is manifested by chronic sleep impairment, nightmares, intrusive thoughts, flashbacks, depression, exaggerated startle response, some panic attacks with passing thoughts of hurting himself with no intent or plan. The reported symptomatology during this period is consistent with no more than moderate symptoms or moderate difficulty in social, occupational, or school functioning. The Veteran has friends and family that he socializes and thought processes were goal oriented. Collectively, the Board finds that symptomatology approximates occupational and social impairment with reduced reliability and productivity, the criteria for a 50 percent disability rating. The Board also notes that the Veteran has not been found to have 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); or an inability to establish and maintain effective relationships or more severe symptomatology such as to warrant at least the next higher 70 percent rating during the time for which service connection has been established. In addition to the absence of most of the symptoms listed as characteristic of occupational and social impairment with deficiencies in most areas (criteria for a 70 percent rating), the Board also notes that none of the assigned GAF scores, alone, support the assignment of any higher rating. Symptomatology commensurate with a 100 percent schedular evaluation, demonstrating total occupational and social impairment, is likewise, also not shown. The Veteran has been assigned GAF scores of 45 and 55. According to DSM-IV, GAF scores between 51 and 60 denote 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 of 41-50 denotes serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning . The reported symptomatology is consistent with no more than moderate to moderately severe symptoms or difficulty in social, occupational, or school functioning, in this regard, the Veteran had family that he socialized with and enjoys leisure activities, to include bingo. The Board finds that collectively, the GAF scores assigned are consistent with a 50 percent rating. In addition, the Board finds that the evidence does not show during any time prior to May 13, 2008 that he has had occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to his psychiatric symptoms. Period beginning on May 13, 2008 VA medical records show that the Veteran was hospitalized on May 13, 2008, after presenting to the emergency room with complaints of depression and suicidal ideation with no specific plan. He admitted to using cocaine. He drinks beer every day. He denied auditory and visual hallucinations, delusions of persecution and grandiosity. Admitting and discharge diagnoses included depressive disorder, NOS, substance abuse, cocaine, alcohol, and marijuana. Treating mental health records during VA hospitalization reflect that the Veteran did not have suicidal or homicidal ideations or plans. He had mild impairments as to anxiety, PTSD related nightmares, thought content, impulsive/reckless/aggressive behaviors, judgment and insight and medication noncompliance. He had moderate impairments with substance abuse and social/marital/family problems. He had no impairments as to mood disturbance, thought process ,memory, weight loss, speech, legal, goring or violence risk. A GAF score of 40 was assigned at the time of admission and a GAF score of 60 was assigned at the time of discharge. A social work assessment undertaken during his VA hospital admission reflects that the Veteran admitted feeling "like he needed to talk to somebody. [He] lost everything, my girlfriend, wife." The Veteran was separated from his wife and lost his girlfriend of five years, 6 months ago. The Veteran stated that he had no mental health therapist. He vented feelings to being rejected. He has been alone for the past eight months. He reported getting some comfort from his grand children. He had been having suicidal thoughts with no plan and a friend removed any guns he had in the home. The Veteran lives in a trailer behind his father's house. He has 2 children. He stated that his father is very supportive. He helps his father in building projects. The Veteran's is a carpenter and has been self employed "off and on." He was last in business for himself three months earlier. The Veteran drinks about a 6 pack of beer each day and used powdered cocaine the day before his admission. The Veteran was oriented to person, place, time, and situation. His memory was intact. No auditory or visual hallucinations. He reported feelings of helplessness and rejection related to his relationships. A June 2009 VA examination report reflects that the Veteran is diagnosed with PTSD, chronic, and assigned a GAF score of 50. The Veteran reported reexperiencing symptoms including nightmares and olfactory hallucinations that are consistent with flashbacks. He also has an exaggerated startle response. He avoids stressful situations and social encounters with people outside his group of friends and family. He had been intermittently suicidal and had been hospitalized on a psychiatric unit in the past 6 months. The Veteran has nightmares two times a week and that are severe and wake him up from sleep. His mood is chronically low with periods of having passive suicidal thoughts. In 2011, the Veteran was hospitalized at the VA for an unrelated medical condition. He was afforded an inpatient psychiatric evaluation at that time. The Veteran indicated that he occasionally had flashbacks and trauma nightmares, but has not had any significant problems in a long time. He still has occasional dreams of his service. He denied feeling on edge, being easily startled or any sleep disturbance. A December 2012 VA examination report reflects that the Veteran meets the diagnosis for anxiety disorder, not otherwise specified (mixed anxiety-depressive disorder; partial PTSD). The examiner commented that based upon a review of recent treatment records and the current examination, does not meet the full DSM-IV criteria for PTSD, but that of mild to moderate anxiety and depressed mood. The anxiety disorder, NOS, diagnosis given here reflects more accurate DSM-IV clarification of the Veteran's service-connected PTSD condition and is judged to be at least as likely as not a continuation of his service-connected psychiatric condition, albeit, improved from fully diagnostic PTSD. The VA examiner also opined that the Veteran has a long standing history of pain difficulties associated with arthritis that, based upon the record, are as least as likely as not exacerbated and/or maintained by non-PTSD/anxiety disorder, NOS psychological factors (i.e. personality variables and addiction/medication-seeking behaviors). The VA examiner opined that the Veteran's opiod and cocaine use/abuse behavior is more likely than not associated with is pain disorder condition, while his cannabis, alcohol and tobacco use/abuse behavior are as least as likely as not associated with his anxiety disorder, NOS and/or pain disorder conditions. A GAF score of 55 was assigned. The examiner stated that the score reflects an average of daily, global functioning over the most recent 1 year period and the combination of conditions diagnosed above. The VA examiner stated that the Veteran has more than one mental disorder diagnosed and that it is possible to differentiate the symptoms attributable to each diagnosis. The Veteran's anxiety disorder, NOS symptoms, include all PTSD criterion in A, B & C symptoms, anhedonia, decreased appetite, anxiety and depressed mood. Those associated with the non service-connected pain disorder include fluctuating arthralgia (associated with mood change/dimunition), chronic sleep impairment, and fatigue. Symptoms that are commingled include difficulty concentrating, disturbances of motivation and mood, and difficulties establishing and maintaining effective social and work relationships. The VA examiner indicated that the Veteran had occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The examiner indicated that it was not possible to differentiate what portion of the occupational and social impairment was caused by each mental disorder. The Veteran currently resided with a girlfriend of four years in a mobile home trailer provided by family members. He has two adult children and his relationship with them is relatively positive, and he routinely gets together with his siblings and extended family during the major holidays. He loves seeing his 11 grandchildren. He described problems with relationships ever since returning from Vietnam. A typical day for the Veteran involves "puttering around the house, cutting the grass, raking the year, watching television, and then napping." The Veteran stated his primary occupation to be that of a carpenter and building contractor. He stopped working in 2003 due to increasing problems with arthritic pain. The Veteran had recurrent and distressing recollection of the traumatic event in service as well as recurrent distressing dreams. He made efforts to avoid thought, feeling or conversations associated with the trauma and avoided activities, places, or people that arouse recollection or the trauma. He had a sense of a foreshortened future. He had difficulty concentrating. The examiner indicated that the Veteran's PTSD symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. The Veteran had depressed mood, anxiety, chronic sleep impairment, disturbance of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. He also has anehedonia, decreased appetite, and fatigue. Psychological testing endorsed the presence of anxiety symptoms and mild depressive symptoms included loss of pleasure, loss of interest, indecisiveness, decreased appetite, concentration difficulty, and loss of interest in sex. Suicidal ideation and/or intent was denied. The VA examiner opined that the Veteran's psychiatric diagnoses of anxiety disorder, NOS, chronic pain disorder, and polysubstance abuse/dependence would not be sufficient by themselves (separate from the Veteran's claimed non service-connected arthritis condition) to be significant enough in severity to completely precluded physical or sedentary employment. For the period beginning on May 13, 2008, to the present, the Board finds that the Veteran's PTSD symptoms fall within the criteria for a 70 percent disability rating. In this regard, the May 13, 2008, VA hospital record provides the initial evidence that the Veteran's PTSD symptoms have increased in severity during the appeal period to warrant inpatient hospitalization of symptoms. Collectively, the evidence shows that during this period, the Veteran's PTSD symptoms include: chronic sleep disturbance, depressed mood, anxiety, intermittently having suicidal ideation, exaggerated startle response, flashbacks, panic attacks, nightmares, impulsive/reckless/aggressive behaviors, and impaired judgment and insight. Symptoms that are commingled include difficulty concentrating, disturbances of motivation and mood, and difficulties establishing and maintaining effective social and work relationships, these symptoms are also considered in determining that a 70 percent disability rating is appropriately assigned during this period on appeal. See Mittleider v. West, 11 Vet. App. 181(1998) (where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the veteran's service-connected disability). However, the symptoms associated with the Veteran's PTSD do not meet the criteria for the maximum, 100 percent, rating. As noted above, a 100 percent rating requires total occupational and social impairment due to certain symptoms; however, the Board finds that neither the delineated symptoms nor comparable symptoms are shown to be characteristic of the Veteran's PTSD. Evidence of record does not indicate that the Veteran has exhibited persistent delusions; grossly inappropriate behavior; 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. Indeed, as noted throughout the record, the Veteran has a good relationship with his children and grandchildren and that he socializes, even if to a limited extent, with family. Therefore, he is shown to be able to be around other people, even if to a limited degree. In addition, while the Veteran has mildly impaired memory, he has not been found to have any memory loss for names of close relatives, his prior occupation, or his own name. The Veteran has not been deemed unemployable due to his PTSD symptoms. In sum, the psychiatric symptoms shown do not support the assignment of the maximum, 100 percent, schedular rating. Likewise, the Board also notes that the GAF score of 40 assigned on admission to the hospital in May 2008 is largely consistent with the assignment of a 70 percent disability rating. While the GAF score of 55 assigned at the time of the December 2012 VA examination appears to reflect less impairment than is contemplated by a 70 percent rating, the score of 40 appear more consistent with the veteran's current level of disability. According to the DSM-IV, a GAF score of 31 to 40 is indicative of some impairment in reality testing or communication, or major impairment in several areas, such as work, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). Thus, the GAF score of 40, when considered with the veteran's reported symptoms and other objective clinical findings, indicates that the veteran's PTSD results in no more impairment than is contemplated by the current 70 percent rating. The above determinations are based on application of pertinent provisions of VA's rating schedule. Additionally, the Board finds that at no point during either period on appeal has the Veteran's service-connected PTSD been shown to be so exceptional or unusual as to warrant the assignment of any higher rating on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2012). In this regard, there is no evidence of an exceptional or unusual disability picture with related factors, such as marked interference with employment or frequent periods of hospitalization, so as to warrant referral of the case to appropriate VA officials for consideration of an extra schedular rating for these issues. See Shipwash v. Brown, 8 Vet. App. 218 (1995). Here, while the record reflects that the Veteran was hospitalized in may 2008 due to suicidal ideations presumed associated with his service-connected PTSD, such hospitalization and associated symptoms were the basis for the increase in a disability rating to 70 percent, the date of the Veteran's admission for VA hospitalization. No further hospitalizations for the Veteran's service-connected PTSD are shown by the evidence of record Further, there is no objective evidence revealing that his PTSD alone caused marked interference with employment, e.g., employers' statements or sick leave records, beyond that already contemplated by the schedular rating criteria. In this regard, the Veteran has consistently indicated that he is unable to be employed due to his non service-connected arthritis, and that he could probably do a desk job. Further, the December 2012 VA examiner opined that despite the Veteran's service-connected PTSD, such would not prevent sedentary employment. In this case, the Board finds that the schedular criteria are adequate to rate the Veteran's PTSD under consideration during both periods on appeal. The rating schedule fully contemplates the described symptomatology, and provides for ratings higher than those assigned. Thus, the threshold requirement for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) is not met. See Thun v. Peake, 22 Vet. App. 111 (2008). III. TDIU It is the established policy of VA that all Veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A finding of total disability is appropriate "when there is present 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(a)(1), 4.15. A TDIU 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. 38 C.F.R. §§ 3.340 , 3.34l, 4.16(a). In exceptional circumstances, where the Veteran does not meet the aforementioned percentage requirements, a total rating may nonetheless be assigned upon a showing that the individual is unable to obtain or retain substantially gainful employment. 38 C.F.R. § 4.16(b) . The Veteran reports that he is unable to maintain substantially gainful employment due to his service-connected PTSD, which is his only service-connected disability, and as discussed above, is rated as 50 percent for the period prior to May 13, 2008 and 70 percent thereafter. Initially, the Board notes that while the Veteran meets the minimum percentage requirements for consideration of a TDIU pursuant to 38 C.F.R. § 4.16(a) for the period beginning on May 13, 2008, he fails to meet the minimum requirements prior to that period. However, a total rating, on an extra-schedular basis, may nonetheless be granted, in exceptional cases (and pursuant to specifically prescribed procedures), when the Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities (per 38 C.F.R. § 4.16(b) ). Hence, consideration of whether the Veteran is, in fact, unemployable, is still necessary in this case, whether for the period prior to or beginning on May 13, 2008. 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 (2012); see also Van Hoose v. Brown, 4 Vet. App. 361 (1993). Here, the preponderance of the evidence is against a finding that the Veteran is unable to secure and follow a substantially gainful occupation as a result of his service-connected PTSD whether for the period before May 13, 2008, or thereafter. In this regard, the Veteran has consistently reported that he stopped working and was unable to obtain employment due to his non service-connected arthritic condition. In fact, during the May 2004 VA examination, the Veteran stated that he had not worked since September 2003 due to his arthritis in that he cannot use his arms and hands. Moreover, there is no medical evidence that the Veteran is unable to secure and follow a substantially gainful occupation due to his service-connected PTSD. In this regard, the December 2012 VA examiner opined that the Veteran's psychiatric diagnoses would not be sufficient by themselves (separate from the Veteran's claimed non service-connected arthritis condition) to be significant enough in severity to completely precluded physical or sedentary employment. Although the Board has considered the Veteran's assertions as well as his representative's in this appeal, there is no medical evidence indicating that his service-connected PTSD, alone, renders him unable to obtain or retain substantially gainful employment; therefore, the Board must conclude that the criteria for invoking the procedures of 38 C.F.R. 4.16 (b), for assignment of a TDIU, on an extra-schedular basis, are not met. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, the Board has carefully considered the lay evidence offered by the Veteran in the form of his correspondence to VA, his statements to various medical providers and statements offered by his representative. The Veteran has asserted that his service-connected PTSD materially and significantly contribute to his unemployability; however, such contentions are not supported by the objective evidence of record. As noted above, the Veteran has often stated that he thought he could work in an office environment of that due to his non service-connected arthritis, he was unable to work. Such statements support a finding that the Veteran's non service-connected arthritis impacted his ability to obtain or retain gainful employment. Accordingly, even affording the Veteran full competence and credibility, his proffered lay evidence does not show entitlement to a TDIU. Based on the evidence and analysis above the Board finds the Veteran's single service-connected PTSD disability is not sufficient by itself to preclude him from obtaining or maintaining any form of substantially gainful employment consistent with his education and industrial background. Accordingly, the criteria for a TDIU are not met and the claim must be denied. ORDER A rating in excess of 50 percent for PTSD for the period prior to May 13, 2008, is denied. A rating in excess of 70 percent for PTSD for the period beginning on May 13, 2008, is denied. Entitlement to a TDIU is denied. ____________________________________________ FRANK J. FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs