Citation Nr: 1324758 Decision Date: 08/05/13 Archive Date: 08/13/13 DOCKET NO. 10-47 387 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Pittsburgh, Pennsylvania THE ISSUES 1. Entitlement to an evaluation in excess of 50 percent for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), to exclude the period from May 7, 2008 through July 31, 2008, during which the Veteran received a temporary total hospitalization evaluation for this disability. 2. Entitlement to a total rating due to individual unemployability (TDIU) caused by service-connected disabilities. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. Scott Walker, Counsel INTRODUCTION The Veteran served on active duty from December 1967 to October 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Pittsburgh, Pennsylvania. He testified during a Board hearing, held by the undersigned, in March 2011. A copy of the hearing transcript (Transcript) has been associated with the record. FINDINGS OF FACT 1. The Veteran's acquired psychiatric disorder is manifested by obsessive rituals, depression affecting the ability to function appropriately, impaired impulse control, difficulty adapting to stressful circumstances, homicidal ideation, suicidal ideation, and recurrent visual hallucinations. 2. The Veteran is currently service connected for two disabilities: an acquired psychiatric disorder evaluated as 70 percent disabling herein, and for a scar, right medial eyebrow, non-compensably rated, for a combined evaluation of 70 percent. 3. The Veteran meets the schedular requirements of 38 C.F.R. § 4.16(a) for the rating of his disabilities. 4. The competent and credible evidence establishes that the Veteran's service-connected disabilities preclude him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for a rating of 70 percent for PTSD and(MDD, to exclude the period from May 7, 2008 through July 31, 2008, have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code 9411 (2012). 2. The criteria for entitlement to a TDIU rating are met. 38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 3.340, 3.341, 4.16, 4.25 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) Before addressing the merits of the issue, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified in September 2008 of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. This letter accordingly addressed all notice elements and predated the initial adjudication by the RO in March 2009. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded. Nothing more is required in this case. As for the duty to assist, the Veteran's service treatment records have been obtained. Pertinent post-service medical records have been obtained, to the extent available. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board therefore finds that no additional evidence, which may aid the Veteran's claim or might be pertinent to the bases of the claim, has been submitted, identified or remains outstanding, and the duty to assist requirement has been satisfied. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See Green v. Derwinski, 1 Vet. App. 121 (1991). The Veteran was afforded a VA psychiatric examination in October 2008. To that end, when VA undertakes to provide a VA examination, it must ensure that the examination is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The VA examination report is adequate to decide the claim addressed in this section, as the examination report included a thorough review of the file, as well as examination findings relevant to the issue at hand. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). II. Increased Rating The Veteran claims that his currently service-connected psychiatric disorder is more severe than indicated by his current disability rating of 50 percent. The Board points out that disability evaluations are based upon the average impairment of earning capacity as contemplated by the schedule for rating disabilities. See 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. Part 4 (2012). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the veteran's condition. See Schafrath v. Derwinski, 1 Vet. App. 589, 594 (2002). However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). In cases in which a reasonable doubt arises as to the appropriate degree of disability to be assigned, such doubt shall be resolved in favor of the veteran. See 38 C.F.R. § 4.3 (2012). VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim, a practice known as a "staged rating." See Fenderson v. West, 12 Vet. App 119 (1999). The Court has also held that staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. In this case, the evidence of record does not establish distinct time periods in which the issue on appeal resulted in symptoms that warrant staged ratings. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25 (2012). However, the evaluation of the same "disability" or the same "manifestations" under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as "such a result would overcompensate the claimant for the actual impairment of his earning capacity." Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C.A. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. However, if a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). Assignment of a particular Diagnostic Code is "completely dependent on the facts of a particular case," Butts v. Brown, 5 Vet. App. 532, 538 (1993), and one Diagnostic Code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis, and demonstrated symptomatology. Any change in Diagnostic Code by a VA adjudicator must, however, be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2012). The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). 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 claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran's disability has been assigned an evaluation of 50 percent pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9411 (2012). The provisions of 38 C.F.R. § 4.130 relating to rating psychiatric disabilities read in pertinent part as follows: Under this schedule, a 50 percent rating provides for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is provided 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 work-like setting); inability to establish and maintain effective relationships. A 100 percent rating is provided 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. See 38 C.F.R. § 4.130 (2012). The use of the term "such as" in the general rating formula for mental disorders in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). It is not required to find the presence of all, most, or even some, of the enumerated symptoms recited for particular ratings. Id. The use of the phrase "such symptoms as," followed by a list of examples, provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. Id. The Board notes that a Global Assessment of Functioning (GAF) rating is a scale reflecting the psychological, social, and occupational functioning on a hypothetical continuum of mental-health illness. Richard v. Brown, 9 Vet. App. 266, 267 (1996), citing Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994). With regard to GAF scores, scores ranging from 51 to 60 reflect 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). See 38 C.F.R. § 4.130 (incorporating by reference the VA's adoption of the DSM-IV, for rating purposes). In this case, the Veteran was afforded a VA psychiatric examination in October 2008. At that time, the examiner noted that the Veteran had received outpatient treatment for his psychiatric disorder, as well as inpatient treatment from March 6, 2008, through March 19, 2008, from April 2, 2008, through April 11, 2008, and from May 7, 2008, through July 8, 2008. It was further noted that the Veteran took psychiatric medication to help control his symptoms, which were described as ongoing and moderate. A temporary total hospitalization rating was assigned from May 7, 2008, to July 31, 2008. The Veteran reported that he was married, but separated. He had good relationships with his children. He denied taking enjoyment in any activity, and instead sat by himself often thinking about Vietnam. He described a suicide attempt, in March 2008, during which time he drove to the store to buy a hose to attach to his car for the purpose of poisoning himself via carbon monoxide exposure. Before the attempt, he reported to the VA psychiatric unit and was admitted on an inpatient basis as noted above. Following that treatment, he walked over a bridge and considered jumping, but did not, fearing that he might have injured a driver below. He returned to the VA psychiatric unit and was re-admitted for a period of 11 days. When asked about current suicidal ideation, which was described as frequent, the Veteran stated that he had not acted on his thoughts because of his grandson, who was his "salvation." On examination, the Veteran was clean, neatly-groomed, and appropriately dressed. His psychomotor activity was classified as restless, and his speech was hesitant. He was cooperative, friendly, and attentive, though his affect was blunted and his mood was described as anxious and depressed. Impulse control was good. He was oriented to person, place, and time, his thought content was unremarkable, and no delusions were reported or observed. When asked about his thought process, he reported thoughts of a friend who had recently been killed in a mining accident. Sleep impairment was reported, which interfered with his daily activities, as he woke up frequently during the night and experienced 5-6 nightmares per week (a number that had increased in the prior year). The Veteran reported visual hallucinations, though they were not persistent. The examiner reported inappropriate behavior, to include social avoidance, as well as obsessive/ritualistic behavior, such as walking the perimeter of both of his houses each night before bed. While panic attacks were absent, recent homicidal thoughts were reported. More specifically, the Veteran thought of killing a supervisor at his coal mine who disrespected the Veteran and made him look bad by giving his job to someone else. Following this incident, the Veteran once again sought admission to the VA psychiatric ward, as he had a shotgun in his car and was afraid that would use it had he seen the manager in question. At the time of the interview, however, homicidal ideation was not present. The examiner noted that the Veteran had a problem with the activities of daily living, which ranged in degree from no affect to moderate (shopping, due to crowd avoidance). Remote memory and immediate memory were normal, though recent memory was moderately impaired. Anger management problems and social detachment were documented. Two visual flashbacks were reported, wherein a Viet Cong fighter was running in front of his jeep in the coal mine three months prior, and another wherein a Viet Cong fighter was standing next to him. Ultimately, the Veteran's diagnoses of PTSD and MDD were confirmed, and a GAF score of 55 was assigned. It was noted that the Veteran's usual occupation was a foreman in a coal mine, though he was not employed at the time of the examination. The cause of the Veteran's unemployment was two-fold: his psychiatric disorder and the temperature in the winter months. The examiner also pointed out that the Veteran had poor relationships with members of the upper management of the mining company. A review of the Veteran's inpatient psychiatric reports revealed participation in group therapy during his stint in March 2008, noting that he preferred staying in the hospital because it was safe and secure. At the time of discharge, his mental impairment was deemed mild. At the time of his discharge in April 2008, his mental impairment was assessed as mild to moderate. A GAF score of 50 was assigned upon entrance, and a GAF of 60 was provided upon discharge. On each occasion, he had presented with suicidal ideation. He noted problems with work and with his spouse, who was not willing to participate in marital therapy. From May to July 2008, the Veteran was admitted into the PTSD recovery rehabilitation program (PRRP). During that course, it was noted that returning to work following his March 2008 hospitalization presented a set of problems, as he did not get along with his supervisors prior, and he felt degraded by how people made fun of him upon his return. While he reported suicidal ideation prior to his stay in PRRP, during treatment he denied current thoughts of suicide. He participated in several group therapy sessions while in treatment, and voluminous records thereof have been associated with his claims file. The Board has also reviewed the Veteran's VA outpatient reports, to include a March 2011 report in which his examiner stated, "In my opinion, patient's disability due to PTSD is very severe and he was encouraged to request an increase in SC." It was noted that he had felt depressed and anxious, in part due to problems with his daughter, who had been verbally aggressive to the point of legal intervention. The Veteran also reported that, one week prior, he again had thoughts of jumping off a bridge, which he had done on several occasions in the past. He would sit on the edge and contemplate jumping. He also described seeing images around the house, to include silhouettes moving past outside his window, wearing Viet Cong hats. When he went outside with a stick, there was nobody there. He admitted to having these symptoms for a long time, to include while he was still employed. Several lay statements have been associated with the record as well, to include from his spouse, brother, and former co-workers. These documents reveal that the Veteran had a bad temper, at times throwing household objects at his wife over small issues. Verbal abuse was also noted. Violent dreams, in which the Veteran often acted out physically, were reported as well. The Veteran's co-worker reported seeing him "go over the edge," and that he was "out there" when it came to working with management. It was also noted that the Veteran would say things that made the co-worker wonder "where his head was at," such as stating that he would like to see the general manager fall over with a heart attack, hoping to kick in the teeth of the first person attempting to administer CPR. The Veteran testified before the undersigned during a Board hearing held in March 2011. At that time, he indicated that he was experiencing an increase in depression, nightmares, sleep loss, and obsessive rituals. Per his representative, the VA examiner overlooked the severity of the Veteran's symptoms, especially the repeated suicide attempts. See Transcript, p. 4. The Veteran also recounted a tale of taking a rifle to work due to homicidal ideation. He testified that his family had removed his guns from the house, and that he chased a silhouette with a stick on one occasion. He also stated that he would see these silhouettes while working in the mine. On one occasion, he used the lights in his jeep to find the person he saw, but nobody was there. See Transcript, p. 5. The Veteran stated that, although the March 2011 outpatient report (documented above) noted that he was scheduled for an additional VA examination, the examiner was in error and no further examination was conducted. See Transcript, p. 8. Taking this evidence into account, and looking at the evidence in a light most favorable to the Veteran, the Board has determined that the criteria for an evaluation of 70 percent have been met. First, it is clear from the record that the Veteran has undergone several stints of inpatient treatment due specifically to suicidal ideation. In one instance, not only did he have a plan, but he also drove to the store to buy the necessary implements. Thereafter, he was admitted on at least two other instances, with several more thoughts of suicide thereafter. See VA Outpatient treatment report, March 2011. Other symptoms which are often associated with a 70 percent evaluation, evident since the beginning of the appellate period, include obsessive rituals (walking the perimeter of both of his homes every night before bed), depression affecting the ability to function appropriately, impaired impulse control (throwing objects at spouse, bringing a gun to work), and difficulty adapting to stressful circumstances (threatening his managers at work). Although the Veteran's symptoms were described as moderate in 2008, when a GAF of 55 was assigned, the Board notes that this examination was conducted only months following three separate inpatient stints, and repeated plans for suicide. As such, the Board finds that the classification of symptoms as moderate is questionable in this instance. The Board has concluded that the criteria for a rating of 100 percent have not been met in this case. While recurrent visual hallucinations were also reported, it was noted in October 2008 that these were not persistent. Gross impairment in thought processes or communication has not been established during the pendency of this appeal, and while hallucinations were reported, grossly inappropriate behavior was not indicated, nor was the persistent danger of hurting himself or others. Though he brought a gun to work on one occasion, it remained in the Veteran's vehicle, and he realized that this action was inappropriate, seeking treatment thereafter. Further, the record does not demonstrate an intermittent inability to perform activities of daily living, to include maintenance of minimal personal hygiene, which was consistently deemed appropriate by examiners of record. There was no indication of disorientation to time or place, memory loss for names of close relatives, own occupation, or his own name, or symptoms which are commensurate with those listed in the rating criteria for a 100 percent schedular evaluation. As such, the criteria for this rating have not been met. See 38 C.F.R. § 4.130 (2012). In reaching the above conclusions, the Board has not overlooked the Veteran's statements regarding the severity of his service-connected psychiatric symptoms. In this regard, the Veteran is competent to report on factual matters of which he has first-hand knowledge, e.g., experiencing an increased level of psychiatric symptomatology. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, the Board finds the objective medical findings and opinions provided by the VA examiners of record are afforded the greater probative weight. The probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the Board as adjudicator. Guerrieri v. Brown, 4 Vet. App. 467 (1993). The above determination is based upon consideration of applicable rating provisions. It should also be noted that there is a showing that the Veteran's disability has reflected so exceptional or unusual a disability picture as to warrant the assignment of a TDIU, as explained in further detail below. See 38 C.F.R. § 3.321(b)(1) (2012). While the symptoms of his disability have been accurately reflected by the schedular criteria, the Board points out that his disability rating encompasses a significant degree of occupational impairment relative to that rating. For example, the Veteran's current 70 percent rating reflects occupational and social impairment, with deficiencies in most areas. The record lacks evidence reflecting that the Veteran's disability picture is not contemplated by the rating schedule, in that most of the criteria for a higher rating have not been met or approximated. Thus, referral for a determination of whether the Veteran's disability picture requires the assignment of an extraschedular rating for this issue alone is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). However, the Board nonetheless has determined that the Veteran's service-connected disabilities have essentially precluded gainful employment, and therefore a TDIU has been awarded in the following section. In light of the foregoing, the Board finds that the evidence in this case is, at the least, so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). Therefore, the Veteran's claim for entitlement to an evaluation in excess of 50 percent for an acquired psychiatric disorder is granted, and a rating of 70 percent is hereby assigned. III. TDIU A total disability rating may be assigned where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, or if there are two or more disabilities, there shall be at least one ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16(a) (2012). Substantially gainful employment must be reviewed in a practical manner, and mere theoretical ability to engage in substantial gainful employment is not a sufficient basis to deny benefits. The test is whether a particular job is realistically within the physical and mental capabilities of the claimant. Moore v. Derwinski, 1 Vet. App. 356 (1991), Timmerman v. Weinberger, 510 F.2d 439 (8th Cir. 1975). A veteran's service-connected disabilities, alone, must be sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). In determining whether unemployability exists, consideration may be given to the Veteran's level of education, special training and previous work experience, but not to his age or to any impairment caused by non-service-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2012). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, the reasonable doubt will be resolved in favor of the veteran. Reasonable doubt is one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102 (2012). The Veteran satisfies the percentage requirements noted above. The Veteran is service connected for PTSD, rated 70 percent, and for a non-compensable scar. His combined rating is 70 percent. 38 C.F.R. § 4.25, Table I (2012). The Veteran contends that he is entitled to a TDIU rating, as his service-connected disabilities, particularly his PTSD, render him unemployable. Therefore, the Board must address whether any service-connected impairment of mind or body is present that 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 (2012). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. 38 C.F.R. §4.16(a) (2012). In this case, the evidence of record suggests that the Veteran was employed in a coal mine for more than 30 years, with no reference to any formal education. Turning to medical and lay evidence of record, and as noted in detail above, the Veteran received inpatient psychiatric treatment from March 6, 2008, through March 19, 2008, from April 2, 2008, through April 11, 2008, and from May 7, 2008, through July 8, 2008, following recurrent suicidal ideation. Sleep impairment was reported, the severity of which affected the Veteran's daily activities. The Board points out that, when working in inherently dangerous conditions, such as a coal mine, this symptom alone could hamper performance. When looking at other possible careers, however, it is noted that symptoms such as recurrent visual hallucinations, social avoidance, and difficulty adapting to stressful, on-the-job situations are all present in this case. To the last point, it is well-documented that the Veteran entertained the thought of killing a supervisor at his coal mine who, per the Veteran, disrespected him. At that time, the Veteran had a shotgun in his car for the express purpose of carrying out that thought. Other psychiatric symptoms would likely affect the Veteran's performance in any occupation, such as a moderate impairment of recent memory, anger management problems, and social detachment. While the Veteran reported in October 2008 that the cause of his unemployment was two-fold: his psychiatric disorder and the temperature in the winter months, in looking at the evidence in a light most favorable to the Veteran, the Board has determined that his psychiatric condition is of such severity to preclude gainful employment. It has been confirmed by a VA examiner in March 2011 that his PTSD is very severe. Finally, reports from the Veteran's co-worker, who reported seeing him "go over the edge," stated that the Veteran was "out there" when it came to working with management. Again, it was also noted that the Veteran would say things that made the co-worker wonder, such as stating that he would like to see the general manager fall over with a heart attack, hoping to kick in the teeth of the first person attempting to administer CPR. While that incident was directed at a specific individual, the Board finds that the Veteran's anger management problem would translate to most any occupation, as would his social avoidance issues and other severe psychiatric symptomatology. Taking this evidence of record into account, and the Veteran's hearing testimony, the Board finds that Veteran is not capable of performing the physical, and most importantly, the mental acts required by employment. Therefore, the Board must determine whether currently-service-connected disabilities alone, to include PTSD, render the Veteran unemployable. Here, the Board is precluded from rendering its own medical conclusions. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Looking again to the standard of whether a particular job is realistically within the physical and mental capabilities of the claimant, the Board finds that determination does not bar a TDIU grant, and that the Veteran's service-connected disabilities, alone, and specifically his PTSD, are sufficiently severe to produce unemployability. Hatlestad v. Brown, 5 Vet. App. 524 (1993). The record does not indicate that Veteran has any formal education or special training. Even assuming the Veteran were able to find a sedentary job for which he could be trained, the Veteran would still face significant workplace hurdles, such as heightened startle response and outbursts of anger, and deficiencies in mental capacity with regard to his ability to recall recent information. At the very least, a reasonable doubt arises as to his employability, which must be resolved in favor of the Veteran. 38 C.F.R. § 3.102 (2012). As such, the Board finds that the most probative medical and lay evidence establishes that the Veteran would be unable to work solely due to his service-connected disabilities. The Board finds that the Veteran is not currently able to engage in substantial employment due to impairment caused by service-connected disabilities. Medical evidence demonstrates that he is generally incapable of adequate social interaction, and lacks the inability to perform the tasks required by substantial employment. The Board concludes that a total rating for compensation purposes based on individual unemployability due to service-connected disabilities is warranted. Reasonable doubt has been resolved in favor of the Veteran in making this decision. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). (CONTINUED ON NEXT PAGE) ORDER Entitlement to an evaluation of 70 percent, but no higher, for PTSD and MDD, to exclude the period from May 7, 2008 through July 31, 2008, is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a TDIU is granted, subject to the laws and regulations governing the award of monetary benefits. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs