Citation Nr: 1325011 Decision Date: 08/07/13 Archive Date: 08/13/13 DOCKET NO. 09-28 667 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an effective date earlier than June 23, 2008, for the assignment of a 30 percent rating for posttraumatic stress disorder (PTSD). 2. Entitlement to a rating higher than 30 percent for the period prior to September 19, 2012, and to a rating higher than 70 percent for the period since that date for PTSD. 3. Entitlement to a total disability rating on the basis of individual unemployability (TDIU) for the period from April 21, 2009, to April 8, 2012. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD W.T. Snyder, Counsel INTRODUCTION The Veteran served on active duty from November 1966 to November 1968. This appeal to the Board of Veterans' Appeals (Board) arose from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas, that awarded an increased rating for PTSD from 10 to 30 percent, effective in June 2008, and the Veteran appealed. While the case was on appeal, an RO decision review officer, in a September 2012 rating decision, awarded an increased rating from 30 to 70 percent, effective in September 2012. The Veteran has continued his appeal for an even higher rating. See AB v. Brown, 6 Vet. App. 35 (1993) (a veteran is presumed to be seeking the highest possible rating unless he expressly indicates otherwise). A June 2009 rating decision denied a TDIU, which the Veteran, through his then representative, appealed. Although a Statement of the Case (SOC) was not issued, the Board in fact has jurisdiction over it, as the Veteran as consistently asserted that he seeks the highest possible rating, and that he is unable to obtain and maintain substantially gainful employment. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The issue of whether a February 1993 rating decision that granted service connection for PTSD contained clear and mistakable error has been raised by the record, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran perfected an appeal of the issue of entitlement to an effective date earlier than June 23, 2008, for a 30 percent rating for PTSD. 2. In February 2012, prior to the promulgation of a decision on the appeal, the RO received notification from the Veteran, through his then authorized representative, that a withdrawal of the appeal of the earlier effective issue was requested. 3. The preponderance of the evidence of record shows that, for the period prior to September 19, 2012, the Veteran's PTSD more nearly approximated occupational and social impairment with reduced reliability and productivity. 4. For the period since September 19, 2012, the Veteran's PTSD has more nearly approximated occupational and social impairment with deficiencies in most areas. 5. The preponderance of the evidence of record shows that, for the period April 21, 2009, to April 8, 2012, the Veteran was unable to obtain and maintain substantially gainful employment due to his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the Veteran's authorized representative have been met as to the claim of entitlement an effective date earlier than June 23, 2008, for a 30 percent rating for PTSD. 38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. § 20.204 (2012). 2. With resolution of reasonable doubt in the Veteran's favor, the requirements for an evaluation of 50 percent, but no higher, for PTSD are met for the period prior to September 19, 2012. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.6, 4.7, 4.10, 4.130, Diagnostic Code (DC) 9411. 3. The requirements for an evaluation higher than 70 percent for PTSD for the period September 19, 2012, forward, are not met. 38 U.S.C.A. § 1155; 38 C.F.R. § 3.321(b)(1), 4.1, 4.6, 4.7, 4.10, 4.130, DC 9411. 4. The requirements for a TDIU for the period April 21, 2009, to April 8, 2012, are met. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim. 38 U.S.C.A. § 5103(a) (West 2002); C.F.R. § 3.159(b)(1) (2012). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Court Of Appeals For Veterans Claims has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Adequate VCAA notice in an increased rating claim required that VA notify the claimant that, to substantiate such a claim: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) evidence demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008) vacated in part Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009). Prior to issuance of the rating decision on appeal, in a letter issued in July 2008, the RO notified the Veteran of the evidence needed to substantiate his claim for increased ratings. A January 2009 letter informed him of the requirement for a TDIU. The letters also satisfied the second and third elements of the duty to notify by informing the Veteran that VA would try to obtain medical records, employment records, or records held by other Federal agencies, but that he was nevertheless responsible for providing any necessary releases and enough information about the records to enable VA to request them from the person or agency that had them. The Board finds both letters were time- and content-compliant. See 38 C.F.R. § 3.159(b); see also Dingess/Hartman, supra. Hence, the Board finds VA complied with the VCAA notice requirements. The Duty to Assist The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). In the Veteran's case, the RO obtained the outpatient records extant and arranged three examinations for the Veteran. Neither the Veteran nor his representative asserts that there are additional records to be obtained. Hence, the Board finds VA complied with the duty to assist the Veteran with his claims, and there is no issue that precludes the Board from addressing the merits of the Veteran's appeal. See 38 C.F.R. § 3.159(c). Withdrawal of an Appeal The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C.A. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by an appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran's authorized representative has withdrawn this appeal and, hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal and it is dismissed in the action later in this decision. Increased Rating Claim Applicable Law and Regulation Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. VA must also interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. VA must resolve any reasonable doubt regarding the degree of disability in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.3. Where there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7, see also 38 C.F.R. § 4.21. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when either disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating a mental disability, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation 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. When evaluating the level of disability from a mental disability, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126. The symptoms recited in the criteria in the rating schedule for evaluating mental disabilities are "not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In adjudicating a claim for an increased rating, the adjudicator must consider all symptoms of a claimant's service-connected mental condition that affect the level of occupational or social impairment. Id. at 443. A Veteran may only qualify for a given initial or increased rating based on mental disability (psychiatric disability) by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed.Cir.2013). Analysis By way of history, a February 1993 rating decision granted service connection for PTSD with an initial 10 percent rating, effective in August 1992. VA received the Veteran's current claim for an increased rating in June 2008. The rating criteria provide for a 30 percent rating for PTSD symptomatology that results in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, and recent events). 38 C.F.R. § 4.130, DC 9411. A 50 percent evaluation will be assigned with evidence of occupational and social impairment with reduced reliability and productivity due to such symptoms as: a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation applies when a veteran's occupational and social impairment reflects 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships. Id. A 100 percent rating is assigned when there is total occupational and social impairment, due to such symptoms as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The evidence in the claims file shows that between November 2004, the date of the Veteran's prior VA examination, and June 2008, the Veteran had not sought, nor was he involved with, outpatient treatment or therapy for his PTSD. An August 2008 outpatient entry notes the Veteran reported his main PTSD symptoms as sleep disturbance where he awoke with cold sweats due to nightmares, flashbacks, and intrusive thoughts. The examiner noted the Veteran's affect was restricted, and his mood depressed, but he was not hopeless or helpless. The Veteran's speech was well modulated, and his thought content was clear and organized. The Veteran reported his main stressors were financial concerns, marital problems, and his inability to maintain employment. The entry does not connect the employment problems to the PTSD. The examiner noted the Veteran should continue to take Trazodone for his sleep problems, and to return in eight weeks. The August 2008 examination report reflects the examiner conducted a review of the claims file as part of the examination. The Veteran reported the problem that caused him the most difficulty was sleep disturbance, as he got three to four hours a night, maximum, and that was with the benefit of his medication. The Veteran reported that at least twice a month his flashbacks resulted in his feeling disoriented, and he saw things as if her were back in Vietnam. The Veteran related that he was married to his third wife, to whom he had been married for 26 years. He reported further that he started using illicit drugs after he returned from Vietnam, and he believe it was due to the trauma of his Vietnam experience. The Veteran reported one suicide attempt shortly after his return from Vietnam. He reported further that he had some problems with being short-tempered and, in the Veteran's assessment, 60 to 75 percent of his psychological and behavioral problems were due to his PTSD, while the remainder were due to his own doing. The Veteran denied any remission in his PTSD symptoms since the 2004 examination and, in fact, reported they had increased. The examiner noted the Veteran had recently began coming back for outpatient treatment after an extended period of no treatment. He reported the Trazodone had helped him sleep three to four hours a night. The Veteran reported he was retired from active employment due to his post-operative heart disease. He reported further that he and his current wife had five children and 11 grandchildren. He assessed his relationship with his wife as very poor, as there had been two episodes of domestic violence where she twice called the police. The Veteran related that he did not care about his children, but he cared deeply about his grandchildren, as they are the only reason he is not dead. He and his wife cared for two of the grandchildren while their parents work. The Veteran reported he helped with household chores an duties, and that he had no friends. The Veteran reported he no longer used cocaine, as he wanted to spend more time with his grandchildren; and, he currently drank perhaps one beer a month due to the effects of alcohol on his heart medications. Formerly, the Veteran abused alcohol significantly. He still used marihuana a minimum of twice a month, more when he is feeling depressed. Mental status examination revealed the Veteran as casually dressed, and he evidenced fair grooming and hygiene. He evidenced no abnormalities in his posture or psychomotor activity. He was on time, cooperative, and courteous. His speech and communication were normal in rate, rhythm, and volume. The Veteran's thought processes were clear, logical, goal-directed, and coherent. Thought content was relevant and appropriate, as was his behavior. His mood was depressed, and his affect was slightly agitated but generally mood congruent. The examiner noted the Veteran's thoughts of suicide were more in terms of passive thoughts rather than active. He denied any intent or plan or homicide ideation. The Veteran was oriented in all spheres. His remote and recent memory were fair, and he evidenced problems in attention and concentration. He was unable to spell a five-letter word backwards, and he was unable to do serial sevens. The Veteran did evidence good abstract reasoning skills and good social judgment. The examiner noted the Veteran's level of psychological insight appeared to be average or somewhat below. The examiner noted the Veteran had been retired since January 2002, so he did not assess the impact of the Veteran's symptoms on his ability to do his job. Instead, he assessed the impairment of the Veteran's social functioning. The examiner noted the Veteran's PTSD did not prevent him from attending to his activities of daily living. The examiner noted the Veteran did not endorse hypervigilence, but he did report that looked to see if he was being followed when he drove The examiner opined the Veteran's symptoms had increased only slightly since the 2004 examination, and he assessed the Veteran's symptoms as of mild to moderate severity, and his social deficits were moderate. The examiner assigned Axis V, Global Assessment of Functioning (GAF) 60. The GAF score is a scaled rating 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 Diagnostic and Statistical Manual of Mental Disabilities (4th ed.1994) (DSM-IV). The Board notes that a GAF of 60 is at the top end of the range of 51 to 60, and is indicative of moderate symptoms. As noted earlier, upon receipt of the examination report, an October 2008 rating decision awarded an increased rating from 10 to 30 percent. The Board, however, finds the totality of the evidence around the relevant time frame shows the Veteran's PTSD more nearly approximated a 50-percent rating. 38 C.F.R. § 4.7. Although an August 2008 statement (VA Form 21-4138) of the Veteran's wife was received a week prior to the August 2008 examination, it is uncertain if had been placed in the claims file. The examiner provided a comprehensive synopsis of the documentation he reviewed in the claims file, and there was no mention of the wife's statement. In addition to the symptoms the Veteran reported to the examiner, the Veteran's wife noted in her August 2008 statement that the Veteran was continually depressed, and he did not want to shower. She also noted the Veteran had anxiety attacks, and he tended to isolate. Further, the Veteran's short-term memory was almost non-existent, and he did not care if he died. The Veteran's wife did not provided the frequency of the Veteran's anxiety attacks. The observations of the Veteran's wife is competent evidence of the Veteran's symptoms. See 38 C.F.R. § 3.159(a)(1). The evidence of anxiety or panic attacks, and continued depression, brings the 50 percent criteria into play. See 38 C.F.R. § 4.130. Further, while the examiner at the August 2008 examination specifically referenced only remote and recent memory, the examination report notes the Veteran's inability to spell a word backwards or to do serial sevens. That finding supports the Veteran's wife's assessment of the Veteran's short-term memory. There also is the issue of the Veteran's depression. The examiner opined that, while the Veteran's PTSD aggravated his depression, it was not the sole cause. Other factors included the Veteran's disturbed and distressed family relationship, inadequate finances, and the his lingering resentment over how his job ended. The examiner opined further that there was a connection between the Veteran's marihuana use and his depression, as the Veteran reported he used it to help ease his symptoms. There must be evidence that permits the adjudicators to distinguish between manifestations that are service-connected and those that are not. See Waddell v. Brown, 5 Vet. App. 454, 456-57 (1993). When it is not possible to separate the effects of a non- service-connected condition from those of a service- connected condition, VA regulations dictate that such signs and symptoms be attributed to the service-connected condition. See Mittleider v. West, 11 Vet. App. 181, 182 (1998); 38 C.F.R. § 3.102. The Board notes the examiner appeared to attribute all of the Veteran's relational problems to non-PTSD causes, but the Board finds the record shows otherwise. The Veteran reported he had no friends. Even were the Board to agree with the opinion that the Veteran's PTSD only aggravates his depression, the Veteran's symptomatology would still reflect disturbance of mood and motivation. Further, the 30-percent criteria do not capture impairment related to forming and retaining relationships. Thus, even though there was no finding of a flattened affect or abnormal speech, the Veteran's depression combined with the evidence of panic attacks more than once a week and the evidence of the Veteran's difficulties in forming and maintaining relationships, leads the Board to find the Veteran's symptoms more nearly approximated a 50-percent rating as of the August 2008 examination. 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.130, DC 9411. The Board notes further that subsequent examination reports reflect examiner's opinions that the Veteran's depression and marihuana are in fact directly related to his PTSD. The Board finds that a higher, 70-percent, rating was not met or approximated as of the August 2008 examination, as the findings on clinical examination did not show the Veteran's impairment to exist in most areas or due to symptoms such as spatial disorientation, deficiencies in judgment, or illogical speech. Further, the examiner specifically found the Veteran was not suicidal, nor did he display homicide ideation. The Board also notes that the evidence shows the Veteran's depression to has not deprived him of his ability to function independently. Further, the evidence does not show the Veteran's neglect of personal hygiene to have been continuous, as the examiner assessed it as adequate. Finally, while the Veteran's ability to form and maintain relationships is impaired, the evidence shows it is not non-existent. The Veteran reported he loved his grandchildren, despite the conflict with his children, and he maintained a good relationship with his brother. Inasmuch as the Board finds the Veteran's PTSD warrants a 50-percent rating as of the August 2008 examination, the Board now confines the review to whether the Veteran's symptoms met or approximated the 70-percent criteria prior to September 2012. The Board finds they did not. The April 2009 examination report reflects the examiner noted that while the Veteran was listed for outpatient treatment, his contact with mental health had been sporadic. The medication for sleep impairment was noted, but the examiner noted the Veteran was not taking an anti-depressant, or any medication for mood stabilization. The Veteran reported continued problems with flashbacks, nightmares, and sleep impairment. He reported further his relationship with his wife had worsened, and he suspected her of infidelity. The Veteran reported a good relationship with two of his children and his brother. He reported further that he did not have friends, because he learned 20 years earlier that friends were not good for him. He kept mostly to himself to avoid getting into trouble. He spent most of his time isolating at home, and he avoided interacting with his wife. The Veteran also reported continued anxiety, anger, irritability and continued depression. He believed he was depressed because he had not accomplished anything in life. He also reported crying spells and reduced sexual desire. Mental status examination revealed the Veteran as fully alert and oriented. The examiner noted the Veteran's concentration and memory problems were likely due to his substance abuse. The examiner assessed the Veteran's social impairment as severe, but he also opined that if the Veteran were still employed, the impact of the Veteran's PTSD symptoms on his ability to function at his work would be moderate. The examiner assigned Axis V GAF as 60. The Boar notes the examination findings are essentially consistent with those at the August 2008 examinations. The Board also notes the fact that the Veteran emphasized the fact he had no intent of harming himself, despite his thoughts of suicide. The Veteran also reported that, compared to his past, he had learned to control himself and not allow family conflicts to land him in trouble. This speaks to adequate impulse control. Thus, in view of the Veteran's continued ability to maintain a relationship with some of his children, grandchildren, and his brother, as well as the fact that he remained independent in his daily functioning, the Board finds his symptoms continued to more nearly approximate a 50-percent rating. 38 C.F.R. § 4.130, DC 9411. The April 2010 examination report reflects the Veteran had not consulted outpatient treatment since August 2008. He reported he continued to take Trazodone for his sleep impairment but related it was no longer effective; and, when he tried to increase the dosage on his own, he had dry mouth and still did not sleep any better. He reported further that his primary care provider wanted to prescribe an anti-depressant, but it made him too drowsy. The Veteran reported he had been married for 25 years, and his wife was disabled due to uncontrollable hypertension for about three years. He reported further that his sons had become even more belligerent, as they believed he could no longer defend himself due to his heart disease. He related that, seven months earlier, he had to use a baseball bat to defend himself. The Veteran told his wife that if incidents continued to occur, he would move to avoid the stress. He reported he was on fair terms with his daughters, and that his brother was the only person he was close to. As for his marriage, the Veteran reported he had too much invested in it to walk away; so, he felt somewhat trapped in the situation. The Veteran reported he attended church two to three times a year, but he was not close to anyone at his church, as he was a loner and kept to himself-primarily because he could not express his feelings. The Veteran enjoyed fishing because it relaxed him, but he had not fished in two years because of his heart problems. The Veteran denied any legal involvement, and he reported that any incidents at home were in self-defense. Mental status examination revealed the absence of any impairment of thought process or communication. The Veteran was casually dressed, his grooming was adequate, he maintained eye contact, and he was cooperative. The Veteran reported transient weekly thoughts of hurting himself, but he denied any plan to harm himself. He reported further that he was fully independent in his activities of daily living, though he did require occasional help with his feet and getting out of the tub due to his weight. The examiner noted the Veteran was fully oriented. The Veteran reported that sometimes he could not remember anything, but he denied any obsessive or ritualistic behavior that interfered with his routine activities. The Veteran denied he was depressed, but he also said it was part of life for the rest of his life. He reported panic attacks two to three times a month, depending on the problems he faced. He also claimed he did not worry about when the next one would occur. On a scale of 1 to 10, he assessed his mood as 6/10, though he was unsure of the related symptoms. He endorsed low energy and reduced appetite. The examiner noted that no evidence of impaired impulse control was observed. Interestingly, the examiner's Axis I diagnoses reflect the Veteran's marihuana abuse was in full sustained remission, as the Veteran related he had discontinued use completely. The examiner assigned Axis V GAF at 60. In addition to the symptoms noted above, the Veteran reported that he saw shadows/things in the dark when he walked abruptly, and it happened three to four times a week. The Veteran's then representative asserted that the report, combined with the Veteran's other symptoms merited a higher rating. The Board disagrees. The Board first notes that, at the time of the written argument in the Veteran's behalf, the Veteran was rated at 30 percent. Nonetheless, the Board notes the Veteran denied any auditory hallucinations as well as any other symptoms of a psychosis. Further, the examiner did not assess the Veteran's symptoms as severe. The examiner observed the Veteran's most severe impairment was socially, as the Veteran was deemed able to work despite his PTSD, were he still employed. Although the examiner noted the Veteran had isolated himself from outside relations, the evidence shows the Veteran still retained the ability to maintain some family relationships. Thus, in light of the absence of the more severe symptoms of the 70 percent criteria, and the fact the Veteran retained his ability to function independently, despite his continuous depression, the Board finds his PTSD continued to more nearly approximate the 50-percent rating as of the April 2010 examination. 38 C.F.R. §§ 4.1, 4.10, 4.130, DC 9411. The Veteran's next medical assessment was at the September 2012 examination, which resulted in the RO awarding an increased rating from the then 30 percent to 70 percent. The Board does not discern the need for lengthy discussion. The criteria for a 100 percent rating are set earlier in this decision. The September 2012 examination report reflects the Veteran's chronic symptoms are depressed mood; anxiety; chronic sleep impairment; mild memory loss; disturbance of motivation and mood; difficulty maintaining relationships; and difficulty adapting to stressful circumstances. The examiner did not note the presence of any suicide or homicide ideation, obsessive rituals, spatial disorientation, or any of the other significant symptoms of PTSD. The Board notes the examination report reflects the Veteran's relationship with his wife may possibly have improved-at least as per their report at the examination. The report reflects his wife described him as a good grandfather and father but inconsistent of mood, and irritable as a husband. The Veteran assessed his marital relationship as, "Ok." In light of the above, the Board is constrained to find the Veteran's PTSD did not, and has not, more nearly approximated a 100 percent rating since the September 2012 examination, as the Veteran retains independent functioning despite his symptoms. The Board also notes that the examiner at the April 2010 examination noted the Veteran's symptoms might well improved if he availed himself to more treatment and additional medication. Nonetheless, the Board has assessed his appeal on the basis of his symptoms of record, not what they may be with appropriate treatment and medication. As noted earlier, the Veteran is entitled to a staged rating where indicated by the evidence. As discussed in the evidence set forth above, the Board finds the Veteran has received a staged rating for his PTSD in accordance with the evidence of record. In reaching this decision the Board considered the doctrine of reasonable doubt and afforded it where applicable. Otherwise, as the preponderance of the evidence is against ratings higher than those allowed, the doctrine is not for application. Schoolman v. West, 12 Vet. App. 307, 311 (1999). TDIU As earlier noted, the Veteran has asserted since July 2008 that he is unable to obtain and maintain substantially gainful employment. By way of history, documentation in the claims file reflects the Veteran claim entitlement to service connection for his heart disease on a number of occasions, but the claims were denied, as there was no medical evidence of a causal connection with his active service. See 38 C.F.R. § 3.303. As a result of a liberalization of the presumptive service connection provisions related to herbicide exposure, a January 2011 rating decision granted service connection for coronary artery disease (CAD), status post-coronary artery bypass graft, with an initial 30 percent rating, effective in August 1992. A 100 percent evaluation was assigned, effective in June 1995, and a 30 percent evaluation as of August 1996. A January 2013 rating decision awarded a 100 percent evaluation for the period February 21, 2002, to April 19, 2009; a 60 percent for the period April 20, 2009, to April 8, 2012; and, a 100 percent evaluation as of April 9, 2012. The Veteran did not appeal the initial ratings or effective dates assigned by the January 2011 rating decision. As noted earlier, however, the Veteran asserted unemployability due to both his heart and PTSD in his July 2008 claim. In light of the awards of the January 2013 rating decision, however, only the period April 21, 2009, to April 8, 2012, is in issue, as the 100 percent schedular rating mooted any issue as to a rating based on unemployability. Applicable Law and Regulations A TDIU may be assigned where the combined schedular rating for the service-connected disabilities is less than 100 percent, when it is found that the service-connected disabilities render the Veteran unable to secure or follow a substantially gainful occupation. 38 C.F.R. §§ 3.321, 3.340, 3.341, 4.16. Age or intercurrent non-service-connected disability may not be considered in determining entitlement to a total compensation rating. 38 C.F.R. § 4.19. Factors to be considered are the Veteran's employment history and his educational and vocational attainment. Ferraro v. Derwinski, 1 Vet. App. 326, 332 (1991). Under 38 C.F.R. § 4.16(a), if there is only one service-connected disability, the disability shall be ratable at 60 percent or more; if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. Analysis The Board notes that, even without the higher rating allowed in the decision above, the Veteran's heart disability-rated at 60 percent as of April 2009, and the Veteran's PTSD rated at 30 percent resulted in a total combined rating of 70 percent. See 38 C.F.R. § 4.25, Table 1. Hence, the Veteran is eligible for consideration under the scheduler criteria. 38 C.F.R. § 4.16(a). The Social Security Administration determined the Veteran was disabled as of January 2002 based solely on the heart disability. The Veteran historically asserted he stopped working due to his heart disability. The claims file reflects VA denied a TDIU because the heart disorder was not service connected. The PTSD examination reports also noted the Veteran's unemployed status was due to his heart disorder, not his PTSD. The Board notes, however, that the PTSD examiners assessed the impact of the Veteran's PTSD on his employability on the fact that he worked until his heart disorder disabled him. There was no assessment of the cumulative impact of the Veteran's PTSD and his CAD. Neither was there an assessment of the impact of the absence of the distraction of active employment on the PTSD symptoms. The Veteran consistently reported that the lack of a sense of achievement contributed to his depression. The Veteran asserted in his November 2008 Formal claim that, while his heart disorder did in fact render him unable to work, the continued stress and his PTSD also contributed to his inability to work. The Board discerns no basis on which to remand the case for additional medical input and resolves the matter in the Veteran's favor. 38 C.F.R. §§ 3.340, 3.341, 4.1, 4.3, 4.16. ORDER The appeal of the issue of entitlement to an effective date earlier than June 23, 2008, for a 30 percent rating for PTSD is dismissed. Entitlement to a 50 percent evaluation for PTSD for the period prior to September 19, 2012, is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to an evaluation higher than 70 percent for PTSD for the period September 19, 2012, forward, is denied. Entitlement to a TDIU for the period April 21, 2009, to April 8, 2012, is granted, subject to the law and regulations governing the award of monetary benefits. ____________________________________________ Thomas H. O'Shay Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs