Citation Nr: 1323928 Decision Date: 07/26/13 Archive Date: 08/06/13 DOCKET NO. 11-11 560 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial evaluation in excess of 70 percent for service-connected obsessive-compulsive disorder (OCD) for the period prior to February 14, 2012 and for the period since December 27, 2012. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD James A. DeFrank, Counsel INTRODUCTION The Veteran served on active duty from November 1958 to November 1960. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio which implemented the Board's January 2010 decision which granted service connection for OCD and assigned a noncompensable rating based on aggravation as of July 20, 2001. (It was noted that "[p]rior to aggravation by a service connected condition, the disability was considered 70 percent disabling. . .") The appeal also arises from a July 2010 rating decision which denied the Veteran's claim for TDIU. In an October 2012 decision, the Board remanded these issues for additional development. In a February 2013 rating decision, the Appeals Management Center (AMC) increased the Veteran's disability evaluation for OCD to a 70 percent rating effective July 20, 2001, a 100 disability rating effective February 14, 2012 and a 70 percent rating effective December 27, 2012. (It appears that the RO ultimately determined that "...the aggravation deduction is zero.") As a higher schedular evaluation for this disability is possible, the issues of entitlement to an initial rating in excess of 70 percent for the period prior to February 14, 2012 and since December 27, 2012 remain before the Board on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a) (2) (West 2002). FINDINGS OF FACT 1. For the periods period prior to February 14, 2012 and since December 27, 2012, the Veteran's OCD has not resulted in total occupational and social impairment due to gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. 2. The Veteran has been unable to obtain or retain substantially gainful employment due to service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for an initial evaluation in excess of 70 percent for the periods period prior to February 14, 2012 and since December 27, 2012 for service-connected OCD have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321, 4.3, 4.7, 4.130, Diagnostic Code 9404 (2012). 2. The criteria for an award of TDIU are met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). See also 73 Fed. Reg. 23,353-23,356 (April 30, 2008) (concerning revisions to 38 C.F.R. § 3.159). Given the favorable disposition of the claim for entitlement to a TDIU, the Board finds that all notification and development actions needed to fairly adjudicate this claim have been accomplished. In a correspondence dated March 2010, the RO satisfied its duty to notify the Veteran under 38 U.S.C.A. §5103(a) (West 2002) and 38 C.F.R. § 3.159(b) (2012). Specifically, the RO notified the Veteran of: information and evidence necessary to substantiate the claim; information and evidence that VA would seek to provide; and information and evidence that the Veteran was expected to provide. The March 2010 letter also notified the Veteran of the process by which disability ratings and effective dates are established. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Since this claim is the appeal of an initial rating, fully satisfactory notice was delivered after it was adjudicated. However, the RO subsequently readjudicated the claim based on all the evidence in a May 2013 supplemental statements of the case. The Veteran was able to participate effectively in the processing of his claim. There is no indication in the record or reason to believe that the ultimate decision of the originating agency on the merits of the claim would have been different had complete notice been provided at an earlier time. VA has done everything reasonably possible to assist the Veteran with respect to his claim for benefits in accordance with 38 U.S.C.A. § 5103A (West 2002) and 38 C.F.R. § 3.159(c) (2012). Service treatment records have been associated with the claims file. All identified and available treatment records have been secured. As the Board will discuss in detail in the analysis below, the Veteran was provided with VA examinations throughout the appeal period. The reports of these examinations reflect that the examiners reviewed the Veteran's past medical history, recorded his current complaints, conducted appropriate evaluations of the Veteran, and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. Additionally, the Veteran has not stated nor is there evidence indicating that there has been a material change in the severity of his disability since he was last examined in April 2013. See 38 C.F.R. § 3.327(a) (2012). The duty to assist does not require that a claim be remanded solely because of the passage of time since an otherwise adequate VA examination was conducted. See VAOPGCPREC 11-95 (April 7, 1995). The Board finds that the examination reports of record are adequate for purposes of rendering a decision in the instant appeal. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Neither the Veteran nor his representative has contended otherwise. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c) (4) (2012); Barr, 21 Vet. App. at 312. The Board additionally observes that all appropriate due process concerns have been satisfied. See 38 C.F.R. § 3.103 (2012). The Veteran has declined the opportunity to present evidence and argument in support of his claim. Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. Laws and Regulations The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claims or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claims, in which case, the claims are denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2012). The Veteran's entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1 (2012). Where service connection has already been established, and increase in the disability rating is at issue, it is the present level of the disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, in Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. The Court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. See also Hart v. Mansfield, 21 Vet. App. 505 (2008). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2012). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. §4.7 (2012). Factual Background The Veteran underwent a VA examination in October 2002. He attended college for two years but dropped out due to poor grades. He subsequently enlisted in the Army. Following his service, he returned to college and completed his degree in Marketing. In 1970, he took a job at Sears and worked at the display department for 11 years. It was noted that since 1981, he had held several short term, part time positions and had not worked at all at least for the past 10 years. He spent his free time maintaining his home, doing exterior landscaping and interior decorating work for friends. On examination, he presented with good hygiene and was pleasant and cooperative. He was fairly intense and demanded a level of perfectionism. No evidence of psychosis or thought disorder was noted. There were no complaints of difficulty with concentrating and he "breezed through" the mental status examination. The examiner noted that the discrepancy between the Veteran's current report of termination of an 11 year job for OCD symptoms compared to his explanation 10 years ago of the termination being related to economic factors and that his anxiety developed following the termination did not support that obsessive compulsive symptoms were severe enough to "significantly interfere with occupational functioning". In addition, his symptoms presently did not appear severe. The diagnosis was adjustment disorder with mixed anxiety and depressed mood. A GAF score of 58 was assigned. The Veteran underwent a VA examination in May 2004. The Veteran was alert and oriented throughout the evaluation process and exhibited no signs of psychotic symptomatology. His thought processes were connected, coherent and relevant. His memory was intact and judgment and insight were considered fair. He reported that he had a girlfriend who had been in his life for the past 6 years but said that more of his friends had moved away. Records indicated that he had been somewhat of a loner over the years. The Veteran insisted that it was difficult for him to function because of his compulsive behavior. He noted that he had not worked full-time since 1981 when he was fired at his job from Sears. The examiner noted that the Veteran did not appear to be grossly incapacitated by his symptoms but did exhibit a reduced level of functioning and efficiency. The examiner also noted that it was conceivable that the onset of his OCD occurred prior to him losing his job at Sears. The diagnosis was OCD. A GAF score of 50 was recorded. In a March 2004 letter, a private physician noted that the Veteran's behavior during his interview was eccentric, even unusual. He did not demonstrate the ability to adhere to standard social protocol of nonverbal communication, including recognizing signals that allow for normal turn taking in conversation. In an April 2005 letter, a private physician indicated that after being employed for about 20 years, the Veteran noted the gradual onset of OCD symptoms including "checking" compulsions which gradually and increasingly interfered with his ability to maintain employment, or to establish and maintain significant personal relationships. The Veteran reported that he had developed a sense of uneasiness and diminished self-esteem which progressively increased and interfered with his ability to work and to establish and maintain significant interpersonal relationships. In a November 2006 letter, a private physician noted that the Veteran reported suffering from symptoms of OCD with severe obsessions with locks, orderliness and perfectionism as well as frequent checking rituals. Symptoms such as these have resulted in a significant restriction of his vocational opportunities due to a desire for routine and may have contributed to his firing from his job from Sears in 1981. He also never married because of significant anxiety symptoms. He entered psychiatric treatment in 1990 and had achieved a stable partial remission of symptoms. The Veteran underwent an Independent Medical Examination (IME) in October 2009. The examiner noted that the criteria for psychopathology were amply met as the Veteran had compulsions to check, some hoarding, and anxiety over orderliness and neatness. The Veteran's OCD appeared to be of moderate to high severity, to judge by his impact on his employability. His treatment appeared to ameliorate the severity of his symptoms without completely eliminating them. The Veteran underwent a VA examination in June 2010. The examiner noted that the Veteran was seen by his treating physician every 3 to 4 months. The Veteran also received treatment at the VA Medical Center (VAMC) once every 6 months. VA clinicians had rated his Global Assessment of Functioning (GAF) scores ranging from 55-80 with the most recent score being 79 in February 2010. The examiner noted that the VA treatment notes suggest that the Veteran's symptoms of OCD had decreased in intensity and that the Veteran was doing well. He had been able to enjoy tennis and golf, had been less preoccupied with his symptoms and had shown good stability with regard to his symptoms. Overall, his OCD symptoms did not appear to worsen since his last VA examination in 2004. The Veteran reported that he last worked full time in 1981. He worked at Sears in merchandising and display for 11 years but was terminated when a dispute arose over his time card. He then worked part time at an Army-Navy store from 1981 to 1983 in sales. Around 1989 he reported that he could not function anymore and was diagnosed with OCD at that time. He had not worked for 22 years and reported that he could not work because he was slow at performing tasks, had to check things multiple times, and had difficulty with timeliness because he had to check things multiple times before leaving the house. He was single and had never been married. He had no children but did have 2 nephews and a niece. He had some infrequent contact with his nephew. He reported having a couple of close friends that he saw a few times a month. He used to enjoy collecting stamps but no longer did this. He enjoyed walking and renting movies from the library. He also enjoyed going to the lake and gardening. He was able to manage all his own self-care. He took care of his own shopping, cleaning and cooking and was able to pay his own bills. On examination, he was casually, cleanly and neatly dressed. He was alert, cooperative and showed good eye contact. He was oriented to time, place and person. His psychomotor activity was within normal limits and his speech was clear and of normal volume and articulation. His mood was anxious and his affect was congruent with his mood. His thought process was goal oriented and had no derailment, loose or clanging associations, thought blocking or neologisms. He had no signs of delusional or frankly paranoid belief systems. He denied any hallucinations. He reported that his mood fluctuated and he felt depressed 3 to 4 days out of the week. His energy and motivation was low and his concentration was limited. His appetite was fair but he had difficulty falling and staying asleep without medication. With medication, he could get 6 to 7 hours a sleep a night. He reported suicidal ideation in the past but denied any current suicidal ideation and denied any plan or intent as it was against his religious beliefs to hurt himself. He endorsed occasional feelings of worthlessness or hopelessness. Regarding his OCD, he identified that his main compulsion was checking as he had to put things in order. He indicated that he typically spent about 14 hours a day checking. Each time he left the house it took him 5 to 7 minutes to check the door to make sure it was shut. He indicated that his checking interfered significantly with his daily routine. He reported that his OCD symptoms severely distress him to the point where he had considered suicide in the past. He had been unable to resist his compulsions or spend less time performing them to any extent as he always yielded to his compulsions. He reported having very little control over his compulsions. He reported that his OCD limited his functioning as he did not want to participate in activities. He did not appear to be bothered by recurrent or obsessive thoughts. On psychometric testing, the most prominent feature of his responses was somatic discomfort. He may appear preoccupied with health and bodily functions. The scores suggested that he likely felt tense, anxious, agitated, and jumpy. He may have problems with his sleep and concentration. He was also very likely experiencing feelings of depression and guilt. His level of efficiency was likely low and he may struggle carrying out his responsibilities. He was likely dependent on others and may struggle to make decisions about everyday matters. He may be resistant to change. The diagnosis was OCD. The examiner noted that there did not appear to be multiple mental disorders. A GAF score of 65 was assigned because of the mild number, frequency and intensity of symptoms associated with a mild to moderate reduction of social, vocational and mental functioning. The examiner noted that there appeared to be conflicting information regarding the current level of severity of his symptoms. The Veteran indicated that his symptoms were so severe that it "crippled" his ability to function properly but a review of his VA treatment records indicates that he had consistently reported to VA treatment providers that his symptoms were well managed with his current medication regimen and that he was less preoccupied with his symptoms. Due to these inconsistencies, the examiner noted that it was somewhat difficult to ascertain the current severity of his symptoms. As various VA medical professionals have noted that the Veteran's symptoms had remained stable and were well managed, the examiner opined that it seemed reasonable to assert that his symptoms of OCD had not increased in intensity or severity since his last examination. In terms of social functioning, the Veteran was able to maintain several relationships and participate in activities with his friends. He attended religious services and participated in hobbies. Therefore, despite his reports that his symptoms crippled his functioning, providers' reports of his behavior indicate that his social functioning was intact and likely mildly comprised by his symptoms. With regard to occupational functioning, he had not worked full-time since 1981. There was no evidence that the loss of his job was associated with OCD. Because he had not worked in over 20 years, there was not a recent point of reference regarding the effect of his symptoms on occupational functioning. Therefore, to the extent which his symptoms affected his current activities was the reference point this examiner used to project how his symptoms may impact his occupational functioning. His recent and remote memory appeared intact and would not likely compromise his occupational functioning. His ability to understand and remember simple instructions would not likely be compromised by his OCD symptoms. However, due to how his symptoms affect his concentration, he may have mild to moderate difficulty completing tasks that require him to follow detailed instructions or that require sustained attention. His symptoms did not appear to affect his ability to interact with others and he had several friendships and was able to attend social gatherings. His ability to perform activities in a scheduled time, maintain regular attendance and be punctual may be mildly affected by his symptoms as he had difficulty being on time for events and had taken longer time to complete tasks. His ability to tolerate stress or changes in his work setting may be mildly affected by his symptoms. He did not suffer from gross impairment in his thought processes, delusions or hallucinations. He was not a danger to himself or others. Overall, the extent to which the Veteran's OCD affected his occupational functioning would likely vary according to the nature of the work and the structure of the work environment. It was at least as likely as not that the Veteran maintained the ability to function in a workplace environment. A March 2011 VA treatment report assigned a GAF score of 70. The Veteran underwent a VA examination in December 2012. The Veteran reported having a very limited social support system and overall poor quality of life. He had a current GAF score of 54. The examiner determined that the Veteran had occupational and social impairment with reduced reliability and productivity. The Veteran reported that he currently had no regular social interactions beyond periodic contact with his nephew who he contacted or visited once every 3 or 4 months. He noted that his 12 year relationship with his girlfriend ended a few months ago. He spent most of his time in his apartment and denied engaging in any hobbies, interests or activities. He reported that he spent most of his days engaging in compulsive behaviors but that he still did his own shopping, preparing his meals and managing his money. He had not been employed in over 25 years and had not actively sought out employment since 1990. He remained adamantly convinced that he was unable to work due to his various symptoms of tinnitus and OCD. Since his last examination, he was hospitalized once for depression and suicidal ideation following an aborted suicide attempt in January 2012. He was held for observation for 2 days. The examiner noted that his GAF scores had ranged from a low of 50 to a high of 70. On examination, he was pleasant and cooperative. His eye contact was adequate and the rate and flow of his speech was normal. His psychomotor activity was within normal limits. His thinking was coherent and goal directed. He appeared to have no difficulty focusing his attention during the session. No gross disturbances in thought processes or communication were observed. There were no compulsive behaviors reported/observed during the interview. He was fully oriented to person, place and time. In addition to his checking behaviors, the Veteran reported hearing voices sometimes in his head, warning him that something bad would happen if he did not engage in his compulsive behaviors. He also noted an increasing sense of paranoia. He had difficulty falling and staying asleep. His appetite was reportedly minimal. The examiner noted that when attempting to assess the severity of the Veteran's OCD symptoms, the Veteran answered in ways that conveyed only extreme or severe level of impairment. Few if any OCD symptoms were denied or reported to be at a mild level of impairment. He had symptoms of depressed mood, anxiety, suspiciousness, obsessional rituals which interfered with routine activity and persistent delusions or hallucinations. He was capable of managing his financial affairs. The examiner determined that the Veteran continued to meet the criteria for OCD and that this condition presented a moderate and at times severe level of impairment. The examiner noted that some of the information provided by the Veteran was possibly overstated as part of an effort to convince the examiner of the seriousness of his condition. Furthermore, VA treatment noted and notes from the Valley Counseling Services were more consistent with a moderate level of impairment. Other than his reported suicide attempt, his treatment providers have noted that his symptoms were fairly stable and were managed with his current medications. Although it was noted that he possibly over reported some of his symptoms, the examiner also noted that the Veteran definitely struggled with his OCD. He had been unemployed for 25 years. The examiner indicated that the nature of the work and the work environment that he might be in would very likely impact the extent to which the Veteran's OCD symptoms would impair his employability. Given this unknown set of circumstances, it was at least as likely as not that he could possibly be mild to moderately impaired. He was able to logically and coherently express himself as evidenced by his interview behavior. There appeared to be no problems with his recent and remote memory. There could be slight impairment to him being on time for work but it was noted that he was on time for this examination and a review of the progress notes did not indicate that he was late for any appointments. His ability to understand and remember simple instructions would not likely be impaired. His ability to follow detailed or complicated instructions or tasks could be moderately compromised by his obsessions. His ability to tolerate changes in his work routine could be mildly affected. His ability to interact with others would likely not be greatly impacted. His ability to perform time limited tasks could be moderately to severely impacted by his checking behavior. A GAF score of 54 was assigned. This range reflected a moderate difficulty in social/occupational functioning. This rating was based on the current severity of his signs and symptoms as well as his ability to independently take care of his shopping, cleaning, cooking and other activities of daily living. Additionally, although socially isolated, he had been able to attend religious services and maintain long term relationships with a nephew and a female friend before she moved out of the area. As the Veteran did not currently exhibit suicidal ideation or intent, a GAF score in the 41 to 50 range was not appropriate. A March 2013 VA treatment note assigned a GAF score of 60. The Veteran underwent a VA examination in April 2013. The Veteran cooperated fully and maintained good eye contact. He was oriented to person, place and time. He endorsed compulsive/ritualistic behaviors that interfered significantly with functioning such as hand washing, organizing things and checking. He endorsed anxious and depressive symptoms but denied panic attacks. No hypomania/mania was noted. He had restricted range and his affect was anxious and depressed. He denied current suicidal or homicidal ideation. He denied current delusions and auditory/visual hallucinations. However he endorsed fleeting suicidal ideation with a plan in December 2012. He had a recent diagnosis of a psychotic disorder due to audio/visual hallucinations. His thought process was coherent, focused and organized. No significant distractibility, forgetfulness or problems with concentration were noted. No loss or impairment of memory was noted. Sleep was chronically disrupted and his appetite was poor. He was capable of handling basic and complex activities of daily living per recent testing. His insight and judgment were fair. The examiner determined that the Veteran had occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking and/or mood. The examiner noted that since the last VA examination in December 2012, one document had been added which noted that the Veteran reported that he got 4 to 4 1/2 hours of sleep and that during the fall he was paranoid and heard voices telling him to paint some stripes on his face. The Veteran remained single, had no children, had no outside activities and had few social contacts. He reported that his nephew was still his only social contact. Tests to assess his independence in daily activities conducted in February 2013 indicated independence and high functioning. The Veteran had no psychiatric hospitalizations since his first hospitalization in 2012 which was secondary to a suicidal gesture. He now carried a diagnosis of OCD, major depression and psychosis not otherwise specified. The examiner noted that the Veteran had one visual hallucination. The Veteran lived alone and isolated himself. He reported that he hears voices but the last time this happened was several weeks ago. Since then, he has heard a man's voice telling him to "wake up" and has heard chatter. He reported that he was depressed, had no pleasure in things, his sleep was disrupted and his appetite was poor. He also had worthless thoughts. He denied suicidal ideation and planned to go to his nephew's house after this examination. His symptoms included depressed mood, anxiety, chronic sleep impairment, flattened affect, difficulty in understanding complex commands, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances including work and a worklike setting, an inability to establish and maintain effective relationships, suicidal ideation and obsessional rituals which interfered with routine activities. He was capable of managing his financial affairs. The examiner opined that given the Veteran's affliction and the communication shown in the file, and the needs of today's workplaces for written communications and emails, combined with the fact that he would have to recheck things repeatedly, it was at least as likely as not that the OCD would significantly impair his ability to obtain and hold substantially gainful employment. The examiner concurred with the December 2012 examiner that some of the information provided by the Veteran was possibly overstated as part of an effort to convince the examiner of the seriousness of his condition. The notes from the VA and Valley Counseling Services were more consistent with moderate impairment. The examiner noted that the Veteran met the criteria for OCD and for major depressive disorder. The major depressive disorder was as likely as not due to his chronic OCD and psychosocial functioning difficulties due to his OCD symptoms. His OCD and depressive disorder symptoms could be considered collectively and it would be speculative to try to differentiate the symptoms. The examiner also noted that there was not enough evidence to support a diagnosis of psychotic disorder not otherwise specified. Based on the current symptomatology, the Veteran was felt to have serious difficulties with interpersonal functioning which was evidenced by his lack of friends, social withdrawal, social isolation and lack of social activities. He presented as someone with moderate to severe difficulties with interacting socially. He would have significant difficulties in adapting to stressful situations in a work, classroom or social setting. It was estimated that he would have severe difficulties establishing and maintaining effective work relationships and moderate difficulties establishing and maintaining effective social relationships. His thinking processes were logical and would not adversely affect his vocational or social functioning. His communication was somewhat reduced due to overinclusiveness and emotional detachment. He had chronic difficulties with obsessive thoughts, depression and lack of motivation would as likely as not lead to periodic missed days from work and moderate to serious reduction in occupational productivity, reliability, efficiency or work performance. He had received benefit from pharmacological interventions. His symptoms however had remained quite severe since beginning treatment in 1980. It was therefore more likely than not that his symptoms would therefore remain chronic in nature with some periodic worsening in response to additional stressors or losses. His condition was felt to be dependent on the consistent use of medication. If his medication were discontinued, it was more likely than not that his symptoms would quickly exacerbate. The Veteran's ability to understand and follow instructions was considered to be moderately impaired. His ability to retain instructions as well as sustain concentration to perform simple tasks was considered moderately impaired. His ability to sustain concentration to task persistence and pace is considered profoundly impaired. His ability to respond appropriately to coworkers, supervisors, or the general public is considered markedly impaired. His ability to respond appropriately to changes in the work setting is considered profoundly impaired. His ability to be flexible in the workplace is considered profoundly impaired. His ability for impulse control in the workplace was considered moderately impaired. A GAF score of 57 was assigned. I. OCD The Veteran's OCD disability has been assigned a 70 percent evaluation for the period prior to February 14, 2012 and since December 27, 2012 under 38 C.F.R. § 4.130 , Diagnostic Code 9404. Under Diagnostic Code 9404, a 70 percent rating is assigned 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 a worklike setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned 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. Id. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436 (2002). GAF scores are a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health- illness." See Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing the American Psychiatric Association 's DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS, Fourth Edition (DSM- IV), p. 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See 38 C.F.R. § 4.126 (2012); VAOPGCPREC10-95 (Mar. 1995); 60 Fed. Reg. 43186 (1995). According to the DSM-IV, GAF scores ranging between 61 to 70 reflect 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, and has some meaningful interpersonal relationships. GAF scores ranging from 51 to 60 reflect more moderate symptoms [e.g., flat affect and circumstantial speech, occasional panic attacks] or moderate difficulty in social, occupational, or school functioning [e.g., few friends, conflicts with peers or co- workers]. Scores ranging from 41 to 50 reflect serious symptoms [e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting] or any serious impairment in social, occupational or school functioning [e.g., no friends, unable to keep a job]. Scores ranging from 31 to 40 reflect some impairment in reality testing or communication [e.g., speech is at times illogical, obscure, or irrelevant] or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood [e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up other children, is defiant at home, and is failing at school]. In addition to OCD, for which service connection has been established, the record shows additional diagnoses of major depression and psychosis not otherwise specified. It is now well-settled that the Board is precluded from differentiating between symptomatology attributed to a nonservice-connected disability and a service-connected disability, in the absence of medical evidence which does so. See Mittleider v. West, 11 Vet. App. 181, 182 (1998), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). The medical evidence in the instant case does not differentiate between the symptomatology associated with the Veteran's OCD and that resulting from his nonservice-connected psychiatric disorders. Further, the April 2013 VA examiner noted that the Veteran's OCD and depressive disorder symptoms could be considered collectively and it would be speculative to try to differentiate the symptoms. Accordingly, for the purposes of this decision, the Board will attribute all of the Veteran's psychiatric symptoms to his service-connected OCD. After reviewing evidence of record as a whole, to include the Veteran's ongoing VA treatment reports, his VA examination reports, and his credible lay statements, the Board finds that the assignment of a disability rating greater than 70 percent for the Veteran's service-connected OCD is not warranted. The Veteran was most recently afforded a VA examination in April 2013. After reviewing the Veteran's medical history and upon interview and examination of the Veteran, the April 2013 VA examiner pertinently concluded that the Veteran's PTSD symptomatology manifested in "occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood," which corresponds squarely with the schedular requirements for the assignment of a 70 percent disability rating. Indeed, at no point did the April 2013 VA examiner or any other examiner or treating physician find that the Veteran's OCD causes total occupational and social impairment, as is required for the assignment of a 100 percent rating. In not granting a 100 percent schedular rating for OCD, the Board is not minimizing the severity of the Veteran's symptoms. The Board notes that the evidence demonstrates that the Veteran experiences significant social impairment as a result of his OCD. The Veteran was single as a long term relationship ended, had no children, had no outside activities and had few social contacts. He had isolated himself and he reported that his nephew was still his only social contact. However, as noted above, a 100 percent rating is applicable if the manifestations of the service-connected psychiatric disorder result in total occupational and social impairment. There is no evidence that the Veteran has total social impairment as the April 2013 VA examiner noted that the Veteran presented as someone with moderate to severe difficulties with interacting socially. VA treatment records and VA examinations also show no gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, inability to maintain personal hygiene, disorientation to time or place, or memory loss for names of own relatives, own occupation, or own name. He has also able been to communicate with the VA examiners in a coherent manner. The April 2013 VA examiner also found him competent to handle his financial affairs. Additionally, the Veteran's GAF scores have ranged between 50 to 70 with the most recent GAF score of 54 on his April 2013 VA examination. Although the Veteran's GAF scores have widely varied throughout the applicable period, taken as a whole, they have reflected at worst, moderate difficulty in social/occupational functioning. Additionally, the Board notes that GAF scores are only one indication of the severity of a given service-connected mental disorder. 38 C.F.R. § 4.130, Diagnostic Code 9411; see also Carpenter, supra. Accordingly, in this case, the overall evidence of record on does not reflect that the Veteran's symptomatology was so severe as to merit a 100 percent evaluation. Although the Veteran's symptomatology includes past suicidal ideation which resulted in a February 2012 suicide attempt and subsequent hospitalization, as noted above, the AMC granted a temporary 100 percent disability rating for the hospitalization related to the suicide attempt. The more recent April 2013 VA examination noted that while the Veteran had endorsed fleeting suicidal ideation with a plan in December 2012, he denied current suicidal or homicidal ideation. Moreover, the evidence of record, to include the Veteran's ongoing VA treatment records and his credible lay descriptions of symptoms, simply does not demonstrate that his OCD has caused total occupational and social impairment at any time during the appeal periods. Finally, the Board does not find that consideration of an extraschedular rating under the provisions of 38 C.F.R. § 3.321(b) (1) is warranted for the service-connected OCD disability at any time during the current appeal. That provision provides that, in exceptional circumstances, where the schedular evaluations are found to be inadequate, a veteran may be awarded a rating higher than that encompassed by the schedular criteria, as shown by evidence reflecting that the disability at issue causes marked interference with employment or has in the past or continues to require frequent periods of hospitalization, thereby rendering impractical the use of the regular schedular standards. Id. The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disorder are inadequate. See Fisher v. Principi, 4 Vet. App. 57, 60 (1993) (noting that the "[R]ating schedule will apply unless there are 'exceptional or unusual' factors which render application of the schedule impractical."). Here, the rating criteria reasonably describe the Veteran's disability level and symptomatology associated with his OCD disability. Thus, the Veteran's disability picture is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate. See Thun v. Peake, 22 Vet. App. 111, 115 (2008). Consequently, the Board concludes that referral for extraschedular consideration for this service-connected disability is not warranted. II. TDIU VA will grant a total rating for compensation purposes based on unemployability when the evidence shows that the Veteran is precluded from obtaining or maintaining any gainful employment consistent with his education and occupational experience, by reason of his service-connected disabilities. 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16 (2012). If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation 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. 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. A TDIU for compensation purposes 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 service-connected 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 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16(a). For a veteran to prevail on a claim for a TDIU, the record must reflect some factor which takes the case outside the norm. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is a recognition that the impairment makes it difficult to obtain and keep employment. The question is whether a veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. See 38 C.F.R. § 4.16(a); Van Hoose v. Brown, 4 Vet. App. 361 (1993). In determining whether a veteran is entitled to a TDIU, nonservice-connected disabilities and advanced age may not be considered. As the Veteran's has a 70 percent rating for OCD, he meets the objective, minimum percentage requirements, set forth in 38 C.F.R. §4.16(a), for consideration of a TDIU. The determinative issue, therefore, is whether his service-connected disability renders him incapable of securing or maintaining substantially gainful employment. After careful consideration and resolving reasonable doubt in his favor, the Board finds that the Veteran meets the requirements for a TDIU. The above evidence indicates that the Veteran last worked in 1981 as a result of his disabilities. While the Veteran had held several short term, part time positions since 1981, multiple physicians have determined that the Veteran's ability to establish and maintain effective work relationships was significantly affected by his OCD symptoms. Notably, a private physician in November 2006 reported that the Veteran's OCD symptoms resulted in a significant restriction of his vocational opportunities due to a desire for routine. The most recent VA examiner in April 2013 noted that as a result of the Veteran's OCD disability, he would have severe difficulties establishing and maintaining effective work relationships. The April 2013 VA examiner also noted that the Veteran's ability to respond appropriately to coworkers, supervisors, or the general public is considered markedly impaired, his ability to respond appropriately to changes in the work setting is considered profoundly impaired, and his ability to be flexible in the workplace is considered profoundly impaired. Additionally, there is no contrary medical evidence of record that indicates that the Veteran's service- connected disabilities alone are not of sufficient severity to produce unemployability. While the June 2010 VA examiner determined that it was at least as likely as not that the Veteran maintained the ability to function in a workplace environment, he also noted that the extent to which the Veteran's OCD affected his occupational functioning would likely vary according to the nature of the work and the structure of the work environment. Additionally, the most recent VA examiner in April 2013 determined that it was at least as likely as not that the OCD would significantly impair his ability to obtain and hold substantially gainful employment. In sum, the evidence of record establishes that the Veteran is not able to engage in substantially gainful employment due to his service-connected psychiatric disorder. Inasmuch as the evidence denoting multiple limitations associated with the Veteran's service-connected disability, which is found to render the Veteran unemployable, is not outweighed by evidence to the contrary, entitlement to a TDIU is found to be established. In weighing the evidence, the Board finds that the evidence of record establishes that the Veteran is unable to obtain and maintain substantially gainful employment due to service-connected disability. Accordingly, the Board finds that entitlement to TDIU is warranted. See 38 C.F.R. §§ 3.102, 4.16(a). ORDER Entitlement to an initial evaluation in excess of 70 percent for service-connected OCD for the period prior to February 14, 2012 and for the period since December 27, 2012 is denied. TDIU is granted, subject to the criteria applicable to the payment of monetary benefits. ____________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs