Citation Nr: 1334221 Decision Date: 10/29/13 Archive Date: 11/06/13 DOCKET NO. 09-16 728 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE 1. Entitlement to a higher initial rating for posttraumatic stress disorder (PTSD), rated 30 percent disabling prior to December 30, 2009. 2. Entitlement to an initial rating in excess of 70 percent since December 30, 2009. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU). 4. Entitlement to special monthly compensation (SMC) pursuant to 38 U.S.C.A. § 1114(s). REPRESENTATION Appellant represented by: Georgia Department of Veterans Services ATTORNEY FOR THE BOARD S. Lipstein INTRODUCTION The Veteran had active service from January 1965 to January 1985, including combat service in the Republic of Vietnam and his decorations include the Combat Infantryman Badge (CIB). This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2007 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a Board hearing; however, he failed to attend a hearing in October 2012. Accordingly, the Board will proceed with adjudication of this appeal. The Board observes that a claim for a TDIU has been raised by the Veteran during the course of the current appeal. In light of Rice v. Shinseki, 22 Vet. App. 447 (2009), entitlement to a TDIU rating is properly considered as part of the claim for an increased initial rating for PTSD. As such, the claim for a TDIU rating, as due to the Veteran's service-connected PTSD, may be considered by the Board in tandem with his claim for a higher initial rating. Id. FINDINGS OF FACT 1. For the period prior to December 30, 2009, the preponderance of the evidence shows that the Veteran's PTSD was manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) as the result of mild short-term memory loss; depressed mood without panic attacks; chronic sleep impairment; normal and clear speech; unimpaired judgment; and abnormal abstract thinking; without more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity. 2. For the period from December 30, 2009, the preponderance of the evidence shows that the Veteran's PTSD has not been productive of total occupational and social impairment. 3. Since December 30, 2009, the Veteran's service-connected PTSD alone precludes him from securing or following a substantially gainful occupation. 4. Service connection was established for the Veteran's coronary artery disease, which is rated as 60 percent disabling effective June 1, 2009. CONCLUSIONS OF LAW 1. Prior to December 30, 2009, the criteria for an initial disability rating in excess of 30 percent for PTSD were not met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.130, Diagnostic Code (DC) 9411 (2013). 2. For the period from December 30, 2009, the criteria for an initial disability rating in excess of 70 percent for PTSD have not been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.130, DC 9411 (2013). 3. The criteria for a grant of TDIU due to PTSD, effective December 30, 2009, have been met. 38 U.S.C.A. §§ 1154(a), 1155, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.321, 3.340, 3.341, 4.16 (2013). 4. The criteria for special monthly compensation at the housebound rate, effective December 30, 2009, have been met. 38 U.S.C.A. §§ 1114(s), 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.350 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS PTSD I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented at 38 C.F.R. § 3.159, amended VA's duties to notify and assist a claimant in developing the information and evidence necessary to substantiate a claim. Under 38 U.S.C.A. § 5103, VA must notify the claimant of any information or evidence not of record that is necessary to substantiate the claim and that information or evidence VA will seek to provide, and what parts VA expects the claimant to provide. 38 C.F.R. § 3.159(b). VA must provide such notice to a claimant prior to an initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (AOJ), even if the adjudication occurred prior to the enactment of the VCAA. See Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004). VCAA requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all elements of a claim for service connection, so that VA must provide notice that a disability rating and an effective date will be assigned if service connection is awarded. Dingess v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (2007). With respect to the notice requirements, the United States Court of Appeals of the Federal Circuit (Federal Circuit) has held that once the underlying claim is granted further notice as to downstream questions, such as the effective date, is not required. See Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Accordingly, the Board finds that VA satisfied its duty to notify under the VCAA in accordance with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)(1). The claimant was provided the opportunity to present pertinent evidence. The record contains records of medical treatment received from VA and private treatment providers. The duty to assist includes the duty to provide a medical examination or obtain a medical opinion when such is necessary to make a decision on the claim, as defined by law. In this regard, the October 2006, December 2009, and June 2010 VA examination reports contain the pertinent clinical findings relevant to the pertinent diagnostic code. The Board notes that these VA examiners were provided with an accurate history, the Veteran's history and complaints were recorded, the examination reports set forth detailed examination findings in a manner that allows for informed appellate review under applicable VA laws and regulations, and the examiners offered the necessary findings. Therefore, the Board finds the October 2006, December 2009, and June 2010 VA examination reports to be sufficient and adequate for rating purposes. Significantly, the Board observes that the Veteran has not reported that PTSD has worsened since the most recent VA examination in June 2010. As such, a remand is not required solely due to the passage of time since the June 2010 VA examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 182-83 (2007); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). In sum, there is no evidence of any VA error in notifying or assisting the appellant that reasonably affects the fairness of this adjudication. VA has fulfilled its duty to assist the claimant by obtaining identified and available evidence needed to substantiate the claim, and, as warranted by law. Significantly, the Veteran has not identified, and the record does not otherwise indicate, that any additional evidence exists that has not been obtained and would be necessary for a fair adjudication of the claim. Hence, no further notice or assistance is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Legal Criteria & Factual Background A February 2007 rating decision granted service connection for PTSD and assigned a 30 percent disability rating effective September 21, 2006 under DC 9411. A July 2010 rating decision assigned a 70 percent disability rating effective December 30, 2009. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate DCs. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. If two evaluations are potentially applicable, the higher one 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In Fenderson v. West, 12 Vet. App. 119, 126 (1999), the Court noted a distinction between an appeal involving the Veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, consideration of the appropriateness of "staged rating" also is required. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The Veteran's statements describing the symptoms of his service-connected PTSD are deemed competent evidence, and these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria. 38 C.F.R. § 3.159 (2013). On evaluating the condition of service-connected disability, if it is not possible to separate the effects of a service-connected condition from that of a nonservice-connected condition, then 38 C.F.R. § 3.102 requires that reasonable doubt be resolved in the Veteran's favor; that is, any such ambiguity as to the origin of such signs and symptoms shall be attributed to the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Thus, in this case, if any symptoms cannot be distinguished as between service-connected and nonservice-connected symptomatology, the Board must consider both as service-connected disability. Id. The General Rating Formula for Mental Disorders, including Diagnostic Code 9411 for PTSD, provides the following ratings for psychiatric disabilities. A 30 percent evaluation is assigned when there is occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, DC 9411 (2013). A 50 percent evaluation is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once 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. Id. A 70 percent evaluation is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relationships, 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. Id. Lastly, a 100 percent evaluation is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Consideration is given to the frequency, severity, and duration of psychiatric symptoms, the length of remission, 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. See 38 C.F.R. § 4.126(a). Furthermore, when evaluating the level of disability arising from a mental disorder, 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(b). It is necessary to evaluate a disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2 (2013). In evaluating the severity of the Veteran's PTSD, the Board points out that "it is not the symptoms, but their effects, that determine the level of impairment." Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). When determining the appropriate disability evaluation to assign, however, the Board's "primary consideration" is the Veteran's symptoms. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed Cir. 2013). One factor which may be considered is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) page 32); see also Richard v. Brown, 9 Vet. App. 266 (1996). A GAF score of 11 to 20 indicates that there is some danger of hurting oneself or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement), or an occasional failure to maintain minimal personal hygiene, or gross impairment in communication. A GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). A GAF score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech at times illogical, obscure, or irrelevant), or where there is 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). A GAF score of 41 to 50 indicates 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). A GAF score of 51 to 60 indicates moderate symptoms (e.g., flattened affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). A GAF of 61 to 70 reflects some mild symptoms, or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("(A) medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). The Board has reviewed all the evidence in the record. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran underwent a VA examination in October 2006. He reported sleeplessness and short temper. He stated that the symptoms occurred constantly. He reported that he was not able to work because he could not get along with others. He had not been admitted to a hospital for psychiatric reasons and he was not required to make any emergency room visits for his psychiatric problem. He reported a great relationship with his spouse and children. The Veteran also reported having a great relationship with his three siblings. He denied any major changes in his daily activities since he developed his mental condition. He reported major social function changes since he developed his mental condition, such as not wanting to be around most people or groups. He stated that he had persistent irritability or outbursts of anger, which involved the Veteran being easily frustrated with others when things went wrong. Upon mental status examination, orientation was within normal limits. Appearance, hygiene, and behavior were appropriate. Affect and mood were abnormal with depressed mood, which occurred as often as once a month, with each episode lasting for four days. The Veteran was aggravated, easily frustrated and verbally abusive. Communication, speech, and concentration were within normal limits. Panic attacks were absent. Signs of suspiciousness included being always guarded and refusing to sit in the middle of the room. No hallucination or delusional history was present and no delusions or hallucinations were observed. Obsessional rituals were absent. Thought processes were appropriate. Judgment was not impaired. Abstract thinking was abnormal, described as concrete interpretation of proverbs. Memory was mildly impaired, to include forgetting names, directions, and recent events. The Veteran reported forgetting tasks he had to perform. Suicidal and homicidal ideation were absent. The examiner diagnosed PTSD and assigned a GAF score of 70. The examiner noted that psychiatric symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks, although generally the Veteran was functioning satisfactorily with routine behavior, self-care and normal conversation. The examiner stated that the Veteran appeared to pose no threat of persistent danger or injury to self or others. In February 2008, the Veteran reported at least two panic attacks per week, long term memory loss, difficulty in establishing and maintaining effective work and social relationships, impaired judgment, occupational and social impairment, persistent danger of hurting self or others, and suicidal ideation. The Veteran underwent another VA examination on December 30, 2009. He reported constant chronic insomnia, combat nightmares, irritability with angry outbursts and rages, and hypervigilance. He stated that the symptoms affected his total daily functioning which resulted in frequent emotional distress, strained interpersonal relationships, and fatigue with daytime napping. He and his wife both rated his irritability as severe, and he reported that he tended to fly into irrational rages "if everything doesn't go just right." He blamed his irritability and poor mental focus for his inability to maintain his last job. He reported trouble sleeping, including difficulty initiating and maintaining sleep, nightly combat dreams, daytime fatigue and napping. He stated that he felt safer sleeping during the day, especially when his wife was at home. He reported that his relationship with his wife was strained by his anger issues and obsessive verbal repetition of events that he experienced in Vietnam. He stated that his relationship with his children was strained by his anger issues when they were growing up. He reported that his current relationship with his children was very good. He denied any hospitalizations or emergency room visits for psychiatric reasons. He reported chronic insomnia with daytime fatigue and napping, self-isolation to home, and loss of interest in previous leisure activities. He stated that he avoided crowds, his past and existing interpersonal relationships were strained by his anger issues, and he had no new friends in decades. He reported that he had not worked for 10 years because he was mentally incapable of working. Upon mental status examination, orientation was within normal limits. Appearance, hygiene and behavior were appropriate. The Veteran maintained good eye contact during the examination. He had a depressed mood which occurred near-continuously and affected the ability to function independently. He had amotivation, nocturnal insomnia and daytime hypersomnia, anhedonia with social isolation, guilt, and intermittent suicidal ideation. Communication and speech were within normal limits. The Veteran showed impaired attention and/or focus, which caused him to stop watching long movies and reading. Panic attacks were absent and suspiciousness was not present. There was no report of a history of delusions, and no delusions were observed. Hallucination history was present occasionally, including shadow of a person in his peripheral visual fields on waking from sleep. At time of examination, no hallucination was observed. Obsessional rituals were present and not severe enough to interfere with routine activities. Examples were frequent checking out windows at home due to constant hypervigilance. Thought processes were appropriate. The Veteran was able to read and understand directions. He did not have slowness of thought and did not appear confused. Judgment was not impaired. Abstract thinking was normal. Memory was mildly impaired, including forgetting names, directions, and recent events. Suicidal ideation was present, including thoughts of killing himself in a high speed car crash, but he insisted that he would never do such a thing as long as his wife was alive. Homicidal ideation was absent. Behavioral, cognitive, social, affective or somatic symptoms attributed to PTSD were described as angry outbursts, difficulty focusing, self-isolation, emotional distress (intense anxiety, sadness and guilt), and nausea triggered by reminders of the bloody ambush in service. The examiner diagnosed PTSD and chronic major depressive disorder. The examiner stated that the symptoms of each mental disorder can be delineated from each other. PTSD symptoms were re-experiencing, avoidance behavior, hypervigilance, and exaggerated startle response. Depression symptoms were sadness, amotivation, loss of appetite, and suicidal thoughts. Sleep disturbance, anhedonia, guilt, irritability, and difficulty concentrating were common symptoms of both. The examiner assigned a GAF score of 50. The examiner noted that the Veteran was unable to sustain employment in his last self-owned business due to extreme irritability, resulting in very low frustration tolerance and rages, as well as difficulty with mental focus and task completion. The examiner stated that the Veteran was intermittently unable to perform activities of daily living (but he could provide self-care) because of depressive amotivation. He had difficulty establishing and maintaining effective work/school and social relationships because of severe irritability and angry outbursts/rages. He had difficulty maintaining effective family role functioning because of severe irritability/angry outbursts in the past and depressive amotivation more recently. He had intermittent inability to perform recreation or leisurely pursuits because of anhedonia and amotivation. He had intermittent interference with physical health because of anger-fueled defiance against complying with prescribed medications, as well as depressive amotivation. He had no difficulty understanding commands. The examiner stated that the Veteran appeared to pose no threat of persistent danger or injury to self or others. The Veteran underwent another VA examination in June 2010. He reported sleep disturbance, mood disturbance, nightmares, anxiety, panic attacks, anger, irritability, hypervigilance, and trouble concentrating. He stated that the severity of the symptoms were moderate, constant, continuous or ongoing. He reported that the symptoms affected daily functioning which resulted in relation, social and occupational problems. He stated that he had trouble sleeping for 42 years. He reported trouble falling and staying asleep. He denied a history of violent behavior and suicide attempts. He denied hospitalization or emergency room visits for psychiatric reasons. He reported that his relationship with siblings was fair. He stated that his relationship with his wife was up and down. He reported loss of interest and motivation. He stated that he had social withdrawal and isolation. He reported that these social function changes occurred within the previous year. He stated that he had not worked in four years, and that he was unable to deal with stress, being around people, and had trouble concentrating. He reported that he was unemployed due to the effects primarily of PTSD. Upon mental status examination, orientation was within normal limits. Appearance, hygiene, and behavior were appropriate. The Veteran maintained good eye contact during the examination. Affect and mood showed a disturbance of motivation and mood, anxiety, and depressed mood. The Veteran felt sad, anxious, angry, and irritable with loss of interest and motivation. Communication and speech were within normal limits. The Veteran showed impaired attention and/or focus. He had trouble concentrating due to impaired focus and attention. Panic attacks were present and occurred less than once per week. The attacks caused anxiety and fear. There were signs of suspiciousness with hypervigilance. There was no report of a history of delusions or hallucinations. At time of examination, no delusions or hallucinations were observed. Obsessive-compulsive behavior was absent. Thought process were appropriate. The Veteran was able to understand directions. He did not have slowness of thought, nor did he appear confused. Judgment was not impaired. Abstract thinking was normal. Memory was mildly impaired and he forgot names, directions, and recent events. He was forgetful due to trouble concentrating and focusing. Suicidal ideation and homicidal ideation were absent. Behavioral, cognitive, social, affective or somatic symptoms attributed to PTSD were described as mood disturbance, anxiety, irritability, loss of motivation, and trouble concentrating. The examiner diagnosed PTSD and stated that the Veteran is unable to maintain gainful employment at present due to the clinically significant symptoms of PTSD. The examiner noted that the Veteran did not have difficulty performing activities of daily living. He had difficulty establishing and maintaining effective work/school and social relationships because of PTSD. He was able to maintain effective family role functioning. He had occasional interference with recreation or leisurely pursuits because of PTSD. He had occasional interference with physical health because of multiple medical problems. He had no difficulty understanding commands. The examiner stated that the Veteran appeared to pose no threat of persistent danger or injury to self or others. Analysis Prior to December 30, 2009 The evidence does not show characteristics of a 50 percent rating, including circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of long-term memory; impaired judgment; or impaired abstract thinking. Rather, the October 2006 VA examiner noted that the Veteran's speech was within normal limits; panic attacks were absent; his judgment was not impaired; and his thought processes were appropriate. He did have some mild memory impairment, to include forgetting names, directions, and recent events, and affect and mood were abnormal with depressed mood. Additionally, abstract thinking was abnormal, described as concrete interpretation of proverbs. However, the evidence does not reflect that the Veteran's depressed mood, mild memory loss, and abnormal abstract thinking caused occupational or social impairment with reduced reliability and productivity. For example, the October 2006 VA examiner noted that psychiatric symptoms caused occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks, although generally the Veteran was functioning satisfactorily with routine behavior, self-care and normal conversation. Additionally, as noted above, the October 2006 VA examiner assigned a GAF score of 70, which would indicate extremely mid symptomatology. The Board notes that, in February 2008, the Veteran reported at least two panic attacks per week, long term memory loss, difficulty in establishing and maintaining effective work and social relationships, impaired judgment, occupational and social impairment, persistent danger of hurting self or others, and suicidal ideation. However, the Board places greater probative weight to the clinical evaluation provided by the October 2006 VA examiner, who is a Board certified psychiatrist, and has greater expertise, training, and objectivity than the Veteran to evaluate his PTSD symptoms. Even considering the Veteran's statement with regard to the symptoms noted above, the statement does not reflect occupational and social impairment with reduced reliability and productivity. Accordingly, the Board finds that the Veteran's disability picture has not been manifest by occupational and social impairment with reduced reliability and productivity, as contemplated by a rating of 50 percent under Diagnostic Code 9411, and the reasonable doubt standard of proof is not applicable. 38 C.F.R. § 4.3. From December 30, 2009 For the reasons that follow the Board finds that the preponderance of the evidence is against a finding that the Veteran's PTSD more closely approximates the criteria for the highest rating of 100 under the assigned diagnostic criteria (Diagnostic Code 9411). The December 30, 2009 and June 2010 VA examination reports reflect that the Veteran's PTSD has been productive of constant chronic insomnia, combat nightmares, irritability with angry outbursts and rages, hypervigilance, anxiety, panic attacks, trouble concentrating, self-isolation, and loss of interest in previous leisure activities; however, the Veteran's PTSD has not been productive of the types of symptoms that are contemplated by a rating of 100 percent under Diagnostic Code 9411, such 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; disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. For example, the December 30, 2009 and June 2010 VA examiners noted that the Veteran's orientation was within normal limits. Moreover, the December 30, 2009 and June 2010 VA examiners found that appearance, hygiene and behavior were appropriate, communication and speech were within normal limits, no delusions or hallucinations were observed, and the Veteran appeared to pose no threat of persistent danger or injury to self or others. Additionally, the December 30, 2009 and June 2010 VA examiners found that memory was mildly impaired, including forgetting names, directions, and recent events. Thus, the evidence does not reflect memory loss for names of close relatives, own occupation, or own name. Moreover, the June 30, 2009 VA examiner noted that the Veteran was intermittently unable to perform activities of daily living, although this was due to depressive amotivation. Additionally, the June 2010 VA examiner noted that the Veteran did not have difficulty performing activities of daily living. Thus, the evidence does not reflect intermittent inability to perform activities of daily living due to PTSD. Finally, as noted above, the GAF scores ranged from 50 to 55, which is demonstrative of serious, but not total, psychiatric impairment. Although the Veteran is irritable and had difficulty in work and interpersonal relationships, the evidence shows that he does maintain a few relationships with his siblings, wife, and children. Accordingly, the Board finds that the Veteran's disability picture has not been manifest by total psychiatric (occupational and social) impairment, as contemplated by a rating of 100 percent under Diagnostic Code 9411, and the reasonable doubt standard of proof is not applicable. 38 C.F.R. § 4.3. Extraschedular Consideration Further, in exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). The Board finds that the rating criteria contemplate the Veteran's PTSD, which is rated based on the social and occupational impairment stemming from his psychiatric disability, manifestations that are contemplated in the rating criteria. The rating criteria are therefore adequate to evaluate the Veteran's PTSD and referral for consideration of extraschedular rating is not warranted. TDIU Criteria & Analysis A total disability rating 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 the result of service-connected disabilities. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. Consideration may be given to a veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or the impairment caused by any nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. To qualify for a total rating for compensation purposes, the evidence must show: (1) a single disability rated as 100 percent disabling; or (2) that the veteran is unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities and there is one disability ratable at 60 percent or more, or, if more than one disability, at least one disability ratable at 40 percent or more and a combined disability rating of 70 percent. 38 C.F.R. § 4.16(a). Disabilities that are not service connected cannot serve as a basis for a total disability rating. 38 C.F.R. §§ 3.341, 4.19. Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, "entitlement to a TDIU is based on an individual's particular circumstances." Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, in adjudicating a TDIU claim, VA must take into account the individual veteran's education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164, 168 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering veteran's experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering veteran's 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering veteran's master degree in education and his part-time work as a tutor). The Veteran is currently in receipt of a combined 100 percent disability rating effective December 18, 2009. Because the Veteran is also in receipt of a 70 percent rating for PTSD, effective December 30, 2009, his disability satisfies the schedular criteria for a TDIU rating under 38 C.F.R. § 4.16(a) (2013). As noted above, the December 30, 2009 VA examiner noted that the Veteran was unable to sustain employment in his last self-owned business due to extreme irritability, resulting in very low frustration tolerance and rages, as well as difficulty with mental focus and task completion. In addition, the June 2010 VA examiner stated that the Veteran is unable to maintain gainful employment at present due to the clinically significant symptoms of PTSD. As such, both examiners determined that due solely to his PTSD the Veteran was unable to secure or follow a substantially gainful occupation. Given the impairments stemming from the Veteran's service-connected PTSD, the Veteran's former employment in a self-owned business, and in light of the December 2009 and June 2010 VA examination opinions, resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for a TDIU due solely to PTSD have been met, effective December 30, 2009. SMC Criteria & Analysis As noted above, entitlement to a TDIU due to PTSD is granted, effective December 30, 2009, due to the Veteran's PTSD alone. Additionally, service connection was established for numerous other service-connected disabilities, including the Veteran's coronary artery disease, which is rated as 100 percent disabling from February 25, 2009, and 60 percent disabling effective June 1, 2009. Thus, the Board must consider whether the Veteran was entitled to SMC, pursuant to VA's "well-established" duty to maximize a claimant's benefits. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008) (finding that SMC "benefits are to be accorded when a Veteran becomes eligible without need for a separate claim" and remanding, pursuant to VA's duty to maximize benefits, for VA to determine whether the Veteran's posttraumatic stress disorder, rated 70 percent disabling, would entitle him to a TDIU and, therefore, to SMC). Special monthly compensation is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. This requirement is met when the Veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i). Subsection 1114(s) requires that a disabled Veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for the special monthly compensation provided by that statute. Under the law, subsection 1114(s) benefits are not available to a Veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. The Court has held that although a TDIU may satisfy the "rated as total" element of section 1114(s), a TDIU based on multiple underlying disabilities cannot satisfy the section 1114(s) requirement of "a service-connected disability" because that requirement must be met by a single disability. The Court declared, however, if a Veteran were awarded a TDIU based on multiple underlying disabilities and then later receives a schedular disability rating for a single, separate disability that would, by itself, create the basis for an award of a TDIU, that the order of the awards was not relevant to the inquiry as to whether any of the disabilities alone would render the Veteran unemployable and thus entitled to a TDIU rating based on that condition alone. Buie v. Shinseki, 24 Vet. App. 242, 250 (2010). In this case, the Board notes that the Veteran is assigned a TDIU based solely due to his PTSD, effective December 30, 2009. The Board finds that although the PTSD was not rated as 100 percent, for SMC purposes this disability satisfied the requirement of a "service-connected disability rated as total." See Buie v. Shinseki, 24 Vet. App. 242, 251 (2011); see also Bradley v. Peake, 22 Vet. App. 280, 293 (2008). Because the Veteran has a single service-connected disability rated as total (i.e. PTSD), and has an additional service-connected disability (i.e. coronary artery disease) that is independently rated at 60 percent, the criteria for SMC at the housebound rate were met as of December 30, 2009. Thus, in light of the Court's decisions in Bradley and in Buie, entitlement to SMC at the housebound rate under 38 U.S.C.A. § 1114(s) is granted, effective December 30, 2009. ORDER An initial schedular rating for PTSD in excess of 30 percent prior to December 30, 2009 is denied. An initial schedular rating in excess of 70 percent for PTSD since December 30, 2009, is denied. Subject to the law and regulations governing payment of monetary benefits, a TDIU due PTSD alone is granted, effective December 30, 2009. Subject to the law and regulations governing payment of monetary benefits, entitlement to special monthly compensation at the housebound rate under 38 U.S.C.A. § 1114(s) is granted, effective December 30, 2009. ____________________________________________ STEVEN D. REISS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs